■t?C4.G 


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A  TEXT-BOOK 


OF  THE 


Practice  of  Medicine 


BY 

JAMES  M,  ANDERS,  MX>.,  Ph.D.,  LL.D. 

Professor  of  Medicine  and  Clinical  Medicine  at  the  Medico-Chirurgical  College  ;  Physician  to 

the    Medico=Chirurgical  Hospital  :  Consulting   Physician    to   the   Jewish    Hospital 

and  to  the  Widener  Home  for  Crippled  Children  ;  formerly  Physician  to 

the  Philadelphia  and  to  the  Protestant  Episcopal  Hospitals, 

Philadelphia ;  Officier  de  I'lnstruction  Publique. 


ILLUSTRATED 


ELEVENTH  EDITION,  THOROUGHLY  REVISED 


PHILADELPHIA  AND  LONDON 

W,   B.    SAUNDERS    COMPANY 

J9J3 


Copyright,  1897,  by  W.  B.  Saunders.     Revised,  reprinted,   and  recopyrightcd   iMarch,   1898.     Re 
printed   September,   1898.     Revised,  reprinted,   and   recopyrightcd  August,  1899.     Reprinted 
December,  1899.      Revised,  reprinted,  and  recopyrighted  oeptember,  1900,  and  July,  1901. 
Reprinted  February,  1902,  and  January,  7903.     Revised,  reprinted,  and  recopyrighted 
August,    1903.       Reprinted    March,    1904.       Revised,    reprinted,    and    recopy- 
righted  August,   1905.       Reprinted    February,    1906.       Revised,    reprinted, 
and    recopyrighted   August,   1907.     Reprinted    March,   1908.     Revised, 
reprinted,    and    recopyrighted    August,   1909.     Reprinted    October, 
igio.      Revised,  reprinted,  and  recopyrighted  August,  1911. 
Revised,  reprinted,  and  recopyrighted  September,  1913. 


Copyright,  1913,  by  W.  B.  Saunders  Company. 


PRINTED    IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE  TO  THE  ELEVENTH  EDITION. 


The  revision  of  this  Edition,  upon  which  constant  serious  considera- 
tion has  been  bestowed  during  the  past  two  years  so  as  to  bring  it  abreast 
of  our  present  knowledge  of  the  diagnosis  and  treatment  of  disease,  has 
it  is  hoped  yielded  substantial  improvements.  It  is  believed  that  by 
far  the  majority  of  modern  methods  of  diagnosis  of  medical  complaints 
have  been  presented  with  sufficient  detail,  while  it  has  been  found  neces- 
sary to  make  mere  mention  of  a  few  special  tests,  together  with  their 
references,  owing  to  the  exigencies  of  space.  The  subject  of  the  treat- 
ment of  individual  diseases  in  text-books  of  medicine  too  often  receives 
scantier  attention  than  its  intrinsic  importance  would  seem  to  warrant. 
This  branch  of  my  theme  has,  therefore,  received  close  scrutiny,  and 
where  demanded  it  has  been  enlarged. 

Great  care  has  also  been  taken  to  harmonize  the  Pathologic  Sections 
with  the  present-day  opinion  of  specialists  in  this  department  of  mechcal 
science.  As  in  former  editions,  so  in  the  present  one,  the  new  matter 
introduced  has  been  systematically  classified. 

While  the  work  throughout  has  been  carefully  revised,  among  the 
more  important  additions  may  be  mentioned:  McPhedran's  sign  of 
peritonitis  in  typhoid  fever,  Burke's  reflex  sign  in  typhoid  fever,  Prender- 
gast's  test  in  typhoid  fever,  phlebotomy  and  transfusion  in  hemorrhage 
of  typhoid  fever,  hot-air  inhalations  in  diphtheria,  Lee's  sign  in  acute 
articular  rheumatism.  Iron's  method  of  diag-nosis  of  gonorrheal  arthritis, 
Pastia's  sign  of  scarlet  fever,  copper  arsenite  and  copper  sulphate  in 
amebic  dysentery,  Erb's  syphilitic  spinal  paralysis,  Weil's  test  in 
syphilis,  vegetable  days  in  diabetes,  sugar  solution  in  diabetic  acidosis, 
effect  of  atophan  in  gouty  subjects,  radium  emanations  in  gout,  salvarsan 
and  sodium  cacodylate  in  progressive  pernicious  anemia,  benzol  in 
leukemia,  vaccine  treatment  of  goiter,  hexamethylenamine  in  acute 
bronchitis,  artificial  pneumothorax  in  hemoptysis,  Schepelmann's 
sign  in  acute  plastic  pleurisy,  oxygen  in  sero-fibrinous  pleurisy.  Stem's 
sign  in  tricuspid  incompetency,  Graham-Steell  murmur  in  pulmonary 
incompetency,  Karell  milk-cure  in  valvular  heart  disease,  electricity  in 
arterial  sclerosis,  diastolic  expiration  in  aneurysm.  Boas'  method  of 
testing  motor  function  of  stomach,  McCaskey's  method  of  treating 
gastroptosis,  Meiostagmin  reaction  in  gastric  cancer,  Falk  and  Salomon's 
reaction  in  gastric  cancer,  larval  superacidity,  Boas'  phenolphthalein 

1 


2  PREFACE   TO    THE  ELEVENTH  EHITIOS. 

test  for  diagnosis  of  intestinal  disease,  Bastedo's  test  in  appendicitis, 
chloride  retention  theory  of  renal  dropsy,  circumscribed  serous  spinal 
meningitis,  progressive  lenticular  degeneration,  dysbasia  lordotica 
progressiva,  myotonia  atropliica,  and  tiie  Towns-Lambert  method  of 
treating  morphinism. 

Of  the  new  subjects  which  have  been  discussed,  the  following  may 
be  enumerated:  Diseases  of  the  parathyroid  gland,  auricular  fibrillation, 
auricular  flutter,  extra  systole,  streptococcus  tonsillitis,  stenosis  of  the 
duodenum,  Lane's  kink  of  the  ileum,  status  thymico-lymphaticus.  In 
addition  the  following  subjects  have  been  rewritten:  Antityphoid  vac- 
cination, diseases  of  the  thjanus  gland,  and  pellagra. 

I  can  only  hope  that  the  present  Edition  will  maintain  the  position 
and  standing  which  its  predecessors  have  hitherto  held.  My  indebted- 
ness to  Dr.  H.  Leon  Jameson  for  kind  aid  cannot  be  sufficiently  expressed. 
The  Section  on  Nervous  Diseases  was  kindly  revised  by  Dr.  Charles  S. 
Potts,  who  by  reason  of  his  standing  as  a  neurologist  is  eminently  fitted 
for  the  task. 

JAMES  M.  ANDERS. 

1605  Walnut  Street,  Philadelphia, 
September,  1913. 


PREFACE. 


This  work  is  meant  to  introduce  the  student  to  the  present  state  of 
our  knowledge  of  the  practice  of  medicine  in  general  and  of  the  diagno- 
sis, differential  diagnosis,  and  treatment  of  disease  in  particular.  The 
historic  development  of  the  subjects  treated  has  been  either  briefly  given 
or  intendedly  omitted,  since  this  scarcely  falls  within  the  scope  of  a  prac- 
tical treatise  on  medicine.  Although  the  book  as  a  whole  is  submitted 
to  the  critical  judgment  of  a  learned  profession,  it  may  be  pardonable  to 
emphasize,  provisionally,  a  few  features  pertaining  to  the  mode  of  treat- 
ing the  separate  subjects,  or  the  arrangement  of  the  material  under  the 
latter — to  indicate  some  of  the  more  salient  lineaments,  so  to  speak,  in 
the  general  design.  Since  in  medical  schools  it  is  taught  from  a  separate 
chair,  the  pathology  (special)  of  the  individual  affections  has  almost  in- 
variably been  taken  up  before  the  etiology ;  from  this  point  the  student 
will  find  the  story  of  each  affection  a  continuous  one.  The  practitioner, 
however,  must  ever  aim  to  associate  the  clinical  symptoms  with  the 
morbid  lesions. 

Under  special  etiology  the  bacteriology  has  been  prominently  men- 
tioned, since  we  owe  to  it  the  rapid  progress  that  is  being  made  in  the 
study  of  the  causation  of  disease. 

The  differential  diagnosis  has  in  many  instances  been  tabulated — an 
ear-mark  that  I  confidently  believe  will  be  found  especially  helpful.  It 
may  be  stated  that  not  less  than  fifty-six  diagnostic  tables  are  scattered 
throughout  the  work,  and  that  by  far  the  greater  number  of  these  are 
my  own. 

Such  formulae  have  been  introduced  into  the  text,  and  only  such,  as  a 
more,  or  less  extended  experience  has  shown  to  be  possessed  of  real  thera- 
peutic importance.  Whilst  these,  and  all  additional  points  relating  to 
the  treatment  of  the  single  affections,  may  serve  as  guides,  particularly 
to  the  beginner,  I  fully  appreciate  how  often  the  practising  physician  is 


4  PREFACE. 

placed  in  a  position  in  which  he  is  compelled  to  form  a  therapeutic 
judgment  for  himself.  Whenever  the  dosage  is  stated,  the  metric  equiv- 
alent is  placed  in  parentheses,  the  number  of  grams  being  stated  in  round 
numbers  (sj — 4.0 ;.  5J — 32.0)  in  order  to  render  it  of  greater  practical 
value.  In  all  instances,  however,  in  which  this  would  involve  an  im- 
portant dift'erence  in  quantity  the  exact  decimal  figures  are  given.  A 
consiilerable  variation  from  the  usual  classification  of  diseases  may  be 
observed,  but  this  is  accounted  for  in  the  text  wherever  it  occurs. 

Preference  has  been  given  to  the  modern  orthography  and  termi- 
nology, not  only  because  it  is  more  euphonious,  but  also  because  of  its 
adoption  by  the  standard  lexicographers. 

I  have  gleaned  without  stint  from  medical  literature  Avith  a  view  to 
bringing  the  book  up  to  date,  and  if  I  have  failed  to  give  full  credit  in 
every  instance,  my  grateful  acknowledgments  are  here  due  and  are 
cheerfully  made.  The  chief  results  of  my  personal  experience  and  obser- 
vation, extending  over  a  period  of  two  decades,  and  derived  from  both 
hospital  and  private  practice,  will  also  be  found  upon  these  pages. 

I  wish  to  thank  Prof  W.  C.  HoUopeter,  who  has  written  some  of  the 
articles  upon  the  diseases  of  children,  as  measles,  chicken-pox,  mumps, 
whooping-cough,  and  the  acute  diarrheas,  and  who  has  kindly  aided  in 
the  preparation  of  those  upon  diphtheria  and  scarlatina. 

My  cordial  thanks  are  due  also  to  Dr.  C.  L.  Furbush  for  kind  aid 
in  preparing  some  of  the  illustrations,  to  Doctors  Robert  N.  Willson, 
Howard  S.  Anders,  and  Geo.  W.  Pfromm  for  valuable  assistance  while 
the  work  was  passing  through  the  press,  and  to  Dr.  A.  M.  Davis  for 
preparing  the  index. 

JAMES   M.  ANDERS. 


CONTENTS. 


PART  I.— INFECTIOUS  DISEASES. 


I'AfJK 


Typhoid  Fever 17. 

Paratyphoid  Covers ''IJ 

Tyj)hus  Fever ^*_' 

Dysentery if 

Bacillary  Dysentery  (Acute  Dysentery)      ^^ 

Catarrhal  Dysentery i'' 

Diphtheritic  Dysentery '4 

Secondary  Diphtheritic  Dysentery 76 

Chronic  Dysentery • '° 

Cholera  (Epidemic) °P 

Yellow  Fever J" 

Cerebro-spinal  Meningitis ^2 

Lobar  Pneumonia ■*  '"' 

Secopdary  Pneumonia        !•/" 

Influenza iqu 

Dengue • \f 

The  Plague !    '         l2 

Erysipelas jiT 

Diphtheria    .:.... 1^1 

Septicemia ' ^2 

Pyemia ^_ 

Acute  Articular  Rheumatism 1'4 

Subacute  Articular  Rheumatism 184 

Gonorrheal  Arthritis '    185 

Variola ;    186 

Vaccination "^^^ 

Varicella 202 

Scarlet  Fever ^r^ 

Fourth  Disease ^-.^ 

Measles      220 

Rubella qo^ 

Whooping-cough '^ 

Parotitis °    ]    ;^" 

Tuberculosis -^. 

Bovine  Tuberculosis • "^-^^ 

Tuberculosis  of  the  Lymph-glands '--i^ 

Acute  Tuberculosis °    -j^b 

General  Miliary  Tuberculosis '    °    °    Z,t 

Typhoid  Form      '.   11    '1% 

Pulmonary  Jborm -^° 

Cerebral  or  Meningeal  Form °    249 

Acute  Pneumonic  Phthisis '.9-7 

Chronic  Tuberculosis  ._ '*''.*.    o'^l 

Pseudo-tuberculosis      -1* 

Fibroid  Phthisis '-Lj 

Tuberculosis  of  the  Alimentary  Tract '    1-^ 

Tuberculosis  of  the  Serous  Membranes ^i_^ 

Tuberculosis  of  the  Pericardium '^oa 

Tuberculosis  of  the  Peritoneum •    •    •        '    '    ];^X 

Tuberculosis  of  the  Liver  •    •    •    •    ■ '-^^ 

Tuberculosis  of  the  Genito-urinary  System_    ■••••• -^^e 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus 28o 

Tuberculosis  of  the  Mammary  Glands -ho 

Tuberculosis  of  the  Brain -Jo 

Tuberculosis  of  the  Spinal  Cord '  -»£ 

Tuberculosis  of  the  Heart -»' 

Tuberculosis  of  the  Arteries  and  ^^eins -^^ 

Treatment  of  Tuberculosis .299 

Leprosy ^^02 

Glanders ' 304 

Actinomycosis ■ '..'....  30G 

Anthrax • 

5 


6  CONTENTS. 

PAGE 

Ilvdiophobia 309 

IVumus 812 

Beri-bori 31G 

Malta  Fever 319 

Probable  Infeclious  Diseases 321 

Muscular  Kbeuiualisui 321 

Chronic  Articular.Kbeumatisra 324 

Mountain  Fever 32(5 

Kockv  Mountain  Spotted  Fever 326 

Weil's  Disease 328 

Sciiiarnintieber 328 

Fel.ricula 329 

Milk-siekness 330 

Miliary  Fever  . 331 

Foot-;uul-ni()utii  Disease ...  332 

Glandular  Fever 332 

PART    II.— ANIMAL    PARASITIC    DISEASES. 

Parasites  of  Man 334 

Amebic  Dvsenterv 334 

Flagellata".    .    .  ' .•   ...  338 

Mastigophora 338 

Trypanosomiasis 338 

Sleeping  Sickness 338 

Febrile  Tropical  Splenomegaly 340 

Psorospermiasis 341 

Malarial  Fever 342 

Dislomiasis 361 

Cestodes     ....        363 

Eehinococcus  Disease 363 

Tieniie  or  Tape-worms 367 

Tsenia  Nana 371 

Tsenia  Flavopunctata 371 

Nematodes 372 

Ascaria.sis 372 

Uncinariasis  ... 375 

Trichiniasis 377 

Filariasis 381 

Dracontiasis 383 

Other  Filaria; 384 

Other  and  Uncommon  Nematodes 384 

Parasitic  Amchnida 385 

Other  Parasitic  Insects 385 

Pediculosis         385 

Cimex  Leetularius 386 

Pulex  Irritans 386 

Piilex  Penetrans 387 

Ixodes 387 

Dermany.ssus  ,\vinm  et  Gallinae 387 

Culicidie 387 

Hirudo 387 

Estrid* 387 

Muscidte 387 

Syphilis 388 

Visceral  Syphilis 394 

Syphilis  of  the  Liver 396 

Syphilis  of  the  Alimentary  Tract 397 

Svphilis  of  the  Lungs .    .  .S98 

Syphilis  of  the  Spleen 399 

Syphilis  of  the  Circulatory  System      400 

Syphilis  of  the  .Vrteries 400 

Syphilis  of  the  Kidneys 400 

Svphihs  of  tlie  Joint-s' 400 

Syphilis  of  the  Testicles 401 


CONTENTS.  7 

Diagnosis  of  Syphilis 4(j] 

Treatment  of  Syphilis 4q;^ 

Spii'illosis      4(j7 

PART    HI— CONSTITUTIONAL    DISEASES. 

Diabetes 413 

Diabetes  Insipidus •.    _  425 

Arthritis  Deformans 427 

GoH. 432 

Lithemia 440 

Rachitis 442 

Scorbutus 447 

Infantile  Scorbutus 450 

Purpura 452 

Hemophilia 455 

Hemorrhagic  Diseases  of  the  New-born 458 

PART    IV.— DISEASES    OF   THE   BLOOD   AND   THE    DUCTLESS 

GLANDS. 

Anemia 459 

The  Primary  or  Essential  Anen^ias 460 

Chlorosis 460 

Progressive  Pernicious  Anemia , 465 

The  Secondary  Anemias 472 

Leukemia  ( Leukocythemia)  . 475 

Leukanemia 483 

Chloroma 483 

Pseudo-leukemia 483 

Anaemia  Infantum  Pseudo-leuksemica 488 

Splenic  Anemia 488 

Polycythemia  with  Splenic  Tumor 489 

Diseases  of  the  Ductless  Glands 490 

Diseases  of  the  Suprarenal  Capsules 490 

Addison's  Disease 490 

Diseases  of  the  Thymus  Gland 494 

Enlargement  of  Thymus 494 

Status  Thymico-Lymphaticus 494 

Diseases  of  the  Thyroid  Gland 495 

Thyroiditis 495 

Goiter 496 

Exophthalmic  Goiter 498 

Myxedema    .    .            502 

Diseases  of  the  Parathyroid  Glands 506 

PART  V — DISEASES  OF  THE   RESPIRATORY   SYSTEM. 
L  DISEASES  OF  THE  NOSE. 

Acute  Rhinitis .507 

Chronic  Rhinitis 508 

Autumnal  Catarrh 511 

Epistaxis 512 

II.  DISEASES  OF  THE  LARYNX. 

Acute  Catarrhal  Laryngitis 513 

Chronic  Laryngitis 515 

Spasmodic  Laryngitis 517 

Edematous  Laryngitis 519 

Tumors  of  the  Larynx 520 

III.  DISEASES  OF  THE  BRONCHI. 

Catarrhal  Bronchitis 520 

Acute  Bronchitis 521 

Chronic  Bronchitis 525 

Bronchiectasis 529 

Bronchial  Stenosis 532 

Asthma 533 

Fibrinous  Bronchitis 538 


8  coy'TKyTS. 


IV.  DISEASES  OF  THE  LUNGS. 


I'AGE 


Circulatory  Disturbances  in  tlie  Lungs v>40 

Congestion  of  the  Lungs -i-iO 

Active  HyiRMeniiii o40 

Passive  Hvpcieuiiu 541 

Pulmonary  Edema 542 

Hemoptysis  .    .    .    .• •_>3'1 

Pneumorrliagia <J'^0 

Pulmonary  Embolism 550 

Chronic  Interstitial  Pneumonia 552 

Broncho-pneumonia 554 

I'ulmonarv  Atelecttisis 561 

Empiiyseiiia 5f>4 

lnterlol>nlar  Emphysema 5G4 

Vesicular  Emphysema 564 

Compensating  Emphysema 564 

Hypertrophic  Emphysema 565 

Senile  Emphysema 570 

(langrene  of  the  Lungs 571 

Abscess  of  the  Linigs •>7.'i 

Pneumonokoniosis 57.) 

New  (irowths  of  the  L\nigs 577 

Carcinoma  of  the  Lung ^7/ 

Sarcoma  of  the  Lung 579 

Hydatid  Cyst  of  the  Lung 579 

V.   DISEASES  OF  THE  PLEURA. 

Pleurisy • 5B0 

Acute  Plastic  Pleurisy 581 

Sero-fibrinous  Pleurisy 58o 

Empyema 597 

Chronic  Pleurisy ■    f  601 

Pneumothorax      .    .        603 

Hvdrothorax 608 

New  Growths  of  the  Pleura 609 

Diseases  of  the  Mediastinum ■  '.'J 

Inflammation  of  the  Mediastinum .  ',^ 

Tumors  of  the  Mediastinum •  ,'  ,' 

Mediastinal  Hemorrhage ''^'^ 

PART    VL— DISEASES    OF    THE    CIRCULATORY    SYSTEM. 

I.  DISEASES  OF  THE  PERICARDIUM. 

PericJirditis 615 

Acute  Plastic  or  Fibrinous  Pericarditis 615 

iSero-librinous  Pericarditis 618 

Purulent  Pericarditis 623 

Hemorrhagic  Pericarditis 624 

Adhesive  I'ericarditis 624 

Hydropericardiuin 626 

Hemopericardium .• 61^ 

Pneumopericardium ''2' 

II.  DISEASES  OF  THE  HEART. 

Endocarditis 628 

Simple  Acute  Endocarditis 628 

I'lcerative  Endocarditis .    .  f,32 

Chronic  Endocarditis 636 

Aortic  Incompetency 639 

Aortic  Stenosis 645 

Mitral  Incompetency 647 

Mitral  Stenosis 653 

Tricuspid  Incompetency 657 

Tricuspid  Stenosis 660 


CONTENTS.  9 

T-A'.V. 

Pulmonary  Incompetency 001 

Pulmonary  Stenosis 002 

Combined  Forms  of  Cardiac  Diseases 002 

Cardiac  Thrombosis 070 

Hyperti-ophy  of  the  Heart 077 

Dilatation  of  the  Heart 084 

Myocarditis 090 

Acute  Myocarditis 090 

Chronic  Myocarditis 091 

Diseases  of  the  Coronary  Arteries 695 

Degenerations  of  the  lieart 690 

Fatty  Degeneration -    ■  090 

Fatty  Overgrowth -    -  098 

Fatty  Infdtration 699 

Brown  Atrophy 700 

Calcareous  Degeneration =•    •  700 

Amyloid  Degeneration 700 

Hyaline  Degeneration 700 

Cardiac  Aneurysm 700 

Rupture  of  the  Heart 701 

Minor  Affections  of  the  Heart 702 

New  Growths 702 

Parasites 702 

Misplacement 703 

Floating  Heart 703 

III.  NEUROSES  OF  THE  HEART. 

Palpitation '^03 

Tachycardia ™2 

Brachycai'dia jy' 

Arrhythmia  . 1^^ 

Auricular  Fibrillation ^10 

Auricular  Flutter ■■ ^H 

Stokes-Adams  Disease l}" 

Angina  Pectoris  ...>...... '1" 

IV.   CONGENITAL  AFFECTIONS  OF  THE  HEART. 

Arrested  Development 716 

Fetal  Endocarditis .  716 

V.  DISEASES  OF  THE  ARTERIES 

Acute  Aortitis •  718 

Arterial  Sclerosis .  718 

Aneurysm 723 

Aneurysm  of  the  Thoracic  Aorta 724 

Aneurysm  of  the  Abdominal  Aorta • 732 

Aneurysm  of  the  Pulmonary  Artery • 733 

Aneurysm  of  the  Coronary  Arteries .    >  734 

Aneurysm  of  the  Celiac  Axis 734 

Aneurysm  of  the  Splenic  Artery ■ 734 

Aneurysm  of  the  Hepatic  Artery =  734 

Aneurysm  of  the  Superior  Mesenteric  Artery 734 

Aneurysm  of  the  Inferior  Mesenteric  Artery 734 

Aneurysm  of  the  Renal  Arteries 734 

Arterio-venous  Aneurysm 735 

Congenital  Aneurysm 735 

PART    VII.— DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

I.  DISEASES  OF  THE  MOUTH. 

Stomatitis • 737 

Catarrhal  Stomatitis ^   >  737 

Aphthous  Stomatitis i^^ 

Aphtha  Cachectica  (Riga's  Disease) =    •  '^^ 

Membranous  Stomatitis =    •  •'^^ 


10  CONTENTS. 

I  Icerative  or  Fetid  Stomatitis 741 

Neurotic  Ukeration 742 

Parasitic  Stoiuatiiis 743 

La  Perleche 745 

Gangrenous  Stomatitis 745 

Mercurial  Stomatitis 747 

11.  DISEASES  OF  THE  TONGUE. 

Glossitis 748 

Acute  Glossitis 74g 

Chronic  Sujierficial  Glossitis 749 

Glossitis  Desiccans 75O 

Lingual  Psoriasis 75O 

Leukoplakia  Oris 750 

Angina  Ludovici 75I 

III.  DISEASES  OF  THE  SALIVARY  GLANDS. 

Hypersecretion 751 

Xerostotna 752 

Glassblowers'  Month 752 

Symptomatic  Parotitis 752 

Chronic  Parotitis 75,3 

IV.   DISEASES  OF  THE  TONSILS. 

Acute  Tonsillitis •    ,    ,  753 

Chronic  Tonsillitis 758 

V.  DISEASES  OF  THE  PHARYNX. 

Pharyngitis 761 

Acute  Pharvngitis 761 

Membranous  Pharyngitis 763 

Chronic  Pharyngitis 763 

Acute  Infectious  Phlegmon  of  the  Throat      765 

Retropharyngeal  Abscess 765 

VI.    DISEASES  OF  THE  ESOPHAGUS. 

Esophagitis v  766 

Acute  Esophagitis        766 

Chronic  Esophagitis 767 

Ulcer  of  the  Esophagus          767 

Carcinoma  of  the  Esophagus 768 

Rupture  of  tlie  Esophagus 769 

Neuroses  of  the  Esophagus 770 

Muscular  Spasm 770 

Paralysis  of  the  Esophagus 771 

Dilatation  of  the  Esophagus 771 

Esophageal  Diverticulum 772 

Stricture  of  the  Esophagus 774 

VII.  DISEASES  OF  THE  STOMACH. 

Methods  of  Diagnosis 776 

Examination  of  the  Gastric  Functions 778 

Physical  or  External  Examination 782 

Malposition  of  the  Stomach 784 

Gasiroptosis 784 

Dilatation  of  the  Stomacii 786 

Inflammatory  Diseases  of  the  Stomach   ... 790 

Acute  Catarrhal  Gastritis 790 

Toxic  Gastritis 793 

Diphtheritic  Gastritis 794 

Acute  Suppurative  Gastritis      794 

Chronic  Catarrhal  Gastritis 796 

Gastric  Ulcer 804 

Ilour-glass  Stomach 808 

Carcinoma  of  the  Stomach 813 

Hypertrophic  Stenosis  of  the  PylorUB 819 


CONTENTS.  11 

PAGE 

Benign  Cirrhosis  of  Stomach 820 

Hematemesis 8'20 

Neuroses  of  the  Stomach 821 

Nervous  Dyspepsia 8'21 

Special  Forms  of  Gastric    Neuroses,  Characterized   by  Marked   and    reculia/- 

Anomalies  of  Sensation,  Motility,  and  Secretion 82;i 

Neuroses  of  Secretion      82;-> 

Hyperchlorhydria 82;-> 

Neuroses  of  Motility 820 

Increased  Peristalsis  of  the  Stomach >^2fj 

Diminished  Peristalsis  of  the  Stomach    , 827 

Neuroses  of  Sensation 827 

Cardialgia 827 

Hyperesthesia  of  the  Stomach «29 

Anorexia 829 

Hyperorexia 830 

VIII.  DISEASES  OF  THE  INTESTINES. 

Methods  of  Diagnosis ^'^^ 

Enteroptosis "•-'f 

Intestinal  Catarrh •  ^•'■'' 

Diarrheas  of  Children •    '  °43 

Acute  Gastro-intestinal  Catarrh 843 

Celiac  Disease • 846 

Phlegmonous  Enteritis •  847 

Croupous  or  Diphtheritic  Enteritis      • 847 

Sprue  (Psilosis) • 848 

Cholera  Morbus 848 

Intestinal  Infarction 850 

Intestinal  Ulcers 850 

Duodenal  Ulcer 850 

Follicular  Ulcers ■    ■  853 

Stercoral  Ulcers •  8-53 

Simple  Ulcerative  Colitis •    •  853 

Solitary  Ulcers 854 

Diffuse  Catarrhal  Ulcer .^ -    •  854 

Cancerous  Ulcer ;  Tuberculous  Ulcer ;  Amebic  Ulcer 854 

Appendicitis         854 

Chronic  Appendicitis ^ 865 

Typhlitis   .    .    .  _ ; 870 

Intestinal  Calculi • 870 

Intestinal  Obstruction 871 

Stenosis  of  the  Duodenum 877 

Carcinoma  of  the  Intestine 877 

Habitual  Constipation 880 

Dilatation  of  the  Colon 883 

Coloptosis ■ 884 

Intestinal  Auto-intoxication 884 

Neuroses  of  the  Intestine 886 

Secretory  Disturbances 886 

Mucous  Colic o    .    c 886 

Sensory  Disturbances » 887 

Enteralgia •  _ 887 

Diminished  Intestinal  Sensibility 888 

Disturbances  of  Motility 888 

Nervous  Diarrhea 888 

Enterospasm 889 

Constipation 889 

IX.  DISEASES  OF  THE  LIVER. 

Anomalies  in  Shape  and  Position 891 

Jaundice 892 

Catarrhal  Jaundice 892 

Other  Forms  of  Jaundice 896 

Acute  Infectious  Cholecystitis ■  896 

Chronic  Cholecystitis 897 


12  CONTENTS. 

PA«K 

Caliulinis  (  holorvstitis 898 

Chronic  ObstriKtioii  of  the  Duct  by  Gall-stones VIOO 

Obstruction  of  tlie  Common  Duct 900 

Ubstrui'tion  of  tlie  Cystic  Duct 902 

More  Keinote  Efteots  of  Gall-stones 902 

Carcinoma  of  the  Bile-ducts 900 

Stenosis  of  tlie  Bile-ducts 907 

Icterus  Nei>natortini 909 

Vascular  (Circulatory)  Affections  of  the  Liver 909 

Anemia      ..." 909 

Hyperemia 910 

Acute  Hyperemia 910 

Passive  Hyperemia 910 

Diseases  of  the  Portal  \'ein 911 

Thrombosis  and  Kml)olism 911 

Suppurative  Pylephlebitis 91l! 

Stenosis 914 

Artections  of  the  Hepatic  Blood-vessels 914 

Atrophy  and  Hypertrophy  of  the  Liver 914 

Hepatic  Inliltrations  and  Degenerations 91.") 

Amyloid  Infdtr.ition        915 

Fatty  Liver 917 

Fatty  Infiltration 917 

Fatty  Dcgenenition 918 

Perihepatitis 919 

Acute  Perihep.'ititis 919 

Chronic  Perihepatitis 921 

Ab.sce.ss  of  the  Liver 922 

Acute  Yellow  .\ trophy 927 

The  Liver  in  Phosphorus-poisoning 929 

Cirrhosis  of  the  Liver 931 

Carcinoma  of  the  Liver 989 

Other  New  Growths  in  the  Liver 944 

X.   DISEASES  OF  THE  SPLEEN. 

Dislocation  of  the  Spleen ,  945 

Splenic  Hyperemia 946 

Splenitis 94() 

Amyloid  Degeneration  of  the  Spleen 948 

Morbid  Growths  of  the  Spleen 949 

Rupture  of  the  Sjjleen 949 

XL    DISEASES   OF  THE   PANCREAS. 

Acute  Pancreatitis 949 

Hemorrhagic  Pancreatitis 949 

Suppurative  Pancreatitis 951 

Gangrenous  Pancreatitis 952 

Chronic  Pancreatitis 953 

Pancreatic  Hemorrhage 954 

Carcinoma  of  the  Pancreas 955 

Other  Tumors  of  the  Pancreas 957 

Pancreatic  Cyst 957 

Pancreatic  Calculi -  958 

XIL  DISEASES  OF  THE   PERITONEUM. 

Acute  Peritonitis 959 

Peritonitis  in  Children 963 

Localized  or  Partial  Peritonitis 963 

Chronic  Peritonitis      967 

Ascites 970 

New  Growths  in  the  Peritoneum      975 

Carcinoma  of  the  Peritoneum 975 

Other  Tumors  of  the  Peritoneum 977 

Fibromata  and  Lipomata 977 


CONTENTS.  13 

PART    VIII.— DISEASES    OF    THE    URINARY     SYSTEM. 
I.    DISEASES  OF  THE   KIDNEY. 

I'AfJR 

Mobility  of  the  Kidney •^"■'^ 

Circulatory  Disorders  of  the  Kidneys !:»H2 

Active  Hyperemia ' 9*^^ 

Passive  liypv^remia      9H3 

Embolic  Infarctions *^H.S 

Special  Pathologic  States  of  the  Urine *JS4 

Plematuria '^4 

Hemoglobinuria ^So 

Albuminuria 987 

Proteinuria 990 

Indicanuria 991 

Pyuria 992 

Chyluria 9'.i:3 

Choluria 9<)4 

Urobilinuria 995 

Glycosuria 9'Jo 

Acetonuria,  Diacetonuria,  and  Oxybutyria 998 

Lithuria ■    •        999 

Oxaluria 1000 

Phosphaturia 1001 

Leucinuria  and  Tyrosinuria 1002 

Cystinuria 1002 

Various  other  Conditions 1003 

The  Nephritides 1005 

Morphologic  Constituents  of  the  Urine  in  Eenal  Disease 1005 

Dropsy  of  Eenal  Disease 1007 

Uremia 1008 

Amyloid  Kidney 1012 

Nephrolithiasis 1014 

Acute  Nephritis ._ 1020 

Acute  Interstitial  Non-suppurative  Nephritis 1026 

Emulsion-albuminuria 1027 

Chronic  Nephritis  (Exudative)    .    .    ." 1027 

Chronic  Nephritis  (Non-exudative) 1032 

Pyelitis  •    •    •  _ ....    =    .  1040 

Hydronephrosis 1043 

Perinephric  Abscess 1046 

Cystic  Kidney 1048 

New  Growths  of  the  Kidney 1049 

II.  DISEASES  OF  THE  BLADDER. 

Cystitis '    •   •  1051 

Acute  Cystitis 1052 

Chronic  Cystitis •    •  lOoo 

Neoplasms  of  the  Bladder 1056 

Vesical  Hemorrhage 10'^^ 

Neuroses  of  the  Bladder 1058 

Irritability  of  the  Bladder 1058 

Neuroses  of  Micturition 1060 

PART    IX.— DISEASES    OF    THE    NERVOUS    SYSTEM. 

Introduction      • 1063 

General  and  Topical  Diagnosis 1074 

I.    DISEASES   OF  THE  PERIPHERAL  NERVES. 

Neuralgia 1077 

Tic  Douloureux 1079 

Neuralgia  of  the  Neck  and  Trunk 1081 

Neuralgia  of  the  Extremities \0S\ 

Neuritis 1084 

Progressive  Neural  Muscular  Atrophy 1088 

Neuromata 1089 


14  CONTENTS. 

PAfiE 

Diseases  of  the  Cranial  Nerves lUDO 

Diseases  of  the  Olfactory  Nerve ]0i»0 

Diseases  of  the  KetiiKi,  Optic  Nerve,  and  Tract IdlU 

Diseases  of  tlie  Motor  Nerves  of  the  Eyeball UUt') 

Diseases  of  the  Fiftii  Nerve 1011!) 

Di.seases  of  the  Seventh  or  Facial  Nerve 1100 

Diseases  of  the  Auditory  Nerve 1104 

Meniere's  Disease 1105 

Diseases  of  the  (ilosso-pharyngeal  Nerve 1106 

Diseases  of  the  Pneuniogastric  Nerve llOfi 

Diseases  of  tlie  Spinal  Accessorv  Nerve 1110 

Torticollis ' 1110 

Paralysis  of  the  Spinal  Accessory  Nerve 1112 

Diseases  of  the  Hypoglossal  Nerve 1113 

Diseases  of  the  Spinal  Nerves 1114 

Diseases  of  tlie  Cervical  Plexus 1114 

Diseases  of  the  Brachial  Plexus 1114 

Diseases  of  the  Lumbar  and  Sacral  Plexuses 1117 

II.   INFLAMMATION  OF  THE  MENINGES. 

Inflammation  of  the  Dura  Mater 1118 

C<?rebral  Pachymeningitis 1118 

Spinal  Pachymeningitis 1119 

Leptomeningitis 1121 

Cerebral  Leptomeningitis 1121 

Serous  Meningitis 1123 

Acute  Spinal  Leptomeningitis 1123 

Chronic  Leptomeningitis - 1125 

III.   DISEASES  OF  SPJNAL  CORD. 

Hemorrhage  into  the  Spinal  Meninges 1125 

Hyperemia  and  Anemia  of  the  Cord 1126 

Hemorrhage  into  the  Spinal  Cord 1126 

Cai.sson  Disease 1127 

Bulbar  Paralysis      .    .    . 1129 

Acute  Anterior  Poliomyelitis 1130 

Es-sential  Paralysis  of  Children 1130 

Chronic  Poliomyelitis  in  Adults 1132 

Acute  Po.sterior  Poliomyelitis .  1132 

Acute  .\scen(ling  Paralysis 1133 

Acute  Myelitis 1134 

Chronic  Myelitis 1137 

Compression  of  the  Spinal  Cord 1138 

Primary  Lateral  Sclerosis 1140 

Progressive  Sj)inal  Muscular  Atrophy 1142 

Amyotrophic  Lateral  Sclerosis 1143 

Unilateral  Ascending  and  Unilateral  Descending  Paralysis 1144 

Intermittent  Paraplegia 1145 

Tabes  Dorsalis 1145 

Hereditary  Ataxia 1151 

Friedreich's  Disease 1151 

Hereflitary  Cerebellar  Ataxia 1152 

Ataxic  Paraplegia 1152 

Combined  Systemic  Sclerosis 1153 

Syringomyelia 1154 

Tumoi-s  of  the  Spinal  Cord  and  its  Membranes 1156 

Lesions  of  the  Conus  Medullaris,  Epiconus,  and  the  Cauda  E<juina 1159 

IV.   DISEASES  OF  THE   BRAIN. 

Disturbances  of  Circulation  of  the  Brain  and  Meninges 1160 

Hyperemia 1161 

Anemia      1161 

Edema  of  the  Brain 1162 

Vascular  Degeneration 1162 


■CONTENTS.  15 

PAGB 

Apoplexy 1103 

Cerebral  Plemorrhage llGii 

p]mbolism  and  Thrombosis 1170 

Cerebral  Palsies  of  Children ]17.'i 

Aphasia.    .    .    .  _ 1175 

Progressive  Lenticular  Degeneration 1180 

Inflammation  of  the  Brain 1181 

Suppurative  Encephalitis 1181 

Acute  Hemorrhagic  Encephalitis 11 8I-5 

Intracranial  Growths      \\H'.'> 

Chronic  Hydrocephalus 1190 

External  Hydroceplialus 1190 

Internal  Hydrocephalus 1190 

Acute  Delirium 1192 

Senile  Dementia 1194 

V.  DISEASES   OF   BRAIN   AND   CORD. 

Multiple  Sclerosis 1195 

Pseudosclerosis  and  Diffuse  Sclerosis 1198 

Cerebrospinal  Syphilis 1198 

General  Paralysis  of  the  Insane    ......        1198 

VI.  GENERAL  AND  FUNCTIONAL  DISEASES. 

Infantile  Convulsions 1202 

Epilepsy 1204 

Migraine .  1209 

Acute  Chorea 1211 

Huntingdon's  Chorea 1213 

Paramyoclonns  Multiplex 1214 

Electric  Chorea  of  Dubini 1215 

Dysbasia  Lordotica  Progressiva 1216 

Tic 121« 

General  Tic 1218 

Saltatoric  Spasm » 1219 

Paralysis  Agitans     ....        1219 

Other  Forms  of  Tremor 1221 

Tetany 1221 

Periodic  Paralysis 1224 

Hysteria 1224 

Neurasthenia 1235 

Traumatic  Neuroses 1242 

Psychasthenia 1242 

Occupation-Neuroses 1243 

Acromegaly 1244 

Adiposis  Dolorosa 1247 

Amaurotic  Family  Idiocy 1248 

VII.   VASOMOTOR  AND  TROPHIC   DISORDERS. 

Angioneurotic  Edema 1249 

Raynaud's  Disease 1250 

Erythromelalgia 1252 

Acroparesthesia 1253 

Neuralgia  Paraesthetica  ...... 1254 

Scleroderma  DifFusum 1254 

Morphea 1256 

Ainhum 1256 

Progressive  Hemiatrophy  of  the  Face 1256 

PART  X.— DISEASES  OF  THE  MUSCLES. 

Myositis 1259 

Infectious  Myositis 1259 

Progressive  Ossifying  Myositis 1260 

Muscular  Dystrophies 1260 

Pseudohypertrophic  Muscular  Paralysis 1261 

Hereditary  Muscular  Paralysis 1261 


1 6  CONTENTS. 

PAUK 

Scapuloliiimeial  ur  Juvenile  Type 1262 

F;ui<vs<.>apuloliuniei-.il  Type 1202 

Myotonia  Atrophica 1263 

Artlirilif  Miis»ular  Atrophy 126:> 

Muscular  Atrophies 12tj4 

Mus<^u1ar  Hypertrophy 1264 

Thomsens  l>is*.-aW 12t)4 

Mvatouia  Cou^ienita 1266 

Mya>thenia(;ravis 1267 

PART    XI.— THE    INTOXICATIONS;    0BE5ITY;    HEAT-STROKE. 

The  Intoxirations 1-68 

Alcoholism , 1268 

(iinger  and  Cologne-water  Inebriety 1275 

Morphinism      I'-i^o 

Plumliism      l-~8 

Am-nicism l-'80 

Mercurialism 1282 

FoiMl-int'ection  and  Ptomain-poisoning 1283 

(irain-  and  Vegetable-poisoning 128o 

Obesity 128" 

Ailituisis  Tuberosa  Simplex 1292 

Heat-stroke 1293 


Index - -   -1299 


PART  i. 

INFECTIOUS    DISEASES. 


TYPHOID   FEVER. 

{Enteric  Fever;  Abdominal  Typhus;  lleo-typhoid ;  Nerven  Fieber.) 

Definition. — An  acute  infectious  disease  of  which  the  definitive 
cause  is  the  specific  bacillus  of  Eberth  (bacillus  typhosus).  It  is  char- 
acterized, pathologically,  by  hyperplasia  and  sloughing  of  Peyer's  patches 
and  the  solitary  follicles  of  the  intestines  coupled  with  parenchymatous 
changes  in  the  principal  viscera,  and  clinically  by  its  gradual  onset, 
peculiar  temperature-curve,  swelling  of  the  spleen,  rose-colored  spots, 
diarrhea,  tympanites,  sero-reaction,  and  a  liability  to  certain  complica- 
tions (intestinal  hemorrhage,  perforation,  etc.).  The  disease  is  a  bacter- 
emia, and  typhoid  infection  is  no  longer  an  anatomic  entity,  and  does 
not  always  produce  typical  typhoid  fever. 

History. — Although  known  beyond  the  reach  of  tradition,  typhoid 
fever  was  clearly  distinguished  from  typhus  at  a  comparatively  recent 
date.  Louis  of  Paris  in  1829  proposed  the  term  typlioide^  but  it  re- 
mained for  Gerhard  of  Philadelphia  to  discriminate  typhoid  from 
typhus  fever  as  the  result  of  his  own  precise  clinical  observations. 
His  account  of  the  disease  was  ably  corroborated  by  the  writings  of 
E.  Hale  and  James  Jackson,  Sr.  (1838,  1839).  Later,  Shattuck  of 
Boston  and  Jenner  of  London  made  important  contributions  to  the 
subject.  Shattuck's  experiments  on  typhus  and  typhoid  fevers  at  the 
London  Fever  Hospital  in  England,  and  Alfred  Still^'s  studies  of  the 
former  affection  in  Dublin  and  Naples,  and  of  the  latter  in  Paris,  in- 
creased greatly  our  knowledge  of  these  diseases.  As  a  result  of  the 
labors  of  the  above-mentioned  American  authors  the  true  nature  and 
identity  of  typhoid  fever  were  appreciated  in  America  at  an  earlier  day 
than  in  either  France  or  England. 

Briefly,  the  decade  from  1840  to  1850  witnessed  the  overthrow  of 
erroneous  notions  concerning  the  similarity  of  typhoid  and  typhus  fevers, 
on  the  one  hand,  and  the  establishment  of  their  points  of  dissimilarity  on 
the  other. 

Pathology. — The  lesions  produced  by  typhoid  fever  may  conve- 
niently be  divided  into  two  groups :  (1)  Primary  lesions,  due  to  the 
direct  effect  of  the  special  bacillus  upon  the  lymph-follicles  of  the 
intestines,  the  mesenteric  and  other  lymph-glands,  the  gall-bladder,  and 
the  spleen.  Typhoid  septicemia  without  localizing  lesions  is  also  a  rec- 
ognized form  of  the  disease.  (2)  Secondary  lesions,  due  chiefly  to  the 
2  17 


18  INFECTIOUS  DISEASES. 

indirect  effect  of  the  typhoid  bacillus  and  secondary  infection,  for  the 
occurrence  of  -wliich  the  essential  lesions  furnish  the  golden  opportunity. 

(1)  The  primary  morbid  changes  in  the  Peycr's  patches  and  solitary 
glands  of  tlie  intrstincs  are  divided,  usually,  into  four  stages: 

(a)  The  Stage  of  Infiltration. — The  lymph-follicles  become  engorged 
(hyperplasia),  particularly  Peyer's  glands  in  the  ileum  and  near  to  the 
valve,  and,  to  a  lesser  extent,  in  the  lower  part  of  the  jejunum.  Fre- 
quently the  solitary  glands  in  the  small  intestines,  the  colon,  and  rarely 
the  rectum,  become  similarly  infiltrated.  In  mild  cases  a  few  Peyer's 
patches  in  the  lower  part  of  the  ileum  arc  alone  the  seat  of  infiltration 
and  subse([uent  changes.  The  follicles  are  grayish- white  in  color,  and 
may  project  from  3  to  5  mm.  or  more.  Rarely  the  solitary  glands, 
which  vary  in  size  from  a  mustard-seed  to  a  large  pea,  also  become  promi- 
nent and  show  a  bold  attempt  at  pedunculation. 

The  histologic  chan;/es  at  first  consist  in  a  marked  dilatation  of  the 
capillary  blood-vessels,  which  later  are  more  or  less  compressed  (as  a 
consequence  of  cell-infiltration),  giving  to  the  follicles  their  whitish, 
anemic  appearance.  The  cellular  elements  partake  of  the  nature  of 
lymph-corpuscles.  Some  of  these  cells  are  larger  and  are  epithelioid  in 
character,  with  ten  or  more  nuclei.  The  mucosa  and  muscularis  ad- 
jacent to  the  glandular  structures  may  be  similarly  infiltrated. 

From  the  eighth  to  the  tenth  day  the  stage  of  infiltration  terminates 
either  in  resolution  (rare)  or  in  necrosis  and  sloughing.  Tlie  infiltrated 
cells  may  undergo  granular  or  fatty  degeneration,  followed  by  absorption. 
This  process — resolution — during  its  progress  produces  pitting  of  the 
swollen  follicles.  In  consequence  of  these  minute  points  of  necrosis 
the  plaques  now  present  a  characteristic  reticulated  appearance  (plaques 
a  surface  reticulde).  When  resolution  occurs  accompanied  by  destruc- 
tion of  the  follicles,  small  hemorrhages  may  take  place  into  the  glandu- 
lar structure.  These  hemorrhages  may  occasion  pigmentary  deposits  in 
the  follicular  depressions,  giving  rise  to  the  so-called  "  shaven-beard  " 
appearance. 

(h)  Necrosis  or  Sloughing. — In  all  save  the  milder  grades  of  cell- 
infiltration  the  hyperplasia  of  the  lymphatic  tissue  cannot  subside  before 
necrosis  occurs.  The  latter  process  results  partly  from  compression  and 
choking  of  the  blood-vessels  by  the  cell-proliferation,  and  partly 
from  the  direct  action  of  the  typhoid  bacillus,  leading  to  so-called 
anemic  necrosis.  Thus,  necrotic  crusts  (sloughs)  are  formed,  Avhich  are 
gradually  separated  and  cast  off.  While  not  all  of  the  glands  of  Peyer 
which  are  the  seat  of  cellular  infiltration  undergo  subsequent  necrosis, 
as  a  rule  those  situated  in  the  lower  portion  of  the  ileum  do,  and  show 
the  process  in  its  completest  development.  The  depth  to  Avhich  the 
necrosis  extends  is  quite  variable.  It  may  involve  only  the  most  super- 
ficial layers  of  the  mucosa,  or  it  may  extend  in  depth  till  it  reaches,  or 
even  perforates,  the  outer  or  serous  coat ;  but  usually  this  work  of 
destruction  does  not  dip  below  the  submucosa  or  muscularis.  The 
necrosed  portions  become  detached — a  process  that  proceeds  from  the 
periphery  toward  the  center — leaving  behind  the  typhoid  ulcer.  The 
stage  of  necrosis  and  sloughing  begins  betAveen  the  eighth  and  tenth 
days,  and  ends  on  or  about  the  twenty-first  day. 

(c)  Stage   of  Ulceration. — The   size  and  shape  of  the  ulcers  corre- 


TYPHOID  FEVER.  19 

spond  exactly  to  the  necrosed  areas  in  these  respects.  A  singh;  gland 
of  Peyer  generally  presents  several  ulcers  of  irregular  outline  separated 
by  strips  of  mucous  membrane.  Rarely,  the  entire  pla(iue  is  implicated, 
in  which  case  a  large  oval  ulcer  is  the  result,  and  at  the  lower  end  of  the 
ileum  the  ulcers  often  coalesce  until  they  almost  encircle  the  bowel.  The 
ulcers  of  the  solitary  glands  assume  a  rounded  form.  The  character 
of  the  floor  of  the  ulcer  will  vary  with  the  character  of  the  intestinal 
coat  which  forms  its  base,  though  usually  it  is  clean  and  smooth.  The 
edges  are  usually  irregular,  engorged,  soft,  and  frequently  overhanging. 
In  the  lower  segment  of  the  ileum  ulcers  may  be  numerous,  and  in  about 
25  per  cent,  of  the  cases  the  typhoid  ulcers  are  found  in  the  largo 
intestines — ^'.  e.,  in  the  cecum  and  colon. 

Hemorrhage  usually  results  from  erosion  of  a  vessel — an  accident 
which  is  occasioned  by  the  separation  of  the  sloughs — but  small  bleed- 
ings may  take  place  from  the  swollen,  hyperemic  edges  of  an  ulcer. 
Perforation  of  the  bowel  occurs  in  a  small  percentage  of  cases  (about 
6  per  cent.).  J.  A.  Scott  has  pointed  out  two  varieties  :  (a)  Circular, 
pin-point  in  size,  due  to  a  perforative  necrosis  (common),  and  {b)  a  large 
aperture  (as  the  result  of  extensive  necrosis)  ranging  in  size  from  the 
finger-tip  to  3  cm.  in  diameter.  The  perforations  may  be  multiple, 
though  they  are  usually  single.  The  small,  deep  ulcers  are  more  apt  to 
lead  to  complete  perforation  than  larger  ones,  and  the  site  of  the  orifice 
is  usually  in  the  course  of  the  lower  third  of  the  ileum.  The  lesions  of 
peritonitis  invariably  follow.  Perforation  of  the  large  boAvel  is  exceed- 
ingly rare.  Exceptionally,  the  appendix  is  the  seat  of  ulcer.  Localized 
abscesses  have  been  found  under  these  circumstances.  During  the 
stages  of  necrosis  and  ulceration  a  catarrhal  state  of  the  mucosa  of  the 
intestines  exists.  The  diarrhea  which  usually  accompanies  typhoid  is 
ascribable,  in  part  at  least,  to  the  catarrhal  state  of  the  large  bowel. 

(d)  Healing  follows  promptly  upon  the  formation  of  the  ulcer.  At 
first  a  granular  tissue  covers  its  floor.  The  mucous  membrane  is  replaced, 
including  the  glandular  elements  and  epithelial  layer,  and,  as  in  the 
stage  of  necrosis  and  sloughing,  so  the  healing  process  advances  inward 
from  the  border  of  the  ulcer.  Indeed,  it  is  this  process  that  dislodges 
the  necrotic  crust.  Occasionally,  ulcers  are  seen  extending  in  one  direc- 
tion while  healing  in  another.  The  cicatrix  formed  by  the  healing  of  an 
ulcer  presents  a  smooth  and  often  pigmented  surface. 

The  stages  thus  far  described  do  not,  strictly  speaking,  follow  one 
another,  since  two  or  more  may  be  illustrated  at  once  by  a  group  of 
ulcers  occupying  the  intestine.  When  death  occurs  during  a  relapse 
fresh  ulcers  are  observed  by  the  side  of  those  partially  healed. 

The  Mesenteric  Q-lands. — Changes  in  the  mesenteric  glands  occur 
simultaneously  with  those  in  the  intestines,  and  those  situated  opposite 
to  the  lower  third  of  the  ileum,  the  portion  of  the  bowel  showing  the 
most  extensive  ulceration,  are  most  profoundly  involved.  Hyperemia, 
and  later  swelling  due  to  cell-infiltration,  are  among  the  earliest  changes, 
and  correspond  with  the  lesions  noted  in  the  intestines  [vide  supra). 
The  mesenteric  glands  exhibit  great  variations  in  size,  ranging,  as  they 
do,  from  that  of  a  pea  to  a  hen's  egg.  Their  color  appearance  is  a  gray- 
ish red.  Resolution  commonly  occurs,  but,  if  it  does  not,  then  necrosis 
of  the  central   portion  (due,   most   probably,    to  the  same    causes    that 


20  INFECTIOUS  DISEASES. 

produce  necrosis  of  the  intestinal  lymph-follicles)  occurs.  Le  Conte* 
believes  that  perforation  of  the  capsule  of  the  trlands,  when  it  occurs,  is 
due  either  to  the  presence  of  the  staphylococcus  or  streptococcus  or  to 
thrombosis  of  the  larger  vessels  of  the  mesentery  outside  of  the  glands. 
Still  other  glands  become  hyperemic  and  swollen  (retroperitoneal,  bron- 
chial) ;  but  these  usually  tend  toward  resolution. 

T/ic  S/'lt'e)i. — With  rare  exceptions  the  spleen  becomes  enlarged  in 
typhoid  fever.  At  first  hyperemic,  the  tissue  then  grows  soft  and  gran- 
ular, and  at  times  is  almost  diffluent  on  section.  Infarction  is  not  a  rare 
occurrence  and  may  lead  to  suppuration.  Keen  has  searched  the  litera- 
ture and  found  only  9  cases  of  abscess.  In  rare  instances,  either  spon- 
taneously or  as  the  result  of  injury,  the  spleen  may  rupture,  and  the 
records  of  2000  post-mortems  at  the  Munich  Pathologic  Institute  furnish 
5  cases.     Perisplenitis  rarely  occurs  (vide  Spleno-ty|)lioid,  p.  45). 

Gall-bladder. — The  gall-bladder  may  show  catarrhal  inflammation, 
and  rarely  a  croupous,  diphtheritic,  or  ulcerative  inflammation  leading  to 
perforation.  Westcott  has  tabulated  30  cases  of  typhoid  infection  of  the 
gall-bladder  that  resulted  in  perforation.  Chiari's  ^  and  Fle.xner's^  figures 
show  that  typhoid  bacilli  are  found  in  the  gall-bladder  in  more  than  50 
per  cent,  of  the  fatiil  cases.  Chiarolanza*  found  that  typlioid  bacilli  in- 
jected intravenously  reached  the  gall-bladder  in  17  out  of  23  cases,  enter- 
ing through  the  capillaries  of  the  mucosa  and  submucosa.  (  Vide  Acute 
Infectious  Cholecystitis.) 

Mallory  has  shown  that  the  typhoid  bacillus  produces  a  toxin  which 
causes  proliferation  of  the  endothelial  cells  along  the  line  of  absorption 
from  the  intestines,  both  in  the  lymphatics  and  blood-vessels.  These 
cells  increase  in  size  and  number,  and  manifest  ])hagocytic  properties. 

(2)  Secondary  Lesions  due  Chiefly  to  the  Continued  Fever  and  to  Secon- 
dary Infections. — The  lesions  in  other  organs  are  of  subsidiary  importance, 
and  are,  for  the  most  part,  secondary  in  nature,  though  we  cannot  draw 
a  sharp  line  of  distinction  between  these  and  those  that  are  primary.  In 
the  kidneys,  pleura,  pharynx,  larynx  and  tonsils  primary  implantation 
of  the  typhoid  bacillus  may  rarely  occur  (vide  infra). 

The  liver  early  becomes  hyperemic,  and  later  is  softer  and  paler  than 
is  natural.  Handford  has  described  necrotic  areas,  and  Wagner  minute 
lymphomata.  Rarely  infarction  and  abscess  occur.  Mesenteric  abscess 
and  perforative  appendicitis  may  be  followed  by  pylephlebitis.  The  micro- 
scope reveals  parenchymatous  and  granular  degeneration.  The  cells  con- 
tain an  abundance  of  fat,  whilst  their  nuclei  have  lost,  in  great  part, 
their  outline. 

The  kidneys,  like  the  liver,  exhibit  parenchymatous  degeneration. 
They  are  somewhat  pale-looking,  are  cloudy  on  section,  and  slightly 
swollen,  and  under  the  microscope  granular  and  fatty  degeneration  of 
the  epithelial  cells  of  the  convoluted  tubules  is  observed.  More  rarely 
the  lesions  are  those  of  acute  hemorrhagic  nephritis.  Small  areas  of 
round-cell  infiltration  may  develop  late  in  the  course  of  typhoid,  and 
these  may  present  an  appearance  similar  to  lymphomata  or  may  undergo 
softening  and  suppuration,  giving  rise  to  miliary  abscesses.  The  mu- 
cous membrane  of  the  pelvis  of  the  kidney  is  not  infrequently  the  seat 
of  a  mild  grade  of  catarrh,  and,  rarely,  of  diphtheritic  inflammation. 

'  Jcmr.  Am.  Med.  ^.s.sor.,  Oct.  22,  1904.      '  Pr,ig.  med.  Woch.,  1903,  No.  22. 

■'  Johns  Hopkins  Hosp.  Reports,  vol.  v.      *  Zlsohr./.  Hygiene  u.  InJ'ectionskr.,  1908,  Ixii.,  1. 


TYPHOID  FEVER.  21 

Typhoid  cystitis  is  still  more  common,  and  the  bladder  may  also  be  the 
seat  of  diphtheritic  inflammation.  Rarely  orchitis  is  encountered.  On 
making  cultures  from  sections  of  the  kidneys  not  a  few  observers  have 
been  able  to  demonstrate  the  presence  of  the  specific  bacillus  of  typhoid. 

In  the  lungs  are  found  morbid  lesions  in  nearly  all  cases  of  typhoid 
fever,  and  belonging  to  the  essential  pathologic  processes  is  bronchitis, 
due  to  a  congested  and  catarrhal  state  of  the  bronchial  mucous  mem- 
brane. The  lesions  of  lobular  pneumonia  present  a  complicating  con- 
dition in  many  instances  ;  those  of  lobar  pneumonia  also  may  be  present, 
though  less  commonly.  The  so-called  hypostatic  congestion  is  often 
found,  but  is,  I  think,  less  frequent  than  is  supposed  by  many  authors. 
Embolic  infarctions,  having  their  origin  in  thrombi  occupying  the  right 
side  of  the  heart,  are  sometimes  present.     Gangrene  may  also  occur. 

Pleurisy  is  rarely  met  with.  It  is  generally  of  the  plastic  vari- 
ety, although  empyema  occurred  in  nearly  2  per  cent,  of  the  Munich 
cases.  The  initial  lesion  may  be  pleuritic.  ( Vide  Pleuro-typhoid, 
p.  45.) 

The  larynx  and  the  pharynx  may  manifest  changes.  Ulcers  have 
been  observed  on  the  epiglottis  and  posterior  wall  of  the  larynx,  and  I 
have  more  than  once  seen  them  on  the  pharynx  (jPharingo-typhoid). 
When  situated  in  the  larynx  they  may  extend  in  depth  till  they  reach  the 
perichondrium,  causing  perichondritis,  with  or  without  edema  of  the 
larynx.  Typhoid  bacilli  have  been  found  in  the  ulcers  (Eichhorst). 
Catarrhal,  or  even  croupous,  pharyngitis  may  occur,  and  a  swelling  of 
the  follicles  of  the  pharynx  and  base  of  the  tongue  is  to  be  noticed  in 
many  cases.  True  aphthous  changes,  affecting  the  mouth  and  pharynx, 
may  be  present  as  a  secondary  event.  The  tonsils  may  present  ulcers 
(Tonsillo-typhoid.)  The  mucosa  of  the  stomach  is  sometimes  congested, 
and  may  be  the  seat  of  typhoid  ulcers,  although  this  is  rare. 

Perito7iitis  is  always  found  in  fatal  cases  in  which  the  bowel  has  been 
perforated.  The  condition  is  a  general  one,  save  in  the  rare  instances 
mentioned  below,  and  there  is  usually  much  fibrino-purulent  effusion 
present.  Diffuse  peritonitis  may  be  present  without  perforation,  and 
results  sometimes  from  a  localization  of  the  typhoid  poison  in  the  peri- 
toneum, from  rupture  of  suppurating  mesenteric  glands,  and  from  direct 
extension  of  intestinal  inflammation  to  the  peritoneum. 

The  heart  may  be  the  seat  of  morbid  changes.  Acute  endocarditis 
may  be  a  very  rare  complication,  while  pericarditis  occurs  relatively 
more  often — viz.  in  14  of  the  Munich  post-mortems  before  mentioned. 
Myocarditis  is  a  common  event,  the  cardiac  muscle  exhibiting  parenchy- 
matous and,  less  commonly,  hyaline  degeneration,  and  the  latter  change 
sometimes  leads  to  sudden  rupture  of  the  muscular  fibers,  with  a  fatal 
result  (myocardite  segmentaire).  It  is,  however,  a  significant  fact  that 
in  many  instances,  even  of  the  severest  type,  the  cell-fibers  may  show 
slight,  if  any,  noticeable  change.  Out  of  48  cases,  16  showed  granular 
or  fatty  degeneration,  and  3  a  proliferative  endarteritis  in  the  small  ves- 
sels (Dewevre). 

The  arteries  have,  in  a  number  of  instances,  been  found  to  be  the 
seat  of  two  forms  of  arteritis  (Barie) :  {a)  Acute  obliterating  arteritis 
and  {b)  partial   arteritis.     These  conditions  may  affect  the  smaller  ves- 


OO 


INFECTIOUS  DISEASES. 


sels.  particularly  those  of  the  heart,  but  they  occur  most  commonly  in 
the  arteries  of  the  lower  extremities.  Tiiron'ibi  are  found  in  the  right 
chambers  of  the  heart  and  in  the  veins — most  fretjuently  in  the  femoral, 
and  less  often  in  the  cerebral,  sinuses.  According  to  Flexner,  thrombi 
may  be  caused  by  auto-agglutination  of  the  red  cells. 

The  vohmtarji  muscles  undergo  parenchymatous  and,  occasionally,  a 
hyaline  change,  though  this  is  not  a  feature  ])eculiar  to  typhoid  feVer. 
The  latter  form  of  degeneration  does  not  aftect  the  ^vhole  muscle,  but 
only  certain  libers,  and,  as  a  rule,  the  recti  abdominis,  the  diaphragm,  the 
adductors  of  the  thigh,  and  the  pectorals  are  the  seats  of  the  lesion.  The 
parts  affected  are  pale  and  possess  a  grayish,  waxy  lustre.  Histolog- 
ically, the  process  implies  the  transformation  of  the  muscular  fibers,  and 
especially  the  cement  substance,  into  a  homogeneous,  pliable  mass.  Regen- 
eration of  the  fibers  occurs  during  convalescence.  Hemorrhages  into, 
and  rarely  abscesses  in,  the  intermuscular  tissue  occur. 

The  nervous  system  presents  no  gross  lesions,  if  we  except  menin- 
gitis, the  latter  occurring  as  a  complication  ;  but  it  is  exceedingly  rare, 
having  been  present  in  only  11  of  the  2000  Munich  cases.  In  a  few 
instances  large  cerebral  hemorrhages  have  been  met  with,  but  these  are 
apparently  coincidental,  while  capillary  hemorrhages  into  the  cortex 
may  be  numerous.  Meningeal  hemorrhages  may  also  occur.  Slight 
edema  of  the  cerebral  cortex  has  been  noted.  The  peripheral  nerves 
are  not  infrequently  the  seat  of  parenchymatous  change,  with  or  with- 
out local  neuritis,  and  the  ganglia  of  the  trunks  of  the  vagi  exhibit  an 
inflammatory  change  w  hich  Levin  believes  is  the  cause  of  the  laryngitis, 
pharyngitis,  pharyngolysis,  and  arrhythmia  sometimes  observed. 

The  hlood  shows  few  important  alterations.  The  red  blood-corpuscles 
are  relatively  increased  during  the  febrile  period  and  markedly  dimin- 
ished during  convalescence,  but  the  great  loss  of  water  during  the 
former  period  and  a  reabsorption  during  the  latter  will  explain  these 
interesting  facts  (Henry).     Leukocytosis  is  absent  {vide  infra,  p.  40). 

Ktiology. — Bacteriology. — The  bacterium  which  is  the  specific  cause 
of  typlioid  fever  was  discovered  by  Eberth,  whose  researches  were  later 
confirmed  by  the  investigations  of  Gaffky  and  others. 

G-eneral  Characters. — It  is  a  short,  thick  bacillus,  about  three  times 
as  long  as  it  is  broad,  with  rounded  ends  (Fig.  1).  It  is  motile,  due  to 
the  presence  of  cilia,  and  when  stained,  exhibits  vacuolations  that  have 
been  mistaken  for  spores.     It  is  easily  stained  with  all  the  anilin  dyes. 

Cliaracteristic  Growth. — Upon  gelatin  plates  it  develops  in  grayish 
translucent  colonies  with  irregular  borders  and  ridged  surfaces.  Upon 
agar  the  growth  is  not  characteristic ;  upon  the  potato,  especially  if  it 
has  been  rendered  slightly  acid,  it  forms  a  perfectly  transparent  growth 
that  is  only  evident  as  a  slight  apparent  increase  of  moisture  upon  the 
surface,  and  as  offering  a  greater  resistance  to  the  point  of  the  needle 
when  scraped  across  it.  It  neither  coagulates  milk,  li(juefies  gelatin, 
nor  produces  indol.  The  organism  never  forms  spores.  Moreover,  the 
bacillus  has  no  greater  powers  of  resistance  than  the  ordinary  bacteria. 

Experimental  T3nplioid. — Inoculated  into  lower  animals,  the  bacillus 
frequently  causes  fatal  results  without  producing  the  lesions  characteris- 
tic of  typhoid  in  iiuman  beings,  although  occasionally  typical  typhoid 
ulcers  have  been  found.    The  susceptibility  of  lower  animals,  though  nor- 


TYPIIOW  FEVER. 


23 


I 


i 


"--   ■' V 

Fig.  1— Typhoid  bacilli  with  flagella;  X  1000. 


mally  slight,  can  be  increased  by  preliminary  injections  of  saprophytic 
bacteria,  this  result  having  been  obtained  by  Alessi  when  he   exposed 

animals    to   the    gases    produced    by  _^ 

putrefying    matters.       It    has    been  .^^^  ***        "^v,^ 

found  that  the  ulcerative  intestinal 
lesions  produced  by  the  inoculation 
of  the  bacilli  or  their  toxins  in  large 
quantities  into  the  blood  of  rabbits 
may  also  be  caused  by  other  bacteria, 
including  the  bacillus  coli  commune. 
Metchnikoff,^  however,  has  adminis- 
tered foods  contaminated  with  weak 
dilutions  of  bacillus-infected  feces  to 
chimpanzees ;  they  contracted  char- 
acteristic typhoid  fever. 

Usually,  in  making  a  hacteriologic 
diagnosis  the  typhoid  bacillus  is  to 
be  differentiated  from  those  organisms 
that  morphologically  resemble  it  and  present  almost  identical  characteris- 
tics upon  various  culture-media,  such  as  the  bacillus  of  Shiga,  paracolon 
bacilli,  and  the  bacillus  coli  communis.  These  organisms  can  now  be 
separated  from  the  bacillus  of  Eberth,  bacteriologists  having  pointed  out 
the  fundamental  differences  between  these  related  forms.  Smith  and 
Tennant,  in  a  study  of  the  1898  epidemic  of  typhoid  in  Belfast,  failed 
to  find  typhoid  bacilli  in  the  water-supply,  but  were  able  to  isolate  vari- 
eties of  the  bacillus  coli  communis. 

The  real  poison  of  typhoid  fever  is  most  probably  a  ferment  (?) 
secreted  by  the  bacillus — typho-toxin  ;  and  Brieger  has  extracted  the 
latter  agent,  finding  that  it  produces  the  fever,  nervous  symptoms,  and 
the  other  manifestations  characteristic  of  the  affection. 

Distribution  in  the  Body. — The  bacillus  has  been  found  in  the  intes- 
tinal tract,  the  lymph-glands,  the  contents  of  the  intestine,  the  spleen, 
the  liver,  the  gall-bladder,  the  rose-colored  spots,  the  blood,  and  the 
bile.  The  bacillus  typhosus  is  demonstrable  in  the  stools  (in  about  50 
per  cent,  of  the  cases),  the  urine  (Wright  and  Semple),  the  sputa,  the 
vomita,  milk,  and  the  sweat.  The  bacillus  typhosus  is  most  abundant  in 
the  duodenum  and  jejunum;  it  is  practically  constant  in  cultures  made 
from  the  mucosa  of  the  stomach  (Jiirgens).  Less  commonly  it  has  been 
found  in  foci  of   suppuration  and  in  exudations  (pleural,  endocardial). 

The  Bacilli  Outside  the  Body. — The  bacilli  cannot  maintain  a  perma- 
nent existence  outside  the  human  body.  From  time  to  time,  however, 
the  conditions  indispensable  to  the  growth  and  development  of  the  ty- 
phoid germs  prevail,  and  corresponding  with  such  periods  of  time  more 
or  less  extensive  epidemic  outbreaks  of  the  disease  may  occur.  It  is 
known  that  the  typhoid  bacilli  may  retain  their  vitality  for  from  seven 
to  fourteen  days  in  water,  disappearing  from  the  same  on  account  of  the 
presence  of  saprophytes  ;  but  an  epidemic  or  an  endemic  of  typhoid  fever 
implies  persistent  contamination  of  the  drinking-water.  Multiplication 
of  the  bacilli  may  take  place  in  water,  in  milk  (very  rapidly),  and  in  the 
soil,  where  they  preserve  their  vitality  under  favorable  conditions  (for 
eleven  months — Robertson).     Freezing  does  not  kill  them,  as  they  may 

^  Jour.  Amer.  Med.  Assoc,  April  16,  1910. 


24  INFECTIOUS  DISEASES. 

live  in  ice  for  several  months  (Prudden).     Thej  have  been  discovered  in 
infected  Avater,  but  they  are  thorouirlily  destroyed  by  boiling. 

Predisposing  Causes. — {a)  Q-eographic  Location. — In  temperate  zones 
typhoid  fever  prevails  constantly  to  a  greater  or  less  extent,  and  is  the 
most  important  infection.  It  has  been  shown  in  recent  times  to  be 
comparatively  common  in  the  tropics  (c.  g.,  India)  as  "well  as  in  many 
cold  latitudes  (Iceland.  Norway).  It  exhibits  an  appalling  prevalence  and 
fatality  in  armies  in  the  field.  For  example,  in  the  Spanish-American 
war  one-fifth  of  the  soldiers  in  the  national  encampments  suffered  from 
the  disease,  with  1580  deaths  ;  while  in  the  South  African  war  the  British 
army  lost  7991  men  from  typhoid  fever  and  only  7582  died  of  wounds. 

{l))  Seasons  exert  a  decided  influence  upon  the  frequency  of  the 
occurrence  of  typhoid.  According  to  the  statistics  of  Murchison,  Bart- 
lett,  Osier,  Hirsh,  and  others,  the  time  of  greatest  liability  to  typhoid 
fever  is  during  the  late  summer  and  the  early  autumn  (August,  Septem- 
ber, and  October).  The  remaining  summer  and  autumn  months  yield  a 
relatively  larger  number  of  cases  than  the  winter  and  spring  :  again,  in 
winter  more  cases  are  met  with  than  in  the  spring,  which  furnishes  few- 
est number  of  cases.  After  hot  and  dry  summers  typlioid  fever  is  espe- 
cially apt  to  be  prevalent,  and,  according  to  Baumgarten,  a  relatively 
large  amount  of  dust  in  the  atmosphere  may  disseminate  the  typhoid 
germs.     Epidemics,  however,  may  occur  at  any  season. 

[c]  Condition  of  the  "  GS-round  Soil." — Pettenkofer  and  his  disciples 
contend  that  when  the  standing  water  in  the  soil  reaches  a  high  level 
fewer  cases  occur,  and  when  it  falls  to  a  low  level  or  below  the  mean 
height  the  cases  become  more  numerous.  This  dictum,  however,  has  not 
as  yet  been  conclusively  proven  Avith  reference  to  many  localities.  The 
poisoned  foci,  may  be  more  eifectively  drained  by  the  springs  and 
streams,  since  the  latter  contain  an  increased  quantity  of  solid  matter 
when  the  ground-water  is  low.  Epidemics  of  typhoid  fever,  however, 
occur  repeatedly  without  regard  to  the  condition  of  the  ground-water. 

{d)  Age. — Typhoid  fever  may  occur  at  any  age.  It  is,  however,  espe- 
cially frequent  among  young,  robust  individuals  between  the  ages  of 
fifteen  and  thirty  j-ears.  Later  in  life  it  becomes  progressively  less  fre- 
quent, though  cases  have  occurred  at  or  beyond  the  seventieth  year. 
Young  children  are  not  exempt,  and  cases  among  them  are  of  rather 
frequent  occurrence,  if  we  except  those  under  one  year  of  age.  When 
contracted  late  in  pregnancy  typhoid  may  be  congenital  (Freund  and 
Levy).  The  typhoid  bacilli  have  been  successfully  cultivated  from  the 
fetus,  and  Moss^  and  Fraenkel  ^  have  confirmed  the  observation  that  the 
Widal  test  can  be  obtained  from  the  placenta  and  blood  of  the  fetus. 

(e)  Sex  probably  does  not  aff"ect  the  degree  of  liability  in  typhoid. 

(/)  Individual  Predisposition. — This  may  be  acquired  or  inherited. 
An  instance  of  acquired  predisposition  is  to  be  noted  in  the  great  sus- 
ceptibility which  exists  among  persons  who  have  recently  moved  from 
rural  districts  to  cities.  Thus,  Louis  found  "that  of  129  cases,  73  had 
not  resided  in  Paris  over  ten  months,  and  102  not  over  twenty  months." 
Defective  ventilation,  filth,  overcrowding,  and  imperfect  drainage  increase 
susceptibility.  There  is  evidence  to  show  that  the  disease  is  on  tlie  in- 
crease in  rural  sections.  Predisposition  to  typhoid  may  also  be  inherited. 
Most  persons,  however,  enjoy  natural  immunity  from  the  affection. 
*  Joum.  des  Practiciens,  Jan.  28,  1899. 


TYPlIOll)  FEVER.  25 

(//)  Intestinal  Catarrh. — Cases  of  influenza  with  catarrh  of  the  gastro- 
intestinal tract  may  be  followed  by  typhoid  fever. 

(A)  Nervous  Influences. — Great  miental  excitement  and  overwork. 

Immunity. — The  occurrence  of  typhoid  fever  confers  an  approximate, 
though  not  an  absolute,  immunity  against  subsequent  attacks. 

In  this  connection  two  questions  present  themselves  for  ronsidoi'iitiou  : 
(1)  What  are  the  methods  of  conveyance  of  the  poison  into  the  body  ? 

IsoLated  cases  and  epidemics  of  typhoid  fever  are  alike  to  be  attributed 
to  antecedent  cases  of  the  disease,  and  this  fact  presupposes  that  the 
bacillus  of  typhoid  leaves  the  body  of  the  sufferer.  It  does  so  in  the 
stools,  the  urine,  and  occasionally  in  the  vomitus  and  sputum,  i'ark 
states  that  examinations,  both  in  Europe  and  America,  show  that  fully  2 
per  cent,  of  persons  who  have  had  typhoid  fever  are  typhoid  bacilli 
carriers.  Hutchinson's^  investigations  show  that  8.3  per  cent,  of  typhoid 
fever  patients  are  excreting  the  causal  organisms  when  discharged  from 
the  hospital,  while  6.3  per  cent,  of  these  do  not  continue  to  be  infective 
for  more  than  one  month  from  that  time.  A  few  of  them  pass  infected 
urine,  but  most,  infected  feces.  During  the  declining  and  post-febrile 
stages  the  urine  is  probably  the  most  dangerous  excretion  containing 
bacilli.  Finally,  one  in  every  five  hundred  healthy  adults  who  have 
never  knowingly  had  typhoid  fever  is  a  carrier  through  contact  with  in- 
fection. It  would  seem  that  there  are  several  periods  of  "  effectiveness  " 
and  "ineffectiveness"  (the  latter  coinciding  w'ith  the  early  months  of  the 
year)  of  typhoid  bacilli  carriers.  According  to  the  Germans,  the  most 
common  soui'ce  of  the  bacillus  is  a  patient  or  chronic  carrier,  the  latter 
causing  about  10  per  cent,  of  the  cases.  Conradi  claims  that  four  times 
as  many  women  as  men  become  chronic  carriers.  Typhoid  bacilluria 
may  persist  for  a  long  time  after  apparent  recovery.  The  dejecta  and 
the  urine,  which  are  the  principal  sources  of  infection,  may  be  conveyed 
to  well  persons  by — 

(a)  Infected  Drinking  Water. — In  most  instances  the  poison  is  trans- 
mitted from  those  affected  wdth  the  disease  to  those  in  health  through  the 
drinking-water  supply,  as  shown  by  many  epidemic  outbreaks  in  which 
the  mode  of  origin  has  been  traced.  Wells,  storage  reservoirs,  springs, 
and  rivers  may  become  contaminated  and  cause  an  epidemic. 

In  the  spring  of  1885  a  most  deplorable  epidemic  occurred  in  Plymouth, 
Penna.,  a  town  of  8000  inhabitants.  At  first  the  nature  of  the  affection 
was  not  recognized,  and  before  it  ceased  to  appear  1200  persons  were 
affected,  with  130  resulting  deaths.  This  epidemic  was  investigated  by 
Shakespeare  and  L.  H.  Taylor,  and  was  found  to  have  arisen  from  a 
single  case  of  typhoid  occurring  in  a  house  on  a  hill  which  sloped  toward 
the  water-supply  of  the  town.  This  patient  was  ill  during  January, 
February,  and  March,  while  the  ground  was  frozen  and  covered  with 
snow,  upon  which  the  dejecta  were  thrown.  On  March  25th  there  was  a 
considerable  rainfall,  followed  by  a  sudden  thaw,  and  the  water  ran  at 
once  through  the  various  surface  channels  into  a  brook,  which  in  turn 
emptied  into  the  reservoir.  On  April  10th  other  cases  of  the  disease 
appeared,  and  those  citizens  who  obtained  their  water  from  other  sources 
than  the  infected  reservoir  escaped.      The  recent  outbreaks  at  Maidstone 

^  Medical  Chronicle,  Jan.,  1912. 


26  INFECTIOUS  DISEASES. 

(1897)  and  at  Butler.  Pa.  (1903),  are  equally  convincing  and  instructive 
as  regards  the  causative  iniluence  of  a  contaminated  water-supply. 

(h)  Infected  milk  fre([ucntly  conveys  the  poison.  It  may  become  pol- 
luted by  water  which  has  been  used  either  to  Avasb  the  cans  or  for  diluting 
purposes,  or  the  bacilli  may  be  transferred  to  milk  by  the  unclean  hands 
of  the  milker.  iS^umerous  instructive  epidemics,  originating  in  infected 
milk,  have  been  reported.  E.  B.  Bigelow  has  reported  a  milk-borne 
ejudemic  which  was  traced  to  one  male  bacillus-carrier,  and  involving 
20-t  cases.  The  occurrence  of  numerous  cases  among  children  suggests 
contaminated  milk. 

Solid  forms  of  food  (salads,  celery,  fruits)  may  be  contaminated  by 
infected  water  or  dust  or  by  the  fingers  of  the  nurse  or  the  patient. 
During  the  late  Spanish-American  Avar  the  typhoid  bacilli  may  have 
been  conveyed  from  the  latrines  directly  to  the  victims  or  to  the  kitchens 
and  mess-tables  by  swarms  of  flies.  Vaughan^  confirms  this  view,  and 
has  also  observed  that  "  officers  w^hose  mess-tents  were  protected  by 
means  of  screens  suffered  proportionately  less  from  typhoid  fever  than 
did  those  whose  tents  were  not  so  protected."  He  believes  that  fecal 
matter  containing  the  typhoid  germ  may  adhere  to  the  fly,  and  be 
mechanically  transported,  and  further  suggests  the  possibility  of  the 
bacilli  being  carried  in  the  digestive  organs  of  the  fly,  and  deposited 
with  its  excrement.  H.  W.  Conn  has  shown  that  oysters  while  being 
ftittened  or  freshened  may  become  infected  with  water  polluted  by 
sewage,  and  Foote  has  shown  that  the  typhoid  bacillus  will  not  only 
retain  its  vitality  in  the  salt  water  in  which  the  oysters  are  fed,  but  that 
it  will  live  even  longer  in  the  oyster  itself.  Phillip  Mai'vel  has  reported 
a  small  epidemic  (comprising  a  total  of  72  cases)  due  to  infected  oysters 
that  occurred  at  Atlantic  City  during  the  months  of  August,  September, 
and  October  of  1902.  Newsholme"  attributed  one-third  of  a  total  of  56 
cases  of  typhoid  to  the  eating  of  raw  shell-fish. 

(c)  Contagion  or  Direct  Transmission. — This  necessitates  direct  con- 
tact with  the  typhoid  stools.  It  affords  a  ready  explanation  for  contrac- 
tion of  the  disease  by  internes  and  nurses  who  attend  to  the  stools,  the 
bed-  and  the  body-linen  of  the  patient,  and  by  laundresses,  who  are 
affected  with  great  relative  frequency.  Out  of  1500  cases  treated  in  the 
Johns  Hopkins  Hospital,  31  were  contracted  in  this  manner  (Futcher). 

(d)  "  Ground-soU." — The  typhoid  poison  which  leaves  the  body  must 
undergo  development  in  the  ground-soil  before  it  is  potent  to  cause  the 
disease  in  others  (Pettenkofer).  The  former  great  prevalence  of  typhoid 
in  Munich  was  due  to  pollution  of  the  soil  (Childs). 

(e)  Sewer-gas. — The  recent  researches  of  Bergey  and  of  Abbott  show 
that  sewer-gas,  ^^cr  se,  cannot  cause  typhoid  fever. 

(/)  Sand-storms. — Tooth  states  that  sand-storms  may  contaminate 
articles  of  food  with  the  bacillus. 

(^)  The  hands  of  chronic  carriers  may  be  the  medium  of  transference. 
Courmont^  claims  that  dogs  are  typhoid  bacilli  carriers. 

(2)  Through  what  channel  or  channels  does  the  bacillus  enter? 

(a)  In  the  vast  majority  of  the  cases  the  bacilli  are  swallowed.     In  the 

stomach  they  meet  with  the  acid  gastric  secretions,  which  often  destroy 

them.     The  alkaline  juices  of  the  small  intestine,  however,  furnish  every 

condition  necessary  for  their  further  growth  and   development.     They 

1  Phiia.  Med.  Jour.,  June  9,  1900.  «  5,.^   ^/g^  j^;^,.^  june  g,  1895. 

^  Bulletin  de  P Academic  de  Medecine,  Paris,  June  28,  1910. 


TYPHOID  FEVER.  27 

penetrate  the  mucosa  and  attack  primarily  tlie  solitary  follicles  and 
Peyer's  plaques.  Next  they  invade  the  mesenteric  glands,  reaching  the 
circulation,  spleen,  liver,  and  other  organs  a  little  later. 

(i)  The  possibility  that  the  bacilli  may  reach  the  blood-stream  through 
the  respiratory  organs  must  be  conceded  ;  and  hence  the  added  possi- 
bility that  they  may  set  up  initiatory  lesions  either  in  the  tonsils,  lungs, 
or  pleura,  passing  thence  into  the  circulation,  must  also  be  granted. 
Yaughan  inclines  to  the  opinion  that  the  bacillus  may  be  inhaled  in  the 
infected  dust  by  troops  on  the  march.  Complete  desiccation,  however, 
soon  destroys  the  typhoid  germ.  Primary  localization  of  great  severity 
may  also  occur  in  the  kidneys  and  cerebrospinal  meninges,  giving  rise 
to  special  clinical  varieties  {vide  infra). 

{c)  Typhoid  Septicemia. — By  this  is  meant  a  general  infection  with  the 
bacilli  without  localized  lesions.  The  special  mode  of  infection  is  not 
clear.  Brion  and  Kayser  *  conclude  from  extensive  bacteriologic  and 
clinical  studies  that  typhoid  fever  may  start  as  a  lymph-and-blood  aiFec- 
tionr  (possibly  entering  by  way  of  the  tonsils). 

{d)  Typhoid  infection  predisposes  the  system  to  secondary  infections 
with  various  bacilli  (streptococcus,  staphylococcus,  bacillus  coli  commune, 
pneumococcus).  The  portals  of  entrance  for  these  micro-organisms  are 
various  (e.  ^.,  respiratory  tract,  lymphatics). 

Clinical  History. — I.  Incubation. — The  average  duration  of  the 
period  of  incubation,  or  the  time  between  the  introduction  of  the  poison 
into  the  system  and  the  appearance  of  the  first  active  symptoms,  ranges 
from  ten  days  to  three  weeks ;  this  interval  may  rarely  be  shorter, 
although  oftener  it  is  somewhat  longer.  During  this  period  the  patient 
may  experience  no  deviation  from  health,  but  in  most  cases  there  are 
prodromal  symptoms,  such  as  languor,  loss  of  appetite,  nausea,  headache, 
neuro-muscular  pains  in  the  back  and  limbs,  a  disinclination  to  exercise, 
etc.     These  symptoms  last  from  a  few  days  to  a  week  or  more. 

11.  General  Symptomatology  and  Course. — On  account  of  the  peculiar 
temperature-curve  in  typhoid  fever  its  course  falls  naturally  into  three 
periods — the  stage  of  development ;  the  acme  or  fastigium  (correspond- 
ing to  the  height  of  the  disease) ;  and  the  stage  of  decline  or  deferves- 
cence. It  is  convenient  to  speak  of  the  various  weeks  of  the  affection 
when  referring  to  these  stages.  Thus,  the  first  week  represents  the 
stage  of  development  {stadium  incrementi),  the  second  and  third  weeks 
(in  cases  of  average  severity)  the  fastigium,  while  the  fourth  week  in  the 
typical  form  (the  third  week  in  mild  cases)  corresponds  to  the  third  stage 
{stadium  decrementi)  of  the  disease. 

(a)  Stage  of  Development. — The  invasion,  as  a  rule,  is  gradual,  the 
symptoms  being  chilliness  and  feverishness,  with  increase  in  the  severity 
of  the  prodromal  symptoms.  Typhoid  fever  rarely  starts  in  with  a  dis- 
tinct rigor.  At  or  about  this  time  nose-bleed  may  betray  the  nature  of 
the  disease.  The  symptoms  just  described  are  quickly  followed  by  a 
prostration  sufiiciently  well  marked  to  compel  most  patients  to  take  to 
their  beds.  From  this  latter  event  is  usually  dated  the  onset  of  the  aifec- 
tion.  It  is  safer,  however,  to  regard  the  time  of  occurrence  of  the  above- 
mentioned  symptoms  (elevation  of  temperature,  with  its  attendant 
discomforts)  as  the  time  of  onset,  since  many  patients  continue  in  their 
avocations  for  days  after  the  first  symptoms  appear.      The  onset  may  be 

^  Deutsches  Archivf.  klin.  Medicin,  last  indexed,  vol.  xlv.,  p.  1S32. 


28  INFECTIOUS  DISEASES. 

marked  by  symptoms  resembling  influenza  (Bunce).  In  my  experience 
ciises  in  which  general  pains,  including  backache  or  slight  pharyngitis, 
are  seen  at  the  onset  are  not  rare.  Again,  invasion  may  be  usiiered  in 
by  various  nervous  symptoms  {e.  g.,  convulsions,  in  children)  or  marked 
pulmonary  features,  especially  those  of  severe  bronchitis. 

With  the  progress  of  the  initial  period  the  symptoms  usually  increase 
in  severity  ;  the  fever  rises  day  by  day,  terrace-like,  till,  at  the  end  of 
four  or  five  days,  the  second  stage,  or  fastigium,  is  reached.  Anorexia, 
thirst,  and  headache  are  often  marked,  the  skin  hot  and  dry  to  the  feel, 
the  tongue  coated,  the  sleep  disturbed,  and  constipation  is  generally 
present.  The  patient  may  complain  of  sensations  of  chilliness  alternat- 
ing with  flushings  of  heat,  and  there  is  a  slight  cough.  The  puhe  is 
somewhat  quickened  (from  90  to  110  per  minute)  and  is  full. 

The  pht/sical  sig7is  are  not  prominent.  The  abdomen  is  often  slightly 
distended  and  tender;  the  spleen  is  found  to  be  swollen.  The  associa- 
tion of  splenic  enlargement  and  dry  bronchitis  point  to  this  disease. 

(b)  Fastigium,  or  the  second  stage,  commences  on  the  fourth  or  fifth 
day,  and  lasts,  in  typical  cases,  about  two  weeks.  During  the  first  week 
of  the  fastigium  (the  second  of  the  disease)  the  general  symptoms  become 
more  marked.  Thefei'er  remains  high,  the  evening  temperature  usually 
reaching  103°  or  104°  F.  (40.°  C),  and  exhibits  the  continued  type. 
The  pnlse  is  accelerated,  but  not  dicrotic.  The  headache  disappears,  and 
mental  dulness  and  slowness  are  conspicuous,  but  there  may  be  mild 
delirium,  particularly  at  night.  There  is  a  dry  cough  and  the  physical 
signs  indicate  more  or  less  extensive  bronchitis.  The  tongue  is  coated 
and  may  become  dry,  the  belly  is  somewhat  swollen  and  tender,  and 
diarrhea  replaces  constipation.  The  spleen  is  decidedly  enlarged,  and 
about  the  eighth  day  of  the  disease  a  number  of  roseate  spots  appear  on 
the  trunk.  During  the  latter  part  of  this  week  a  grave  or  even  fatal 
condition  may  be  developed  as  a  result  of  intense  nervous  or  pulmonary 
symptoms,  intestinal  hemorrhage,  or  perforation. 

During  the  second  week  of  the  fastigium  (the  third  week  of  the  dis- 
ease) the  marked  general  symptoms  already  noted  persist  in  severe  types 
of  the  aflFection.  The  j^ulse  varies  from  110  to  130,  and  is  now  often 
dicrotic,  while  the  temperature  may  approach  the  remittent  type.  In 
addition  this  period  furnishes  most  of  the  untoward  complicdtions  (lobu- 
lar pneumonia,  hypostatic  congestion  of  the  lungs,  intestinal  hemorrhage, 
perforation,  peritonitis),  and  in  the  absence  of  serious  local  complications 
grave  general  conditions  may  be  presented.  The  duration  of  this  stage 
varies  with  the  severity  of  the  type. 

(c)  Stage  of  Decline  or  Defervescence. — At  the  end  of  the  second 
stage,  and  about  the  twenty-first  day  of  the  disease,  in  favorable  cases 
the  fever  begins  to  decline,  and  with  it  the  other  general  and  local 
.symptoms  gradually  disappear.  This  is  followed  by  true  convalescence. 
In  protracted  cases,  however,  the  fourth  week  of  the  disease  may  present 
much  the  same  clinical  indications  as  the  third,  and  these  may  even  be 
intensified.  Frequently  an  aggravated  type  of  the  typhoid  state  is  now 
superadded,  the  symptoms  being  stupor,  muttering  delirium,  subsultus 
tendinum,  a  rapid,  feeble  pulse,  a  dry,  brown  tongue,  marked  diarrhea, 
greatly  swollen  belly,  and  an  involuntary  discharge  of  feces  and  urine. 
Inflammatory  complications  may  add  to  the  perils  of  the  condition. 

In  not  a  fcAv  cases  the  febrile  period  is  prolonged  into  the  fifth,  and 


TYPHOID  FEVER.  29 

rarely  into  the  sixth  or  even  the  seventh  week,  and  the  fever  observed 
when  defervescence  is  retarded  presents  an  irregular  type.  1  have  else- 
where reported  a  case  in  which  it  lasted  not  less  than  seven  weeks.' 
About  this  time  recrudescences  and  relapses  may  occur  in  typical  cases. 
Different  epidemics  of  typhoid  fever,  however,  vary  so  greatly  in  their 
clinical  characteristics  as  to  make  it  impossible  to  include  all  cases  in 
any  outline  of  the  course  of  the  disease  that  might  be  attempted. 

III.  Chief  Clinical  Features  in  Detail. — (a)  Course  of  the  Fever. — 
During  the  stage  of  development  (the  first  four  or  five  daysj  the  temper- 
ature usually  rises  in  "  step-ladder  "  fashion.  The  evening  exacerbation 
is  on  each  day  from  a  degree  and  a  half  to  two  degrees  higher  than  on 
the  preceding,  and  the  same  is  true  of  the  morning  remissions.  A 
glance  at  the  temperature-charts  (Figs.  2  and  3)  will  show  that  the 
morning  remissions  touch  a  level  from  one-half  to  one  degree  lower  than 
the  preceding  evening  registers.     This  stage  is  rarely  met. 

When  the  fastigium  is  reached,  the  evening  temperature  may  be 
103°,  104°,  or  105°  F.  (39.4°-40.5°  C),  and  is  usually  thus  main- 
tained, with  the  slight  morning  remissions.  The  tide-like  character  of 
fever-curve  seen  in  the  initial  period  is  absent.  Often,  during  the 
latter  half  of  the  fastigium  (the  third  or  fourth  week  of  the  disease) 
the  morning  fall  of  temperature  becomes  decidedly  greater.  According 
to  my  own  observation,  the  height  of  the  fastigium  is  reached  a  day  or 
two  after  its  onset  or  at  the  end  of  the  first  week  of  the  affection.  Marked 
morning  remissions  are  a  favorable  indication.  On  the  other  hand,  and 
contrary  to  the  general  rule,  the  morning  temperature  may  be  higher 
than  the  evening,  forming  a  somewhat  unfavorable  symptom.  Morning 
temperatures  of  104°  F.  (40°  C.)  or  over  are  indicative  of  a  serious 
type.  In  many  instances  of  mild  grade  the  evening  temperature  at  no 
time  exceeds  103°  (39.4°  C),  but  oscillates  between  100|°  and  102|° 
F.  (38.1°— 39.2°  C).  In  cases  of  average  intensity  the  morning  remis- 
sions touch  102°-102f°  F.  (39.2°  C),  and  the  evening  exacerbations 
reach  104-1 04f°  F.  (40.3°  C).  When  the  temperature  rises  above  105° 
F.  (40.5°  C.)  hyperpyrexia  exists.  Ampugnani  made  studies  of  hourly 
charts  from  200  cases  of  typhoid  fever,  and  found  the  maximum  tem- 
perature to  occur  between  three  and  six  o'clock  in  the  afternoon,  and 
the  minimum  between  four  and  eight  o'clock  in  the  morning.  The 
duration  of  the  fastigium  exhibits  a  wide  range  and  is  dependent  upon 
a  variety  of  conditions — e.  g.  the  degree  of  mildness  or  severity  of  the 
type,  the  presence  or  absence  of  complications,  etc.  In  cases  of  a  mild 
character  it  lasts  from  a  few  days  to  one  week ;  in  cases  of  average  severity, 
from  ten  days  to  two  weeks;  in  the  severest  forms,  from  two  to  four  weeks. 

In  typical  cases  the  end  of  the  fastigium  marks  the  beginning  of  the 
last  stage  (that  of  defervescence),  and  during  this  period  the  tempera- 
ture falls  by  lysis.  Measured  by  days,  it  declines  by  degrees,  both 
the  morning  and  evening  temperatures  being  often  one  or  two  degrees 
lower  than  on  the  preceding  day.  Thus  is  formed  a  more  or  less  regu- 
lar step-like  line  of  descent.  To  this  general  rule  there  are  two  nota- 
ble exceptions :  From  the  beginning  of  the  period  of  defervescence  the 
morning  remissions  may  strike  the  normal  point,  while  the  evening  ex- 


^  "A  Case  of  Typhoid  Fever;  numerous  Intestinal  Hemorrhages,  the  Amount  of 
od  Lof 
Recovery, 


Blood  Lost  being  Seventy-eight  and  one-half  Ounces  ;  and  Obstinate  Vomiting,  with 
r,"  International  Clinics,  vol.  i.  5th  series,  April,  1895,  p.  29. 


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TYPHOID  FEVER.  31 

acerbations  become  less  and  less  marked,  until  they  also  touch  the 
normal.  Under  these  circumstances  the  temperature-curve  resembles 
somewhat  that  of  the  quotidian  intermittents,  and  rarely  the  tertian 
fever-curve  obtains.  In  comparatively  rare  instances  the  morning  tem- 
perature shows  a  deeper  remission  on  each  successive  day,  while  the 
evening  temperature  remains  high  for  several  days,  when  it  also  declines. 
This  period  lasts  from  one  week  to  ten  days — a  longer  time  than  the 
initial  stage  with  its  ascending  type  of  fever. 

In  the  severe  and  protracted  forms  of  typhoid  fever  there  occurs 
between  the  second  stage  (fastigium)  and  the  tliird  stage  (defervescence) 
another,  to  which  Wunderlich  has  given  the  name  of  the  "  ambiguous 
period."  This  lasts  from  a  few  days  to  a  week  or  more,  and  is  charac- 
terized by  a  striking  diurnal  range  of  temperature,  with  marked  irreg- 
ularities. It  is  probable  that  it  is  sometimes  produced  by  an  auto- 
intoxication. 

Abnormal  Course  of  the  Fever. — The  pyrexial  peculiarities  yet  to 
be  pointed  out  are  less  usual  than  the  foregoing,  although  of  sufficient 
frequency  of  occurrence  to  demand  a  brief  description. 

The  first  stage  varies  but  little  from  the  regular  course  described 
above.  A  sudden  elevation  of  temperature,  however,  is  seen  in  those 
cases  that  begin  with  a  severe  rigor,  accompanied  by  pneumonic,  catar- 
rhal, and  gastro-intestinal  symptoms.  Pepper  and  Stengel  have  reported 
seven  cases  with  acute  onset,  and  Moore,  of  Dublin,  states  that  the 
whole  course  (since  1889)  has  become  more  typhus-like  than  formerly. 

In  the  lightest  forms  the  fastigium  may  be  practically  absent, 
defervescence  setting  in  upon  the  first  day  of  the  fastigium.  There  is 
also  a  class  of  cases  in  which,  throughout  the  greater  part  of  their 
course,  the  fever  is  distinctly  intermittent  or  remittent,  and  in  which 
careful  blood-examination  fails  to  disclose  the  plasmodium  malarice.  The 
same  form  of  temperature-curve  is  seen  in  those  rare  instances  of  typhoid 
fever  which  occur  in  subjects  previously  infected  with  malaria.  These 
two  classes  of  cases  run  a  favorable  course  as  a  rule. 

Sudden  deep  temporary  drops  in  the  temperature  may  occur  during 
the  fastigium.  (1)  This  may  take  place  during  the  early  part  of  the 
fastigium  without  obvious  cause.  (2)  Intestinal  hemorrhage  almost 
invariably  produces  a  sudden,  and  sometimes  a  great,  fall  of  tempera- 
ture. Osier  has  reported  a  case  in  which  a  drop  of  10°  F.  (5.5°  C.) 
followed  melena.  The  blood  does  not  appear  in  the  evacuations  of  the 
patient  for  six  to  twelve  hours  or  more  after  the  temperature  has  begun 
to  fall ;  and  hence  a  critical  decline  of  temperature  during  the  latter 
part  of  the  second  and  the  third  week  of  the  disease  suggests  that  hemor- 
rhage has  probably  taken  place.  (3)  The  occurrence  of  jjeritonitis  is 
marked  by  a  sudden  and  considerable  fall  of  temperature.  (4)  In  the 
female,  abortion  or  premature  delivery  occurring  in  the  course  of 
typhoid  fever  produces  a  decided  lowering  of  the  temperature.  (5) 
Collapse  of  the  circulation  sometimes  occurs  Avith  a  notable  remission 
of  temperature — an  ominous  association  of  events,  and  one  which  I 
observed  in  two  cases  occurring  in  females  in  the  Medico-Chirurgical 
Hospital.  In  one  of  these  cases  two  such  periods  of  collapse  occurred, 
and  in  the  other  three,  though  both  finally  recovered  under  prompt  and 
continuous  stimulation     Occasionally  hyperpyrexia  is  observed  in  typhoid 


32  INFECTIOUS  DISEASES. 

fever,  and  most  freiiuently  just  before  dissolution,  when  the  thermometer 
may  register  108°  or  even  i09°  F.  (42.7°  C).  A  fresh  rise  with  marked 
irregidarity  of  temperature  may  occur  during  the  latter  part  of  the  fas- 
tigiuni  or  the  period  of  decline,  and  is  often  dependent  upon  some  local 
complication  (late  pneumonia,  parotitis,  etc.). 

The  stage  of  defervescence  is  sometimes  much  prolonged,  though 
most  frequently  there  is  simply  a  slight  evening  elevation  (99°  to  100°  F. — 
37.7°  C),  the  morning  temperature  being  normal.  The  causes  of  retarded 
decline  are,  for  the  most  part,  obscure.  I  believe  that  many  of  them  are 
ascribable  to  a  mild  grade  of  auto-intoxication,  and  in  my  hands  a  mild 
saline  laxative  has  been  the  means  of  cutting  them  short  in  a  number 
of  instances.  An  examination  should,  however,  be  made  for  some 
localized  intlammatory  complication,  though  this  is  not  always  dis- 
cernible, as  in  the  case  of  suppuration  in  the  mesenteric  glands.  Sluor- 
gish  typhoid  ulcers,  which  refuse  to  heal  promptly,  may  act  as  a  cause 
of  the  slow  decline  ;  they  are  often  due  to  the  post-typhoid  anemia  and 
exhaustion. 

Post-typhoid  Elevations  of  Teynperature. — After  both  the  evening 
and  morning  temperatures  have  become  normal,  fresh  temporary  eleva- 
tions (102°  or  103°  F.— 38.8°  or  39.4°  C.)  frequently  appear.  They 
are,  as  a  rule,  unassociated  with  any  other  symptoms,  and  at  the  end 
of  a  few  days  the  temperature  falls  rapidly  to  the  normal.  These  are 
termed  recrudescences,  and  are  to  be  distinguished  from  true  typhoid 
relapses.  They  are  probably  produced  in  various  ways — by  errors  in 
diet,  constipation,  mental  emotion,  excitement.  ''There  are  cases  in  which 
the  presence  of  the  fever  seems  to  be  really  a  nervous  phenomenon  " 
(Osier).  It  is  most  common  in  children  and  in  persons  of  a  decidedly 
nervous  temperament.  Certain  local  secjuelae  may  cause  post-typhoid 
fever,  such  as  abscess  and  periostitis.  Rarely  during  convalescence  a 
sudden  and  marked  elevation  of  temperature,  accompanied  or  not  by 
rigor,  occurs,  but  it  is  usually  of  short  duration  and  seldom  is  of  serious 
import.  I  saw,  with  the  attending  physician,  Dr.  Modell,  a  case  in 
which  the  temperature  had  been  normal  for  six  days,  when  rigors,  fol- 
lowed by  steep  elevations  of  temperature,  occurred  several  times  and  at 
intervals  of  thirty-six  or  forty-eight  hours.  These  high  temperatures 
were  followed  by  a  rapid  decline  to  the  normal  and  by  sweating,  leaving 
the  patient  profoundly  exhausted.  Subsequently  the  convalescence  was 
slow,  but  uninterrupted. 

Afebrile  Typhoid. — As  the  term  indicates,  typhoid  fever  may  run 
a  course  attended  with  all  of  the  characteristic  symptoms  save  only  the 
fever.      Cases  of  this  kind  are  of  great  rarity. 

(h)  Skin. — The  eruption  is  highly  characteristic,  and  usually  decides 
the  diagnosis.  It  makes  its  appearance  on  or  about  the  eighth  day,  and 
sometimes  a  little  later.  Occasionally  it  does  not  appear  until  the  tenth 
or  twelfth  day  of  the  disease.  It  consists  of  distinct,  rose-colored,  and 
slightly  elevated  papules,  having  a  rounded  or  lenticular  form  and  a 
diameter  varying  from  one  or  two  to  three  lines.  The  papules  are 
almost  invariably  found  upon  the  trunk,  and  especially  upon  the  upper 
part  of  the  abdomen  and  the  lower  part  of  the  thorax,  to  which  regions 
they  may  be  wholly  confined.  They  may,  however,  be  absent  from  the 
usual  seats  and  present  elsewhere,  so  that  the  sides  of  the  trunk,  the 


TYPHOID  FEVER.  33 

back,  and  the  thighs  should  always  be  inspected.  They  disappear 
upon  pressure,  but  reappear  when  the  pressure  is  removed.  These 
rose-colored  spots  last  three  or  four  days,  and  appear  in  successive 
crops,  each  one  being  made  up,  usually,  of  a  few  spots — a  half-dozen  to 
a  dozen.  Rarely  the  eruption  is  abundant  on  the  trunk,  even  extend- 
ing to  the  extremities  and  head;  but  there  is  no  direct  correspondence 
between  the  extent  of  the  eruption  and  the  severity  of  the  cases.  Occa- 
sionally the  spots  are  entirely  absent — a  condition  most  frequently  met 
with  in  children,  and  less  often  in  elderly  persons. 

Other  eruptions  are  often  present,  and  their  negative  diagnostic 
value  must  be  kept  in  remembrance.  Minute  pearly  vesicles  (sudamina) 
may  appear.  They  are  limited  to  the  abdomen,  the  axilla,  and  to  the 
inner  surface  of  the  thighs  as  a  rule,  and  are  in  great  measure  due  to 
profuse  sweating. 

A  scarlet-colored  erythematous  eruption  sometimes  appears  at  a  com- 
paratively early  period  in  typhoid  fever.  Urticaria  and  purpura  are 
rarely  seen.  Out  of  250  cases  of  typhoid  fever  among  the  soldiers  in 
the  Spanish-American  war  treated  in  the  Medico-Chirurgical  Hospital 
two  manifested  purpuric  spots.  Extensive  ecchymoses  may  occur,  but 
are  rare,  and  merely  symptomatic  of  the  hemorrhagic  diathesis.  Cutane- 
ous hoils  and  abscesses  due  to  secondary  infection  with  the  pyogenic 
cocci  are  a  comparatively  frequent  and  late  development  in  the  course 
of  the  disease.  Peliomaia  typhosa  in  the  form  of  little  bluish  subcutic- 
ular spots  (the  "  t^ches  bleuatres  "  of  the  French  writers)  may  appear; 
but  they  are  not  related  specially  to  typhoid  fever,  and  in  a  recent  case 
of  my  own  were  undoubtedly  due  to  pediculi.  Giangrene,  chiefly  of  the 
lower  extremities,  has  been  noted  in  214  cases  (Keen),  and  is  due  to  the 
diffusion  of  the  bacilli  and  their  toxic  products,  to  an  obliterating 
endarteritis,   thrombosis,   or  embolism. 

Profuse  siveats  form  a  conspicuous  symptom  in  many  epidemics  of 
the  disease,  with  or  without  accompanying  fits  of  chilliness  or  rigors, 
and  constitute  the  sudoral  form  of  typhoid  fever  (Jaccoud).  Some  of 
these  cases  resemble  ordinary  intermittents.  Edema  of  the  skin  may 
be  observed  and  is  due  most  frequently  to  anemia  or  cachexia,  though 
sometimes  to  nephritis.  A  local  form  of  edema  affecting  the  leg  is  not 
uncommon,  and  for  this  form  thrombosis  of  the  femoral  vein  is  chiefly 
responsible.  A  peculiar  "  musty  "  odor  is  exhaled  from  the  skin  in 
some  instances  of  typhoid  fever.  The  patient  assumes  the  dorsal 
decubitus  and  is  exposed,  particularly  in  cases  of  prolonged  duration, 
to  the  danger  of  the  formation  of  bedsores.  They  are  most  prone  to 
occur  on  the  nates  and  the  heels,  and,  once  started,  they  are  apt  to 
spread  till  they  attain  to  large  dimensions,  with  extensive  undermining 
of  the  skin.  The  condition  is  now  serious.  During  and  after  the  con- 
clusion of  convalescence  the  hair  falls  out,  but,  fortunately,  it  is  invari- 
ably renewed.  The  nails  sometimes  become  roughened  and  brittle, 
while  transverse  pale  lines  or  ridges  can  usually  be  observed  in  them, 
marking  the  impairment  of  nutrition  during  the  disease  {vide  Relapse). 
Jaundice,  due  to  a  variety  of  causes,  is  a  rare  symptom,  and  generally  does 
not  come  on  until  the  middle  of,  or  until  late  in.  the  disease  (Da  Costa) 

(c)  Digestive  System. — The  symptoms  referable  to  the  gastro-iutes- 
tinal  canal,  though  not  very  striking  in  most  cases,  are  of  the  utmost 
3 


34  INFECTIOUS  DISEASES. 

importance  and  interest  because  of  their  direct  connection  with  the 
pathognomonic  lesions  of  typhoid.  Beginning  with  the  intestinal  canal, 
and  thence  proceeding  to  the  symptoms  presented  by  the  stomach,  spleen, 
liver,  throat,  and  mouth,  will  be  a  natural  and  convenient  order. 

At  the  onset  of  typhoid  fever  constipation  is  the  general  rule,  and 
this  may  persist  to  the  end  of  the  illness,  though  more  commonly  a 
moderate  diarrhea  appears.  Osier  ^  in  the  Johns  Hopkins  Hospital, 
however,  met  an  initial  diarrhea  in  322  out  of  829  cases.  During  the 
second  week  of  the  affection  the  stools  number,  on  the  average,  from 
two  to  four  or  more  daily.  It  is  only  in  comparatively  rare  instances 
that  ten  or  more  movements  per  diem  occur,  and  the  severity  of  the  diar- 
rhea depends  largely  upon  the  degree  of  catarrh,  particularly  of  the  large 
intestine.  When,  however,  the  ulcerative  process  is  chiefly  limited  to 
the  colon,  it  is  an  important  factor  in  the  production  of  the  diarrhea. 
Indeed,  in  those  instances — not  altogether  rare — in  which  there  is  urgent 
diarrhea  of  a  dysenteric  character,  the  ulcers  are  especially  marked  in 
the  colon,  with  diphtheritic  inflammation  of  the  surrounding  mucosa. 
Involuntary  discharge  of  the  feces  may  occur. 

The  stools  present  a  characteristic  yellow  appearance,  suggesting  by 
their  color  and  consistence  a  comparison  with  pea  soup.  They  are  usu- 
ally either  fluid  or  of  the  consistence  of  jelly,  and  are  offensive  and  of 
an  alkaline  reaction.  On  standing  they  separate  into  two  layers^r-an 
upper,  liquid,  cloudy  layer,  and  a  lower,  thick  yellow,  sedimentary  layer, 
in  which,  on  macroscopic  examination,  remnants  of  food  and  grayish 
yellow  fragments  (necrotic  crusts  of  Peyer's  plaques)  from  a  half  to  an 
inch  in  length  may  be  detected.  Microscopically,  they  have  been  found 
to  contain  undigested  particles  of  food,  epithelial  debris,  blood-corpus- 
cles, crystals  of  triple  phosphates  in  abundance,  and  innumerable  bac- 
teria. Laboratory  experimentalists  are  able  to  demonstrate  the  pres- 
ence of  the  typhoid  bacillus  in  the  dejecta.  Tympanites,  mainly 
affecting  the  colon,  is  a  common  though  rarely  a  striking  feature,  and 
cases  of  a  quite  serious  nature  are  observed  in  which  the  abdomen 
presents  a  concavity  throughout  the  entire  illness.  The  latter  is  less 
unfavorable,  by  far,  as  a  symptom  than  excessive  tympanites,  which 
interferes  with  both  the  respiration  and  heart  action.  Tympanites  is 
apt  to  be  most  marked  in  serious  cases  which  have  diarrhea  as  a  promi- 
nent symptom,  though  the  latter  may  not  even  be  present.  It  is  due  to 
the  generation  of  gas  from  decomposing  food,  and  to  the  arrest  of  peri- 
staltic movements  in  consequence  of  degeneration  of  the  muscularis 
of  the  intestines.  Pain  is  absent  in  the  majority  of  cases,  and  when 
present  is  not  intense,  save  in  rare  instances.  Pressure  upon  the  ileo- 
cecal region  usually  causes  a  gurgling  noise,  but,  although  this  symp- 
tom is  commonly  present,  it  is  not  characteristic  of  the  disease.  There 
is  generally  also  a  slight  degree  of  tenderness  of  the  abdomen  under 
pressure,  most  marked  in  the  right  iliac  fossa,  and  lience,  in  all  proba- 
bility, due  to  the  presence  of  ulcers  in  this  region.  Absence  of  tenderness, 
however,  is  not  a  safe  indication  of  the  absence  of  extensive  ulceration. 
Extreme  sensitiveness  generally  denotes  peritonitis  (often  without  per- 
foration), although  the  symptom  may  be  marked  in  constipation. 

Intestinal  hemorrliage  occurs  in  from  4  to  7  per  cent,  of  cases,  its 
1  Philada.  Med.  Jcnini.,  October  15.  1900. 


TYPHOID  FEVER.  35 

frequency  varying  with  different  epidemics.  The  hemorrfiages  appear 
almost  invariably  during  the  latter  part  of  the  second  and  third  week, 
being  caused  by  the  opening  of  blood-vessels  during  the  necrotic  or 
ulcerative  process.  The  amount  may  be  small,  or  it  may  be  from  1 
to  2  or  3  pints  (0.5-1.5  liters),  or  even  more.  In  one  of  my  own 
cases  the  total  amount  of  blood  discharged  from  the  bowel  was  nearly  5 
pints  (2.5  liters),  and  yet  the  patient  recovered.  The  blood  presents  a 
dark  hue,  and  that  which  is  passed  last  may  be  tarry.  Roman  has  exam- 
ined the  feces  in  50  cases  of  typhoid  fever  with  a  view  to  the  detection 
of  occult  bleeding.  Blood  was  found  in  14  cases,  and  of  these,  7  were 
severe,  3  moderately  severe,  and  4  slight. 

The  significance  of  intestinal  hemorrhage  is  always  grave.  On  the 
other  hand,  recovery  is  possible  even  if  the  hemorrhage  be  copious 
and  oft-repeated;  and  in  general  terms .'t  may  be  said  that  death  super- 
venes in  from  30  to  40  per  cent,  of  all  cases.  R.  G.  Curtin  has 
recorded  60  cases,  of  which  46.6  per  cent,  died;  he  argues  that  cold 
applications  to  the  skin  and  the  necessary  disturbance  in  giving  a  cold 
bath  tend  to  produce  melena.  It  occurred  in  more  than  the  usual  pro- 
portion of  cases  under  my  care  during  the  Spanish- American  ^ar, 
probably  owing  to  the  fact  that  the  men  were  conveyed  from  the  various 
distant  camps  to  the  hospital.  A  fatal  result  may  occur  as  the  direct 
effect  of  a  profuse  hemorrhage.  When  death  does  not  follow  immediately, 
the  signs  of  collapse  and  of  anemia  appear ;  yet  intestinal  hemorrhage 
sometimes  exerts  a  favorable  influence,  stupor  and  delirium  quickly 
giving  place  to  consciousness.  When  typhoid  fever  occurs  in  the 
hemorrhagic  diathesis,  hemorrhage  occurs  from  various  outlets. 

Perforation,  which  almost  invariably  produces  fatal  diffuse  peritonitis, 
is  the  accident  most  to  be  dreaded.  It  does  not  bear  a  fixed  relation 
to  the  severity  of  the  affection.  According  to  Fitz,  who  tabulated 
4680  cases  of  typhoid  fever,  there  is  a  mortality  of  6.58  per  cent,  from 
perforation  of  the  bowel.  Scott's  statistics,  embracing  9713  cases  from 
English,  Canadian,  and  American  hospitals,  give  a  mortality  of  3.6  per 
cent,  from  perforation.  It  is  much  more  common  in  males  than  in 
females,  and  appears  in  a  ratio  of  about  71  to  29.  Age  has  a  decided 
influence,  the  complication  occurring  oftenest  between  ten  and  forty 
years  of  age,  while  in  children  it  is  rare.  It  may  occur  at  any  time 
in  the  course  of  typhoid  fever,  but  it  is  most  common  between  the 
second  and  fourth  weeks  of  the  disease.  In  the  cases  analyzed  by 
Fitz  perforation  was  found  in  the  ileum  in  81.4  per  cent.,  in  the 
large  intestine  in  12.9  per  cent.,  in  the  vermiform  appendix  in  2.5 
per  cent.,  and  in  the  jejunum  in  1.29  per  cent.  The  accession  of  hyper- 
tension of  the  pulse  is  indicative  of  approaching  perforation.  The  acci- 
dent is  usually  announced  by  the  sudden  advent  of  acute  pain  in  the 
abdomen,  quickly  followed  by  the  symptoms  of  collapse;  and  the  fact 
that  diffuse  peritonitis,  following  perforation,  may  develop  insidiously 
must  be  recollected.  The  abdominal  muscles  become  rigid,  sensitive  to 
touch,  and  later  tympanites  develops.  Fluctuation  can  sometimes  be 
elicited.  On  percussion  splenic  and  hepatic  dulness  is  often  absent,  but 
hepatic  dulness  is  also  wanting  when  the  distended  intestines  lie  in  front 
of  the  liver.  Shifting  dulness  in  the  right  flank  may  be  an  early  sign. 
The  collapse  of  the  circulatory  system  is  evidenced  by  the  pinched  features, 


36  INFECTIOUS  DISEASES. 

hollow  cheeks,  vomiting,  and  the  small,  frequent  pulse.  A  rising  leuko- 
cytosis is  a  valuable  diagnostic  symptom.  Crile  found  a  rise  in  the  blood- 
pressure  in  cases.  Wilson  has  emphasized  the  importance  of  an  early 
diagnosis  and  of  immediate  resort  to  operative  intervention. 

The  instances  that  develop  independently  of  actual  perforation  usually 
assume  the  local,  or  circumscribed  form  of  peritonitis  ;  they  are  occasioned 
in  various  ways — e.  g.^  by  direct  extension  of  the  inflammatory  process 
from  the  intestinal  ulcers,  primary  localization  of  the  virus  in  the  peri- 
toneum, and  rupture  of  the  mesenteric  glands.  The  condition  presents 
corresponding  areas  of  tenderness  under  gentle,  and  especially  under  pro- 
longed, pressure,  but  it  is  difiicult  to  diagnose  intra-intestinal  states. 
Generalized  peritonitis  may  succeed  the  circumscribed  variety.  A. 
McPhedran*  calls  attention  to  a  serous  peritoneal  effusion  (ascites)  and 
to  the  physical  signs  of  exudate  in  the  peritoneal  cavity. 

The  mesenteric  lymph-glands  may  soften  or  suppurate  {vide  Pathol- 
ogy), and,  as  before  mentioned,  may  be  the  exciting  cause  of  a  recrudes- 
cence, or  they  may  rupture  and  cause  diffuse  peritonitis. 

The  Spleen. — With  few  exceptions  the  spleen  is  enlarged  in  ty- 
phoid fever,  the  edge  usually  being  palpable  below  the  margin  of  the 
ribs,  on  or  before  the  commencement  of  the  fastigium.  It  generally  goes 
on  increasing  in  size  till  near  the  beginning  of  the  third  week,  and 
lessens  during  the  latter  part  of  the  third  and  fourth  weeks.  Swelling  of 
the  spleen  is  sometimes  absent  after  a  copious  intestinal  hemorrhage  and 
in  elderly  typhoid  subjects.  When  the  tympanites  is  excessive,  we  can  in 
most  cases  satisfy  ourselves  of  its  existence  or  non-existence  by  cai'eful 
palpation.  Suppurative  infarcts  or  softening  of  the  spleen  may  start  a 
peritonitis.  Rarely  spontaneous  rupture  of  the  organ  may  occur,  which 
is  manifested  by  intense  pain  in  the  splenic  region.  Bryan  reports  a  case 
and  has  collected  24  others  from  the  literature. 

The  Liver. — A  slight  swelling  of  the  liver  can  sometimes  be  detected. 
Among  the  least  frequent  complications  is  jaundice  (vide  .supra) ;  it  may 
be  due  to  cholangitis,  to  abscess,  and  to  gall-stones.  Cholecystitis  caused 
by  the  typhoid  bacillus  (vide  Pathology)  may  arise  during  the  attack  or 
long  after  complete  recovery.  In  most  cases  the  lesions  are  catarrhal, 
but  they  may  be  suppurative,  in  which  event  perforation  followed  by 
peritonitis  may  occur.  Calculous  cholecystitis  is  frequently  caused  by 
the  typhoid  bacilli,  but  may  not  manifest  itself  for  a  variable  number  of 
years.  Suppurative  pylephlebitis,  secondary  to  perforative  appendicitis, 
may  be  a  complication.     Multiple  abscess  may  occur. 

The  Stomach. — The  stomach  presents  no  characteristic  symptoms.  Of 
the  anorexia  enough  has  been  said,  })Ut  during  convalescence  the  appe- 
tite returns,  becoming  even  voracious.  Nausea  and  vomiting  may  occur 
during  any  stage  of  the  disease,  but  are  most  common  at  the  beginning. 
When  they  appear  as  late  symptoms  they  are  probably  excited  either  by 
a  typhoid  ulcer  or  by  peritonitis.  Nausea  is  often  traceable  to  other 
causes — e.  g.,  to  errors  in  diet,  or  to  the  use  of  irritating  medicaments, 
but  vomiting  also  occurs  from  unknown  and  inevitable  causes.  It  may 
become  a  grave  symptom.  Hiccough  is  a  rare  but  serious  symi)tom. 
Hematemesis  has  been  observed,  although  practically  unknown. 

The  Pharynx. — Tlie  pharynx  frequently  shows   'catarrhal  irritation, 
1  Cleveland  Med.  Jour.,  June,  1911. 


TYPHOID  FEVER.  37 

and  the  patient  may  complain  of  dryness  or  a  burning  sensation  in  the 
throat.  Actual  sore  throat,  may  be  present  at  the  time  of  onset,  asso- 
ciated with  a  diffuse  erythematous  rash,  suggesting  scarlatina. 

The  To7isils. — There  is  a  special  form  of  typhoid — tonsUlo-typhoid 
or  pharyngo-fyphoid — in  which  there  appear  upon  the  tonsils  peculiar 
patchy  elevations,  whitish  in  color,  which  undergo  subsequent  ulcera- 
tion. It  is  not  improbable  that  these  lesions  result  from  the  local  action 
of  the  specific  bacillus  in  an  unusual  situation.  Thrush,  affecting  the 
mouth,  throat,  and  even  extending  to  the  esophagus,  not  infrequently 
arises  as  a  complication.  The  tongue  is  heavily  coated,  as  a  rule,  with 
a  yellowish-white  fur ;  later  it  clears  off  near  the  edges  and  tip,  while 
the  center  becomes  dry  or  brown  and  sometimes  fissured.  The  lips 
are  also  dry,  sometimes  fissured,  and  often  covered  with  dry,  black 
crusts  (sordes).  Ulcerative  stomatitis  may  occur  if  the  mouth  be  not 
kept  clean.  Under  these  circumstances  secondary  lesions  evincing 
unpleasant  and  even  serious  symptoms  may  also  arise  in  organs  more 
or  less  remote  from  the  mouth,  and  among  these  is  parotitis,  which  is 
most  probably  caused  by  the  staphylococcus  or  streptococcus  reaching 
the  parotid  gland  by  way  of  Steno's  duct.  The  condition  is  betrayed 
by  such  symptoms  as  pain,  redness,  and  finally  by  fluctuation,  with  an 
elevation  of  the  bodily  temperature.  It  is  a  late-appearing  develop- 
ment, and  is  usually  unilateral,  though  it  may  be  bilateral.  Suppura- 
tive otitis  media,  a  rarer  complication,  arises  in  a  similar  manner,  the 
pathogenetic  agents  reaching  the  ear  through  the  Eustachian  tube. 

{d)  Respiratory  System. — As  pointed  out  in  the  section  on  Pathology, 
bronchitis  is  almost  invariably  present,  but  in  the  majority  of  instances 
the  cough  is  slight.  The  condition  is  recognized  by  the  existence  of 
numerous  sibilant  r^les.  Very  rarely  is  it  a  striking  feature  in  the 
early  stage  of  typhoid  fever,  and  then,  except  this  fact  be  remembered, 
room  for  error  of  diagnosis  exists.  Moreover,  in  cases  that  are  im- 
properly treated  the  bronchial  secretions  are  apt  to  accumulate,  and  a 
well-marked  bronchitis  may  be  the  result.  It  may  be  said,  however, 
that,  as  a  rule,  bronchitis  does  not  assume  a  severe  type  in  cases  which 
receive  proper  attention  from  the  beginning,  provided  the  patient  be 
not  unusually  stupid  or  unconscious.  When  the  nervous  phenomena 
are  pronounced,  and  the  patient  maintains  the  dorsal  decubitus,  bron- 
chitis of  a  severe  grade  and  affecting  the  smaller  bronchi  is  almost  in- 
evitable. The  occurrence  of  an  intense  generalized  bronchitis  is  also 
favored  by  conditions  such  as  corpulence,  advanced  age,  and  emphysema. 
These  cases  are  apt  to  lead  to  lobular  infiltration — aspiration-pneumonia. 

Lobular  pneumonia  may  take  on  a  putrid  nature  and  the  consoli- 
dated area  may  become  gangrenous.  As  a  sequel,  pleurisy  with  efl"usion 
or  empyema  may  originate  in  consequence  of  the  infiltrated  lobules 
being  contiguous  to  the  pleura.  If  the  lobules  occupying  the 
periphery  of  the  lung  become  gangrenous,  perforation  of  the  pleura, 
leading  to  pyopneumothorax.,  may  result.  As  pointed  out  by  Gordinier 
and  Lartigau,^  in  the  majority  of  instances  of  typhoid  pleurisies  the 
aspirated  fluid  has  been  found  to  be  purulent  in  character.  Lobular 
pneumonia  may  be  attended  with  hurried  breathing  or  troublesome  cough. 
^  Am,Qr.  Journ.  Med.  Sci.,  January,  1901. 


38  INFECTIOUS  DISEASES. 

More  commonly,  the  local  symptoms  are  in  abeyance,  and  this  is  espe- 
cially true  of  the  severer  cases  which  are  attended  with  profound  nervous 
prostration  and  more  or  less  unconsciousness.  Sole  reliance  is  to  be 
placed  upon  the  results  of  a  physical  exammation,  which  should  be 
repeated  daily.  Points  or  surfaces  of  dulness,  near  the  bases  of  the 
lungs,  are  found  on  percussion.  Fine  moist  rales,  heard  in  every  direc- 
tion, and  especially  marked  toward  the  bottom  of  the  thorax,  form  a 
characteristic  sign.  A  certain  diagnosis  of  lobular  pneumonia  demands 
the  combined  presence  of  both  the  circumscribed  dulness  and  moist  rales. 

Lobar  pneumonia  is  a  not  uncommon  complication.  In  a  small  per- 
centage of  cases  it  develops  early,  and  is  most  probably  the  result  of  a 
special  concentration  of  the  poison  in  the  lungs,  giving  rise  to  the  so- 
called  pneumo-iyphoid  fever  {vide  infra.  Varieties).  These  cases  are 
often  mistaken  for  primary  lobar  pneumonia.  Their  onset  may  or  may 
not  be  marked  by  a  rigor,  but  it  is  usually  more  gradual  than  that  of 
primary  lobar  pneumonia.  At  the  end  of  the  first  week  or  thereabouts 
the  pulmonary  symptoms  gradually  abate,  while  those  characteristic  of 
typhoid  (enlarged  spleen,  roseate  spots,  etc.)  come  to  the  fore.  Wagner, 
Leichtenstein,  and  Aufrecht  entertain  grave  doubts  as  to  the  existence 
of  a  pneumo-typhoid.  I  have,  however,  had  under  my  care  a  case  in  the 
Medico- Chirurgical  Hospital  that  was  proven  by  the  Widal  reaction. 
Lobar  pneumonia  more  often  develops  as  a  late  complication — in  the 
second  or  third  week,  or  even  during  convalescence — but  it  is  not  at- 
tended by  the  usual  phenomena  (rigor,  cough,  rusty  expectoration,  intense 
chest-pain),  and  hence  may  be  easily  overlooked.  The  temperature  may 
be  either  quite  elevated  or  at  times  only  moderately  so.  Lobar  pneu- 
monia, the  complication,  is  principally  due  to  the  pneumococcus.  The 
diagnosis  is  to  be  made  from  the  physical  signs,  together  with  the  pecu- 
liar temperature-curve,  Avhich  may  present  marked  irregularities.  Pul- 
monary infarction  and  abscess  of  the  lungs  are  occasional  complications. 

Hypostatic  congestion  of  the  lungs,  due  to  enfeeblement  of  the  cardio- 
pulmonary circulation,  is  a  frequent  concomitant,  appearing  in  the  third 
week  of  the  disease.  It  is  generally  bilateral,  and  is  promoted  by  the 
effects  of  gravitation.  It  is  almost  always  associated  with  more  or  less 
edema  of  the  lungs.  The  subjective  symptoms,  including  fever,  are 
usually  negative,  Avhile  the  objective  signs  are  those  of  partial  or  com- 
plete consolidation  of  the  bases  (defective  resonance  or  dulness,  broncho- 
vesicular  breathing,  with  moist  rS:les).  Miliary  tuberculosis  rarely 
develops  as  either  a  complicating  affection  or,  it  may  be,  as  a  sequel.  Of 
249  autopsies  in  fatal  cases  of  typhoid  fever  only  four  showed  acute 
tuberculosis  to  have  been  associated.^ 

Laryngitis,  indicated  by  hoarseness,  is  an  occasional  complication. 
The  laryngeal  ulcers  may  extend  in  depth  to  the  perichondrium,  and 
promote  that  grave  condition,  perichondritis,  leading  to  necrosis  of  the 
cartilages  with  edema  of  the  glottis  and  stenosis.  A  third  form  of  laryn- 
geal complication  is  that  in  which  the  muscles  are  deprived  of  their 
function  because  of  paralysis  (Gibb). 

Epistaxis  appears  early  in  some  cases  and  is  a  valuable  diagnostic 
symptom.     It  may  also  occur  during  the  fastigium,  particularly  toward 

^  "  The  Eelation  of  Typhoid  Fever  to  Acute  Tuberculosis,"  Amer.  Jour.  Med.  Sciences^ 
May  4,  1904,  by  the  writer. 


TYPHOID  FEVER.  39 

its  close,  when  it  is  of  no  diagnostic,  but  of  grave  prognostic,  significance. 
In  a  case  I  saw  with  the  late  Dr.  Snively  it  led  to  a  fatal  issue. 

(e)  The  circulatory  system  presents  no  characteristic  symptoms.  The 
heart-sounds  are  but  little  affected,  as  a  rule.  In  cases  of  asthenic  type 
and  in  severe  typical  instances  the  first  sound  of  the  heart  may  grow 
quite  feeble  and  ultimately  resemble  the  second  (embryocardia).  Under 
these  circumstances  a  soft  systolic  murmur  may  be  faintly  heard  along 
the  left  border  of  the  sternum.  Among  occasional  complications  pre- 
sented by  the  heart  is  pericarditis,  and  still  less  frequent  is  endocarditis. 
Myocarditis  is  more  common.  The  sudden  development  of  circulatory 
collapse  in  the  course  of  typhoid  fever,  as  previously  noted,  may  be  due 
chiefly  to  myocardial  inflammation  ;  and  there  may  be  a  brief  though 
alarming  derangement  of  the  heart  action,  due  to  functional  disturbances. 

The  pulse  is  accelerated,  but  not,  as  a  general  rule,  in  proportion  to 
the  height  of  the  temperature  until  late  in  the  affection.  Its  average 
rate  is  from  84  to  108.  The  temperature,  moreover,  may  be  of  average 
height,  while  the  pulse  is  normal  or  only  slightly  quickened  throughout; 
and  hence  the  increase  in  the  pulse-rate  cannot  be  due  solely  to  the  ele- 
vation of  temperature.  As  before  intimated,  the  extreme  debility  which 
comes  on  during  the  third  week  in  severe  cases  may  have,  as  one  of  its 
manifestations,  a  very  rapid  pulse,  reaching  to  160  or  more  (the  so-called 
running  pulse),  and  with  or  without  marked  irregularity.  Slight  irreg- 
ularity is  sometimes  observed,  either  during  the  height  or  decline  of  the 
afiection,  but  as  a  rule  proves  of  no  serious  consequence.  Marked  tem- 
porary accelerations  are  often  caused  by  undue  exertion  or  mental  excite- 
ment. The  lowered  arterial  tension  is  shown  by  a  dicrotism  of  the  pulse — 
a  non-characteristic  symptom^  however,  since  it  is  well  marked  in  other 
acute  infectious  diseases,  although  less  commonly.  During  convales- 
cence the  pulse  often  becomes  abnormally  slow  (brachycardia).  Per 
contra,  less  commonly,  the  pulse-rate  is  increased  during  convalescence. 
I  have  found  the  systolic  arterial  pressure  during  the  fastigium  to  range 
from  110  to  125  mm.  Hg.  (Riva-Rocci  instrument);  it  declines  further 
late  in  the  disease.  The  fall  in  the  diastolic  pressure  is  proportional. 
During  convalescence  the  blood-pressure  again  rises,  reaching  the  normal 
in  from  two  to  four  weeks. 

Venous  thrombosis  occurs  in  1  per  cent,  of  all  cases  (Murchison). 
Its  most  frequent  seat  is  the  left  femoral,  and  the  next  most  frequent 
the  right  femoral  vein,  and  it  is  the  immediate  result  of  cardiac  weak- 
ness, except  perhaps  in  those  rare  instances  that  arise  early  in  typhoid. 
In  most  cases  there  is,  doubtless,  more  or  less  phlebitis,  and  the  bacilli 
have  been  found  in  the  thrombus.  The  condition  may  be  bilateral. 
Coming  on,  as  it  usually  does,  during  convalescence,  it  manifests  itself 
by  swelling  and  edema  of  the  extremity  affected.  There  are  pain  in  the 
thighs  and  calves,  and  tenderness  over  the  course  of  the  vein,  and  often 
over  the  calf  of  the  leg  as  well.  It  causes  Jever  of  a  moderate  grade  and 
irregular  type.  In  the  course  of  from  two  to  three  weeks  the  swollen 
member  may  be  reduced  to  its  normal  dimensions.  This  complication  is 
usually  not  serious,  but  occasionally  clotting  extends  into  the  pelvic  veins, 
and  into  the  vena  cava,  thence  even  into  the  right  auricle,  inducing  fatal 
syncope,  and  sudden  death  has  resulted  from  the  detachment  of  emboli. 


40 


INFECTIOUS  DISEASES. 


The  thrombus  may  undergo  suppuration,  leading  to  systemic  septic 
infection. 

Thrombosis  and  emboUsm  in  the  arteries,  with  renal,  splenic,  and  pul- 
monary infarcts,  may  be  encountered  in  typhoid  fever. 

The  large  or  small  arteries  may  become  obliterated,  either  by  em- 
bolism or  thrombosis,  in  extremely  rare  instances,  but  whether  the  throm- 
bosis under  these  circumstances  is  brought  about  by  a  peculiar  condition 
of  the  blood  which  favors  clotting,  or  by  a  localized  arteritis,  is  not 
definitely  known.  If,  as  is  usual,  the  femoral  artery  be  involved,  the 
blood-supply  to  the  foot  and  leg  is  cut  off  and  gangrene  of  those  parts 
must    follow.     The    condition    may    be    bilateral.      It  may  be    detected 


WEEKS           I            11          III         IV          V 

VI        VII      VIII       IX         X          WEEKS 

yooi 

'I  ' 

90^ 

J    ■^si:;:::::"  _                ::::      ' 

80< 

70% 

---    -      .   _.L^ 

^/_   __.<^___         ■        ■■- 

: — r  ::"_::  :;;;:;._;:;;? 

6Q% 

.-     -  -..J .... 

50% 

,.._«,.-.,           _     __  ___ 

2  000  000    -    "--  ±-  ;::::::::n:;:;;?::::::" 

40^ 

30^ 

20<(; 

lOOjt 
90% 
BQ% 
10% 
60% 
50% 
W% 
30% 


Fig.  4— Chart 


illustrating  the  hlood 
middle  curve,  hem 


changes 
oglobin ; 


n  typhoid 
jwer  curv 


fever :  upper 
e,  white  corpu; 


curve,  red  corpuscles; 
^cles. 


early,  owing  to  the  absence  of  a  femoral  pulse,  before  the  signs  of  gan- 
grene appear.      The  condition  is  highly  dangerous. 

The  blood  presents  certain  changes,  some  of  which  are  valuable  for 
diagnostic  purposes.  The  red  corpuscles  may  be  relatively  increased  in 
number  during  the  febrile  period,  owing  to  loss  of  water  {e.  g.,  profuse 
sweats,  diarrhea).  There  is,  in  most  instances,  little  or  no  decrease  in 
the  number  of  red  corpuscles  till  the  end  of  the  second  week.  They  are 
markedly  diminished,  as  a  rule,  during  convalescence,  the  oligocythemia 
bearing  a  close  relation  to  the  severity  of  the  disease. 

There  is  a  greater  relative  decrease  in  the  amount  of  hemoglobin 
than  in  the  number  of  red  corpuscles.  The  number  of  white  corpuscles 
remains  at  or  a  little  below  the  health  standard  until  late  convalescence, 
when  it  sinks  to  a  moderate  degree — furnishing  a  count  of  about  2000 
per  c.mm.  [leukopenia).  This  fact  is  an  important  aid  in  the  differentia- 
tion of  uncomplicated  typhoid  fever  from  leukocytotic  affections.     Leuko- 


TYPHOID  FEVER.  41 

cytosis,  however,  occurs  in  typhoid,  with  hemorrhage  and  perforation,  and 
especially  in  connection  with  "  large  ahscesses,  phlebitis,  peritonitis,  pneu- 
monia, pleurisy,  periostitis,  cystitis,  and  cliolecystitis  "  ('J'liayerj.  Tran- 
sient leukocytosis  occurs  after  cold  baths.  Naegeli  ^  found  an  early  neu- 
trophilic leukocytosis  of  moderate  degree  which  rapidly  decreases.  In  the 
second  stage  neutrophiles  and  lymphocytes  are  still  further  decreased, 
the  former  at  last  disappearing,  while  the  latter  begin  to  increase  again, 
and  so  continue  until  defervescence.  During  the  decline  of  the  fever  the 
neutrophiles  reach  their  minimum,  the  lymphocytes  are  greatly  increased, 
and  the  eosinophile  cells  gradually  return  to  their  normal  number.  After 
the  disappearance  of  the  fever  a  lymphocytosis  may  occur.  'We  blood- 
characters  in  typhoid  are  shown  in  the  accompanying  chart  (Fig.  4j. 

(/)  Nervous  System. — The  persistent  headache  that  is  almost  always 
present  is  among  the  most  prominent  symptoms  during  the  first  week, 
but  it  diminishes  steadily  during  the  early  part  of  the  second,  as  a  rule. 
It  affects  the  temporal,  occipital,  and  cervical  regions,  and  when  the 
onset  is  comparatively  sudden,  pain  in  the  back  is  also  a  more  or  less 
conspicuous  feature  during  the  first  few  days  of  the  illness.  In  a  small 
class  of  cases,  however,  the  effects  of  the  typhoid  bacilli  or  their  toxins 
are  manifested  solely  in  the  nervous  system  from  the  very  onset.  In 
such  there  are  violent  headaches,  retraction  of  the  head,  rigidity,  pho- 
tophobia, and  muscular  twitchings  (rarely  convulsions) — all  of  which 
symptoms  indicate  meningitis.  The  diagnosis  of  meningitis  as  a  com- 
plication must  be  made  with  extreme  caution,  since,  no  matter  how  com- 
plete the  clinical  picture  may  be,  the  post-mortem  examination  usu- 
ally reveals  a  total  absence  of  meningeal  inflammation.  It  must  be  recol- 
lected, however,  that  the  lesions  may  be  wholly  microscopic.  Vertigo 
may  accompany  the  headache,  but  it  seldom  outlasts  the  latter.  Before 
delirium  manifests  itself  wakefulness  and  restlessness  at  night  are  very 
annoying,  and  later  the  same  symptoms  may  be  observed  associated  with 
the  delirium.  In  cases  of  moderate  severity  mental  dulness,  and  even 
uctual  hebetude,  are  almost  invariably  present.  Questions  are  apt  to  be 
answered  inconsistently  and  in  monosyllables. 

Delirium  is  frequent  in  the  severer  cases.  It  is,  however,  not  an 
uncommon  event  for  those  of  moderate  severity  to  be  free  from  this 
symptom  throughout  the  attack.  It  is,  as  a  rule,  most  marked  at  night 
or  at  some  time  when  the  patient  is  left  alone.  His  delusions  may 
impel  him  to  attempt  to  leave  his  bed,  but  more  commonly  there  is 
mild  or  noisi/  delirium,  with  more  or  less  restlessness.  He  may  lie 
somnolent,  soliloquizing  in  a  loud  whisper  (muttering  delirium),  and 
this  so-called  typhomania  may  gradually  give  place  to  actual  coma  to- 
ward the  close  of  the  middle  period  of  the  disease.  In  not  a  few  cases 
— mild  or  severe — coma  is  developed  suddenly,  and  is  often  a  mortal 
symptom.  Still  another  unfavorable  sign  is  a  picking  at  the  bed-clothes 
or  a  grasping  at  imaginary  objects  (carphologia). 

The  delirium  may  assume  an  hysteric  type,  the  patient  usually  ex- 
hibiting the  saddest  emotions,  and  if  he  be  an  alcoholic  he  may  be 
seized  with  delirium  tremens.  In  a  case  of  typhoid  fever  that  I  saw 
with  Dr.  S.  W.  Morton  hysteric  delirium  developed  during  early  conva- 
lescence, but  did  not  last  more  than  twenty-four  or  thirty-six  hours. 
^  Deutsche  Archiv/iir  klin.  Med.,  Band  Ixvii.,  Hefte  3  n.  4. 


42  INFECTIOUS  DISEASES. 

The  motor  nerves  also  present  notable  disturbances  in  association 
with  the  sopor  and  the  forms  of  delirium  previously  described.  Slight 
twitchings  of  the  muscles  of  the  face  and  extremities  are  quite  common, 
and  when  they  affect  the  tendons  of  the  wrist  and  fingers  the  term  suh- 
sulhis  tendinmn  is  applied.  The  lips,  tongue  (especially  when  pro- 
truded), lower  jaw,  and  even  the  extremities,  are  often  in  a  state  of  con- 
stant tremor.  During  this  motor  irritability  the  reflexes  are  increased, 
but  when  profound  coma  comes  on  they  are  either  largely  diminished  or 
totally  abolished.  The  toxins  of  the  typhoid  bacillus,  acting  poisonously 
upon  the  nervous  centers,  are  undoubtedly  the  cause  of  the  nervous 
symptoms  in  typhoid. 

Nervous  complications  and  sequeJce  may  arise.  Chief  among  these 
is  paralysis,  which  is  most  probably  due  to  neuritis.  The  lesion  may 
involve  one,  two,  or  more  nerves,  and  in  this  way  we  may  have  either  a 
paralysis  of  one  limb  or,  more  rarely,  a  true  paraplegia.  Aphasia  may 
be  a  sequel,  particularly  in  children.  Hemiplegia.,  due  to  hemorrhage 
or  a  localized  encephalitis,  may  occur  either  as  a  complication  or 
sequence  of  the  disease.  Following  typhoid  fever,  the  patient  may  ex- 
hibit evidences  of  mental  enfeeblement,  and  even  insanity  where  a  pre- 
disposition to  this  condition  has  existed;  and  insanity  is  relatively  more 
common  after  this  disease  than  after  any  others  belonging  to  the  same 
class.  I  have  seen  four  instances,  all  of  which  recovered,  while  Osier  has 
seen  five,  four  of  which  ended  similarly.  It  is  in  most  cases,  as  pointed 
out  by  Wood,  a  confusional  insanity,  due  to  exhaustion  and  impairment 
of  the  nutrition  of  the  nerve-centers,  while  in  a  smaller  contingent  it 
takes  the  form  of  a  true  melancholia.  After  the  conclusion  of  typhoid, 
as  well  as  during  its  course,  neuralgia  afi"ecting  the  occipital  and  other 
cranial  nerves  is  not  infrequent.  Great  hyperesthesia  of  the  skin  and 
muscles  is  common  during  convalescence,  attacking  the  lower  extremities 
by  preference  (Striimpell).  The  so-called  "  typhoid  spine  "  (Gibney) 
has  also  been  observed,  and  consists  in  an  acute  inflammation  of  one  or 
more  vertebrae  following  typhoid.  The  chief  symptoms  are  pain  in  the 
back  and  hips  of  a  lancinating  character.  The  point  of  origin  appears 
to  be  the  small  of  the  back  ;  thence  the  pains  extend  paroxysmally  up 
and  along  the  spine  and  to  the  abdomen.  They  subside  gradually, 
leaving  the  back  weak  and  painful  on  attempts  at  turning  in  bed,  etc. 
Plantar  and  other  skin-reflexes  are  increased,  and  the  knee-jerks  are 
preserved.  G.  E.  de  Schweinitz  has  described  at  length  the  ocular 
complications  and  sequelce  of  typhoid  fever.  Affections  of  the  conjunc- 
tiva and  cornea  and  retinal  hemorrhage  are  perhaps  the  most  frequent, 
although  optic  neuritis  and  affections  of  the  uveal  tract  also  occur. 

(^)  The  Urinary  System. —  Urine. — The  urine  is  lessened  in  quantity 
and  high-colored,  with  an  increased  specific  gravity  up  to  the  arrival  of 
the  stage  of  decline.  About  this  time,  and  rarely  earlier,  it  grows 
light  in  color,  larger  in  quantity  than  the  normal,  and  the  specific 
gravity  is  relatively  diminished.  Both  urea  and  uric  acid  are  increased 
during  the  earlier  stages,  and  sometimes  throughout  the  attack,  while 
during  convalescence  both  are  diminished.  On  the  other  hand,  the 
chlorids  are  diminished  during  the  active  stages  of  the  disease  and  in- 
creased during  its  decline.  Afebrile  albuminuria  is  quite  common,  and 
the  sediment  may  show  an  excess  of  renal  epithelium,  a  few  blood-cells, 
.  and  occasionally  renal  casts. 


TYPHOID  FEVER.  43 

Acute  nephritis  may  develop  as  a  complication  in  the  earlier  or  later 
course  of  the  disease,  and  can  be  recognized  to  a  certainty  only  by  a 
thorough  appreciation  of  the  urinary  phenomena.  The  urine  is  dimin- 
ished in  quantity,  being  often  scanty,  and  there  may  be  retention.  It 
contains  characteristic  morphologic  elements  (albumin,  casts,  blood,  and 
epithelium).  The  development  of  the  typhoid  state  in  this  affection  is 
rendered  much  more  probable  in  the  presence  of  this  complication,  and, 
moreover,  uremic  symptoms  often  put  in  an  appearance  at  this  juncture, 
and  then  the  situation  is  really  serious.  Acute  nephritis  may  arise  at 
one  or  other  of  three  different  periods,  and  its  significance  varies  with 
the  time  of  onset :  {a)  at  the  beginning  of  the  fever,  when  it  often 
obscures  the  true  nature  of  the  malady.  This  is  the  nephro-typhoid  of 
the  German  authors,  and  will  be  referred  to  hereafter  {vide  infra,  Varie- 
ties) ;  (h)  in  the  early  part  of  the  fastigium  or  the  second  week  of  the 
disease.  Coming  on  at  this  time — an  event  which  I  have  observed  in  two 
instances — it  is  probably  to  be  ascribed  to  the  local  effect  of  the  toxin 
upon  the  renal  tissues.  Both  of  my  own  instances  proved  fatal,  and  in 
both  an  autopsy  was  refused.  Wagner^  has  had  5  cases  of  recovery  in 
succession,  but  the  high  mortality  mentioned  by  Amat — 10  deaths  in  12 
cases — is  the  more  common  experience,  (c)  Acute  nephritis  may  arise 
as  a  sequel  of  typhoid,  when  there  is  almost  invariably  associated  a  de- 
cided edema.     In  this  category  of  cases  recovery  is  to  be  expected. 

The  diazo-reaction  of  Ehrlich  is  a  valuable  aid  in  diagnosis,  but 
may  be  present  also  in  acute  phthisis,  meningitis,  measles,  pneumonia, 
yellow  fever,  and  other  fevers.  To  obtain  it  two  other  solutions  {a  and  h) 
are  needed :  We  mix  1  part  of  solution  (a),  which  consists  of  a  0.5  per 
cent,  solution  of  sodium  nitrite,  with  50  parts  of  solution  (6),  which  con- 
sists of  2  grams  of  sulfanilic  acid,  150  c.c.  of  hydrochloric  acid,  and 
1000  c.c.  of  distilled  water.  To  this  an  equal  volume  of  urine  is  added, 
and  the  contents  of  the  test-tube  are  then  thoroughly  shaken.  A  layer 
of  ammonium  hydrate  is  now  superimposed,  and  at  the  line  of  contact  a 
ruby  or  pink  ring  develops.  A  more  reliable  change,  however,  is  a  rose- 
red  (pink)  hue  of  the  foam.  Says  Cummins,  "  Upon  employing  a  dilution 
of  1  :  150  other  conditions  are  eliminated  (except  a  small  percentage  of 
tuberculous  cases)."  It  is  present  in  about  70  per  cent,  of  the  cases. 
The  reaction  begins  about  the  beginning  of  the  second  week,  sometimes 
later,  and  lasts  usually  until  defervescence  is  well  advanced.  A  brownish 
ring  is  given  by  normal  urine. 

Diabetes  mellitus  is,  in  extremely  rare  instances,  developed  after 
typhoid.  Hematuria  has  also  been  observed  as  a  symptom  of  the  hem- 
orrhagic diathesis. 

There  is  a  post-typhoid,  diphtheritic  pyelitis  in  which  the  pelves 
and  calices  of  the  kidneys  are  the  seat  of  membranous  exudation,  and 
later  of  erosion  and  ulceration.  The  urine  generally  contains  blood 
and  pus. 

Simple  vesical  catarrh  may  rarely  result  from  catheterization  for  re- 
tention. Typhoid  cystitis,  in  which  the  bacilli  are  found  in  pure  culture 
in  the  urine,  is  not  rare  [vide  p.  53).  It  occurs  principally  in  patients 
who  are  predisposed  by  local  conditions. 

Orchitis,  epididymitis,  spermatocystitis,  prostatitis,  and  ovaritis  are 
^  Deutsch.  Archivfiir  klin.  Med.,  Bd.  xxv.  and  xxxvii. 


44  INFECTIOUS  DISEASES. 

occasional  sequels.  Blumenfeld  collected  69  cases  of  orchitis ;  it  gen- 
erally develops  suddenly  during  convalescence. 

(It)  The  Joints. — Typhoid,  septic  and  rheumatic  arthritis  may  occa- 
sionally arise  as  a  complication.  The  first  is  usually  mon-articular  (par- 
ticularly in  the  hip) ;  the  last  two  comvaowXy  polyarticular.  Keen  has 
collected  "in  all  84  cases  involving  the  joints." 

(<)  The  Bones. — Periostitis,  due  to  injury  and  muscular  strain  and 
often  leading  to  necrosis,  is  a  not  rare  sequel  of  typhoid.  The  favorite 
seats  are  the  tibia  and  ribs,  though  in  a  case  of  my  own  at  the  Philadel- 
phia Hospital  it  affected  the  os  calcis.  Ebermaier  found  the  bacillus 
typhosus  in  the  pus  from  2  cases  of  suppurative  post-typhoid  periosti- 
tis, although  other  bacilli  (streptococci,  staphylococci,  pneumococci)  are 
at  times  associated.  Osteomyelitis  may  also  occur.  Keen  has  collected 
.  216  cases  in  which  the  bones  were  attacked. 

(y)  The  Muscles. — As  in  the  case  of  the  heart,  so  the  voluntary 
muscles  exhibit  hyaline  degeneration ;  also  abscesses,  in  consequence  of 
secondary  infection  or  of  infection  with  the  typhoid  bacillus  itself. 
Typhoid  abscesses  likewise  result  from  perforations  of  the  gut. 

Associated  Acute  Infectious  Diseases. — Malarial  fever  may  be  com- 
bined with  typhoid,  though  the  relationship  is  not  a  vital  one.  In  an 
analysis  of  2122  cases  of  malaria  typhoid  fever  was  associated  in  8.^ 
Many  instances  of  so-called  typhoid-malarial  fever,  however,  would  be 
shown  to  be  pure  typhoid  by  a  careful  blood-examination. 

Pseudo-membranous  inflammation,  as  above  intimated,  may  occur  in 
the  naso-pharynx,  larynx,  gall-bladder,  and  genitals.  Measles,  scarla- 
tina, and  chielken-pox  have  also  been  known  to  arise  in  the  course  of,  or 
during  convalescence  from,  typhoid  fever. 

Erysipelas  is  a  rare  secondary  affection  coming  on  either  during  the 
height  of  the  affection  or  (more  frequently)  after  its  close.  Typhus  fever 
may  be  associated  with  typhoid,  but  this  is  rare. 

Clinical  Varieties  of  Typhoid  Fever. — These  are  numerous,  and  may 
grow  out  of  peculiarities  manifested  during  the  course  of  the  affec- 
tion, as  may  be  observed  not  only  in  different  epidemics,  but  also  in  the 
same  epidemic.  The  groups  of  cases  described  here  have  reference  par- 
ticularly to  the  degree  of  severity  of  the  type,  which  varies  between 
the  wide  limits  of  extreme  mildness  on  the  one  hand  and  extreme  severity 
on  the  other.  The  course  of  the  disease  may  also  be  modified  by  the 
occurrence  of  one  or  more  of  its  manifold  complications. 

(1)  The  Mnd  or  Rudimentary  Form  (Typhus  Laevissimus). — Of  this 
variety  many  cases  occur,  and  especially  among  children.  The  spleen 
is  almost  always  enlarged,  the  roseate  spots  are  sometimes  present,  while 
the  temperature  is  moderately  elevated  and  often  partakes  of  the  same 
character  as  that  of  true  typhoid.  The  fever,  however,  may  pursue  the 
remittent  type.  Complications  presented  by  special  organs  are  usually 
absent,  but  grave  accidents  (intestinal  hemorrhage,  perforation)  are  not 
impossible. 

The  diagnosis  is  always  difficult,  owing  to  the  feeble  development 
of  the  characteristic  symptoms,  and  in  the  total  absence  of  the  latter  is 
out  of  the  question ;  but  the  recognition  is  assured  if  a  casual  connec- 

^  "The  Complications  of  Malaria,"  Journal  of  the  American  Medical  Association,  vol. 
xxiv.,  p.  919,  by  the  author. 


TYPHOID  FEVER.  45 

tion  between  them  and  typicnl   cases  can  be  shown  to  exist,  and  if  the 
Widal  test  gives  a  positive  result. 

(2)  The  abortive  form  has  a  sudden  onset,  and  is  often  marked  by 
fits  of  shivering.  The  characteristic  features  of  the  disease  (enlarge- 
ment of  the  spleen,  abdominal  symptoms,  rose  spots,  etc.)  appear  earlier 
than  in  the  usual  type,  and  soon  become  quite  well  marked.  The  fas- 
tigium  is  short,  and  the  temperature,  from  the  seventh  to  the  twelfth 
day  of  the  illness,  declines  by  a  prompt  lysis,  with  profuse  sweating. 
With  the  rather  rapid  fall  of  temperature  there  is  a  no  less  rapid  im- 
provement in  every  other  leading  symptom.      Convalescence  is  speedy. 

(3)  The  Ambulatory  Form  (Latent  or  Walking  Typhoid). — The  pa- 
tient continues  to  walk  about,  either  experiencing  but  slight  disturbance 
or  being  unwilling  to  take  to  his  bed.  Such  cases  do  not  come  under 
the  care  of  the  physician  in  many  instances.  Others,  on  account  of 
debility,  anorexia,  diarrhea,  and  other  vague  symptoms,  finally  consult 
their  physician,  who  may  discover  the  presence  of  all  the  characteristic 
features  of  the  disease.  A  third  contingent,  belonging  to  this  form, 
continue  to  move  about,  or  even  to  follow  their  usual  vocations,  till 
seized  suddenly  with  profuse  intestinal  hemorrhage  or  general  diffuse 
peritonitis  following  perforation. 

(4)  The  afebrile  is  an  exceedingly  rare  form  of  the  affection — in  this 
country  at  least.  Liebermeister,  however,  has  met  with  a  number  of 
cases  at  Basle,  the  symptoms  being  lassitude,  depression,  headache, 
neuro-muscular  pains,  anorexia,  slow  pulse,  furred  tongue,  constipa- 
tion or  diarrhea,  with  enlargement  of  the  spleen  and  roseate  spots. 
These  cases  are  often  confined  to  bed,  and  there  are  occasional  attempts 
at  evening  exacerbations  of  temperature  (100.5°  F. — 38°   C). 

(5)  Severe  or  Grave  Forms. — These  may  be  dependent  either  wholly 
or  in  great  part  upon  the  degree  of  virulence  of  the  typhoid  poison. 
A  profound  intoxication  of  the  system,  as  shown  by  high  temperature, 
violent  nervous  symptoms,  and  great  prostration,  is  noted.  The  grave 
types  may  arise  in  the  course  of  cases  of  average  severity  from  the  de- 
velopment of  serious  complications.  Again,  to  serious  forms  belong  those 
cases  that  begin  with  the  characteristic  symptoms  of  a  localized  inflam- 
mation— e.g.  the  cerehro-spinal  form.,  in  which  the  nervous  symptoms 
greatly  predominate  at  the  onset;  the  nephro-typlioid  (before  alluded  to). 
in  which  the  preliminary  symptoms  are  those  of  acute  Bright's  disease ; 
the  pnewno -typhoid  [vide  supra).,  which  begins  with  the  manifestations 
of  a  more  or  less  frank  pneumonia. 

Pleuro-typhoid. — The  cases  begin  as  an  acute  pleurisy,  and  are  fol- 
lowed, soon  or  late,  by  the  diagnostic  evidences  of  typhoid  fever.  Tala- 
mon  ^  distinguishes  these  cases  from  simple  pleurisy  by  the  intensity  and 
continuous  course  of  the  fever,  by  the  general  depression,  headache,  and 
vertigo,  and  by  the  sleeplessness.  Eiselt^  has  described  a  special  form 
under  the  name  spleno-typhoid,  in  which  the  spleen  is  enormously  en- 
larged without  characteristic  intestinal  lesions.  Perisplenitis  with  adhe- 
sions may  be  noted.  The  sudoral  form  and  tonsiUo-fyphoid  (before  de- 
scribed) also  belong  to  this  category.  The  fever  is  often  of  remittent 
type. 

^  Iji  Medecine  moderne,  Paris,  1891. 

^  La  Semaine  mediccde,  August  27,  1891. 


46  INFECTIOUS  DISEASES. 

Typhoid  septicemia  may  present  the  grave  symptoms  of  an  extreme 
intoxication,  often  merging  into  the  typhoid  state.  Visceral  and  cuta- 
neous hemorrhages  may  be  superadded.  Cases  of  hemorrhagic  typhoid 
fever  have  been  reported  by  A.  A.  Eshncr  and  T.  H.  Weiseuberg*  and 
others.  They  are  probably  due  ''  to  a  condition  of  systemic  intoxication 
and  septicemia  "  (Nicholls  and  Learmouth).  Many  circumstances  con- 
nected with  the  individual  influence  decidedly  the  general  course  of  the 
affection,  and  these  are  based  upon  such  factors  as  age,  habits,  etc. 

(6)  Tyrlioid  Fever  in  Children. — The  onset  is  rather  more  abrupt 
than  in  the  adult,  and  certain  prodromal  symptoms  are  rarely  present 
(epistaxis,  chilliness).  On  the  other  hand,  bronchial  and  nervous  symp- 
toms are  often  quite  pronounced.  Again,  during  the  fastigium  some  of 
the  usual  typhoid  features  may  be  missing — e.  g.  diarrhea  and  tympan- 
ites— while  the  eruption  may  either  be  slight  or  absent.  The  dispropor- 
tion between  pulse-ratio  and  temperature  is  less  marked  than  in  adults  (But- 
ler).     Intestinal  hemorrhage  is  rare  and  perforation  almost  never  occurs. 

(7)  Typhoid  Fever  in  the  Aged. — The  course  of  the  aifection  presents 
no  regular  type.  The  temperature  is  not  as  high  as  usual,  but  there  is 
marked  adynamia  and  serious  danger  from  certain  complications,  such 
as  pneumonia,  nephritis,  coma,  cardiac  exhaustion,  and  the  like. 

The  diagnosis  is  difficult,  owing  to  the  prominence  of  the  nervous 
and  pulmonary  symptoms  on  the  one  hand,  and  the  frequent  absence  of 
the  more  characteristic  symptoms  of  typhoid  on  the  other. 

Diagnosis. — Unless  all  the  chief  characteristic  features  be  pres- 
ent with  a  clear  history,  it  is  a  golden  rule  not  to  make  a  positive  diag- 
nosis. Obviously,  then,  the  physician  at  the  first  visit,  often  about  the 
close  of  the  first  week,  cannot,  in  many  cases,  diagnosticate  typhoid  with 
absolute  certainty.  If  the  case  have  been  a  typical  one,  the  history  of  the 
gradual  development  of  the  disease,  marked  by  such  symptoms  as  languor, 
anorexia,  headache,  dulness,  slight  chills,  increasing  fever,  and  sometimes 
nose-bleed,  will  be  obtained,  and  justify  a  strong  suspicion  of  typhoid. 
When,  in  addition,  diarrhea  and  the  objective  symptoms,  splenic  enlarge- 
ment, dry  bronchitis,  tympanites,  gurgling,  with  tenderness  in  the 
ileo-cecal  region,  are  present,  the  diagnosis  of  typhoid  is  made  highly 
probable.  After  the  lapse  of  a  few  days — the  beginning  of  the  second 
week — the  roseate  spots  usually  appear.  The  most  certain  method  of 
making  an  early,  positive  diagnosis  is  by  an  examination  of  the  blood 
for  the  bacillus  typhosus.  Mabee  and  Taft^  have  described  the  method 
of  making  blood-cultures  from  the  ear,  and  found  that  in  early  cases  of 
typhoid  (/.  e.,  within  the  first  week)  an  accurate  diagnosis  in  from  90  to 
100  per  cent,  is  easily  possible.  Says  Peabody,^  while  blood-culture  in 
ox  bile  is  the  earliest  indication,  at  a  later  stage,  when  the  organism  can 
no  longer  be  isolated  from  the  blood,  the  agglutination  reaction  {vide 
infra)  is  usually  present.  In  obscure  cases  the  occurrence  of  intestinal 
hemorrhage  or  a  characteristic  decline  by  lysis  is  helpful.  To  show  a 
casual  relation  between  an  obscure  case  and  one  that  is  clearly  typhoid 
leaves  little  to  be  desired.  The  diagnosis  should  include  the  particular 
stage  of  the  disease.  Briefly,  the  most  trustworthy  diagnostic  features 
are  the  gradual  onset,  peculiar  temperature-curve  (made  up  of  the  "  step- 

^  Amer.  Jour.  Med.  Sci.,  March,  1901. 

'  Boston  Med.  and  Surg.  Jour.,  June  1,  1908. 


TYPHOID  FEVER.  47 

ladder"  stage  of  development,  the  continued  type  of  the  fa.stigiurn,  and 
the  decline  by  lysis),  enlarged  spleen,  the  rose-colored  spots,  cultural 
experiments,  and  the  sero-reaction. 

tSerwrn-diagnosis. — The  results  of  the  investigations  of  Pfoiffer  and, 
later,  those  of  Grliber  and  Widal  have  given  us  a  specific  sero-reaction. 

Johnston  recommends  the  following  technic  :  The  blood  is  obtained 
upon  a  clean  glass  slide  from  a  needle-prick  of  the  ear  or  finger 
of  the  suspected  case.  It  is  allowed  to  dry,  and  is  then  carried  to  the 
laboratory.  A  loop  of  bouillon-culture  of  genuine  typhoid  bacilli  is 
placed  upon  a  clean  cover-glass,  and  to  this  is  added  a  large  loopful  of 
a  watery  solution  of  the  dried  blood-specimen.  The  cover-glass  is  in- 
verted over  the  concavity  of  a  hollow  slide  and  sealed  at  the  edges  with 
melted  vaselin.  Under  the  microscope,  with  a  high-power  dry  lens  or 
with  a  one-twelfth  oil-immersion  lens,  a  rapid  clumping  of  the  bacilli 
in  the  hanging  drop  can  be  observed,^  and  their  motions  cease  almost 
instantly. 

Diagnostic  Value. — There  is  a  general  consensus  of  scientific  opinion 
as  to  the  great  clinical  value  of  the  Widal  reaction.  The  large  statis- 
tics of  Kneass  and  Stengel,  based  on  2283  cases,  coupled  with  more 
recent  available  figures,  show  the  presence  of  the  reaction  in  95.2  per 
cent.,  and  no  reaction  in  non-typhoid  cases  in  98  per  cent.  A,  C.  Ab- 
bott^ reports  that,  according  to  the  records  of  Widal  reactions  in  4154 
cases,  the  error  does  not  exceed  2.8  per  cent. 

Of  230  cases  examined,  219  gave  a  positive  result  (Anders  and 
McFarland^).  In  128  of  these  cases  this  result  was  obtained  prior  to 
the  appearance  of  the  rose  spots,  or  before  the  eighth  day ;  in  36  cases 
the  first  reaction  occurred  during  the  second  week ;  in  45,  between  the 
seventeenth  and  twenty-first  days  of  the  disease ;  in  8,  not  until  the 
twenty-fifth  day,  and  in  2  cases  as  late  as  the  twenty-eighth  day. 

Interfering  Conditions. — In  the  first  place,  a  previous  attack  of 
typhoid  fever  may  produce  a  reaction.  In  39  cases  of  pure  typhoid 
tested  at  periods  of  from  one  to  eighteen  months  after  defervescence,  13 
reacted  positively  (Cabot  and  Lowell).  It  may  be  possible  for  the  scene 
to  be  dominated  by  some  other  morbid  process  (tuberculosis,  etc.). 
Kraus  *  found  that  a  complicating  pneumonia  caused  the  Widal  reaction 
to  disappear.  On  the  other  hand,  the  reaction  may  be  present  in  Weils 
disease  and  in  meat  poisoning  when  the  Bacillus  enteritidis  (Gartner)  is 
present.  Again,  exceptional  cases  occur  with  no  reaction  throughout. 
Brill  has  reported  17  cases  of  this  sort ;  in  such  cases^  however,  the  ex- 
amination must  be  repeated  until  after  convalescence  is  completed. 

Conradi^  has  discovered  a  new  method  of  cultivating  typhoid  bacilli. 
A  small  amount  of  blood  is  obtained  by  lancing  the  ear;  this  is  inocu- 
lated into  a  small  sterile  bottle  of  bile,  to  which  a  little  peptone  and 
glycerin  has  been  added.  After  sixteen  hours  the  bile  is  reinoculated 
onto  lactose-litmus  agar.  A  positive  diagnosis  can  be  made  in  thirty 
hours. 

1  Medical  News,  Nov.  14,  1896.  2  p^^7„,  j/g^/,  jowr.,  Feb.  25,  1899. 

3  Phila.  Med.  Jour.,  April  8,  1899.  ^  Zeit.  f.  Heilk.,  Bd.  xxi.,  H.  5. 

^  Miinch.  med.   Wochensehr.,  1906,  vol.  liii,  p.  1654. 


48  INFECTIOUS  DISEASES. 

Chantemesse '  suggests  an  ophthalmic  test,  but  the  cutaneous  reaction 
is  a  more  simple  test  and  "gave  positive  results  in  every  case  in  which  it 
was  employed"  (Deehan).  C  B.  Burke ^  has  described  a  new  reflex 
sign.  Prendergast  proposes  a  new  typhoid  fever  test  consisting  in  the 
injection  with  a  fine  hypodermic  needle  of  a  few  drops  of  a  suspension  of 
dead  typhoid  bacilli  of  the  strengtli  of  less  than  5,000,000  per  c.c.  No 
reaction  occurs  in  tyjdioid  infection,  but  in  the  non-typhoid  patient  a 
well-marked  area  of  redness  around  the  injection  develops  within  twenty- 
four  hours. 

The  cases  that  begin  Avith  the  well-defined  local  inflammatory  lesions 
previously  referred  to  (tonsillo-typhoid,  pneumo-typhoid,  pleuro-typhoid, 
nepliro-ty])hoid)  cannot  be  recognized  at  the  outset.  The  same  local 
inflammatory  conditions  may,  independently  of  typhoid  fever,  be  com- 
bined with  a  genuine  typhoid  state.  In  all  instances  of  typlioid  fever 
in  which,  at  the  time  of  onset,  localization  occurs,  the  degree  of  fever 
and  prostration  are  apt  to  be  out  of  pi-oportion  to  the  local  symptoms, 
and  the  former  are  apt  to  continue  after  the  subsidence  of  the  latter.  A 
careful  observation  of  the  symptoms  after  the  first  week  will  usually 
detect  undoubted  symptoms  of  typhoid.  The  Widal  test  decides  these 
cases.  Blood-cultures  if  made  early  will  also  set  the  diagnosis  at  rest. 
The  bacilli  may  be  obtained  from  the  stools  and  urine. 

Differential  Diagnosis. — (1)  Typhus  fever  (rarely  met  with)  is  to  be  dif- 
ferentiated by  its  appearance  as  an  epidemic,  by  its  sudden  onset,  by  the 
deeper  stupor,  the  besotted  expression  of  tlie  features,  the  injected  con- 
junctivae, the  contracted  pupils,  the  appearance  on  the  fourth  day  of 
macula;  which  are  transformed  into  petechit«  ;  by  the  shorter  course,  the 
termination  by  crisis,  and  the  absence  of  the  Widal  reaction. 

(2)  Acute  miliary  tuberculosis  is  to  be  differentiated  from  typhoid  fever 
by  the  greater  frequency  of  the  pulse  and  respirations,  the  cough,  and  in 
some  instances  by  the  expectoration ;  by  the  diff'use  cyanosis  and  the 
presence  (sometimes)  of  choroidal  tubercles.  Blood-exaniinations  may 
show  leukocytosis,  but  the  large  mononuclears  are  not  increased  as  in 
typhoid  fever.  There  is  an  absence  of  the  temperature-curve,  the  pulse, 
the  characteristic  eruption,  and  the  Widal  reaction  and  abdominal  symp- 
toms of  typhoid.  In  doubtful  cases  lumbar  puncture  and  blood-cultures 
should  be  undertaken,  as  tubercle  or  typhoid  bacilli  may  be  found. 

(.3)  Malarial  fever  may  assume  the  continued  form  of  fever — e.  g.,  the 
festivo-antumnal  type,  in  which  chills  may  be  absent — and  there  are 
typhoids  that  affect  both  remittent  and  intermittent  malarial  fevers. 
Malaria  can  be  differentiated  from  typhoid  fever  only  by  the  detection 
of  Laverans  hematozoa  in  the  blood. 

Should  tjipho-malarial  fever  be  suspected  and  the  typhoid  symptoms 
be  unequivocal,  the  finding  of  the  malarial  organism  would  establish  the 
diagnosis  and  diff'erentiate  the  hybrid  from  pui-e  typhoid. 

(4)  Relapsing  fever  is  distinguished  by  its  abrupt  onset,  with  rigor, 
high  fever,  pain  in  the  epigastrium  ;  by  its  brief  duration,  termination  by 
crisis,  and  the  occurrence  of  a  relapse  at  the  end  of  a  week  ;  by  the 
absence  of  the  characteristic  eruption  and  the  sero-reaction  of  typhoid. 
The  finding  of  the  spirilla  discriminates  relapsing  fever. 

(5)  Meningitis. — In  striking  contrast  with  the  specific  typhoid  symp- 

^  Progressive  Medicine,  March,  1910,  p.  1S6. 
^New  York  Med.  Jn>jr.,  Deo.  16,  1911. 


TYPHOID  FEVKR.  49 

toms,  meningitis  exhibits  marked  hyperesthesia,  intolerance  of  light  and 
sound,  exaggerated  reflexes,  and  often  muscular  rigidity  before  the 
stage  of  eifusion ;  also  restlessness,  peevishness  (unlike  the  dulness  ob- 
served in  typhoid  patients),  vomiting,  and  constipation  {vide  Acute 
Miliary  Tuberculosis).  The  temperature  maintains  a  lower  level  on  the 
average,  and  is  more  irregular  in  type  than  in  typhoid;  the  pulse  is 
more  irregular,  and  the  nervous  symptoms  assume  greater  prominence 
in  the  earlier  stages,  particularly  headache  and  delirium.  On  the  other 
hand,  true  typhoid  symptoms  are  wanting  in  meningitis. 

(6)  Tuberculous  meningitis  gives  a  characteristic-  previous  or  family 
history,  occurs  in  young  subjects,  and  the  tendon  and  cutaneous  reflexes 
exhibit  wide  variations  as  to  intensity,  within  brief  periods  and  through- 
out the  whole  attack.  An  examination  with  the  ophthalmoscope  may 
reveal  choroidal  tubercles.     The  Widal  reaction  is  missing. 

(7)  Catarrhal  enteritis  in  children,  with  prominent  abdominal  symp- 
toms, may  simulate  typhoid  fever  very  closely.  In  the  former  the 
symptoms  are  all  gastro-intestinal,  save  perhaps  the  occurrence  of  slight 
febrile  disturbance  and  certain  nervous  phenomena,  while  typhoid  fever 
manifests  a  wider  range  of  symptoms  (some  of  which  are  peculiarly  its 
own — notably  the  greater  prostration,  more  marked  fever,  enlargement 
of  the  spleen,  the  sero-reaction,  and  the  characteristic  eruption).  In 
young  children  the  last-named  symptom  may  be  either  wanting  or  atypi- 
cal, in  which  case  the  existence  of  enlargement  of  the  spleen  coupled 
with  other  phenomena,  particularly  the  Widal  reaction,  will  suffice. 

(8)  Salpingitis  on  the  right  side  may  resemble  typhoid.  In  the  former 
there  is  usually  a  clear  history  either  of  antecedent  vaginitis  or  of  an 
abortion,  and  there  exist  special  evidences  of  local  peritonitis,  but  not  the 
classic  features  of  typhoid  fever.  A  digital  examination  per  vaginam^ 
however,  is  necessary  to  the  certitude  of  diagnosis  in  salpingitis. 

The  diagnosis  between  typhoid  fever  and  typhoid  pneumonia, 
influenza,  ulcerative  endocarditis,  and  appendicitis  will  be  considered 
hereafter. 

Prognosis. — As  in  all  other  acute  infectious  diseases,  so  in  typhoid, 
the  prognosis  depends  upon  three  main  considerations : 

(1)  The  severity  of  the  type  of  the  infection,  which  is  indicated  in 
great  measure  by  the  degree  of  fever.  A  temperature  of  106°  F. 
(41.1°  C.)  is  a  serious  symptom,  and,  if  maintained  at  this  point  for  a 
few  days,  an  almost  certainly  mortal  one.  I  have  not  seen  a  single 
instance  in  which  the  temperature  has  touched  106°  F.  (41.1°  C.)  for 
two  or  three  successive  days  that  has  recovered.  If  the  temperature 
mounts  to  and  keeps  at  105°  F.  (40.5°  C.)  for  more  than  three  or  four 
days,  the  prognosis  should  be  made  Avith  due  reserve.  When  the  fas- 
tigium  is  much  prolonged,  even  though  the  fever  be  not  exceptional,  the 
prognosis  is  usually  grave;  while,  on  the  other  hand,  marked  nocturnal 
remissions  are  of  favorable  omen.  A  sudden,  deep  fall,  however,  may 
imply  danger  (intestinal  hemorrhage,  collapse). 

The  researches  of  Isaac  Ott  have  taught  us  that,  while  high  tempera- 
ture is  an  indication  of  danger  in  specific  fevers,  it  is  not  always  the  cause 
of  it.  He  regards  high  temperature  as  being  only  a  part  of  an  infectious 
process,  and  points  out  that  the  thermotaxic  centers  of  the  cortex  may  be 
so  disordered  as  to  alter  the  harmony  between  the  heat-production  and 

4 


50  INFECTIOUS  DISEASES. 

heat-dissipation.  I  nder  these  circumstances  a  specific  fever  of  severe 
form  may  be  associated  with  a  slight  elevation  of  temperature. 

The  power  of  resistance  to  the  influence  of  high  temperature  is  quite 
reliably  indicated  by  the  condition  of  the  heart.  So  long  as  the  pulse  is 
regular  and  its  rate  does  not  exceed  110  or  120  beats  per  minute,  the 
outlook  is  favorable.  When,  however,  the  pulse  maintains  an  average 
rate  of  1-JO  or  more — a  condition  with  which  there  is  usually  associated 
some  degree  of  cyanosis,  pulmonary  congestion,  and  edema — the  outcome 
is  to  be  regarded  as  doubtful.  Collapse  is  apt  to  follow  the  occurrence  of 
sudden  complications  (perforation,  hemorrhage),  but  it  may  also  arise 
causelessly.  The  absence  of  eosiuophiles  from  the  blood-picture  is  an 
unfivorable  prognostic  sign. 

Serious  types  are  also  shown  by  certain  nervous  symptoms,  such  as 
wild  delirium,  stupor,  and  well-marked  symptoms  of  motor  irritation. 

(2)  Circumstances  of  the  Patient. — Certain  individual  peculiarities 
render  the  prognosis  highly  unfavorable.  It  is  had  in  yery  fat  persons. 
In  such  cases  there  is  a  great  danger  of  sudden  collapse,  and  this  fact  also 
holds  to  a  less  degree  with  reference  to  subjects  of  certain  chronic  dis- 
eases (Bright's  disease,  heart  disease,  gout,  emphysema). 

Age  is  an  influential  modifying  factor.  After  puberty  the  gravity  of 
the  disease  increases  with  increasing  years.  Indeed,  it  may  be  said  that, 
as  a  rule,  typhoid  has  an  unfavorable  prognosis  in  persons  past  forty 
years,  for  the  reason  that  at  this  time  of  life  there  is  an  added  liability  to 
pulmonary  complications  and  failure  of  cardiac  reserve.  In  children 
(vide  Clinical  Varieties)  the  tendency  to  hemorrhage  and  peritonitis  is 
reduced  to  a  minimum,  and  the  mortality  is  not  over  1  per  cent. 

The  puerperal  state  renders  a  typhoid  patient  liable  to  many  acci- 
dents and  peculiar  complications,  and  independently  of  pregnancy  the 
disease  is  more  fatal  among  females  than  males.  CJironic  alcoholism 
is  apt  to  be  complicated  with  delirium  tremens,  often  preceded  by  pneu- 
monia.  Such  patients  are  also  prone  to  heart-degeneration  and  ex- 
haustion. 

Environment  aff'ects  the  prognosis,  poor  sanitary  arrangements  and 
poor  attention  greatly  diminishing,  and  the  opposite  conditions  greatly 
augmenting,  the  chances  for  recovery.  Improved  methods  of  treatment 
in  recent  years  have  efi'ected  a  decided  lowering  of  the  death-rate.  Here 
it  may  be  said  that  the  average  mortality  rate  of  typhoid  is  from  8  to 
10  per  cent.,  as  against  15  to  20  per  cent,  formerly.  The  death-rate 
was  2.3  per  cent,  lower  among  the  inoculated  South  African  soldiers  than 
in  the  uninoculated.  It  must  ever  be  remembered,  however,  that  epi- 
demics differ  widely  as  to  their  mortality  list — a  fact  which  makes  a 
precise  statement  regarding  the  question  an  impossibility. 

(3)  The  third  and  last  consideration  is  the  presence  or  absence  of 
dangerous  complications  and  accidents.  These  have  all  been  enumerated 
and  their  prognostic  significance  stated  {supra).  Merely  to  reiterate 
some  of  those  that  lend  fresh  peril  to  the  typhoid  patient,  arranging 
them  with  some  regard  for  the  order  of  their  relative  gravity,  may  prove 
helpful  to  the  student.  They  are — perforation  with  diffuse  peritonitis, 
intestinal  hemorrhage,  lobar  pneumonia,  lobular  pneumonia,  sudden  col- 
lapse (due  to  cardiac  weakness),  excessive  tympanites  (often  with  marked 
diarrhea),  and  hypostatic  congestion  of  the  lungs. 


TYPHOID   FEVER.  51 

Relapses  of  Typhoid  Fever. 

A  relapse  is  a  repetition  of  all  the  characteristics  of  typhoid  after 
the  latter  has  run  its  course.  As  a  rule,  the  return  occurs  from  one 
week  to  ten  days  after  the  beginning  of  convalescence,  though  it  may 
be  either  earlier  or  later ;  and  occasionally  a  relapse  develops  before  the 
temperature  has  become  normal  (^intercurrent  relapse).  The  cause  of 
relapses  is  a  reinvasion  of  the  blood  by  the  typhoid  bacilli  or  their  secre- 
tions from  within  the  body,  and  the  source  of  the  bacilli  is  most  probably 
the  gall-bladder.  The  pathologic  lesions  differ  in  no  essential  way  from 
those  described  as  belonging  to  the  primary  attack,  but  the  stages  through 
which  they  pass  are  not  quite  so  long. 

In  the  interval  between  the  primary  attack  and  the  relapse  there  may 
be  present  suspicious  features,  such  as  a  slight  enlargement  of  the  spleen, 
a  trivial  evening  rise  of  temperature,  an  unnatural  apathy  or  dulness, 
and  a  more  profound  prostration  than  is  usual.  In  the  majority  of  in- 
stances, however,  there  are  no  premonitory  symptoms.  The  onset  is 
rather  more  sudden,  and  rigors  are  more  common,  than  in  primary 
typhoid.  The  temperature,  however,  rises  in  the  characteristic  "  step- 
ladder  "  fashion,  reaching  the  fastigium  in  two  or  three  days,  and  the 
same  relative  abridgment  of  the  fastigium  and  defervescence  is  observed. 
It  follows  that  a  relapse  has  a  shorter  duration  than  a  primary  attack, 
and,  indeed,  it  rarely  exceeds  two  or  three  weeks.  The  temperature 
may,  however,  touch  a  higher  limit  in  the  relapse  than  in  the  primary 
attack  ;  but,  with  rare  exceptions,  when  the  primary  typhoid  is  of  aver- 
age or  even  greater  than  average  severity,  the  temperature  in  the  relapse 
does  not  reach  an  equal  height.  The  characteristic  rash  appears  earlier 
— from  the  second  to  the  fourth  day — and  is  somewhat  darker  and 
coarser  than  that  of  the  first  attack.  The  spleen  swells  rapidly.  The 
intercurrent  relapse  sets  in  while  the  temperature  is  declining ;  the  fever 
again  rises,  and  often  ranges  higher  than  in  the  primary  attack. 

Diagnosis. — Upon  the  points  that  are  distinctive  of  a  primary  attack 
of  typhoid  fever  rests  the  important  diagnosis  between  a  relapse  and  a 
recrudescence  (spurious  relapse).  The  latter  is  usually  attributable  either 
to  errors  in  diet,  to  undue  muscular  exertion,  or  to  great  mental  excite- 
ment ;  and,  whilst  it  occurs  during  convalescence,  it  seldom  lasts  longer 
than  one,  two,  or  three  days,  and  is  not  characterized  by  the  diagnostic 
symptom-group  of  a  relapse  (peculiar  temperature-curve,  enlarged  spleen, 
and  specific  eruption). 

The  prognosis  of  relapses  depends  very  much  upon  the  severity 
of  the  primary  attack,  those  following  severe  attacks  being  relatively 
milder  than  those  that  follow  the  rudimentary,  primary  attacks. 

The  frequency  of  relapses  differs  widely  in  diflFerent  epidemics. 
Hence  the  fact  that  the  percentage  of  relapses  as  estimated  by  difier^ 
ent  authors  ranges  from  3  to  15  per  cent,  need  excite  no  surprise.  The 
relapse  may  repeat  itself  once,  twice,  or  even  thrice,  and  two  relapses 
occur  in  about  1  per  cent,  of  the  cases.  In  a  case  which  I  ^  reported 
three  successive  and  typical  relapses  occurred.  The  pale  line  or  ridge 
which  was  mentioned  (vide  Clinical  History)  as  noticeable  in  the  nails 
after  typhoid  occurs  similarly  after  each  relapse,  and  in  the  afore-men- 
tioned case  of  my  own  four  distinct  whitish,  transverse  ridges  were 
noted.  Da  Costa  has  recorded  five  relapses  in  each  of  two  cases. 
^  3fed.  and  Surg.  Reporter,  vol.  xlvii.,  p.  66. 


52  INFECTIOUS  DISEASES. 

Recurrences. — By  this  term  is  meant  successive  attacks  separated 
by  longer  or  shorter  intervals  after  complete  recovery  from  the  primary 
attack."  Typlioid  fever  usually  bestoAvs  lasting  immunity,  but  this  is  not 
an  invariable  rule.  Eichhorst  has  studied  600  cases,  and  found  that  in 
•28  of  the  number  (4.7  per  cent.)  a  second  attack  occurred.  Soldiers  -who 
are  subjected  to  typhoid  fever,  commonly  give  a  history  of  previous  attacks 
(D.  Parker).  I  have  seen  a  number  of  typical  recurrences  of  typhoid 
fever,  in  two  persons,  the  intervals  having  been  five  and  eight  years  re- 
spectively. Very  rarely  three  separate  attacks  have  occurred  in  the  same 
individual,  and  a  second  is  usually  milder  than  tlie  first  attack. 

Treatment. — (a)  Prophylaxis. — The  municipal  authorities  possess  in 
thorough  filtration  a  power  that  can  be  used  to  advantage.  For  example, 
in  A^ienna,  by  purification  of  the  -water-supply,  the  death-rate  in  typhoid 
fever  was  reduced  from  12.5  per  10,000  to  1.1  per  10,000. 

It  has  been  well  said  that  typhoid  bacilli  do  not  naturally  inhabit 
water  and  milk,  but  man  is  their  natural  host,  hence  the  primary  source 
of  the  bacilli.  Let  us  make  sure  that  every  typhoid  bacillus  is  killed 
immediately  on  leaving  every  host  and  the  disease  is  at  an  end  (McCrae). 
The  best  means  that  can  be  employed  during  the  attack,  with  a  view 
to  limiting  the  spread  of  typhoid,  is  disinfection^  and  the  following  de- 
scription comprises  its  essential  points  : 

Disinfection  in  tyjdioid  may  conveniently  be  divided  into  (a)  that  of 
the  excreta  (stools,  urine,  vomitus,  and  sputum) ;  (b)  of  the  bed  and 
its  coverings  ;  (c)  of  the  patient  and  the  sick-room.  While  all  of  these 
subdivisions  are  of  the  greatest  importance  in  the  treatment  of  a  case, 
the  disinfection  of  the  excreta  (a)  is  perhaps  most  carelessly  performed, 
and  hence  the  importance  of  the  statement  that  all  stools  and  urine 
voided  by  the  patient,  as  well  as  the  vomitus  and  sputa,  should  be 
promptly  treated  as  follows  :  The  excreta  should  be  received  in  a  vessel 
that  can  be  thoroughly  disinfected  inside  and  out  with  any  of  the  several 
standard  solutions,  of"  which  that  of  chloriiiated  lime  (strength,  6  ounces 
per  gallon)  is  the  most  eifective  and  satisfactory. 

it  is  my  custom  to  order  that  one  pint  of  the  chlorinated  lime  solu- 
tion be  placed  in  the  bed-pan  (or  other  appropriate  receptacle)  befoi-e 
the  discharges  are  received  therein,  and  from  one  to  two  pints  after. 
The  whole  is  thoroughly  mixed  by  stirring  and  shaking,  care  being  taken 
that  all  solid  masses  are  broken  up.  The  vessel  is  then  allowed  to  stand 
for  three  hours  before  it  is  emptied  into  the  water-closet.  Phenol  is  also 
efiicient  and  cheap.  The  stool  should  be  mixed  with  about  twice  its 
volume  of  a  1  :  10  to  20  phenol  solution  and  allowed  to  stand  for  several 
hours. 

Gwyn^  has  given  the  following  results  of  his  investigations  into  the 
fjuestion  of  typhoid  bacilli  in  the  urines  of  typhoid  fever  patients: 
They  are  present  in  from  20  to  30  per  cent,  of  the  cases,  and  may 
be  exceedingly  numerous.  The  organisms  may  persist  for  months  or 
years.  For  the  disinfection  of  the  urine  in  the  bladder,  urotropin  is 
serviceable  when  administered  by  the  mouth.  Under  no  circumstances, 
however,  should  its  administration  permit  the  disinfection  of  the  voided 
urine  to  be  neglected.     As  an  irrigation,  Gwyn  recommends  mercuric- 

i  Philada.  Med.  Jour.,  Jan.  12,  1901. 


TYPHOID   FKVFJt.  5'^ 

chlorid  solutions  (1  :  100,000  to  1  :  50,000),  To  disinfect  the  urine, 
''the  best  solutions  are,  plienol  (carbolic  acid)  1  to  20,  in  an  amount 
equal  to  that  of  the  urine,  or  bichlorid  of  mercury  1  to  1000  in  an  amount 
one-fifteenth  that  of  the  fluid  to  b(^  stf'riliz<;d.  These  )iiixture,s  with  the 
urine  should  stand  at  least  two  hours.  "  ^ 

(6)  It  should  be  an  invariable  rule  to  change  the  bed- -and  body-linen 
daily,  and  as  often  as  soiled.  The  mattress  should  be  protected  by  a 
rubber  cover,  and  this,  together  with  the  soiled  linen  and  blankets, 
should  be  received  in  a  sheet  that  has  previously  been  dipped  in  a  5  per 
cent,  solution  of  carbolic  acid.  The  rubber  sheets  are  to  be  washed 
with  the  carbolic-acid  solution,  but  all  other  bed-clothes  miist  be  boiled 
for  half  an  hour.  When  the  patient  leaves  the  sick-room  the  mattresses 
are  to  be  fumigated  and  aired  daily  for  a  week,  and  the  rubber  covers 
and  bedsteads  washed  with  a  solution  of   mercuric  chlorid  (]  :  1000). 

(c)  After  every  stool  the  patient  should  be  cleansed  with  a  compress 
of  cloth  or  cotton  wet  with  a  solution  of  mercuric  chlorid  (1  :  2000)  or 
of  carbolic  acid  (1  :  40).  The  bed-pan  and  hopper  are  to  be  similarly 
treated,  and  the  cloths  used  immmediately  burned.  Fitz  recommends 
that  the  feeding  utensils  be  cleansed  in  boiling  water  after  using. 

Since  it  is  well  known  that  many  epidemics  are  directly  traceable  to 
the  drinking-supply  of  water  and  milk,  it  is  necessary  that  all  water 
and  milk  used  by  the  patient  and  other  members  of  the  household  be 
boileu  for  half  an  hour  before  being  ingested ;  and  if  an  epidemic  be 
prevailing,  the  community  at  large  should  join  in  this  precaution.  In 
view  of  the  significant  rOle  played  by  the  bacilli-carriers,  convalescents 
must  be  regarded  as  dangerous  for  a  long  time  after  apparent  recovery. 
The  patient  should  report  to  the  physician  for  examination  of  the  excreta 
until  it  is  satisfactorily  shown  that  no  more  typhoid  bacilli  are  being 
passed. 

Isolation  of  Patients. — It  is  advisable  to  isolate  typhoid  cases  as  fiir  as 
possible — e.  g.^  in  hospitals,  to  keep  them  in  special  wards ;  in  private 
families,  in  special  apartments.  There  is  incontestable  proof  that  typhoid 
fever  is  feebly  contagious.^  At  the  Johns  Hopkins  Hospital  1.81  per 
cent,  of  all  cases  are  of  hospital  origin  (Cole). 

/  Prophylactic  Inoculations. — Excellent  results  have  followed  the  fre- 
ventive  inoculation  of  healthy  persons  with  typhoid  virus.  The  striking 
results  of  antityphoid  vaccination  are  shown  by  the  Medical  Corps  of  the 
United  States  Army,  e.  g.,  the  Maneuver  Division  at  San  Antonio,  Tex., 
in  1911  :  Mean  strength,  12,801 ;  cases  of  typhoid  fever,  1  ;  deaths  from 
typhoid  fever,  0. 

The  procedure  of  administration  is  as  follows :  "  The  initial  dose  is 
500,000,000,  and  two  successive  doses  of  1,000,000,000  are  given  at  ten- 
day  intervals.  The  antibodies  develop  in  from  five  to  ten  days  later,  and 
are  bacteriolysins,  opsonins,  and  agglutinins,  the  last  in  large  amounts. 
The  last  two  measure  the  antibodies  present,  since  their  quantitative  re- 
lations are  quite  constant.  The  increase  in  agglutinins  is  quite  evident 
in  four  to  five  days  ;  the  fall  begins  in  six  weeks  and  the  normal  is  reached 
in  fifteen  months.  The  injection  is  given  in  the  deltoid  region,  the  skin 
being  previously  washed  with  tricresol  solution  and  soap.      The  needle 

1  Jour,  of  Amer.  Med.  Assoc,  April  6,  1912,  p.  1015. 

^  Philada.  Hosp.  Report,  1891,  vol.  i.,  p.  149,  by  the  writer. 


54  INFECTIOUS  DISEASES. 

puncture  is  closed  Avith  the  compound  solution  of  tricresol  (cresol,  500 ; 
linseed  oil,  350;  potassium  hvdroxid,  80;  water,  to  1000).  Tincture  of 
iodin  may  be  substituted  for  the  latter  purpose,  but  the  compound  cresol 
solution  for  use  in  camps  is  the  ideal  method"  (R.  AV.  Wilcox).^  Irwin 
and  Houston  successfully  treated  a  case  of  persistent  typhoid  bacilluria 
by  means  of  a  .vaccine  prepared  from  typhoid  bacilli. 

(J)  Treatment  of  the  Attack. — (1)  The  general  conduct  of  the  case, 
including  skilful  nursing,  is  of  paramount  importance  to  the  typhoid 
patient.  He  should  be  put  to  bed  as  soon  as  the  indications  point  to 
this  disease,  and  kept  there  continuously  in  the  recumbent  posture  till 
the  end  of  the  attack.  The  sick-room  should  have  a  sunny  exposure  if 
possible ;  should  be  cool  and  well  ventilated,  though  free  from  strong 
currents  ;  and  perfect  cleanliness  both  of  the  room  and  of  the  utensils 
employed  in  the  management  of  the  case  should  be  attempted.  The 
bed  should  be  provided  with  a  woven-wire  mattress,  upon  which  should 
be  placed  one  of  hair.  A  rubber  cloth  is  spread  beneath  the  sheet,  and 
the  latter  kept  smooth  in  order  to  lessen  the  danger  from  bed-sores.  A 
seriously  ill  patient  should  lie  on  an  air-cushion  or,  better  still,  a  water- 
bed,  and  to  avoid  bed-sores  he  should  be  instructed  to  turn  gently  to 
either  side  from  time  to  time.  His  back,  hips,  and  heels  should  be 
bathed  frequently  with  a  mixture  of  alum  and  salt  in  dilute  alcohol. 
The  use  of  the  bed-pan  and  urinal  is  an  absolute  necessity.  When  a 
good  nurse  cannot  be  had,  the  attending  physician  must  note  in  writing 
the  directions  regarding  the  disinfection  of  the  excreta,  bed-linen,  and 
utensils,  as  well  as  regarding  the  exhibition  of  the  food,  medicine,  etc. 
The  mouth  and  throat  should  be  kept  clean,  since  by  so  doing  we  obvi- 
ate unpleasant  and  even  dangerous  complications  (aphthous  ulcer,  thrush, 
parotitis,  lobular  pneumonia,  etc.).  If  they  arise,  the  nurse  or  attendant 
should  w'ash  the  mouth  and  tongue  several  times  daily  with  a  solution 
of  boric  acid  (3  per  cent.),  and  the  throat  may  be  sprayed  at  equal 
intervals  with  a  similar  solution.  A  frequent  moistening  of  the  tongue 
and  mouth,  and  particularly  the  lips,  with  glycerin  and  water  (equal 
parts)  gives  great  comfort  when  they  are  dry  and  parched. 

(2)  An  appropriate  liquid  diet  should  be  employed,  and  the  best 
article  of  food  is  milk,  which  it  is  well  to  dilute  with  plain  water  (or 
lime-water),  since  aerated  waters  are  objectionable  in  that  they  some- 
times increase  the  meteorism.  The  daily  quantity  should  not  be  less 
than  three  pints,  and  it  is  important  that  the  stools  be  examined,  since, 
if  the  milk  be  not  thoroughly  transformed,  curds  or  (on  microscopic  ex- 
amination) numerous  fat-globules  will  be  seen,  in  which  case  a  smaller 
amount  should  be  given.  If  curds  or  fat  are  still  seen,  the  milk 
should  be  peptonized.  Experience  teaches  that  milk  is  often  better 
taken  and  better  borne  when  a  little  brandy,  coffee,  or  tea  is  added  to 
it.  When  milk  cannot  be  taken  or  digested  in  sufficient  amount,  either 
whey,  sour  milk,  or  buttermilk  may  be  tried;  and  if  these  be  distaste- 
ful, we  may  replace  them  (wholly  or  in  part)  by  meat-juices  or  broths 
of  various  sorts,  together  with  one  of  the  standard  infant's  foods  made 
with  milk  or  water.  Albumin-water,  prepared  by  straining  egg-white 
through  a  cloth  and  adding  an  ec^ual  part  of  water,  has  given  much 
satisfaction  in  my  hands.  It  may  be  made  pleasant  to  the  taste  by 
1  Amer.  PracL,  March,  1912. 


TYPHOID  FEVER.  55 

flavoring  with  vanilla  or  lemon,  and  with  meat-juice  and  Ijroth.s  will 
often  support  a  patient  during  the  most  trying  period  of  tlie  attack. 

High  calorie  feeding  is  advised  by  Shattuck,  Robertson,  Shaffer  and 
Coleman,  and  others,  e.  g.,  a  dietary  made  up  as  follows :  a  quart  of  milk, 
a  pint  of  cream,  six  ounces  of  milk-sugar,  eggs,  toast,  butter,  cereals, 
potato,  apple-sauce,  and  the  like.  There  are  typhoid  su})jects  Avho  cannot 
(on  account  of  vomiting,  etc.)  take  per  oram  sufficient  nourisliment  to 
support  life.  In  such  cases  we  may  supplement  the  usual  method  of  feed- 
ing by  rectal  alimentation,  when  from  8  to  4  ounces  (96.0-128.0)  of  pep- 
tonized milk,  \  ounce  (16.0)  of  meat-juice,  and  a  little  egg-white  may  be 
combined,  and  employed  at  intervals  of  four  hours.  In  early  convales- 
cence the  patient  may  take  milk-toast,  well-cooked  plain  rice,  entire  eggs 
(diluted),  or  thin  custai'ds.  Solid  food  should  not  be  allowed  till  the  tem- 
perature has  been  at  the  normal  grade  for  one  week  at  least.  In  cases  in 
which  the  fastigium  tends  to  become  prolonged  with  increasing  prostra- 
tion, and  those  presenting  the  fever  of  exhaustion,  the  administration  of 
soft  food  (eggs,  finely  scraped  meat,  well-cooked  rice,  plain)  is  often  fol- 
lowed by  improvement. 

Pure  cold  water  has  a  positive  value  as  a  diuretic  in  this  disease. 
Gushing  and  Clarke  ^  used  large  quantities  of  water  internally  (a  gallon 
or  more  in  twenty-four  hours),  administering  it  in  small  quantities  at  fre- 
quent, definite  intervals.  The  toxic  symptoms  and  mortality  were  lessened. 
The  internal  use  of  water  stimulates  renal  activity  by  raising  the  blood- 
pressure. 

(3)  Stimulants  are  useful  in  about  50  per  cent,  of  the  cases.  When  the 
first  heart-sound  becomes  weak  or  the  vascular  tone  diminished,  alcohol 
should  be  used  regardless  of  the  temperature.  In  severe  types  whiskv 
is  the  best  form ;  in  milder  ones  some  good  wine,  such  as  port,  sherry,  or 
madeira.  It  is  well  to  begin  with  a  moderate  daily  quantity,  and  then  in- 
crease, if  necessary,  until  the  indication  is  fulfilled.  If  the  patient  so 
desires,  we  may  use  brandy  instead  of  whisky,  and  it  is  usually  toward  the 
close  of  the  second  or  during  the  third  week  of  the  disease  that  the  indi- 
cations for  the  use  of  alcohol  arise.  It  is  not  only  the  best  spur  for  a 
flagging  heart,  but  is  of  equal  value  in  combating  unfavorable  nervous 
symptoms  due  to  the  typhoid  septicemia ;  and  the  time  for  commencing 
its  use  may  be  indicated  first  by  the  latter  symptoms  {e.  g.  delirium, 
coma,  tremor).  The  quantity  to  be  administered  must  be  regulated  by 
its  efiects,  since  it  may  act  injuriously,  and  even  aggravate  the  symptoms, 
though  this  is  seldom  the  case.  Threatened  collapse  may  be  met  by  full 
doses  of  alcohol  (^  ounce — 16.0 — every  hour),  combined  with  strychnin 
(gr.  -^ — 0.004 — every  three  hours),  exhibited  subcutaneously  till  the 
depression  has  been  counteracted.  Effective  doses  of  diffusible  stimulants, 
as  champagne,  are  useful  during  periods  of  sudden  circulatory  depression. 
The  cardiac  stimulants  mentioned  above  may  be  further  supported  by 
the  use  of  digitalis  and  sulphuric  ether.  Stengel  has  recommended 
hypodermic  injections  of  1  to  2  grains  (0.0648-0.1296)  of  camphor 
dissolved  in  15  minims  (1.0)  of  sterilized  olive  oil  as  a  cardiac  stimulant 
in  typhoid  fever. 

(4)  Hydrotherapy. — There  is  at  the  present  day  general  agreement 
among  medical  authors  that  the  best  mode  of  treating  typhoid  fever  is 

1  Amer.  Jour.  Med.  Sci.,  February,  1905. 


56  INFECTIOUS  DISEASES. 

by  means  of  the  cold  hath,  which  was  originally  introduced  by  Currie,  of 
London  (more  than  a  century  ago),  and  reintroduced  and  ^^uccessfullv 
practised  by  Brand,  of  Stettin.  The  benefits  oft'ered  to  the  patient  by 
this  method  are  so  great  and  varied  that  it  becomes  the  duty  of  every 
physician  who  treats  typlioid  fever  to  be  prepared  to  employ  it.  The 
beneficial  influences  of  the  baths  are  as  follows:  (1)  They  absorb  the 
body-heat  directly,  thus  reilucing  the  temperature  and  overcoming  the 
ill  effects  of  high  fever,  this  action  becoming  more  marked  after  a  day  or 
two  of  the  treatment :  (2)  They  improve  the  nervous  symptoms,  diminish- 
ing mental  dulness,  delirium,  stupor,  muscular  tremors  and  twitehings, 
and  inducing  sleep  ;  (o)  They  strengthen  the  heart,  thus  obviating  the 
danger  of  sudden  circulatory  collapse  and  the  consequences  of  increasing 
cardiac  weakness  (hypostatic  congestion  of  the  lungs,  venous  thrombosis, 
etc.) ;  (4)  They  stimulate  the  respirations,  whereby  the  inspirations  are 
deepened  and  the  tendency  to  pulmonary  complications  greatly  lessened, 
especially  severe  bronchitis,  lobular  pneumonia,  etc.  ;  (5)  The  renal  func- 
tion is  invigorated,  and  as  a  result  the  elimination  of  typhotoxins  by  the 
kidneys  is  increased  (Roque  and  Weil) ;  (6)  On  account  of  the  cleanliness 
of  the  skin  which  they  ensure,  bed-sores  rarely  occur ;  (7)  They  may 
shorten  the  stay  in  the  hospital  or  sick-room,  but  not  the  stay  in  bed, 
except,  perhaps,  in  the  lighter  types. 

L  nquestionably,  the  good  efiects  of  this  method  receive  striking  con- 
firmation from  statistical  reports  which  have  been  prepared  by  Brand, 
Osier,  Jiirgensen,  and  others  abroad,  and  by  Baruch,  Wilson,  and  others 
at  home.  According  to  the  warmest  European  advocates  of  the  method, 
the  mortality  is  less  than  0.5  per  cent.  The  results  among  American 
clinicians  give  an  average  mortality  of  7.3  per  cent.  During  five  years 
408  cases  have  been  treated  by  the  bath-n:!ethod  in  the  Royal  Victoria 
Hospital,  Montreal,  with  a  mortality  of  4.4  per  cent. 

The  tub  is  to  be  brought  to  the  bedside  of  the  patient,  and  in  hospital 
practice  both  bed  and  tub  should  be  screened  while  the  bath  is  in  progress. 
After  removing  the  night-dress  and  placing  a  large  napkin  around  the 
loins,  the  patient  should  be  lowered  into  the  bath  by  a  sheet  held  at 
each  corner  by  an  attendant  (and,  if  seriously  ill,  with  the  least  pos- 
sible disturbance),  and  there  carefully  supported  and  held  while  in  the 
bath.  If  sleeping,  the  j^atient  must  be  awakened  and  the  bath  de- 
layed for  ten  or  fifteen  minutes.  Young  subjects  and  adults  in  light 
cases  of  the  disease  may  be  handled  properly  by  two  persons,  but  I  do 
not  approve  of  allowing  the  patient  to  step  fi'om  the  bed  into  the  bath, 
however  light  the  case.  While  in  the  bath  the  skin-surface,  particu- 
larly that  of  the  back  and  limbs,  is  constantly  rubbed  by  the  attendants, 
in  order  to  stimulate  the  peripheral  circulation  and  as  far  as  possible  to 
avert  chilliness  and  discomfort.  The  head  of  the  patient  rests  upon  a 
rubber  air-cushion.  At  first  he  should  be  kept  in  the  bath  five  to 
eight  minutes ;  later,  ten  or  fifteen  minutes,  according  to  the  severity 
of  the  case.  The  head  and  face  are  bathed  at  once  from  a  basin,  and  a 
cold  compress  is  applied  to  the  forehead,  and,  if  prominent  nervous 
symptoms  be  present,  often  associated  with  high  temperature,  water  at 
70°  F.  (21.1°  C)  or  lower  should  be  poured  from  an  elevation  of  about 
six  inches  upon  the  head  and  nape  of  the  neck  several  times  during  the 
bath.     The  ears  must  be  stopped  with  cotton  when  douching  is  practiced. 


^9 


58  INFECTIOUS  DISEASES. 

If  while  in  the  water  the  patient  complains  bitterly  of  the  cold  or  is 
very  restless,  a  stimulant  may  be  administered — f5J  (32.0)  of  whiskey, 
diluted — and  if  this  fails  he  must  be  lifted  into  bed  and  further  stimu- 
lated. If  he  be  very  young,  highly  sensitive,  or  elderly,  it  is  best  to 
place  him  at  the  commencement  in  water  of  a  temperature  of  85°  or 
90°  F.  (29.4°-32.2°  C),  and  then  gradually  cool  it  down  to  80°  F. 
(26.6°  C).  After  he  has  become  accustomed  to  the  bath  he  may  be 
immersed  in  water  at  the  temperature  of  80°  F.  (26.6°  C),  to  be  re- 
duced to  75°  F.  (23.8°  C.)  or  even  70°  F.  (21.1°  C),  below  which  it  is 
unnecessary  to  go  save  in  the  rarest  instances.  This  is  the  gradually 
cooled  bath  of  Ziemssen.  In  the  rigid  Brand  method,  which  is,  perhaps, 
less  generally  adopted  at  present  than  several  years  ago,  the  patient  is 
lifted  at  once  into  a  bath  at  70°  F.  (21.1°  C)  and  kept  there  for  fifteen 
minutes.  He  is  to  be  removed  from  the  bath  to  the  bed  (previously  pro- 
tected by  a  blanket  and  mackintosh),  wiped  off  gently ;  after  which  the 
sheet,  blanket,  etc.,  are  withdrawn  and  he  is  covered  with  a  fresh  blanket. 
If  now  reaction  be  retarded,  some  hot  broth  or  about  an  ounce  of  whisky 
should  be  administered  and  active  friction  applied  to  the  back  and 
extremities. 

The  effect  of  the  bath  is  best  shown  by  the  rectal  temperature, 
which  is  taken  half  an  hour  after  the  conclusion  of  the  bath,  and  again 
a  half  hour  later  if  the  patient  be  not  asleep.  Usually  the  temperature 
will  be  found  to  be  two  or  three  degrees  lower  than  before  the  plunge 


-     ■  ■  -^ 


Fig.  6. — Portable  bath-tub  in  use. 


(see  Fig.  5).  In  obstinate  and  severe  cases  the  fall  may  be  less  than 
one  degree,  in  which  case  it  is  advisable  either  to  prolong  the  bath  to 
twenty  minutes  or  to  reduce  still  further  the  temperature  of  the  water. 
Protracted  warm  baths  are  highly  recommended  by  Reisse  and  others 
when  cold  baths  are  badly  borne  or  are  unproductive  of  good  results. 

In  light  cases  the  cold  bath  should  be  repeated  every  six  or  eight 
hours;  in  severe  ones,  every  three  or  four  hours,  but  more  frequently 
than  once  in  three  hours  is  not  advisable,  even  in  the  worst  cases. 
Sufficient  water  to  immerse  the  patient  to  the  neck  (about  30  gallons — 
114  liters)  should  be  used.  During  the  night  the  patient  should  be 
allowed  to  sleep  for  six  or  eight  hours  if  he  can  do  so. 

There  are  a  number  of   convenient    and    satisfactory  portable  tubs 
in   the  market,  but  that  devised  by  Dr.  C.  L.  Furbush  of  Philadelphia 


TYPHOID  FEVER.  59 

possesses  certain  leading  advantages  (Figs.  G,  7).  The  frame  is 
made  of  light  wood,  and  when  folded  is  4  inches  (10.1-06  cm.)  in 
depth,  14  inches  (35.546  era.)  in  width,  and  5  feet  10  inches  (1.778  m.) 
in  length,  so  that  it  can  be  placed  in  a  closet  or  beneath  a  bed.  Less 
than  two  minutes  are  required  to  prepare  the  bath,  which  the  patient 
receives  while  lying  in  bed.  When  in  use  the  ends  are  fastened  by 
brass  pins  hung  on  small  chains,  and  these  hold  the  frame  in  a  fixed 
position.  The  tub  proper  is  made  of  double-faced  sheeting,  reinforced 
in  the  middle,  so  as  to  resist  the  greatest  amount  of  pressure.  The 
Bides  of  the  sheet  have  a  casing  through  which  is  passed  a  wooden  rod 
4  feet  4  inches  long  (1.320  meters),  and  outside  of  this  a  margin 
of  IJ  inches  (3.808  cm.)  is  left  for  the  brass  eyelets,  through  which 
passes  a  rubber  cord  which  is  covered  with  woven  cotton.  This  cord, 
which  is  attached  to  the  sheet,  is  held  to  the  frame  by  special  brass 
fittings  along  the  lower  sides  of  the  latter.  By  the  use  of  the  cord 
and  wooden  rods  we  have  an  even  tension  on  both  sides,  combined 
with  ample  resistance  to  withstand  the  pressure  of  the  water.  An  ad- 
justable head-rest  fits  into  the  end  of  the  frame.  The  wooden  rod  also 
enables  the  attendant  to  roll  up  the  sheet  quickly  after  the  bath. 
Through  the  bottom  of  the  sheet  a  1-inch  rubber  tube  is  fitted  with  a 
stopper,  and  by  means  of  this  the  tub  can  be  emptied  sooner  than  by  a 
siphon.  The  frame  is  covered  with  ivory-enamel  paint,  and  can  be 
cleansed  easily.  The  entire  weight  of  the  outfit  is  25  pounds  (11.33 
kgms.). 


Fig.  7.— Portable  bath-tub,  folded. 

Brand  recommends  that  the  baths  be  commenced  when  the  tempera- 
ture in  the  rectum  reaches  102.2°  F.  (39°  C).  The  height  of  the  tem- 
perature, per  se,  is  not  to  be  invariably  regarded  as  an  absolute  indi- 
cation for  the  employment  of  the  cold  bath,  since  the  facts  must  be 
recollected  that  the  essential  effect  is  a  stimulation  of  the  nerve-centers 
Avhich  preside  over  the  organic  functions  (respiration,  circulation). 
Baruch  insists  that  the  object  of  cold  baths  with  friction  is  to  sustain  the 
nervous  system  and  circulation  rather  than  for  temperature  reduction. 

The  contraindications  to  the  use  of  baths  are — (1)  Intestinal  hemor- 
rhage, which  is  in  itself  attended  with  danger  and  requires  absolute 
quiet  for  a  time  (four  days),  when  the  baths  may  be  resumed  if  there  is 
no  recurrence.     (2)  Peritonitis,  the  occurrence  of  which  always  excites 


60  INFECTIOUS  DISEASES. 

suspicion  of  perforation.  Here,  again,  rest  and  all  that  the  term  im- 
plies must  be  procured.  (3)  Extreme  Cardiac  Weakness. — The  excite- 
ment in  the  necessary  handling  of  the  patient  connected  with  the  bath 
might  prove  fatal,  as  I  have  witnessed  in  one  instance.  This  condi- 
tion is  sometimes  met  with  in  cases  that  come  under  observation  at  a 
late  period,  and  in  cases  arising  in  aged  and  enfeebled  subjects.  (4) 
Cases  that  have  progressed  to  an  advanced  stage  (the  third  week  of  the 
disease)  should  not  be  immersed.  Dangerous  and  even  fatal  collapse 
has  been  observed  to  follow  cold  baths  under  these  circumstances. 

Substitutes  for  the  Cold  Bath. — The  prejudice  which  exists  against 
the  cold-bath  treatment — at  least  in  America — sometimes  proves  insur- 
mountable. Again,  there  are  many  physicians  who  do  not  avail  them- 
selves of  the  means  at  command  for  carrying  out  hydrotherapy.  In 
consequence  of  these  facts  substitutes  for  the  tub  baths  are  quite  com- 
monly in  vogue.  Among  them,  cold  sponging  of  the  body  of  the  patient 
is  often  resorted  to,  though  it  secures  for  him  trivial  advantages  as  com- 
pared with  those  of  the  baths.  If  this  method  be  employed,  the  water 
should  be  of  the  temperature  of  the  air  of  the  room  or  ward.  The  limbs 
should  be  sponged  and  dried  in  succession,  and  then  the  trunk.  When- 
ever the  temperature  reaches  102.5°  F.  (39.1°  C)  this  measure  is  to  be 
instituted,  each  sponging  being  continued  until  the  desired  effect  has  been 
produced  (a  reduction  of  the  temperature  of  ]i°  to  2°  F. — 1°  C),  unless 
the  patient  gives  signs  of  uneasiness,  when  it  must  be  cut  short.  It 
may  be  repeated  as  often  as  required.  To  the  water  used  equal  parts  of 
vinegar  or  spirits  should  be  added.  The  efficacy  of  the  cool  sponging  is 
enhanced  by  the  simultaneous  application  of  the  ice-cap,  either  constantly 
or  intermittently. 

If  this  method  fails,  as  it  often  does  in  severe  types,  the  cold  pack 
may  form  a  satisfactory  substitute ;  and  I  have  found  it  of  great  use 
with  children,  in  wliom  the  reaction  after  a  cold  bath  is  often  delayed 
or  imperfect.  The  patient  is  placed  upon  a  cot  previously  prepared  by 
spreading  over  it  a  blanket,  which  is  in  turn  covered  with  a  sheet  doubled 
and  wrung  out  of  water  of  the  required  temperature — 70°  to  80°  F. 
(21.1°-26.6°  C).  The  sheet  and  blanket  are  now  Avrapped  about  the 
patient  evenly,  and  he  is  left  in  the  pack  for  a  period  varying  from  a 
half  to  one  hour.  Free  diaphoresis  generally  ensues,  and  this  aids  in 
maintaining  the  fall  of  temperature.  The  effect,  in  most  instances,  is 
to  reduce  the  body-heat  two  degrees  or  more,  and  the  treatment  may  be 
repeated  at  intervals  of  three  or  four  hours  if  needful.  The  wet  sheet 
alone  may  surround  the  patient,  and  be  sprinkled  at  short  intervals  with 
a  watering-pot  containing  water  at  a  temperature  of  70°  F.  (21.1°  C). 
In  desperate  cases  ice-water  enemata  may  be  tried.  If  carefully 
administered  they  accomplish  a  reduction  of  the  temperature  by  two 
or  more  degrees.  Leiter's  coils  may  be  applied  to  the  head,  chest,  or 
abdomen. 

Guaiacol  has  been  used  for  its  antipyretic  effect  by  H.  G.  McCormick 
and  others,  from  10  to  30  minims  (0.666-2.0)  being  applied  to  the  skin 
surface.  I  have  seen  its  use  followed  by  rigors,  hyperpyrexia,  etc.,  but 
McCormick  uses  sufficient  only  to  lower  the  temperature  to  100°  F. 
(37.7°  C),  and  has  thus  avoided  all  ill  effects. 

(5)  Internal  Antip3rretics. — The  most  reliable  of  this  group  of  medic- 


TYPHOID  FEVER.  61 

aments  (phenacetin,  acetanilid,  and  antipyrin)  are  open  to  the  serious 
objection  that  they  depress  cardiac  power.  F^inee  heart-enfeeblernent, 
which  may  develop  either  gradually  or  suddenly,  is  recognized  by  present- 
day  clinicians  as  a  common  danger-signal  of  the  disease,  the  time  lias 
come  when  the  employment  of  coal-tar  products  should  be  discontinued. 

(6)  Intestinal  Antiseptics. — Unquestionably  these  neither  destroy  the 
bacilli  nor  counteract  the  ill  effects  of  their  toxins,  since  both  become 
active  after  they  pass  beyond  the  intestinal  mucosa ;  but  they  are  indi- 
cated in  cases  in  which  tympanites  is  a  prominent  manifestation.  Some 
of  the  toxic  substances  occupying  the  intestines  in  this  disease  result 
from  the  acquired  virulence  of  usually  harmless  organisms,  and  the 
amount  of  decomposable  material  is  increased  owing  to  defective  hepatic 
and  gastric  secretions.  Salol  is  broken  in  the  intestinal  canal  into  car- 
bolic and  salicylic  acids,  and  has  proved  capable  of  controlling  meteiir- 
ism  as  nothing  else  has  done  in  my  hands.  The  dose  is  2  to  3  grains 
(0.1296—0.1944)  every  three  hours,  preferably  administered  in  capsule. 
With  it  I  usually  combine  quinin  in  doses  of  1  to  2  grains  (0.0648-0.1296) 
each.  Henry  speaks  in  favor  of  thymol,  and  guaiacol  carbonate  has 
many  advocates.  Wilcox  ^  urges  that  chlorin  is  capable  of  disinfecting 
the  intestinal  tract.  Acetozone  in  daily  doses  of  15  to  20  grains  is  both 
an  efficient  and  harmless  intestinal  antiseptic ;  it  should  be  dissolved  in  a 
liter  of  water,  flavored  with  some  one  of  the  volatile  oils,  and  taken  in 
divided  portions.  Systematic  lavage  of  the  intestinal  tract  is  advisable 
in  excessive  tympanites.  In  cases  in  which  pronounced  meteorism 
occurs  the  use  of  hydrochloric  acid  in  small  doses  after  each  feeding  is 
serviceable,  since  the  secretion  of  this  agent,  which  normally  inhibits 
putrefactive  changes,  is  lessened.^  Mild  purgation  Avith  calomel,  espe- 
cially in  the  earlier  stages,  is  useful.  Carbolic  acid,  iodin,  sulphocarbolate 
of  zinc,  and  other  antiseptic  agents  have  their  advocates. 

Turpentine  fulfils  a  leading  indication.  When  the  tongue  is  dry  and 
brown,  the  abdomen  distended,  the  general  prostration  marked,  and  often 
muttering  delirium  present — symptoms  of  the  typhoid  state — the  use  of 
this  agent,  together  with  alcoholics,  constitutes  the  best  mode  of  treat- 
ment. Of  the  rectified  oil  of  turpentine,  ITLv-x  (0.333—0.666)  may  be  ad- 
ministered every  third  hour  until  relief  is  afforded. 

(7)  Curative  Inoculations  with  Cultures  and  Serum. — In  1897  Boken- 
ham^  prepared  an  antityphoid  serum  from  the  horse.  Chantemesse* 
has  treated  1000  cases  (using  his  own  serum),  with  a  death-rate  of 
4.3  per  cent.,  while  of  5121  patients  who  received  routine  treat- 
ment during  the  same  period,  17  per  cent.  died.  Hughes  and  Carter 
treated  a  number  of  cases  with  blood-serum  derived  from  convalescent 
cases,  but  apart  from  a  decided  lowering  of  temperature  the  general  course 
of  the  disease  was  not  perceptibly  modified.  H.  Forssman  treated  20 
cases  with  the  typhoid  serum  of  Kraus,  and  in  those  in  which  it  was  used 
early  in  the  first  week,  the  disease  showed  a  mildness,  which  otherwise 
occurred  only  as  an  exception  during  the  epidemic.     M.  W.  Richardson,^ 

1  Med.  News,  February  11,  1899. 

2  See  Therap.  Gaz.,  April  15,  1900,  by  the  writer. 

^  Transactions  London  Pathological  Soc,  vol.  xlix.,  p.  373^ 

^Hyg.  gen.  et  appliq.,  1907,  p.  577. 

^  Boston  Medical  and  Surgical  Journal,  Oct.  3,  1907. 


62  INFECTIOUS  DISEASES. 

from  a  study  of  specific  therapy  in  130  cases  of  typhoid  fever  "with 
Vaughan's  non-toxic  residue  of  the  typhoid  bacillus,  concludes  that  it 
prevents  relapses  if  inoculations  are  continued  into  convalescence.  The 
value  of  vaccines  for  the  following  purposes  must  be  conceded :  "(1)  As  a 
means  of  prophylaxis ;  (2)  in  suitable  cases  when  continued  during  con- 
valescence, to  prevent  relapses  ;  (3)  to  combat  local  infections  with  the 
typhoid  l)acillus,  as,  for  example,  bone  suppurations  which  arise  in  the 
period  of  convalescence ;  and  (4)  for  the  removal  of  the  typhoid  bacilli 
from  the  feces  and  urine  in  the  case  of  typhoid  carriers.  "  ^ 

Chantemesse,  Walters  and  Eaton,  Sadler,  and  others  report  marked 
reduction  of  the  mortality-rate  of  this  disease  under  vaccine  therapy.  All 
observers,  however,  agree  that  very  severe  cases  show  no  improvement. 
The  dosage  has  varied  greatly  with  different  clinicians,  e.g.,  Sadler  found 
an  initial  dose  of  1,000,000  to  2,000,000  killed  bacilli  injected  subcutan- 
eously  most  beneficial,  followed  by  a  smaller  dose  every  four  or  five  days. 
•'  On  the  other  hand,  Walters  and  Eaton  used  doses  of  100,000,000  to 
500,000,000  bacilli."-  W.  Broughton-Alcock  states  that  the  living 
sensibilized  bacilli  should  be  preferred. 

(8)  Treatment  of  Individual  Symptoms  and  Complications. — Headache. 
— Early  in  typhoid  the  headache  demands  relief.  Absolute  rest  and 
cold  to  the  head  frequently  suflSce.  Depressant  analgesics  are  to  be 
avoided  so  far  as  possible,  although  it  sometimes  becomes  necessary  to 
resort  to  them.  At  such  times  those  least  objectionable  are  to  be  selected. 
I  have  found  that  a  mixture  containing  sodium  bromid  (gr.  x  to  xv 
— 0.6480  to  0.9720)  and  the  deodorized  tincture  of  opium  (TTliij  to  v — 
0.1998  to  0.3330)  in  each  dose,  given  at  intervals  of  three  or  four  hours, 
exercises  a  striking  palliative  influence.  In  occasional  instances  the 
above  mixture  fails,  and  then  phenacetin  (gr.  ij  to  iij — 0.1296  to 
0.1944)  may  be  substituted  for  the  opium  in  the  same  combination. 

Insomnia. — The  cold  baths  or  other  measures  calculated  to  relieve 
the  headache  often  procure  for  the  patient  refreshing  sleep.  It  is  im- 
portant not  to  allow  him  to  go  too  long  without  sleep,  since  this  tends 
to  the  development  of  a  pronounced  "typhoid  state"  and  its  concomi- 
tants. When  the  agents  recommended  for  the  headache  fail,  I  employ 
morphin  hypodermically  in  small  doses  (gr.  -J^  to  \ — 0.004  to  0.008) 
during  the  evening  hours  with  excellent  results,  withdrawing  the  remedy 
so  soon  as  decided  amelioration  of  this  symptom  has  taken  place. 
Codein,  sulfonal,  and,  more  recently,  veronal,  trional,  and  chloralamid, 
have  proved  useful. 

Chloral  is  certain  in  its  action,  but  I  have  abandoned  its  use,  since  it 
apparently  produced  circulatory  collapse  in  two  instances. 

Delirium. — Since  the  introduction  of  the  Brand  method  delirium 
rarely  calls  for  special  medication.  I  have  observed,  in  common  with 
others,  particularly  during  the  advanced  stages,  that  in  cases  in  which 
the  circulation  was  feeble  and  in  which  typhomania  was  a  prominent 
feature,  the  administration  of  stimulants  with  a  free  hand  completely 
dispelled  the  nervous  phenomena.  If  alcohol  fails,  ether  (iTtx — 0.666 — 
at  a  dose)  may  be  given  hypodermically,  and  repeated  in  one  or  two 
hours    if  necessary.      To  combine   with  the  arterial  some  nervous  stimu- 

^  Journal  of  the  American  Medical  Ass^ocintinn,  Dec-  10,  1910,  by  the  writer. 
2  Editorial,  .lonr.  Amer.  Med.  Assoc,  June  29,  1912,  p.  2035. 


TYPHOID   FEVER.  63 

lant  (musk,  valerian)  will  be  found  serviceable,  particularly  in  cases  in 
which  the  delirium  assumes  an  hysteric  type.  Of"  special  value  are  the 
bromids,  hyoscin  hydrobromate,  the  persistent  use  of  ice  to  the  head,  and 
the  agents  suggested  for  the  headache  and  insomnia. 

Vomiting  is  rarely  troublesome.  Its  chief  cause  is  the  irritation  of 
the  gastric  mucosa,  from  improper  diet  or  medication.  After  the  re- 
moval of  the  cause,  the  use  of  ice  in  small  pieces  by  .swallowing  affords 
relief.  If  vomiting  occur  during  the  period  of  development,  minute 
doses  of  calomel,  combined  with  sodium  bicarbonate,  may  be  prescribed 
with  good  effect.  If  it  occur  during  the  fastigium,  the  amount  of  milk 
taken  should  be  reduced  by  one-half,  peptonized,  and  then  diluted, 
preferably  with  lime-water.  If  the  patient  experience  a  strong  aversion 
to  milk,  it  must  be  suspended  temporarily  and  albumin  water  and  broths 
substituted.  Dry  champagne  may  be  administered  simultaneously.  Ex- 
cessive irritability  of  the  stomach  calls  for  rest  of  the  organ  for  a  period 
of  twenty-four  hours,  the  patient  being  meanwhile  supported  by  rectal 
alimentation  and  subcutaneous  medication. 

Diarrhea  more  than  any  other  single  symptom  claims  special  attention. 
Two  to  four  movements  daily  do  not  constitute  diarrhea  and  do  not  de- 
mand treatment.  It  may  be  caused  by  overfeeding  or  by  improper  food 
—as  shown  by  the  stools,  as  a  rule — in  which  case  regulation  of  the  diet 
is  curative.  It  is  often  due  to  ulcerated  and  catarrhal  lesions  of  the 
intestines,  and  particularly  the  large.  Unquestionably,  intestinal  anti- 
septics which  possess  the  property  of  insolubility  are  most  valuable. 
Astringents  may  be  combined  with  the  latter  or  given  separately.  The 
subjoined  formulae  have  yielded  good  results  in  my  own  hands : 

!^.  Betanaphtol,  3j  (4.0)  ; 

Bismuth,  subgallat.,     3ij  (8.0). 
M.  et  ft.  capsulse  No.  xxiv. 
Sig.  One  every  two  or  three  hours. 

^.  Plumbi  acetat.,  gr,  xxiv  (1.555) ; 

Phenylis  salicylat.,  3ss(2.0). 

M.  et  ft.  capsules  No.  xii. 
Sig.  One  every  three  or  four  hours,  as  required. 

Large  doses  of  bismuth  (gr.  xxx — 2.0)  every  third  hour  are  useful. 

Late  in  typhoid  fever,  when  the  ulcers  are  fully  developed,  opium  is 
of  service ;  it  tends  to  arrest  the  peristaltic  action  which  keeps  up  the 
diarrhea  and  favors  the  spread  of  the  inflammation  to  the  peritoneum. 
When  distention  is  increased  by  the  use  of  opium  it  is  to  be  omitted.  I 
have  recently  observed  brilliant  results  from  the  use  of  rectal  injections  of 
an  astringent  solution  (tannic  acid  1-2  per  cent.),  alternated  with  an  anti- 
septic solution  (salicylic  acid  1-2  per  cent.),  each  given  once  daily. 

Constipation  is  to  be  relieved  by  simple  enemata  of  soapsuds  every 
second  day.  Calomel  may  be  used  in  the  early  stage  of  dynamic  cases. 
Its  employment  may  be  followed  by  symptoms  of  a  milder  type  than  are 
ordinarily  encountered.  If  constipation  exists  during  the  third  week,  ac- 
companied by  an  oscillating  temperature-curve,  saline  laxatives  in  small 
but  repeated  doses  may  cut  short  the  attack. 


Or, 


64  INFECTIOUS  DISEASES. 

Tympanites. — This  is  sometimes  a  most  distressing  symptom,  and 
treatment  should  be  commenced  early.  As  a  remedy  for  tympanites  tur- 
pentine is  excellent  and  richly  deserves  a  trial,  but  it  does  not,  as  some 
claim,  influence  the  general  course  of  the  disease.  When  employed  for 
this  symptom  alone  I  prefer  to  apply  it  in  the  form  of  stupes  over  the 
abdomen,  although  when,  as  is  frequently  the  case,  the  gases  occupy 
chiefly  the  large  bowel,  turpentine  enemata  should  be  given.  Irrigation 
of  the  colon  with  the  normal  saline  infusion  has  recently  proved  most 
effective  in  relieving  excessive  tympanites.  Eserine,  gr.  yj-^^,  every  third 
hour,  administered  hypodermically,  sometimes  proves  efficient. 

The  meteorism  is  often  increased  by  the  milk  taken,  and  a  change  of 
food  to  meat-juices  and  albumin-water  may  be  tried. 

Hemorrhages. — The  bowel-movements,  if  the  hemorrhage  has  been 
copious,  must  be  allowed  to  pass  into  the  draw-sheet.  The  ice-bag  (sus- 
pended if  possible)  should  be  applied  to  the  right  iliac  region,  and  ice 
ireely  given  by  the  mouth.  Morphin,  to  control  peristalsis,  must  be 
given,  and,  by  preference,  hypodermically.  It  may  be  supplemented  by 
full  doses  of  the  acetate  of  lead.  Cases  in  which  slight  oozing  appears 
from  time  to  time  require  turpentine.  Adrenalin  chlorid  is  serviceable, 
and  Cnrtin '  derived  advantage  from  the  use  of  suprarenal  extract  in 
cases  in  which  there  was  general  hemorrhage.  The  amount  of  food 
should  be  greatly  restricted,  and  in  serious  bleedings  abstinence  from  food 
for  from  twelve  hours  to  three  or  four  days  is  to  be  observed.  When 
feedings  are  resumed,  a  teaspoonful  or  tw^o  of  cold  milk  (repeated  every 
two  hours)  may  be  given  during  the  first  twelve  hours,  then  gradually 
increased  in  amount.  For  severe  hemorrhages,  saline  infusion,  either 
by  the  method  of  intravenous  injection  or  by  hypodermoclysis  or  entero- 
clysis,  is  to  be  strongly  advised.  The  saline  solution  not  only  raises  the 
blood-pressure  in  the  vessels,  but  it  also  has  a  hemostatic  action.  The 
proper  strength  is  8  :  1000,  and  from  10  c.c.  (3  fluidrams)  to  one-half 
liter  may  be  employed  if  the  collapse  is  marked,  and  repeated  several 
times  in  the  course  of  a  day.  Rectal  injections  may  be  somewhat  larger. 
McCrae^  advises  calcium  lactate  in  doses  of  20  grains  a  day  ;  it  may  be 
given  subcutaneously,  if  rapid  action  is  desired,  in  a  1  per  cent,  solution. 
Calcium  salts  are  indicated  where  the  coagulation  time  is  slow.  In  case 
the  blood  gives  a  poor  agglutination  reaction,  phlebotomy  to  the  extent 
of  about  10  ounces  (according  to  the  physical  condition  of  the  patient) 
may  be  tried.  On  the  other  hand,  Avith  the  patient  in  extremis,  trans- 
fusion may  prove  effective. 

Peritonitis. — Operation  for  perforation  offers  some  hope  of  cure,  and 
with  the  progress  of  convalescence  the  chances  of  recovery  from  this  acci- 
dent improve.  Deaver  regards  the  acute  development  of  pain  and  gen- 
eralized abdominal  rigidity"  and  tenderness  as  an  urgent  indication  for 
immediate  celiotomy.  Keen's  statistics  show  that  between  twelve  and 
twenty-four  hours  after  perforation  is  the  most  favorable  time  for  opera- 
tion, this  period  giving  30  per  cent,  of  recoveries.  Le  Conte^  holds  that 
it  should  be  immediately  undertaken.  Rarely,  appendicitis  supervenes 
in  typhoid  fever.     It  demands  prompt  removal  of  the  appendix. 

1  Prnc.epdincjH  Fliila.  Co.  Med.  Soc,  Nov.,  1902. 
^Jour.  Amer.  Med.  A.tsoc,  Sept.  19,  1908. 
^Jour.  Amer.  Med.  Assoc,  Nov.  8,  1902. 


TYrilOID  FEVER.  65 

Lobar  Pneumonia. — Its  treatment,  when  a  complication,  ■will  be  con- 
sidered hereafter  [vide  Secondary  Pneumonia).  Pneumo-typhoid  requires 
the  same  measures,  until  the  true  typhoid  symptoms  arise,  as  primary' 
adynamic  pneumonia  {vide  p.  126). 

The  hypostatic  congestion  of  the  lungs  is  to  he  met  by  heart- 
stimulants  and  by  frequently  changing  the  position  of  the  patient. 

Bronchitis. — No  special  measures  are  necessary  when  the  bron- 
chitis is  confined  to  the  larger  tubes,  as  in  typical  cases,  while,  if 
diffuse,  its  management  is  like  that  of  h-onclto-rrneumnnia  {vide  p. 
559). 

Laryngitis. — For  this  condition  counter-irritation  should  be  tried; 
and  if  this  fails,  a  small  blister  may  be  applied  below  the  angle  of  the 
jaw  on  either  side.  For  edema  of  the  larynx  scarification  and  the 
inhalation  of  steam  are  useful  measures.  Then,  should  suffocation 
become  imminent,  tracheotomy  should  be  performed  without  delay. 
Operation  "gives  a  mortality  of  only  55.5  per  cent."  (Keen). 

Bed-sores. — The  preventive  measures  have  already  been  considered, 
but  the  smallest  bed-sore  demands  active  treatment.  It  is  to  be  kept 
clean  and  dusted  with  a  powder  composed  of  equal  parts  of  boric  acid, 
calomel,  and  bismuth  ;  if  sluggish,  with  a  powder  made  up  of  aristol  and 
iodoform. 

Thrombosis  of  the  femoral  vein  is  best  treated  by  elevating  the  part 
and  keeping  it  at  perfect  rest.  An  ointment  composed  of  equal  parts  of 
unguentum  ichthyol  (12  per  cent.),  lanolin,  and  unguentum  belladonna, 
may  be  applied  along  the  course  of  the  affected  vessel  thi'ice  daily. 

(9)  Management  of  Convalescence. — Some  of  the  points  connected  with 
this  subject  have  already  been  discussed  {diet,  time  for  getting  up,  etc.). 
I  may  add  that  should  a  recrudescence  occur  the  patient  should  be  kept 
at  rest  in  the  recumbent  posture  and  a  return  made  to  the  liquid  forms 
of  food.  Often  a  moderate  laxative  serves  a  good  purpose,  particularly 
if  an  indiscretion  in  diet  have  been  committed.  The  ulcers  may  not  be 
healed,  though  the  temperature  may  have  been  normal  for  a  week  or  ten 
days ;  hence  the  patient  should  not  be  allowed  to  stir  about  for  a  period 
of  two  weeks  after  the  temperature  has  become  normal.  At  first 
his  movements  should  be  slow ;  he  may  soon,  however,  be  allowed  to 
exercise  gently  in  the  open  air  during  seasons  of  favorable  weather. 
Mental  excitement  is  to  be  avoided.  Occasionally  during  convalescence 
the  diarrhea  persists,  being  due  to  colonic  ulceration,  and  is  best  treated 
by  restricting  the  diet  to  milk  and  other  light  forms  of  albuminous  food. 
The  patient  must  be  confined  to  bed.  Medicinal  treatment  by  the  oxid 
of  zinc  internally  and  the  use  of  astringent  and  antiseptic  rectal  injec- 
tions, as  before  indicated,  usually  proves  successful.  Constipation  is  best 
relieved  by  simple  enemata.  Most  patients  require  tonics.  «We  should 
begin  with  a  vegetable  salt  of  iron  in  combination  wifh  a  simple  bitter 
{e.  g.,  infusion  of  gentian),  and  later  an  inorganic  salt  of  iron,  with  quinin 
and  strychnin,  may  be  used.  Relapses  are  to  be  treated  as  primary 
attacks. 


QQ  INFECTIOUS  DISEASES. 

Paratyphoid   Fevers. 

This  term  is  applied  to  a  group  of  affections  that  closely  simulate 
typhoid  fever  clinically,  but  are  due  to  different  niicrobic  cause. 

Pathologfy. — The  anatomic  clumges  are  simply  those  of  septicemia 
with  splenic  swelling  and  occasionally  non-specific  ulcers  in  the  intestine. 
H.  Gr.  Wells  and  L.  0.  Scott  ^  have  summarized  the  pathologic  findings 
of  5  cases  of  paratyphoid  and  concluded  that  its  pathology  is  different 
from  that  of  ordinary  typhoid.  In  3  cases  reported  the  ulcers  resemble 
those  of  dysentery  rather  than  those  of  typhoid ;  there  are  slight,  if  any, 
changes  in  Peyer's  patches  or  the  solitary  follicles.  The  mesenteric 
glands  show  alterations,  and  focal  necroses  have  been  noted  in  the  liver. 

Ktiology. — The  disease  is  not  a  unit,  but  is  probably  caused  by 
several  members  of  the  colon  family.  These  organisms  possess  proper- 
ties intermediate  between  the  bacillus  typhosus  and  the  bacillus  coli 
communis.  Longcope^  and  others  have  found  the  paracolon  bacillus; 
Ruxton,  the  paratyphoid  bacillus,  which  is  closely  related  to  the  bacillus 
typhosus.  The  paratyphoid  bacillus  is  regarded  as  ubiquitous  in  certain 
parts  of  Germany.  The  predisj^osinc/  factors  and  soui'ces  of  infection  are 
about  the  same  as  for  true  typhoid  fever.  Sacquep^e  and  Bellot  traced 
an  epidemic  comprising  19  cases  to  a  cook  (paratyphoid  carrier).  Minertz  * 
claims  paratyphoid  to  be  an  entirely  different  disease  from  typhoid,  his 
experience  confirming  the  fact  that  infection  is  derived  from  meat,  espe- 
cially pork,  and  not  from  human  sources.  Bainbridge*  holds  that  meat- 
poisoning  and  paratyphoid  fever  are  distinct  diseases. 

Symptoms  and  Course. — Typical  cases  usually  manifest  features 
that  should  arouse  suspicion  of  their  true  nature.  Brill  has  contrasted 
the  diagnostic  featui^es  of  true  typhoid  fever  and  these  allied  conditions. 

The  incubation-period  is  somewhat  briefer  and  the  onset  more  abrupt 
than  that  of  true  typhoid.  After  three  or  four  days  of  malaise  the 
temperature  rapidly  rises  to  104°  F.  (40°  C.)  or  over,  replacing  the 
characteristic  step-ladder  curve.  Mental  dulness  and  apathy  develop 
earlier  and  are  marked.  The  initial  headache  is  more  intense,  and 
constipation  is  common,  although  diarrhea  is  also  observed.  Brion's 
figures  show  diarrhea  in  18  per  cent,  of  the  cases  and  melena  in  5  per 
cent.  The  spleen  is  enlarged  and  rose-colored  spots  may  appear,  but  the 
Widal  reaction  is  absent.  The  duration  of  paratyphoid  fever  may  be 
short,  and  the  temperature  decline  by  rapid  lysis  or  crisis,  or  it  may  be 
long.  Convalescence  is  also  less  protracted.  J.  H.  Pratt  refers  to  the 
frequency  of  complications  (4  per  cent.) ;  they  differ  but  little,  either  as 
to  incidence  or  character,  from  those  of  typhoid  fever.      Relapses  occur. 

Diagnosis. — A  bacteriologic  diagnosis  is  essential.  Cultures  of 
paratyphoid  bacilli  can  be  obtained  from  the  feces,  urine,  rose-spots, 
although  i^teferably  from  the  blood  of  the  veins.  The  various  subtypes 
of  paratyphoid  bacillus  may  be  distinguished  from  one  another  by  agglu- 
tination (Bielyaeff).  It  is  necessary  to  test  simultaneously  the  action 
of  serum  upon  the  typhoid  bacillus  and  upon  the  paratyphoid  bacillus 
obtained  from  the  patient.      Swan  ^  suggests  that  if   a  bloo<l-culture  is 

1  The  Journal  of  InfecHoua  Diseases,  I.,  No.  1,  Jan.,  1904. 

^Amer.  Jour.  Med.  Sci.,  Aug.,  1902.  ^  Medizinische  Klinik,  Berlin,  Sept.  25,  1910. 

'^Lancet,  London,  March  30,  1912.  ^  Amer.  Jour.  Med.  ScL,  May,  1906. 


TYPHUS  FEVER.  67 

sterile,  or  if  it  is  impossible  to  make  such  a  culture,  the  patient  should 
be  catheterized  under  aseptic  conditions  and  his  urine  examined  bacterio- 
logically.  The  paracolon  bacillus  may  thus  be  obtained.  Lessieur  and 
Fischer  state  that  the  diagnosis  should  be  based  on  an  examination  of 
the  blood,  as  the  agglutination  test  is  frequently  misleading. 

Prognosis. — The  course  is  usually  favorable,  although  a  few  fatal 
cases  have  been  reported. 

The  treatment  does  not  differ  from  that  of  true  typhoid  fever. 


TYPHUS  FEVER. 

{Ship-fever,  Camp-fever,  Jail-fever,  etc.) 

Definition. — An  acute  contagious  disease  of  unknown  specific  eti- 
ology. It  is  characterized  frequently  by  an  abrupt  invasion,  and  is 
marked  by  rigor,  high  fever,  early  nervous  symptoms  of  great  promi- 
nence, a  maculo-petechial  eruption  appearing  between  the  third  and 
fifth  days,  and  a  termination  by  crisis. 

Historic  Note. — In  1759  the  name  typhus,  which  is  at  pres- 
ent universally  employed,  was  given  to  it  by  Sauvages.  In  pre- 
sanitary  times  it  prevailed  in  epidemic  and  endemic  forms,  particularly 
in  Ireland  and  Russia,  and  its  devastations  among  the  armies  were  more 
destructive  of  human  life  than  even  shot  and  shell. 

In  1812  typhus  fever  first  appeared  in  America  in  the  New  England 
States.  Its  ravages  did  not  cease  until  every  Eastern  State  had  been 
visited  by  the  plague,  when  it  totally  disappeared.  In  1836  it  reappeared 
in  Philadelphia,  and  with  deadly  eifect.  It  has  been  shown  by  Anderson 
and  Goldberger^  that  typhus  is  identical  with  a  disease  described  by 
Brill,  and  so  far  from  being  extinct  in  the  United  States,  as  has  been 
supposed,  it  has  been  endemic  in  Brooklyn,  Chicago,  New  York,  Phila- 
delphia, and  Atlanta  in  this_  country  during  the  last  two  decades. 

Pathology. — After  death  the  eruption  continues  to  be  visible. 
Rigor  mortis  is  often  delayed. 

Certain  organs  may  present  pathologic  appearances,  but  they  are 
not  constant  and  are  the  result  of  the  secondary  infection  which  the 
typhus  invites.  The  serous  membranes  are  the  seat  of  ecchymoses. 
There  is  hyperplasia  of  the  lymph-follicles,  but  no  subsequent  ulcera- 
tion. The  muscles  are  dark  and  often  show  hyaline  and  granular 
changes ;  the  heart-muscle  is  especially  apt  to  undergo  a  granular 
degeneration.  The  spleen  is  considerably  enlarged,  soft  (even  diffluent 
at  times),  and  of  a  dark  (frequently  bluish)  red  color.  The  liver  is 
somewhat  swollen  and  may  be  softened ;  the  kidneys  may  manifest  the 
changes  belonging  to  nephritis  or  mere  congestion.  In  the  lungs  are 
found  a  variety  of  lesions  peculiar  to  different  complicating  conditions 
(bronchitis,  lobular  pneumonia,  lobar  pneumonia,  pulmonary  congestion, 
edema),  and  occasionally  pleurisy  (serofibrinous  or  purulent)  may  be 
present.  Nervous  lesions  are  conspicuous  by  their  absence.  Commonly 
there  is  cerebral  congestion.  Meningitis,  however,  is  rare.  The  blood- 
changes  are  marked,  the  color  being  dark,  the  fluidity  much  increased, 
while  the  coagulability  is  greatly  diminished. 

1 "  PubUc  Health  Report,"  Feb.  2,  1912,  p.  149. 


68  INFECTIOUS  DISEASES. 

Etiology. — The  direct  cause  or  special  micro-organism  connected 
with  the  typhus  contagion  has  not,  as  yet,  been  isolated,  notwithstand- 
ing the  fact  that  the  morphologic  and  biologic  studies  of  the  blood 
obtained  by  Brannan  and  Cheesman  from  the  finger-tips  of  six  patients 
during  the  mild  epidemic  of  typhus  iit  1803  showed  the  presence  of  a 
bacillus  that  proved  pathogenic  for  rabbits,  guinea-pigs,  and  "white 
mice.^  Lewaschew"  has  also  detected  in  the  blood  of  typhus  patients  a 
distinctive  micro-organism. 

It  is  a  known  fact,  nevertheless,  that  when  typhus  arises  in  a  locality 
in  which  it  was  previously  unknown  it  is  dependent  upon  a  transference 
of  the  typhus  virus  from  without,  and  does  not  arise  spontaneously.  The 
diiferent  modes  of  conveyance  of  this  j^oison  are  imperfectly  known;  it 
may  leave  the  body  in  the  expired  air,  in  the  epithelial  scales  thrown  off, 
and  in  other  excretory  or  secretory  products.  The  poison  is  transmitted 
by  contagion  from  the  patient  to  others  Avho  approach  him  ;  and  it  may 
be  transferred  by  means  of  fomites  (wearing  apparel,  articles  of  furni- 
ture, etc.).  Littlejohn^  reports  an  epidemic,  and  states  that  only  those 
in  intimate  contact  with  the  sick  ap))ear  to  become  infected.  Wilder's 
experimental  studies  and  investigations  show  that  three  insects  are  prob- 
able conveyors  of  the  infection.  These  are  the  flea,  the  bedbug,  and  the 
body  louse,  especially  the  latter. 

Predisposing  Causes. — The  influence  of  insanitary  surroundings  upon 
the  spread  of  this  affection  is  positive  and  vital.  Among  special  condi- 
tions mav  be  mentioned  filth,  poverty,  famine,  and  overcrowding,  and 
hence  it  may  be  inferred  that  typhus  is  a  disease  of  the  lower  classes.  It 
prevails  in  jails  and  camps.  Among  additional  etiologic  influences  are 
overwork,  intemperance,  and  depressing  emotions. 

Age. — The  young  and  middle  aged  furnish  a  preponderant  propor- 
tion of  cases,  owing  to  the  fact  that  they  are  more  liable  to  exposure  to 
the  virus  than  during  other  periods  of  life.  Sex  has  no  influence,  and 
the  season  plays  only  a  minor  part.  Epidemics,  however,  occur  oftenest 
in  winter,  since  the  homes  of  the  underfed  pauper  population  are  illy 
ventilated,  and  hence  favor  concentration  of  the  specific  poison.  It 
almo^it  invariably  prevails  in  an  epidemic  form. 

Clinical  History. — Incubation. — This  lasts  from  nine  to  twelve 
days.  There  may  be  prodromal  symptoms  during  the  concluding  days 
of"  this  period,  such  as  anorexia,  general  malaise,  etc.,  but  in  most 
instances  i)iv<ii<ion  is  sudden. 

Pre-emptive  Stage. — The  early  symptoms  are  either  a  series  of  chills 
or  one  severe  rigor,  accompanied  by  vertigo,  tinnitus,  headache,  muscu- 
lar pains,  profound  prostration,  and  fever.  The  teynperature  quickly 
ascends  to  a  high  level,  reaching  104°  or  105°  F.  (40°  or  40.5°  C)  as 
early  as  the  second  or  third  day.  The  fever  is  continuous  in  type, 
and  in  severe  cases  a  serious  systemic  condition  may  often  be  developed. 
The  pulse  is  accelerated  proportionately  to  the  temperature  and  is  of 
good  volume.  Bronchitis  may  be  present,  the  appetite  is  lost,  and  the 
thirst  is  excessive,  while  a  thick,  yellowish-white  coating  covers  the 
tongue.  Vomiting  occurs,  and  may  be  a  prominent  symptom.  The 
urine  is  often  scanty,  its  specific  gravity  is  increased,  and  it  may  contain 
a  trace  of  albumin.      The  cheeks  are  flushed  and  the  eyes  are  injected. 

^  Annual  of  the  Unlverxai  Medical  Sciences,  1893,  p.  60,  section  H. 

^  Ibid.,  p.  61,  section  II.  ^  Public  Health,  Sept.,  1899. 


TYPHUS  FEVER.  69 

J^ervous  symptoms  appear  early — often  at  the  very  onset — and  are 
quite  pronounced.  At  first  there  may  be  either  mild  or  active  delirium, 
but  soon  there  is  stupor  or  even  coma,  and  the  face  takes  on  a  dull, 
stupid,  besotted  appearance.      The  spleen  is  generally  enlarged. 

Eruptive  Stage. — Between  the  third  and  fifth  days  of  the  invasion 
the  characteristic  eruption  appears  without  an  accompanying  decline  in 
the  temperature.  The  rash  comes  out  first  upon  the  trunk  (chest  and 
abdomen),  extending  thence  over  the  rest  of  the  body,  but,  strangely 
enough,  often  sparing  the  face.  The  crimson-red  maculae  are  changed 
in  two  or  three  days  to  a  darker  hue  (petechije),  and  when  coalescence 
occurs  we  have  the  spotted  effect  that  has  caused  the  name  (jf  sp'otted 
fever  to  be  given  to  it.  This  name  is  also  given  to  cerebro-spinal  men- 
ingitis, in  which,  the  eruption,  however,  does  not  appear  at  any  given 
time  and  is  extremely  inconstant.  Not  all  of  the  maculae  are  converted, 
but  some  may  remain  as  rose-spots,  particularly  in  mild  forms  of  typhus, 
and  these  disappear  when  pressed  upon,  while  the  petechise  do  not.  The 
skin-surface  between  the  spots  is  sometimes  diff"usely  hyperemic,  and  the 
eruption  is  usually  rather  abundant,  though  in  well-authenticated  cases 
it  has  been  scanty  or  even  wholly  missing.  The  skin  may  also  present 
darker  and  lighter  blotches,  producing  a  mottled  appearance.  In  the 
stage  of  eruption  the  symptoms  become  aggravated  in  typical  and  severe 
cases.  The  temperature  continues  high,  often  reaching  106°  F.  (41.1° 
C)  or  even  higher,  with  slight  nocturnal  remissions.  The  pulse  becomes 
quite  rapid  (120—140  or  more),  feeble,  sometimes  dichrotic,  and  irregular, 
and  the  respirations  increase  markedly  in  frequency.  At  this  time 
severe  bronchitis,  leading  to  broncho-pneumonia,  is  apt  to  occur  as  a 
complication.  The  tongue  is  brown,  fissured,  tremulous,  and  occasion- 
ally black  and  rolled  up,  without  power  to  protrude  from  the  mouth. 
Sordes  form  on  the  teeth  and  lips.  The  urine  is  scanty,  high-colored, 
and  often  albuminous. 

The  nervous  disturbance  is  intense,  and  may  take  the  form  of  typho- 
mania,  leading  to  complete  coma  or  maniacal  delirium.  The  patient 
often  lies  with  eyes  open,  staring  into  space,  yet  unconscious  {coma-vigil). 
The  motor  nerves  show  derangement  (tremors,  subsultus  tendinum).  and 
carphologia  (picking  at  the  bed-clothes)  is  a  common  symptom.  The 
decubitus  is  dorsal ;  the  flushed  cheeks  become  dusky,  the  face  expres- 
sionless, and  the  pupils  often  contracted.  The  prostration  reaches  an 
extreme  degree,  and  absolute  exhaustion  often  terminates  life. 

As  a  rule,  in  favorable  cases  the  end  of  the  febrile  period  comes  by 
crisis  between  the  fourteenth  and  seventeenth  days  of  the  disease.  Imme- 
diately preceding  the  crisis  there  is  generally  a  sudden  rise  of  the  tem- 
perature (perturbafio  critica),  and  the  decline  may  be  interrupted  by 
slight  exacerbations.  The  occurrence  of  the  crisis  is  marked  by  rapid 
improvement  in  the  symptoms.  The  mind  becomes  clear  (sometimes  fol- 
lowing a  profound  sleep),  the  eruption  fades  quickly,  the  facial  phe- 
nomena disappear  in  inverse  order  of  their  appearance. 

Leading  Symptoms  and  Complications. — Course  of  the  Fever. — Although 
the  temperature  rises  rapidly  on  the  first  day  of  the  illness — the  highest 
grade  is  usually  reached  as  late  as  the  fifth  or  sixth  day.  Hyperpyrexia 
usually  heralds  a  fatal  termination,  the  temperature  mounting  to  108°, 


70  INFECTIOUS  DISEASES. 

109°  F.  (42.7°  C),  or  higher,  though  in  light  cases  the  acme  may  not 
exceed  103°  F.  (39.4°  C).  The  temperature  pursues  the  continued  type 
and  ends  by  crisis.  Occasionally  the  fever  declines  by  rapid  lysis. 
About  the  beginning  of  the  second  week  the  patient  emits  a  disagreeable 
odor  that  is  regarded  as  characteristic  by  some  writers. 

The  limgs  frequently  present  complications  {vide  Pathology),  among 
•which  are  bronchitis,  broncho-pneumonia,  and  hypostatic  congestion. 
Broncho-pneumonia  is  dangerous,  its  develo])ment  often  preceding  a  fatal 
termination,  and  it  may  lead  to  pulmonary  gangrene  and  empyema. 
Sero-iibrinous  pleurisy  and  lobar  pneumonia  also  occur  as  complications, 
and  to  recognize  the  latter  the  physical  signs  must  be  appreciated,  the 
rational  symptoms  being  in  abeyance. 

The  heart  in  typhus  continues  to  grow  progressively  weaker  until,  in 
many  cases,  a  fatal  issue  is  reached.  This  is  manifested  by  the  change 
in  the  character  of  the  first  sound.  A  systolic  murmur  (probably  of 
hemic  origin)  may  be  audible  at  the  apex. 

The  nervous  phenomena  have  been  sufficiently  detailed.  Meningitis 
has  been  met  Avith,  but  is  rare  as  a  complication.  Arnold^  noted  optic 
neuritis  in  8  out  of  14  cases.  Hemorrhagic  nephritis  rarely  supervenes. 
During  the  febrile  period  the  uric  acid  and  urea  increase  in  quantity, 
Avliile  the  chlorids  decrease. 

The  digestive  tract  rarely  presents  distressing  symptoms  and  compli- 
cations. Hematemesis  is  most  common,  and  cancrum  uris  has  been 
noted  occasionally.  Cases  in  -which  the  mouth  does  not  receive  proper 
care  are  apt  to  develop  parotitis,  which  often  passes  on  to  suppuration, 
and  septic  processes,  causing  abscesses  in  different  parts  of  the  body 
(joints,  subcutaneous  tissue),  may  arise  as  complicating  events. 

Among  the  sequelae,  neuritis,  followed  by  paralyses,  deserves  first 
place,  and  gangrene  of  the  extremities  (toes,  fingers)  has   been  observed. 

The  general  course  and  duration  of  typhus  are  variable.  There  is  a 
mild  type  wiiose  course  is  run  in  from  seven  to  ten  days,  and  in  such  the 
crisis  occurs  soon  after  the  appearance  of  the  eruption.  In  this  type 
the  development  of  serious  symptoms  or  grave  complications  is  the  ex- 
ception. A  malignant  type^  however,  also  occurs  {typhus  siderans),  and 
this  often  proves  fatal  before  the  time  for  the  appearance  of  the  rash. 

Some  epidemics  are  characterized  by  the  relative  frequency  of  light 
forms,  and  others  by  the  severer  types  of  the  disease. 

Diagtiosis. — On  the  known  presence  of  an  epidemic,  the  special 
causative  factors  (unhygienic  surroundings,  exposure  to  the  poison)  and 
the  course  and  characteristic  symptoms,  the  diagnosis  of  typhus  fever 
can  be  made.  Of  special  value  is  the  eruption — its  lime  of  appearance 
(third  to  fifth  day),  mode  of  distribution,  and  petechial  character.  The 
recognition  of  lighter  types,  on  the  one  hand,  and  malignant,  on  the 
other,  is  not  possible  from  the  symptoms  alone,  but  here  a  knowledge  of 
the  existence  of  an  epidemic  in  the  vicinity  is  often  helpful. 

Differential  Diagnosis. —  Cerebrospinal  meningitis  may  be  distin- 
guished by  a  more  intense  headache,  by  retraction  of  the  head,  hyper- 
esthesia, intolerance  of  sounds,  photophobia,  palsies  of  the  eye-muscles 
(strabismus),  a  tendency  to  convulsions,  and  by  both  the  absence  of  the 
typhus  eruption  and  the  expressionless  countenance.  Quincke's  lumbar 
puncture  may  be  practised. 

^  Wiener  KUnische  Wochenschr.,  Aug.  17,  1911. 


TYPHUS  FEVER.  71 

Uremia  is  excluded  by  the  previous  history,  tlie  vomiting,  lieadaclio. 
convulsions,  coma,  and  by  tlic  absence  of  the  higli  temperature  and 
petechial  eruption  of  typhus.  Characteristic  urinary  phenomena  are 
associated  in  uremia,  and  rarely  acute  hemorrhagic  nephritia. 

The  eruption  of  malignant  measles  may  bear  a  close  resemblance  to 
that  of  typhus;  the  rash  in  typhus,  however,  appears  first  upon  the 
trunk,  that  of  measles,  upon  the  face.  Koplik's  spots  do  not  appear  in 
typhus.  Points  connected  with  the  epidemicity  of  measles,  as  the  occur- 
rence of  mild  and  typical  cases,  must  be  taken  into  account.  Typhoid 
fever  is  readily  differentiated  from  typhus  {vide  p.  48).  Typhus  fever 
must  also  be  distinguished  from  Rocky  Mountain  Spotted  Fever  {vide 
p.  327). 

Relapses  are  among  the  rarest  of  clinical  events,  and  one  attack,  as  a 
rule,  bestows  immunity  for  life. 

Prognosis. — To  arrive  at  a  correct  prognosis  it  is  necessary  to  con- 
sider (1)  the  degree  of  severity  of  the  particular  type  from  which  the 
patient  is  suffering,  (2)  the  number  and  character  of  the  complicating 
conditions  present,  and  (3)  circumstances  connected  with  the  individual, 
among  which  his  food-supply  and  sanitary  surroundings  are  to  be  recol- 
lected. Improved  sanitation  has  reduced  both  the  incidence  and  mor- 
tality-rate, which  is  now  between  10  and  20  per  cent. 

Treatment. — This  embraces,  in  the  main,  the  same  principles  that 
were  found  to  govern  the  treatment  of  typhoid  fever. 

Prophylaxis  demands  thorough  disinfection  and  absolute  isolation.  A 
special  hospital  for  contagious  diseases  is  always  to  be  preferred  to  the 
best  accommodations  obtainable  in  private  families.  When,  however, 
patients  cannot  be  transferred  to  special  hospital  wards  the  sick-room 
must  be  kept  clean,  well  ventilated,  and  at  a  temperature  ranging  from 
60°  to  65°  F.  (15.5°  to  18.3°  C).  No  one  other  than  the  doctor  and 
nurse  should  be  allowed  to  occupy  or  even  enter  the  room.  The  thorough 
disinfection  already  described  under  Typhoid  Fever  must  be  enforced, 
and  the  importance  of  supplying  fresh  air  to  typhus  patients,  as  empha- 
sized long  since  by  Alonzo  Clark,  has  been  abundantly  shown  by  the 
great  reduction  of  the  mortality-rate  among  those  treated  in  tents  as 
compared  with  that  in  the  hospital  wards. 

The  general  management,  including  the  use  of  stimulants,  in  this 
disease  does  not  differ  from  that  advised  in  typhoid  fever.  Fresh  water 
should  be  given  freely  at  regular  intervals.  Hydrotherapy  constitutes 
the  best  means  at  our  command  for  controlling  the  temperature  and  the 
nervous  symptoms.  In  addition,  the  use  of  antiseptic  agents  and  tonic 
measures  are  to  be  recommended.  The  fact  that  typhus  is  a  self-limiting 
affection  gives  those  measures  that  are  intended  to  combat  exhaustion, 
and  especially  heart  weakness,  first  rank  in  the  treatment  of  this  aff'ection. 
Strychnin  (gr.  -^ — 0.0015)  and  camphor  in  sterilized  oil  (gr.  ij — 0.13); 
one  or  both  may  be  given  hypodermically  every  third  hour  if  there  be 
failure  of  the  circulation. 


72  INFECTIOUS  DISEASES. 


DYSENTERY. 


Definition. — An  infectious  intlaiunuitory  disease  of  the  large  intes- 
tine, c-baracterized  anatomically  by  ulcerati(,)n  of  tbe  intestinal  mucosa, 
and  cliniually  by  frequent  mucous  and  bloody  discbarges,  tenesmus,  fever 
and  prostration  becoming  profound.  It  is  a  truly  epidemic  disease,  yet 
it  also  occurs  constantly  in  endemic  form,  and  particularly  is  this  true  of 
tem))erato  climates. 

Varieties. — Etiologically  considered,  two  varieties  are  recognized: 
(1)  baciUary  and  {-)  amebic.  Under  baeillary  dysentery  a  description 
of  the  sporadic  form  (catarrhal  dysentery)  will  be  given. 

Historic  Note. — Few  diseases  have  been  longer  known  than  dys- 
entery, of  which  we  have  a  description  by  Hippocrates.  Galen  local- 
ized the  chief  seat  of  the  affection  in  the  colon,  and  in  1626,  Sennertus 
defined  its  sporadic  and  epidemic  character  and  some  of  its  leading  clini- 
cal features.  To  Morgagni  belongs  the  credit  of  having  made  the  first 
postmortem  anatomic  study  of  the  disease.  Further  and  more  accu- 
rate pathologic  contributions  were  made  in  the  earlier  part  of  the 
present  century  by  Cruveilhier  and  Rokitansky,  and,  more  recently  still, 
the  whole  subject  of  the  morbid  anatomy  of  this  disease  has  been  care- 
fully investigated  by  Virchow,  Avhose  results  have  settled  most  of  the 
questions  connected  with  the  subject.  In  the  United  States  dysentery 
has  prevailed  epidemically  upward  of  a  century,  the  time  of  greatest 
prevalence  in  different  districts  having  been  about  the  middle  part  of 
the  present  century  (1847-55).  Woodward  has  given  us  the  only  com- 
plete record  of  the  various  outbreaks  in  this  country,  and  an  account  of 
the  ravages  of  dysentery  in  both  armies  during  the  War  of  the  Rebellion 
is  given  in  his  Mepo7't,  which  records  259,071  cases  of  acute  and  28,451 
of  chronic  dysentery.  The  disease  is  far  less  frequent  than  formerly, 
owing  to  the  advance  made  in  recent  times  in  sanitary  science. 

Htiology. — A  few  general  considerations,  having  reference  to  the 
causation  of  the  different  forms  m  common,  may  be  adduced  here. 

Among  predisposing  factors,  season  heads  the  list,  dysentery  being 
most  common  in  the  summer  and  autumn  ;  great  and  sudden  changes  of 
temperature  are  more  potent  than  equal  changes  in  humidity.  Climate 
has  a  marked  effect,  and  high  temperature  must  be  regarded  as  a  power- 
ful agency,  since  the  disease  is  much  more  prevalent  in  warm  than  in  cold 
climates,  though  it  is  met  with  in  epidemic  form  as  far  north  as  Norway. 
Malarial  districts  suffer  more  than  non-malarial.  Unhygienic  coriditions, 
as  shown  by  the  local  epidemic  outbreaks  in  armies,  jails,  barracks, 
institutions,  etc.,  predispose  to  the  affection. 

Among  factors  connected  with  the  individual  are:  {a)  Catarrhal  co\n\\- 
tions  of  the  intestinal  tract,  particularly  if  this  be  caused  by  unripe  fruit 
or  other  unwliolesome  forms  of  food ;  {b)  Age.  Although  no  age  enjoys  im- 
munity against  dysentery,  most  cases  are  met  with  in  adults  under  thirty- 
five  years.      Sex  and  race  are  probably  without  appreciable  influence. 

(1)  Bacillaby  Dysentery. 

(-1  <:ul('  Dijitcntcry.) 
This  term  is  appropriately  applied  to  the  usual  acute  epidemic  form 
of  the  disease.     I  shall  describe  here  two  clinical  types :  («)  catarrhal 


DYSENTERY.  73 

dysentery  anrl  (/>)  diphtheritic.  It  is  pro})able,  hut  not  proved,  that  all 
of  the  cases  of"  bacillary  dysentery  are  due  to  a  common  micro-organism 
— the  Shiga  bacillus  (Bacillus  dysenteriai). 

The  classification  of  catarrhal  dysentery,  therefore,  still  rests  upon  its 
clinical  and  pathologic  manifestations,  although  many,  if  not  all,  of  the 
cases  as  shown  by  the  observations  of  Vedder  and  Duval  ^  are  etiologically 
identical  with  epidemic  tropical  dysentery.  Flexner's  statistical  studies 
indicate  tliat  the  Bacillus  dysenterijB  (especially  the  so-called  "  Flex- 
ner-Harris  ''  type),  can  be  isolated  from  the  intestinal  discharges,  and 
the  intestinal  mucosa  of  "  a  large  percentage  of  children  suffering  from 
the  diarrheal  diseases  prevailing  along  the  Atlantic  sea-board  of  the 
United  States  during  the  summer  months."^ 

(a)  Catarrhal  Dysentery. 

{Sporadic  Dysentery.) 

Pathology. — The  solitary  follicles  are  affected  chiefly,  and  are  the 
seat  of  hyperplasia,  folloAved  by  necrosis,  with  the  formation  of  small 
ulcers.  This  is  common  in  children.  There  may  be  a  purulent  inflam- 
mation of  the  entire  mucosa,  w^ith  more  or  less  erosion  of  the  surface,  and 
superficial  ulceration  exists.  In  both  forms  the  lesions  are  mainly  con- 
fined to  the  large  intestine,  though  the  ileum  is  sometimes  implicated. 

Special  Btiology. — The  catarrhal  form  of  the  disease  is  the  one 
most  commonly  met  in  the  United  States,  and  is  to  be  classed  Avith  acute 
dysentery  ;  it  may  accompany  some  of  the  acute  infections  (scarlatina, 
malaria,  typhoid  fever,  tuberculosis),  and  is  seen  in  institutions. 

Clinical  History. — There  may  be  prodromes.,  lasting  one  or  two 
days,  which  take  the  form  of  a  mild  gastro-intestinal  disorder  (anorexia, 
slight  pains  in  the  abdomen,  followed  by  diarrhea). 

The  characteristic  symptoms  are  mild  colicky  pains  in  the  abdomen, 
followed  by  discharges  from  the  bowel,  which  at  first  number  from 
three  to  six  daily.  Soon  they  become  frequent  and  are  accompanied 
by  straining  and  tenesmus,  and  now  their  number  ranges  from  ten  to 
no  less  than  one  hundred  or  more  per  day.  Indeed,  the  desire  to  go 
to  stool  may  be  almost  constant,  and  the  rectum  is  the  seat  of  intense 
burning  sensations  during  and  after  each  evacuation  of  the  bowel.  The 
character  of  the  discharges  varies  with  the  diflfereut  periods  of  the  aff'ec- 
tion.  During  the  first  thirty-six  or  forty-eight  hours  they  are  feculent 
(sometimes  scybalous  masses),  rather  copious,  and  intermingled  Avith  some 
mucus  and  blood.  For  the  next  four  or  five  days  the  stools  are  scanty, 
measuring  from  2  drams  (8.0)  to  \  ounce  (16.0),  and  are  made  up  of 
a  sero-mucous  fluid  or  of  a  muco-purulent  material  with  blood.  The 
chief  constituents  of  the  stools  are  mucus,  blood,  and  pus,  any  one  of 
which  may  preponderate. 

Microscopic  examination  of  the  usually  glairy  stools  shows  red  blood- 
corpuscles,  numerous  leukocytes,  generally  large,  oval  or  round  epithe- 
lioid cells  containing  fat-2;]obules,  vacuoles,  and  bacteria  (especially 
those  connected  with  putrefaction). 

A  few  shreds  (portions  of  necrosed  mucous  membrane)  may  appear 

^  Jour.  Exper.  Med.,  Feb.  5,  1902. 

■*  Studies  from  the  Rockefeller  Institute  for  Medical  Research.    Reprints,  vol.  ii.,  1904,  p.  134. 


74  INFECTIOUS  DISEASES. 

from  time  to  time  in  the  dejecta.  At  the  close  of  the  first  week,  and  a 
little  later,  the  discharges  become  less  frequent  and  the  amount  of  mucus 
and  blood  diminishes.  The  stools  are  now  of  a  greasy  brown  or  dark- 
green  appearance,  fecal  matter  reappearing  in  them,  and  soon  they  are 
again  fully  formed. 

Other  Symptoms  Referable  to  the  Alimentai^y  Tract. — The  tongue 
has  a  greasy  coating — moist  at  first,  dry  later — and  at  last  may  become 
red  and  glazed.  Anorexia  is  present,  with  excessive  thirst,  and  vomit- 
ing may  rarely  occur.  There  will  usually  be  tenderness  over  the  line  of 
the  colon,  but  there  is  an  absence  of  tympanites. 

The  general  symptoms  are  Avell  marked  only  in  the  severer  types. 
The  patient  is  debilitated,  sometimes  even  collapsed,  as  shown  by  the 
small,  frequent  pulse,  cool  skin-surface,  the  rapid  wasting,  and  weak, 
hoarse  voice.  The  temperature  is  not  much  elevated,  though  it  may 
touch  103°  or  104°  F.  (39°  or  40°  C),  and  the  curve  is  an  irregularly 
remittent  one. 

Diagnosis. — This  can  easily  be  made  upon  the  intestinal  features 
and  from  the  character  of  the  stools — frequent,  small,  slimy  (or  bloody) 
discharges,  accompanied  by  distressing  tenesmus. 

Differential  Diagnosis. — Symptoms  simulating  dysentery  may  appear 
in  the  course  of  certain  rectal  affections,  such  as  strangulated  hemor- 
rhoids, syphilis,  and  epithelioma.  In  these  conditions  there  is  a  different 
history  and  the  symptoms  of  proctitis  are  less  acute,  while  a  physical  ex- 
amination of  the  rectum  will  settle  the  diagnosis  in  doubtful  cases. 

Prognosis. — The  duration  of  mild  cases  is  from  eight  to  ten  days, 
and  in  severe  types  from  three  to  four  weeks.  The  prognosis  varies  ac- 
cording to  the  type  of  the  affection ;  but  commonly  this  is  not  aggravated 
and  recovery  is  to  be  expected.  Occasionally,  however,  the  disease  is 
threatening  to  life.  Serious  nervous  symptoms  (delirium  followed  by 
coma)  may  develop  and  cause  a  fatal  termination.  When  death  occurs  it 
is  usually  due  to  exhaustion,  and  is  seen  particularly  in  persons  previously 
enfeebled  by  disease  or  in  the  very  young  and  the  aged.  Complications 
influencing  the  prognosis  are  exceptional.  This  variety  probably  does 
not  occur  in  extensive  epidemics ;  but  it  prevails  in  tropical  and  sub- 
tropical countries,  and  also  throughout  Europe  and  North  America. 

(6)  Diphtheritic  Dysentery. 

(Acuie  Tropical  Dysentery.) 

Definition. — An  intestinal  inflammation  (usually  colonic),  accom- 
panied by  a  croupous,  or  true,  diphtheritic  exudation.  It  is  epidemic 
in  Japan,  but  prevails  Avherever  large  numbers  of  persons  are  closely 
associated,  as  in  armies,  asylums  for  the  insane,  ships,  and  the  like. 

Pathology. — In  mild  grades  a  grayish-yellow,  croupous  exudate 
appears  upon  the  inflamed  mucosa,  with  a  necrosis  of  the  epithelial 
layer  that  is  often  limited  to  the  top  surface  of  the  folds  of  the  colon. 
In  other  instances  the  diphtheritic  infiltration  involves  all  the  layers  of 
the  bowel,  which  now  becomes  greatly  enlarged,  its  mucous  membrane 
being  converted  into  a  yellowish-brown,  thick,  elastic  mass,  sometimes 
extending  along  the  entire  length  of  the  large  intestine.  The  changes 
may  be   confined  to  the   circumscribed  areas  (flexures  of  the  colon  and 


DYSENTERY.  75 

rectum),  and  thick  sloughs  may  be  cast  off,  leaving  behind  ulcers  of  cor- 
responding size  and  depth.  The  morbid  changes  in  some  cases  are  prin- 
cipally ulcerative  in  character,  simulating  those  described  under  Catairhal 
Dysentery  (vide  p.  73),  Indeed,  the  pathologic  unity  of"  the  various 
forms  of  bacillary  dysentery  would  appear  to  be  almost  established. 

Bacteriology. — The  distinctive  pathogenic  agent  is  the  Bacillus  dysen- 
terice  discovered  by  Shiga  ^  during  his  investigations  into  Japanese  dys- 
entery. Flexner  found  the  same  organism.  Duval,  Harris,  and  Flexner 
have  described  different  races  of  the  Bacillus  dysenterifje,  showing  that 
decisive  criteria  of  difference  are  observable,  which  separate  this  organism 
from  the  Bacillus  typhosus.  The  Bacillus  dysenteriae  is  not  normally 
found  in  the  intestines.  The  Shiga  bacillus,  however,  "  is  inactive  to 
blood-serum  from  typhoid  cases,  but  reacts  with  serum  from  dysenteric 
cases  to  which  bacillus  typhosus  does  not  respond"  (Flexner).  It  may 
be  that  a  number  of  bacilli  which  closely  resemble  one  another,  yet  dif- 
ferent, are  capable  of  causing  epidemics  of  true  dysentery.  PfuhP 
found  dysentery  bacilli  in  the  intestines  of  soldiers  returned  from  China 
one  year  after  the  initial  attack  ;  this  persistence  may  have  a  bearing  on 
the  geographic  distribution  of  bacillary  dysentery  and  its  spread  in  the 
United  States  since  the  Spanish- American  war.. 

Mode  of  Conveyance. — Messrs.  Ryder,  Richards,  Peabody,  Can- 
avan,  and  Southard  studied  an  institutional  epidemic  in  which  the  first 
case  was  probably  an  introduced  probable  carrier ;  they  believe  that  the 
epidemic  was  due  to  flies,  and  that  occasional  cases  of  dysentery  depend 
mainly  on  contact-infection  with  the  products  of  intramural  carriers. 

Clinical  History. — The  affection  usually  has  an  acute  onset,  and 
one  characterized  by  an  appearance  simultaneously  of  severe  local  and 
general  symptoms.  There  may  be  an  initial  ehill,  and  there  is  fever, 
which  rises  rapidly,  together  with  a  marked  and  early  appearing  pros- 
tration and  delirium.  The  fever-curve  is  of  the  irregularly  remittent 
type  and  its  range  is  somewhat  higher  than  in  the  catarrhal  form  of  the 
disease.  The  pulse  is  greatly  accelerated  and  tends  to  become  erratic 
both  as  to  rhythm  and  volume.  Active  delirium  is  common  and  may 
alternate  with  or  merge  into  coma.  Severe  abdominal  pains  are  com- 
plained of,  and  the  discharges  may  be  numerous,  containing  shreds  and 
large  sloughs,  or  even  tubular  pieces,  of  false  membrane.  When  these 
elements  are  present  in  the  stools,  the  latter  are  of  a  dark-brown  color, 
emitting  a  fetid  odor,  and  generally  containing  more  or  less  blood  and 
mucus.  The  dejecta  are  more  hemorrhagic,  as  a  rule,  than  in  the  simple, 
catarrhal  variety.  Tenesmus  may  be  intense.  There  is  an  absence  of 
polynuclear  leukocytosis  in  this  disease. 

The  physical  signs  are  often  prominent.  The  belly  in  most  instances 
is  greatly  distended,  and  on  pressure  very  tender — signs  due  to  the  fact 
that  the  lesions  are  situated  chiefly  in  the  large  bowel. 

The  diagnosis  rests  upon  the  intestinal  symptoms  and  the  character 
of  the  dejections,  associated  with  a  grave  general  condition  suddenly 
developed.  As  accessory  factors  to  the  recognition  of  this  variety  are 
the  finding  of  the  false  membrane  in  the  dejecta,  and  the  appearance  of 
the  cases  in  an  epidemic  form.  An  absolute  diagnosis  demands  either 
the  isolation  of  dysentery  bacilli  from  the  dejecta  (which,  however,  are 

1  Ceniralbl.  f.  Bakf.  u.  Parasitenk,  1898,  xxiv.,  Nos.  22-24. 

2  Munch,  vied.  Wochen.,  Feb.  11,  1902. 


76  INFECTIOUS  DISEASES. 

rarely  present  in  mild  cases  and  durinn;  the  first  days  of  the  disease)  or 
the  agglutination  reaction  of  the  blood-serum,  and  this  serves  to  dift'ei-en- 
tiate  bacillary  dysentery  from  allied  maladies,  including  typhoid  fever. 

Complications. — These  are  both  numerous  and  varied,  and  include 
perforation  of  the  gut  followed  by  peritonitis,  either  localized  or  general- 
ized (according  to  its  seat) :  also  pleurisy,  endocarditis,  pericarditis, 
parotitis,  "anasarca,  phlebitis,  and  nephritis"  (Rumford).  Hepatic 
abscess  is  never  observed  (Shiga). 

The  prognosis  is  almost  wholly  unfavorable.  The  principal  element 
of  danger  is  the  profound  toxemia,  which  rapidly  leads  to  fatal  asthenia 
in  cases  in  which  the  stools  consist  of  a  blackish  fiuid  with  a  horribly 
fetid  odor  and  of  bits  of  gangrenous  masses  (Duncan).  Shiga  states  that 
the  toxemia  is  most  marked  in  cases  in  which  the  lesions  are  located  high 
up  in  the  intestine,  and  that  the  disease  is  most  fatal  in  winter.  The  numer- 
ous complications  also  exercise  a  lethal  tendency.  Occasionally  recovery 
follows,  though  more  frequently  the  disease  takes  on  a  chronic  course. 

Secondary  Diphtheritic  Dysentery. 

Here  the  lesions  are  similar  in  kind,  but  less  intense,  as  a  rule,  than 
those  of  the  primary  form.  This  variety  is  met  with  as  a  terminal  con- 
dition in  not  a  few  acute  and  chronic  diseases  :  it  often  occurs  in  pneu- 
monia (Bristowe),  and  less  commonly  in  typhoid  fever.  Among  chronic 
affections,  upon  which  this  condition  may  become  engrafted,  are  nephritis, 
organic  disease  of  the  heart,  and  pulmonary  tuberculosis. 

No  characteristic  symptoms  attend  upon  its  invasion.  There  may  be 
slight  diarrhea — two  or  four  liquid  stools  daily — but  it  is  not  often  ac- 
companied by  tormina  and  tenesmus,  and  the  discharges  rarely  contain 
any  noticeable  amount  of  blood,  mucus,  or  shreds  of  pseudo-membrane. 
Secondary  diphtheritic  dysentery  often  induces  fatal  asthenia. 

Sequelae  of  Bacillary  Dysentery. — In  all  forms  a  relapse  is 
likely  to  occur,  each  attack  increasing  the  liability  of  the  patient  to  sub- 
sequent ones.  Moreover,  in  persons  who  have  recovered  from  acute 
dysentery  we  often  observe  a  disordered  digestion  and  irritability  of  the 
bowels.  Rarely,  chronic  nephritis  follows  dysentery.  The  most  inter- 
esting sequel,  however,  is  paralysis,  which  occurs  mainly  in  the  form  of 
paraplegia  (S.  Weir  ]\Iitchell).      Stricture  of  the  bowel  is  rare. 

Treatment. — Prophylaxis. — This  embraces  isolation  and  a  thorough 
disinfection  of  the  discharges,  which  contain  the  specific  germ  of  the 
disease,  as  soon  as  passed.  The  drinking-water  during  the  epidemic 
prevalence  of  dysentery  should  be  thoroughly  boiled,  and  healthy  per- 
sons sliould  avoid  cathartics,  the  use  of  improper  food,  or  such  as  stimu- 
lates intestinal  peristalsis,  while  an  unhygienic  environment  (overcrowd- 
ing, etc.)  is  to  be  corrected  as  far  as  possible.  Shiga  recommends  that 
the  dead  bacillus  emulsion  (heated  at  60°  C.  for  thirty  minutes)  and  a 
specific  immune  serum  be  injected  simultaneously.  One  injection  pro- 
duces active  immunity  and  the  author  tested  the  method  on  about  10.000 
men  in  the  district  of  Japan  '•  where  epidemic  dysentery  prevails  most 
seriously,  and  was  able  to  diminish  the  mortality  in  the  district  from  20 
to  30  per  cent,  to  about  zero."  All  sufferers  from  dysentery  must  be 
kept  in  bed,  and  should  occupy  a  well-aired  apartment. 

The  diet  should  consist  of  milk,  whey,  and  light  animal  broths  dur- 
ing the  period  of  active  intestinal  symptoms.    The  blandest  articles  only 


,       DYSENTERY.  77 

are  either  acceptable  to  the  stomach  or  aHowable  in  the  diphtheritic  vari- 
ety, as  Mellin's  food  (especially  for  children),  egg-white,  and  zoolak,  in 
small  portions.  During  convalescence  a  return  to  the  usual  dietary  is 
gradually  to  be  niado.     All  food  should  be  given  lukewarm. 

Alcoholic  Stimulants. — With  the  development  of  asthenia  and  cardiac 
failure  stimulants  must  be  employed,  as  in  other  acute  infectious  diseases. 
Diphtheritic  dysentery  calls  from  the  very  outset  for  free  stimulation. 
The  diffusible  stimulants  (e.  g.,  champagne)  are  often  invaluable.  Strych- 
nin and  digitalis  (hypodermatically)  may  be  required. 

Medicinal  Treatment. — If  scybalous  masses  be  passing,  a  dose  of  castor 
oil  should  be  administered.  It  is  well  to  convert  dysentery  into  diarrhea. 
Measures  to  deplete  the  mucosa  of  the  intestine  and  at  the  same  time  in- 
hibit undue  peristalsis  are  most  effective,  as  magnesium  sulphate.  Dram 
doses  may  be  given  every  hour  or  two,  until  the  stools  contain  fecal 
matter  and  no  more  blood  or  mucus.  In  the  later  stages  purgatives  are 
attended  with  baneful  effect. 

Ipecacuanha  has  long  been,  and  still  is,  regarded  as  possessing  a 
specific  influence  in  cases  of  dysentery.  Its  administration  is  usually 
preceded  by  a  dose  of  opium  (laudanum  or  morphin)  which  is  given 
when  the  stomach  has  been  empty  for  a  few  hours.  Most  authors  rec- 
ommend that  large  doses — gr.  xx  to  3j  (1.29  to  4.0) — should  be  admin- 
istered ;  but  it  is  probable  that  a  small  dose — gr.  -g-  to  ^  (0.010  to  0.016) 
every  half  hour — is  quite  as  effective ;  and  in  children  the  smaller  doses 
are  to  be  preferred  and  will  be  found  to  be  quite  efficacious.  Other 
remedies  should  also  be  employed,  and  among  these  opium  is  particularly 
beneficial  in  combination  with  ipecacuanha  or  in  the  form  of  Dover's 
powder,  which  contains  both  agencies.  Three  chief  symptomatic  indi- 
cations are  met  by  the  opium — pain,  restlessness,  and  undue  peristalsis 
— and  to  obtain  the  best  effects  from  the  opiate  it  should  be  adminis- 
tered in  the  form  of  morphin  hypodermically.  In  cases  in  which  tenes- 
mus is  an  unusually  distressing  feature  §in  opium  suppository  (gr.  ij — 
0.1296)  or  laudanum  (iTLxxx — 2.0,  by  enema)  exercises  a  beneficial 
effect.  Bismuth  in  full  doses  is  useful  (3ss— j — 2.0-4  0  every  two  hours), 
and  I  have  frequently  found  the  combined  use  of  Dover  powder,  bismuth 
subnitrate,  and  salol  of  signal  service.  Cunningham,  Stengel,  and 
others  have  reported  curative  effects  from  the  employment  of  sulphur ; 
and  Richmann  prescribes  the  following  powder : 

^.   Sulphur  sublimat.,       .  gr.  xviij  (1.20)  ; 

Pulv.  Doveri,  gr.  v  (0.33). 

M.  ft.  chart.  No.  i. 
S.   To  be  taken  every  fourth  hour. 

Antiseptic  substances  by  the  mouth  for  the  purpose  of  disinfecting 
the  intestinal  canal  and  favoring  the  healing  of  the  ulcerated  surfaces 
after  the  removal  of  the  necrotic  pseudo-membrane,  such  as  benzo- 
naphtol  (gr.  xl-lx — 2.592-3.788 — in  the  twenty-four  hours  in  divided 
doses),  salol,  opium,  and  silver  nitrate  are  among  the  remedies  of 
choice.  The  naphtol  preparations  being  insoluble  should  be  given  in 
capsule  and  the  silver  nitrate  in  pill  form  one  hour  after  food.  Iodo- 
form in  a  pill  or  capsule  in  doses  of  i^  to  3  grains  (.032  to  .194  gm.)  has 
been  much  lauded.  Bose  and  Vedel  employed  in  4  cases  intravenous 
injections   of  sodium   chlorid,    7 :  1000   being  the  maximum   strength. 


78  INFECTIOUS  DISEASES. 

The  injections  should  be  made  early,  and  repeated,  so  that  they  will  de- 
velop sustained  general  reaction  and  a  modification  of  the  general  condi- 
tion which  can  lead  to  recovery.  Care  should  be  taken  as  to  the  quantity 
used  and  the  rapidity  with  which  it  is  injected  (^  to  3  ounces  each  minute 
should  not  be  exceeded).  Kendall  advises  de.xtrose  infusions  (25  per  cent.) 
in  normal  saline  solution  ;  this  tends  to  restore  the  normal  dextrose. 

Antiseptic  irrigation  of  the  bowel  would  be,  if  properly  carried  out, 
a  curative  measure,  since  liy  this  means  we  may  destroy  the  distinct 
micro-organisms.  Unfortunately,  the  bowel  is  frequently  so  irritable  as 
to  seriously  interfere  with  this  mode  of  medication.  Preliminary  to 
their  use  we  may  also  employ  cocain  in  the  form  of  a  suppository,  or  a 
small  quantity  of  a  solution  of  cocain  (4  per  cent.),  or  a  laudanum 
enema  (Tflxxx — 2.0,  in  starch-water),  after  which  a  large  injection  may 
be  tolerated  if  administered  slowly  and  the  flow  be  interrupted  at  inter- 
vals. Among  the  best  agents  are  silver  nitrate  (gr.  ss-j — 0.032-0.064 
— ad  5J — 32.0),  tannic  acid  (1  to  2  per  cent.),  salicylic  acid  (1  to  2  per 
cent.),  and  mercuric  chlorid  (1  :  GOOO).  I  have  for  a  number  of  years 
been  in  tlie  habit  of  employing  these  astringent  and  antiseptic  solutions 
alternately,  administering  each  once  daily.  Kuzmitzky,'  MacDonald, 
and  others  have  obtained  good  results  with  rectal  injections  of  a  tepid 
solution  of  potassium  permanganate  (1  :  4000)  twice  daily.  The  temper- 
ature of  the  water  should,  at  first,  range  from  100°  to  110°  F.  (37.7°  to 
43.3°  C),  and  subsequently  this  may  be  reduced.  The  patient  during 
the  administration  of  the  enemata  should  assume  the  dorsal  position, 
with  the  hips  well  elevated,  and  he  should  be  turned  from  side  to  side 
during  the  injections.  The  existence  of  great  irritability  of  the  bowel 
may  be  met  by  using  two  catheters  side  by  side,  one  of  them  serving  as 
an  outflow.  Kruse^  has  produced  a  serum  and  has  treated  100  cases 
with  8  deaths.  Shiga  has  also  discovered  a  serum  of  which  he  injects 
one  dose  of  10  c.c.  in  mild  cases.  In  cases  of  medium  severity,  a  second 
dose  of  10  c.c.  is  injected  after  from  six  to  ten  hours,  while  in  severe 
cases,  a  daily  dose  of  20  c.c.  is  repeated  for  two  or  three  days.  The 
mortality  of  dysentery  under  the  use  of  this  serum  is  reduced  to  less 
than  one-half  from  that  obtained  from  medical  treatment. 

Local  means,  in  the  form  of  hot  fomentations,  light  poultices,  and 
turpentine  stupes,  often  afi"ord  much  comfort.  The  various  complications 
must  be  met  by  appropriate  treatment,  as  under  other  circumstances. 

Chronic  Dysentery. 

This  form  of  the  disease  almost  always  succeeds  an  acute  attack.  A. 
Bassler  thinks  that  "  chronic  dysentery  due  to  the  Bacillus  coli  conuuuiiis  " 
seems  warranted. 

Pathology. — In  most  instances  the  large  intestine  is  still  the  seat> 
of  ulceration.  Some  of  the  ulcers  show  no  signs  of  healing ;  in  others 
this  process  is  going  on  ;  while  in  still  others  it  is  completed  and  puckered 
cicatrices  are  presented.  The  ulcers  are  deeply  pigmented,  as  is  the 
unnlcerated  mucosa,  which  often  presents  a  slate-gray  or  blackish  color. 
The  submucous  and  muscular  coats  are  hypertropliied,  as  a  rule,  with 
occasional  narrowing  of  the  lumen  of  the  bowel,  and  cystic  degeneration 
of  the  intestinal  glands  is  sometimes  observed.     In  a  small  percentage 

1  Woenno.  Med.  Jour.,  Nov.,  1902.  ^  Deutsch.  Med.  Woch.,  .Jan.  1  and  l.=l.  1903. 


DYSENTERY.  79 

of  the  cases  ulceration  does  not  occur,  the  mucosa  presenting  an  uneven, 
puckered  aspect,  due  to  deposits  of  fibrous  tissue. 

Symptoms  and  Diagnosis. — Many  of  the  most  characteristic  fea- 
tures of  the  acute  form  are  either  but  feebly  expressed  or  altogether 
wanting.  This  is  particularly  true  of  the  tormina  and  tenesmus.  Cer- 
tain elements  found  in  the  stools  of  the  acute  type  (blood,  shreds  of  pseudo- 
membrane,  and  tissue)  are  also  rarely  present.  True  dysenteric  nymp- 
toms,  however,  may  arise  during  acute  exacerbations,  with  or  without 
pain  or  tenesmus ;  then  from  three  or  four  to  a  dozen  or  more  fluid 
dejections  are  passed  daily.  The  latter  are  often  frothy  (when  starchy 
articles  of  food  are  taken),  composed  chiefly  of  fecal  matter  and  undi- 
gested particles  of  food  and  mucus ;  and  in  severe  forms  blood  and  pus 
may  be  constantly  present  in  the  discharges.  In  many  cases  the  stools 
are  semifluid  (pultaceous),  and  rarely  they  contain  scybala ;  or  the  rather 
frequent  liquid  or  semifluid  discharges  may  alternate  with  constipatifn. 
The  lesions  are  then  apt  to  be  situated  in  the  lowest  portion  of  the  large 
intestine.  The  character  of  the  discharges  is  much  influenced  by  the 
sort  of  food  taken  ;  thus,  when  a  mixed  dietary  is  partaken  of,  they  are 
thin,  more  frequent,  and  contain  more  undigested  masses  of  food.  Gas- 
eous distention  of  the  intestines  is  often  an  annoying  symptom. 

The  physical  signs  are  negative,  save  only  tenderness  over  the  colon. 

Associated  symptoms  referable  to  other  organs  are  not  without  value 
in  the  diagnosis.  The  gastric  digestion  is  poor,  the  appetite  generally 
impaired  (though  variable),  and  the  tongue  is  clean,  red,  and  glazed, 
presenting  the  appearance  of  raw  beef.  There  are  progressive  emacia- 
tion and  asthenia,  which  eventually  reach  an  extreme  degree.  The  skin- 
surface  becomes  dry,  harsh,  and  cool,  the  facies  grim,  the  pulse  exceed- 
ingly feeble,  the  mental  faculties  greatly  weakened  in  the  advanced 
stage ;  and,  as  in  the  acute  form  so  in  the  chronic,  death  is  usually  due 
to  asthenia — with  this  difi'erence,  that  in  the  latter  the  end  is  reached 
more  slowly.     Peritonitis  in  consequence  of  perforation  is  rare. 

Differential  Diagnosis. — The  disease  is  to  be  discriminated  from  chronic 
diarrhea.  In  chronic  dysentery  there  is  the  history  of  an  antecedent 
acute  attack,  with  the  appearance  from  time  to  time  of  exacerbating 
periods  when  mucus,  pus,  and  often  blood  are  contained  in  the  discharges. 
The  latter  are,  at  the  same  time,  more  frequent  and  apt  to  be  accom- 
panied by  more  or  less  abdominal  pain  and  tenesmus,  and  the  presence 
of  these  features  would  serve  to  eliminate  chronic  diarrhea.  From  tuber- 
culous ulceration  of  the  intestines  it  is  distinguished  by  the  absence  of 
any  history  of  tuberculosis,  family  or  personal,  and  of  tuberculous  new 
growths  in  other  portions  of  the  body,  particularly  the  lungs. 

The  complications  are  the  same  as  in  acute  dysentery,  if  we 
except  the  greater  liability,  due  to  the  great  and  protracted  weakness 
of  the  patient,  to  certain  serious  intervening  diseases  (chronic  nephritis, 
tuberculosis,  pneumonia).     Ulceration  of  the  cornea  has  been  noted. 

The  duration  is  long,  the  disease  lasting  for  months  or  even  years. 

Treatment. — This  should  be  directed  mainly  to  the  local  condition, 
and  should  consist  in  methodic  irrigation  of  the  bowel  with  a  view  to 
promoting  the  healing  of  the  ulcers.  Formerly  it  was  sought  to  accom- 
plish the  latter  indication  by  the  use  of  certain  remedies  internally,  as 
silver  nitrate,  balsam  of  copaiba,  bismuth  subnitrate,  etc.,  but  the  only 
preparation  which  I  have  found  useful  is  the  zinc  oxid  (gr.  v-x — 0.324- 


80  INFECTIOUS  DISEASES. 

0.648)  three  times  daily.  The  hitter  preparation  is  decidedly  j^alliative, 
soiiK'times  even  curative. 

Intestinal  irrt(/ation  is  to  be  tried,  and  various  disinfectants  and 
astringent  remedies  should  be  alternated  as  advocated  in  the  acute 
form.  Among  individual  remedies  the  silver  nitrate  (gr.  ss-ij — 0.032- 
0.129 — ad  3J — o2.0)  every  second  day  is  doubtless  the  best.  On  interven- 
ing days  antiseptic  remedies  may  be  used  in  solution,  such  as  mercuric 
chlorid  (1 :  6000)  or  salicylic  acid  (1  to  2  per  cent.);  and  of  other  use- 
ful agents  I  may  mention  tannic  acid,  alum,  acetate  of  lead,  and  creolin. 

I'rior  to  the  use  of  any  of  the  above-mentioned  enemata  the  bowels 
should  be  Avell  flushed  Avith  a  large  injection  of  tepid  water,  so  as  to 
remove  the  fecal  and  other  irritating  materials.  The  same  details  are  to 
be  observed  in  cariving  out  this  mode  of  treatment  as  in  the  acute  forms 
of  dysentery,  (jalluy  '  has  related  the  curative  effect.-^  of  large  enemata 
of  a  solution  of  crystallized  silver  nitrate  in  distilled  water,  a  scruple  to 
a  quart  (1.296  per  liter),  to  which  20  or  3')  drops  of  laudanum  have  been 
added.  Amelioration  follows  the  thinl  or  fourth  washing,  but  a  course 
of  sixty  is  recommended  to  secure  permanent  relief.  The  lower  pai't  of 
the  rectum  should  be  examined  with  the  speculum,  and  appropriate 
topical  applications  made  if  ulcers  in  this  situation  be  discovered.  It  has 
been  suggested  that  to])ical  therapy  can  be  facilitated  in  chnniic  cases  by 
the  production  of  an  artificial  anus,  in  the  left  iliac  region,  or  an  appen- 
dicostomy,  but  the  value  of  the  method  is  still  doubtful. 

The  dietetic  treatment  in  chronic  dysentery  is  of  the  utmost  import- 
ance, and  light  forms  of  proteids  are  to  be  selected,  to  the  exclusion  of 
vegetable  substances.  Milk  is  excellent  when  it  can  be  taken.  It  is 
well  to  examine  the  stools,  and  if  on  microscopic  examination  curds  or 
numerous  fat-globules  appear,  the  amount  of  milk  should  be  reduced  or 
skim-milk  substituted.  Egg-white,  meat-broths  or  beef-juice,  whey,  and 
even  light,  nutritious  solids  may  be  allowed.  The  patient  should  wear 
flannels  next  the  skin,  and,  while  open-air  exercise  is  useful,  it  should  be 
moderate.  During  inclement  weather  the  patient  should  remain  in-doors. 
I  have  known  change  of  climate,  with  proper  regulation  of  the  mode  of 
living,  to  be  productive  of  rather  brilliant  results.  Tonics  and  alcoholic 
stimulants  are  sometimes  re(iuired  to  assist  the  appetite,  digestion,  and 
systemic  strength,  and  among  the  most  efficacious  tonic  remedies  are 
iron,  strychnin,  mineral  acids,  and  arsenic. 


CHOLERA  (EPIDEMIO). 

{Asiatic  Cholera;    Cholera  Algicla,  etc.) 

Definition. — Cholera  is  an  acute,  infectious,  epidemic  disease,  due 
to  the  spinllum  of  Koch  (vibrio  cholerse  Asiatica?) ;  and  its  characteristic 
symptoms  are  copious  watery  dejections,  painful  cramps,  collapse,  and 
sup])ression  of  the  excretions.      In  some  localities  it  is  endemic. 

Historic  Note. — During  the  Middle  Ages  cholera  made  deplor- 
able ravages,  chiefly  along  the  belts  of  the  Ganges,  and  has  probably 
been  endemic  in  India  for  centuries.     Only  during  the  present  century, 

' "  Radical  Cure  for  Chronic  Dysentery  of  Recun-ent  Type,"  British  Med.  Joui-nal, 
No.  1779,  p.  276. 


CHOLERA.  81 

however,  has  the  disease  been  widely  known  in  Europe  and  America,  and 
when  it  has  appeared  it  has  always  been  in  the  epidemic  form.  The 
march  of  epidemics  has  been  from  east  to  west,  along  the  lines  of  com- 
merce and  travel  by  land  or  sea,  sometimes  spreading  over  the  entire 
globe.  Space  forbids  an  account  of  the  progress  of  the  various  cholera 
outbreaks  in  Europe  and  America.  It  may  be  stated  that  there  have 
been  no  distinct  epidemic  visitations  in  America  since  1873.  In  India, 
Mecca,  Java,  China,  and  in  the  Philippine  Islands  numerous  cases  ap- 
peared during  the  winter,  spring,  and  summer  of  1902. 

Pathology. — The  body  is  much  emaciated,  the  features  sharp 
and  drawn,  and  the  skin  of  the  dependent  parts  presents  a  mottled 
appearance.  A  post-mortem  rise  of  temperature  often  occurs.  The 
tissues  are  dry,  owing  to  the  draining  of  the  liquids  of  the  body,  and 
hence  putrefaction  is  delayed.  Rigor  mortis  comes  on  directly  after 
death,  is  persistent,  and  the  muscles  often  contract  so  as  to  cause  the 
body  to  assume  various  uncommon  positions. 

The  Visceral  Lesions. — The  chief  of  these  are  confined  to  the  intestinal 
canal,  and  depend  largely  upon  the  period  of  the  disease  at  which  death 
occurs.  In  the  early  stage  the  serosa  of  the  small  bowel  is  congested, 
presenting  a  roseate  hue.  The  muscularis  is  relaxed.  The  mucosa  is 
the  seat  of  catarrh,  being  deeply  injected,  swollen,  at  times  edematous, 
and  often  coated  in  the  early  stage  with  more  or  less  tough  mucus. 
Shortly  the  coils  of  intestine  are  filled  with  an  almost  transparent  or 
slightly  turbid  liquid  (''  rice-water  "),  and  occasionally  a  small  amount 
of  clotted  blood  is  seen.  The  solitary  follicles  and  Peyer's  patches  are 
swollen,  and,  in  rare  instances,  become  ulcerated.  Denudation  of  the 
epithelial  lining — most  probably  a  post-mortem  change — is  the  rule,  and 
ecchymotic  spots  are  visible  in  the  intestinal  mucosa.  If  the  patient  has 
died  late  in  the  disease  (stage  of  reaction),  patches  of  false  membrane 
may  be  found  anywhere  along  the  intestinal  canal,  although  chiefly  in 
the  large  bowel  ;  and  this  secondary  croupous-diphtheritic  process  may 
attack  other  mucous  surfaces  (bile-ducts,  vagina). 

The  stomach  shows  changes  similar  to  those  found  in  the  intestines. 
At  first  the  mucosa  is  congested  ;  then,  as  the  result  of  transudation,  it 
becomes  filled  with  "  rice-water  "  material.  At  last  the  organ  is  empty 
and  collapsed.     The  esophagus  also  exhibits  analogous  lesions. 

The  spleen  is  small,  as  a  rule,  though  if  death  occur  late  it  may  show 
some  degree  of  enlargement  with  softening. 

The  liver  presents  marked  passive  hyperemia  and  cloudy  swelling, 
with  minute  spots  of  beginning  fatty  change.  Desquamation  of  the 
epithelium  of  the  cystic  mucosa  may  occur  and  block  the  bile-ducts. 

The  kidneys  show  important  lesions,  being  enlarged  from  passive  con- 
gestion, especially  the  cortex,  and  the  capsule  being  somewhat  adherent. 
They  exhibit  cloudy  swelling  and  decided  coagulation-necrosis.  Desqua- 
mation of  the  epithelium  in  the  urinifei'ous  tubules  is  extensive.  Micro- 
scopically, the  histologic  changes  are  those  of  acute  nephritis  in  the  cases 
in  which  death  takes  place  in  the  advanced  stage.  The  bladder-changes 
differ  in  no  way  from  those  of  other  mucous  membranes.  Its  mucosa  is 
congested,  ecchymotic,  and  may  show  diphtheritic  deposit.  The  ureters 
and  the  pelves  of  the  kidneys  may  present  identical  appearances. 

The  Circulatory  System. — The  pericardium  is  dry,  the  parietal  layer 
being  covered  with  an  adhesive  secretion,  while  the  visceral  layer  is  the 
6 


INFECTIOUS  DISEASES. 


seat  of  eccbymosis.  The  heart  is  dry  and  anemic  looking.  The  left 
ventricle  is  contracted,  while  the  right  is  often  distended  with  blood  and 
soft  clots.  ( hitside  of  the  heart  the  veins,  including  the  cerebral  sinuses, 
contain  most  of  the  blood.  The  blood  is  thick  and  its  color  dark,  resem- 
bling '*the  juice  of  huckleberries  ';  its  specific  gravity,  albumin,  and 
corpuscles  are  all  increased,  while  its  coagulability  is  decreased. 

Respiratory  Organs. — The  larynx,  trachea,  and  bronchi  are  hyperemic, 
and  at  first  covered  with  tenacious  mucus  ;  later  they  may  present  ecchy- 
moses  and  diphtheritic  processes. 

When  death  occurs  before  the  stage  of  reaction  the  lungs  are  blood- 
less, collapsed,  and  the  mouth  of  the  i)ulmonary  artery  may  be  distended. 
If  life  is  prolonged  until  the  third  stage,  the  lungs  may  show  conges- 
tion and  edema  or  pulmonary  infarction.  The  post-mortem  may  now 
also  exhibit  the  lesions  of  broncho-  or  lobar  pneumonia. 

The  brain  and  its  membranes  may  be  the  seat  of  hyperemia,  except 
when  death  takes  place  at  a  late  period,  and  then  the  brain-substance 
niav  be  nim-e  or  less  bloodless  and  edematous. 

etiology. — The  causes  are  (a)  specific  and  (b)  predisposing, 
(a)  The  specific  cause  is  the  spirillum  of  Koch,  which  is  found  in  the 
intestinal  canal  of  persons  ill  of  cholera.  Recent  investigations  into  the 
bacteriology  of  the  affection  show^  that  almost  uniformly  the  cholera 
vibrio  is  associated  with  certain  bacteria,  most  commonly  the  bacillus 
coli  communis.  True  cholera  is  a  7iitrite--po\sonmg,  the  result  of  the 
growth  of  the  specific  spirillum.  Koch's  organism  is  not  found  in  any 
other  disease.  Its  form  is  that  of  a  slightly  curved  rod,  and  its  length 
about  half  that  of  the  tubercle  bacillus,  but  it  is  thicker  and  sometimes  has 
the  form  of  the  letter  S  (Fig.  8).  The  cholera  vibrio  is  motile,  its  motility 
beinor  due  to  a  sins:le  fiasrellum  attached  to  one  end.  It  has  been  grown 
successfully  on  media  of  various  sorts  {e.g.  nutrient  gelatine,  forming  coloi'- 
less  colonies  and  liquefying  the  gelatine)  and  equally  successfully  inocu- 
lated upon  inferior  animals. 

The  organism  is  found  in  a 
variety  of  positions — in  the  intes- 
tine, the  dejecta  (even  quite  early), 
and  in  great  profusion  in  the 
pathognomonic  "rice-water"  stools. 
Kemp  in  his  review  has  shown  that 
the  spirillum  is  often  absent  from  the 
evacuations,  and  that  in  these  cases 
the  bacterium  coli  is  usually  present 
and  sometimes  streptococci.  He  be- 
lieves, however,  that  the  apparent  ab- 
sence is  due  to  faulty  technique.  It 
may  be  seen  in  the  stools  and  vomitus 
(rare)  of  well  persons  during  epidem- 
ics, displaying  virulent  properties. 
Outside  the  body  they  preserve 
their  vitality  in  river  or  well  Avater  or  upon  the  surface  of  moist  linen  for  sev- 
eral weeks.  C.  Friinkel  studied  them  in  flowing  water,  and  in  other  epidemic 
outbreaks  they  have  been  found  in  the  water  used  for  drinking  purposes. 

(h)  Predisposing  Causes. — (1)  Locality. — Near  to  the  sea-coast  cholera 
is  more  common  than  in  the  inland  districts  or  towns,  and  the  frequency 


Fig.  8.— Comma  liacilli  irnmi  the  mouth); 
X  1000  (Gunther). 


CHOLERA.  83 

of  occurrence  lessens  with  increasing  altitude,  this  fact  possibly  being  due 
to  a  gradual  decrease  in  soil  humidity  and  porosity. 

(2)  Atmospheric  Temperature. — The  spirillum  of  cholera  can  only 
flourish  in  a  warm  climate;  hence  the  disease  is  endemic  in  certain  trop- 
ical and  subtropical  climates  ;  and  hence  also  its  epidemic  prevalence  is 
confined  to  temperate  latitudes. 

(3)  Seasons. — For  obvious  reasons  it  is  more  common  in  the  warm 
than  in  the  cold  months,  most  epidemics,  both  in  Europe  and  America, 
having  occurred  toward  the  close  of  summer  and  in  the  early  autumn. 
Winter  frosts  usually  arrest  an  epidemic. 

(4)  Age,  as  a  rule,  has  no  decided  effect.  Old  people,  however,  are 
very  prone  to  the  affection.     Sex  is  without  perceptible  influence. 

(5)  Debilitating  Causes. — Whenever  the  private  conditions  correspond 
to  rigid  scientific  requirements  during  epidemic  outbreaks  cholera  becomes 
less  prevalent  and  also  less  virulent.  On  the  other  hand,  defective  munici- 
pal sanitation,  disregard  of  proper  hygienic  rules,  intemperance,  over- 
crowding, etc.,  all  predispose  markedly  to  the  disease. 

(6)  Mere  attacks  of  intestinal  disorder  due  to  improper  diet,  cold,  etc., 
are  potent  to  disseminate  the  disease. 

Modes  of  Infection. — The  spirilla  leave  the  body  with  the  stools,  but 
the  most  frequent  bearer  of  cholera-poison  is  the  drinking-water.  Natur- 
ally, the  individual  susceptibility  varies  greatly  (many  persons  being 
even  insusceptible),  and  yet  the  degree  of  contamination  of  the  drink- 
ing-water and  the  virulence  of  epidemics  are  almost  strictly  proportion- 
ate. As  an  illustration,  Vienna  had  enjoyed  exemption  from  cholera  for 
nineteen  years — a  fact  attributed  to  the  excellent  quality  of  the  drink- 
ing-water and  to  hygienic  improvements.  In  the  same  city  the  mor- 
tality-rate in  the  more  recent  epidemics  has  been  small  (7  per  1000)  for 
a  like  reason.  On  the  other  hand,  in  1872  there  occurred  in  a  single 
commune  (Hamburg),  which  had  a  polluted  water-supply  (the  Elbe)  and 
no  filtration  plant,  17,862  cases,  with  the  enormous  death-rate  of  42.3 
per  cent.  Koch  holds  that  man,  not  noticeably  diseased,  is  the  real 
bearer  and  reproducer  of  the  cholera  vibrios. 

The  choleraic  poison  may  be  conveyed  with  the  water  used  for  washing, 
cooking,  and  other  purposes  to  other  fluids  imbibed  by  man  (beer,  milk, 
tea),  and  also  to  food-stuffs  taken  by  him  (lettuce,  cresses,  and  other 
raw  vegetables,  fruits,  meats,  bread,  butter).  The  organisms  live  and 
maintain  their  virulence  on  these  articles  of  food  from  four  to  seven 
days  at  least.  The  infection  may  reach  the  esophagus  with  the  water 
used  for  washing  the  mouth  or  teeth,  or  that  used  for  washing  the 
utensils,  dishes,  food-receptacles,  etc.  Again,  the  hands,  commonly 
those  of  laundresses  and  nurses,  may  become  soiled  in  the  careless 
handling  of  bed-linen  or  garments  worn  by  cholera  patients  or  the 
stools,  and  convey  the  poison  to  the  mouth  or  lips,  to  be  carried  into 
the  stomach  along  with  the  drink  or  food.  Healthy  bacilli-carriers  have 
been  found  in  ships  arriving  from  Mediterranean  ports.  Flies  may  trans- 
fer the  infectious  element  to  food-articles  (Simmonds,  MacKaig,  and 
others). 

Cholera  is  not  contagious  from  mere  contact  with  those  ill  of  the  disease. 
It  is  not  acquired  by  inhalation  (Shakespeare),  and,  since  desiccation 
rapidly  kills  the  organism,  there  is  little  probability  that  the  latter  is  air- 
borne.    Nor  is  there  any  clinical  evidence  to  show  that  the  poison  may 


84  INFECTIOUS  DISEASES. 

enter  the  system  througli  the  .skin  surfafo.  rmbably  the  germs  are  s/raJ- 
lowed,  and  the  acid  gastric  juice  may  then  destroy  them  if  tlie  size  of  the 
dose  of  the  poison  is  not  too  large,  or  they  may  ])ass  into  the  intestinal  canal 
and  there  manifest  pathogenic  powers.  After  the  spirillum  reaches  the 
intestine,  whether  or  not  an  attack  is  the  result  depends  both  u])on  the 
size  of  the  poisonous  dose  and  upon  the  personal  degree  of  in)muiiity. 

Oj)posed  to  the  drinking-water  theory  of  tliis  disease  is  that  of  Pet- 
tenkofer,  which  contends  that  the  spirilla  found  in  the  serous  evacua- 
tions of  cholera  patients  must  enter  an  a])pr(ipriate  soil  and  there  undergo 
further  development  before  becoming  pathogenic.  While  soils  possessing 
a  certain  degree  of  moisture  and  perviousness  and  contaminated  with 
organic  matter  favor  the  growth  and  multiplication  of  the  specific  organ- 
ism, these  telluric  conditions  are  not  essential,  as  is  shown  by  the  viru- 
lence of  the  stools  when  swallowed  in  ample  quantity.  Pettenkofer  and 
l\ubino'  claim  that  the  fidly  developed  ])oison  rises  from  the  subsoil  into 
the  lower  atmospheric  strata  as  a  miasm. 

Immunity  is  not  conferred  by  a  previous  attack  of  cholera.  Pfeiffer 
and  Marx  have  proved  the  existence  in  the  blood-serum  of  human  beings 
of  bactericidal  bodies  (not  a  true  antitoxin)  that  cause  rapid  destruction 
of  the  cholera  bacilli.  To  these  anti-bodies  is  ascribed  the  "  Pfeiffer  serum 
reaction.'"  by  means  of  which  the  vibrios  are  diiferentiated  from  other 
micro-organisms.  Pfeiffer  and  Marx  have  also  shown  that  the  virus  of 
cholera  can  be  effectively  preserved  by  a  0.5  per  cent,  solution  of  car- 
bolic acid,   and  that  it  in  no  way  impairs  its  immunizing  properties. 

Clinical  History. — The  incubation  period  varies  from  a  few  hours 
to  five  days  (average  two  to  three  days).  During  this  prodromal  period  the 
patient  is  either  quite  well  or  (during  the  latter  portion)  exhibits  certain 
local  symptoms.  These  are  occasionally  nausea,  a  feeling  of  distress  in 
the  abdomen,  increased  peristalsis  which  may  be  visible  or  palpable, 
slight  pain  and  tenderness,  and  either  a  mild  or  a  decided  diarrhea.  The 
discharges  are  feculent,  colored,  and  semifluid,  or,  more  rarely,  quite  fluid, 
and  may  be  quite  copious.  These  symptoms  may  all  be  present,  though 
oftener  a  few,  and  rarely  a  single  one.  is  noted ;  moreover,  they  are  not 
distinctive  unless  seen  during  an  epidemic  and  unless  the  patients  have 
been  exposed  to  the  poison.  Prostration  may  be  marked  and  there  may 
be  slight  muscular  cramps.  The  so-called  premonitory  diarrhea  may 
terminate  in  recovery  at  the  end  of  from  one  to  three  days,  or  be  followed 
by  an  attack  of  cholera.     This  has  three  stages. 

(1)  Stage  of  Serous  Diarrhea. — Tlie  dejecta  are  generally  painless,  very 
frequent,  odorless,  copious,  and  fluid  or  watery,  and  usually  present  the 
characteristic  "rice-water"  appearance.  Rarely  they  are  distinctly  col- 
ored with  bile,  and  in  severe  cases  with  blood,  and  rarely  also  are  they 
frothy.  Suspended  in  them  are  numerous  small,  whitish,  mucous  flakes ; 
their  reaction  is  neutral  or  alkaline,  and  they  contain  a  small  percentage 
of  solid  constituents  made  up  largely  of  albumin  and  sodium  chlorid. 
The  microscope  brings  to  view  epithelium,  mucus,  triple  phosphates,  and 
numberless  micro-organisms,  of  which  latter  the  only  ones  characteristic 
are  the  comma-spirilla  of  Koch.  In  cholera  sicca  these  serous  evacua- 
tions are  absent.  Death  comes  quickly,  and  post-mortem  examinations 
show  the  intestine  to  be  filled  with  "rice-water"  material,  which  is  prob- 
ably retained  because  of  speedy  paralysis  of  the  musculature. 
'  SajoTw^s  Annual,  1899,  vol.  ii.,  p.  214. 


CHOLERA.  85 

Gastric  symptoms  appear  early.  Vomiting  soon  becomes  frefjuent, 
and  at  first  the  vomitns  may  be  bilious;  later  it  is  characteristically 
serous  and  excessive  in  amount.  Thirst  is  almost  intolerable,  anorexia 
is  complete,  and  the  tongue  often  has  a  thick  coating,  which  early 
becomes  dry.  Gastro-intestinalpam  is  not  severe,  but  a  feeling  of"  press- 
ure or  burning  in  the  abdomen  is  experienced,  and  occasionally  there 
are  griping  pains  with  tenesmus.  The  physical  sicjns  are  few.  The 
belly  is  usually  flat  and  flaccid,  though  it  may  bo  sca))hoid  and  hard, 
and  in  some  cases  palpation  detects  fluctuation. 

Painful  cramps  in  the  muscles  form  an  early  characteristic  symptom. 
They  affect  the  voluntary  muscles  of  the  legs,  calves,  and  feet,  more 
rarely  the  arras  and  hands  also.  Their  duration  is  momentary,  but 
they  recur  at  intervals,  and  are  due  to  the  local  action  of  the  toxins. 

Owing  to  the  withdrawal  of  fluid  from  the  lymphatics  and  blood- 
vessels the  tissues  become  dry  and  shrivelled  and  the  blood  much  thicker. 
This  condition  of  the  blood  obviously  increases  the  labor  of  the  heart, 
which  beats  rapidly,  and  there  may  be  at  first  a  distressing  palpitation ; 
but  soon  the  heart  grows  more  and  more  feeble  and  venous  stasis  ensues. 
The  pulse  is  at  first  rapid,  soft,  and  small;  it  may  then  be  lost  at  the 
wrist.     The  cardiac  impulse  and  heart-sounds  may  at  last  disappear. 

The  fades  and  general  appearance  also  indicate  loss  of  fluid.  The 
cutaneous  surfaces  of  the  face  and  extremities  grow  cool:  there  is  rapid 
general  emaciation,  which  may  become  most  pronounced,  and  the  skin  is 
wrinkled.  The  complexion  assumes  a  livid  or  blue-gray  tint,  while  the 
lips  become  quite  dark.  The  extremities  are  cyanotic  (the  finger-tips  in 
particular),  the  orbits  are  deeply  sunken,  the  cheeks  hollow,  the  features 
intensely  pincned,  the  voice  husky  and  feeble,  and  there  is  utter  prostra- 
tion. The  suiface-temperature  drops  below  the  normal,  even  to  96°  or 
95°  F.  (35.5°-35°  C),  while,  per  contra.,  the  internal  or  rectal  tempera- 
ture rises  to  102°  F.  (38.8°  C.)  or  over.  The  mind  may  remain  clear  until 
the  close,  but  oftener  the  patient  is  apathetic,  and  in  grave  cases  this  condi- 
tion may  deepen  into  stupor  or  even  actual  coma.  The  reflexes  are  greatly 
diminished.  S.  Rogers^  found  a  variable  degreeof  leukocytosis,  and  thelaro-e 
mononuclear  cells  were  usually  increased — an  important  diagnostic  sign. 

The  urine  becomes  very  scanty  and  is  highly  concentrated,  the  stand- 
ing specimen  depositing  a  heavy  sediment.  On  analysis  albumin  and 
casts  (chiefly  granular)  are  found.  In  the  serious  forms  the  kidneys  fail 
to  eliminate  the  urea,  and  there  is  finally  complete  anuria. 

(2)  Stage  of  Algidity  or  Collapse. — The  symptoms  which  characterize 
this  grave  condition  are  the  same  as  those  noted  under  the  latter  part  of 
the  first  stage,  only  intensified.  Asthenia  is  extreme  ;  the  jjulse  is  miss- 
ing and  the  heart  beats  faintly  ;  the  voice  is  lost ;  resjnrations  are  per- 
ceptibly shallow  ;  lividity  is  intense ;  the  surface  ice-cold ;  and  there  is 
usually  stupor  or  even  coma.  The  excessive  serous  discharges  have  given 
place  to  mere  dribblings  from  the  now  relaxed  anus.  During  this  stage. 
which  may  last  a  few  or  many  hours,  the  faint  glimmerings  of  the  vital 
spark  are  often  extinguished. 

(3)  Stage  of  Reaction. — This  sets  in  promptly,  and  the  case  may 
pursue  a  favorable  course,  with  return  to  accustomed  health  by  the  end 
of  a  week  or  ten  days.  The  first  urine  passed  is  usually  albuminous 
and  contains  tube-casts.     Relapses  into  the  stage  of  collapse  may  occur 

1  Brit.  Med.  Jour.,  July  12,  1902. 


86  INFECTIOUS  DISEASES. 

ami  be  repeated ;  in  many  instances,  however,  this  stage  is  both  pro- 
tracted and  dangerous.  It  is  aptly  termed  cholera  typhoid,  since  a  gen- 
uine typhoid  state  develops.  The  skin  may  present  so-called  choleraic 
eruptions  (macular,  roseolar  erythema).  Recovery  may  now  take  place, 
or  a  great  diversity  of  local  secondary  inflammation  may  supervene. 

Acute  neph7-itis  may  arise  in  this  stage  and  lead  either  slowly  or 
directly  to  uremic  poisoning,  as  shown  by  the  projection  upon  the  scene 
of  grave  nervous  phenomena — headache,  vomiting,  delirium  or  coma, 
and  convulsions.      A  fatal  result  may  be  looked  for. 

Complications. — In  this  place  are  to  be  enumerated  the  conditions 
due  to  secon(hiry  inlection,  including  (commonly)  septic  and  pyemic 
processes.  Diphtheritic  inflammations  affecting  mucous  surfaces,  but 
especially  the  throat,  colon,  and  the  external  genitals,  are  among  the 
more  common.  Bronchitis,  pneumonia,  and  pleurisy  may  arise,  and 
erysipelas  and  ])arotitis  are  not  rare.  During  convalescence  digestive 
disorders  may  show  themselves,  and  indiscretions  in  diet  may  precipi- 
tate a  relapse. 

Clinical  Types. — {a)  "  Premonitory  Diarrhea." — This  type  has  been 
outlined  with  suflficient  fulness  in  the  foregoing  discussion. 

(/))  "  Cholerine,"  in  which  the  symptoms  are  mild,  resembling  those  of 
cholera  nostras.  Many  of  the  symptoms  characteristic  of  true  cholera 
are  also  present,  particularly  the  cramps  and  2^'^'ostration,  cold  extremi- 
ties, and  scanty  albuminous  urine.  The  stools,  however,  are  not  typical 
of  the  disease,  but  are  feculent  in  character,  as  in  ordinary  cholera 
morbus.     The  duration  is  from  seven  to  ten  days,  subject  to  relapses. 

(c)  The  more  typical  forms — both  moderate  and  severe — have  been 
described  under  the  Clinical  History  [mipra). 

(d)  The  Foudroyant  or  Asphyxic  Form. — This  may  kill  instantly  ; 
more  frequently  the  patient  lives  for  a  fcAv  hours,  with  or  without  vomit- 
ing and  purging.  Qholera  sicca  should  be  classed  with  this  type.  The 
virulence  of  the  cholera-poison  explains  the  intensity  of  the  symptoms. 

Differential  Diagnosis. — This  is  difficult  in  the  absence  of  an 
epidemic  unless  bacteriologic  and  microscopic  tests  be  made,  and  yet 
these  alone  differentiate  a  sporadic  case.  The  disease  most  commonly 
mistaken  for  cholera  (especially  cholerine)  is  cholera  morbus,  and  the  fol- 
lowing points  pertaining  to  the  latter  disease  will  eliminate  it :  1.  No 
connection  with  a  previous  case,  but  a  frequent  history  of  dietetic  impru- 
dence. 2.  Absence  of  "rice-water"  stools,  which  remain  turbid  with 
feces  or  covered  with  bile  or  blood.  3.  Presence  of  colicky  pains,  but 
absence  of  painful  tonic  cramps  of  legs  and  feet,  4.  Absence  of 
cyanosis  and  collapse,  as  a  rule,  and  of  urinary  suppression.  5.  No 
cholera  spirilla  in  the  stools. 

Arsenic-poisoning  and  other  forms  o^  g astro-enteritis  must  be  discrimi- 
nated by  the  history,  the  character  of  the  stools,  the  absence  of  violent 
muscle-cramps  and  of  the  effects  of  great  loss  of  fluid  (cyanosis,  shrunken 
body,  profound  collapse).      Chemical  tests  are  not  to  be  neglected. 

Prognosis. — This  is  dependent  mainly  on  the  type.  Thus  "  chol- 
erine "  is  very  rarely  fatal.  It  is  impossible  to  state  the  average  mor- 
tality, since  it  varies  with  each  epidemic,  but  it  has  been  found  to  range 
from  20  to  80  per  cent.  Many  sufferers  perish  during  the  latter  part  of 
the  first  day  or  during  the  algid  period  ;  still  more  during  the  stage 
of  reaction,  the  dangers  of  the  latter  period  being  as  follows :  asthenia, 


CHOLERA.  87 

cholera,  nephritis  with  uremia,  and  the  various  complications  ((vide  supra). 
The  greater  the  difference  between  the  surface  temperature  and  that  of 
the  rectum,  the  more  unfavorable  the  prognosis.  The  personal  circum- 
stances which  render  an  attack  grave  are  old  age,  alcoholism,  previous 
ill-health,  and  debility.  On  the  other  hand,  the  death-rate  may  readily 
be  lowered  by  prompt  and  judicious  treatment. 

Treatment. — Prophylaxis, — It  has  been  owing  in  great  measure  to 
the  efficient  quarantine  system  of  the  United  States  that  cholera  has  not 
gained  a  foothold  on  our  shores  since  1873. 

Individual  Prophylaxis. — In  the  first  place,  those  nursing  the  sick 
can  prevent  the  spread  of  cholera  by  prompt  and  thorough  disinfection. 
The  dejecta  may  be  disinfected  by  pouring  upon  and  mixing  with  them 
an  equal  part  of  a  5  per  cent,  solution  of  carbolic  acid  or  an  equal 
volume  of  a  freshly  prepared  solution  of  chlorid  of  lime.  The  discharges 
thus  treated  must  be  covered  and  allowed  to  stand  from  fifteen  minutes 
to  half  an  hour,  and  then  emptied  into  a  pit  in  the  earth  containing 
quicklime,  with  which  they  should  also  be  covered.  It  is  of  the  utmost 
importance  to  guard  against  a  pollution  of  the  water-supply  by  these  pits. 
Soiled  clothing,  linen,  and  the  like  should  be  promptly  disinfected,  and 
bedding  had  better  be  burned ;  none  but  the  attendants  should  be  per- 
mitted to  enter  the  sick-room.  The  dishes  used  should  be  disinfected 
immediately  after  use  or  before  leaving  the  sick-chamber.  After  handling 
the  patient  or  anything  that  he  has  soiled  the  attendants  should  first  dis- 
infect and  then  carefully  wash  their  hands.  After  vomiting  and  after  an 
evacuation  of  the  bowels  the  mouth  and  the  parts  around  the  anus  should 
be  wiped  with  a  cloth  wet  with  a  solution  (1 :  2000)  of  mercuric  chlorid. 
The  internal  use  of  sulphuric  acid  is  an  important  prophylactic.  If  con- 
valescence supervene,  the  patient  should  be  kept  isolated  for  a  week  and 
the  stools  disinfected  during  that  time.  For  the  treatment  of  carriers 
an  occasional  course  of  calomel,  with  gallic  acid  in  small  doses  during  the 
intervals,  are  measures  to  be  recommended. 

Persons  exposed  should  use  boiled  milk  and  water  only.  Certain 
forms  of  food  must  be  avoided,  especially  salads  and  unripe  fruits  ;  also 
alcoholic  stimulants.  All  uncooked  food  may  be  pernicious.  Such  per- 
sons should  lead  regular  lives,  avoiding  fatigue,  excesses,  etc.,  and  in- 
testinal disturbance  must  be  met  speedily  by  the  use  of  antiseptics, 
opiates,  and  astringents.  In  India,  Haff'kine^  has  used  a  protective  virus 
with  encouraging  results.  Thus,  "  of  1735  persons  not  inoculated  in  a 
certain  section,  174  took  the  disease  and  113  died,  whereas  of  500  inoc- 
ulated but  21  were  aff'ected  and  19  died."  He  has  made,  altogether, 
70,000  injections  in  40,000  patients  without  a  single  accident,  and  claims 
that  the  results  have  been  entirely  favorable.  Klein  concludes  against 
Haff'kine's  anticholera  inoculations,  which,  however,  produce  a  temporary 
active  immunity.  Pfeiff'er  and  Kolle's  method,  the  injection  of  dead 
cholera  vibrios,  is  to  be  preferred.  Immunity  as  the  result  of  vaccina- 
tion is  to  be  advised  in  countries  where  cholera  is  endemic  and  from  time 
to  time  epidemic — e.  g.,  India.  Kraus  has  obtained  a  specific  toxin  and 
antitoxin,  but  their  practical  value  remains  to  be  determined. 

Treatment  of  the  Attack. — (a)  Premonitory  Diarrhea. — In  the  instances 
which  are  not   preceded  by   premonitory   diarrhea  opportunity  to  pre- 
vent the  attacks  does  not  present  itself.     To  dispel  the  organisms  from 
-  Miinch.  med.  Woch.,  Jan.  29^  1895. 


88 


INFECTIO  US  DTSEA  SES. 


the  intestinal  canal,  castor  oil  and  especially  a  course  of  calomel  have 
been  used.  In  this  stage  a  double  indication  is  presented — "  to  restrain 
the  development  of  the  bacilli  in  the  intestine  and  to  neutralize  the 
cholera-poison."  To  meet  this  Cantani  proposes  tannic  acid  by  irriga- 
tion (enteroclysis).  He  injects  into  the  intestine  4-  to  2^-  quarts  (liters) 
of  water,  or  infusion  of  chamomile  containing  ^iss  to  ^v  (6.0  to  20.0)  of 
tannic  acid.  gtt.  xx  to  xxx  (1.20)  of  laudanum,  and  .oV-xij  (20,0-50.0) 
of  gum  arabic  at  a  temperature  of  80°  F.  Injections  should  be  repeated 
four  times  a  day,  and  in  grave  cases  after  each  evacuation.^  For  the 
same  purpose  acetate  of  lead  and  opium,  or  large  doses  of  bismuth,  Avith 
or  without  Dover's  powder,  have  been  much  employed. 

(h)  Stage  of  Serous  Diarrhea. — The  chief  indication  is  to  restore  to 
the  blood  the  watery  elements  Avithdrawn  by  the  diarrhea.  Not  a  moment 
is  to  be  wasted.  Opium,  and  preferably  the  salts  of  morphin,  may  be 
administered  hypodermically  (gr.  ]  to  ^ — 0.0162-0.0216),  if  the  evacua- 
tions prove  too  exhausting.  Cantani  advocates  the  injection  of  an 
artificial   serum   {hypodermochjsi^)   containing    1    dram   (4.0)   of  sodium 


Fig.  9.— 1,  fountain  syringe :  2,  cock ;  8,  attachment  for  cannula  ;  -I,  needle ;  5,  cannula ;  fi,  soft- 
rubber  rectal  tube,  with  two  lateral  openings,  one  a  lialf  inch  from  the  end  (not  visible),  the  other 
two  inches  from  the  end.  The  latter  is  to  be  introduced  Ijv  a  eniiibiiied  r<itatory  and  pushing 
motion  to  the  depth  of  ten  inches  in  enteroclysis,  and  the  fluid  then  allowed  to  enter  the  colon 
slowly. 

chlorid  and  gr.  xlvj  (3.0)  of  sodium  carbonate  per  quart  (liter)  of  ster- 
ilized water  warmed  up  to  104°  F.  (40°  C.)  into  the  subcutaneous  con- 
nective tissue.  This  solution  may  be  introduced  through  the  cannula  of 
an  ordinary  aspirator,  the  fluid  flowing  by  gentle  pressure.  Shakespeai-e 
recommends  for  hypodermoclysis  a  fountain  syringe  with  a  long  flexible 
tube  furnished  with  a  cock  ;  with  another  shorter  tube,  one  end  attached 
to  the  cock,  the  other  having  a  needle-pointed  cannula,  a  little  longer, 
stronger,  and  with  a  somewhat  wider  caliber  than  the  ordinary  hypo- 
dermic needle  (Fig.  9).  The  tube  and  cannula  are  first  perfectly  filled 
with  a  fluid,  and  then  the  cannula  is  inserted  well  in  between  the  skin 
^  Anr>ual  of  the  Universal  Medical  Sciences,  1893. 


YELLOW  FEVER.  89 

and  deep  fascia  of  the  flanks,  buttocks,  or  interscapular  region.  The 
fluid  should  be  made  to  flow  slowly,  allowing  fifteen  to  twenty  minutes 
for  the  introduction  of  1  quart.  This  is  preferred  to  intravenous  injec- 
tion, in  which  the  licjuid  is  diffused  slowly. 

The  vomitinji  is  to  be  relieved  by  bits  of  ice,  small  ar/iounts  of  brandy 
and  water  at  brief  intervals,  cocain,  or  by  lavage.  Jn  this  stage  reme- 
dies by  the  mouth  should  be  avoided,  since  they  aggravate  the  gastric 
disturbance.  Thebaud  has  treated  8  cases  of  cholera  in  Indo-China 
with  a  3  :  1000  solution  of  sodium  bicarbonate,  to  drink  freely,  up  lo 
3  quarts  a  day.  Heat  should  be  applied  externally  with  a  view  to 
assisting  the  periphei'al  circulation,  and  thus  obviating  collapse.  Warm 
baths  have  been  recommended  for  this  purpose.  Stimulants  must  be 
used  to  fulfil  the  same  indications.  They  are  of  superior  value  even  to 
the  above-mentioned  measures,  and  are  to  be  given  hypodermically,  and 
either  brandy,  ammonia,  or  strychnin  may  be  employed  in  large  doses. 

((,')  Stage  of  Algidity. — If  this  develop,  the  case  is  desperate.  The 
treatment  of  the  preceding  stage  is  to  be  persevered  with,  and  enteroclysis 
and  hypodermoclysis,  hypodermic  stimulation,  and  the  external  application 
of  heat  (e.  g..,  warm  baths,  to  which  from  200  to  300  grams  of  mustard  have 
been  added)  are  especially  indicated.  Additionally,  intravenous  injections 
of  fluids  have  been  strongly  urged  by  informed  observers.  For  this  purpose 
the  following  standard  of  saline  fluid  may  be  chosen  :  sodium  bicarbonate  1 
part,  sodium  chlorid  6  parts,  boiled  water  1000  parts.  The  temperature 
of  the  fluid  when  injected  varies  from  100|°  to  104°  F.  (38°  to  40°  C), 
more  frequently  the  latter  (Shakespeare).  The  quantity  demanded  may 
be  1  or  2  quarts  (liters),  and  the  injection  may  need  to  be  repeated  in 
from  one  to  three  or  four  hours.  Strychnin,  hypodermatically,  should 
also  be  used. 

(d)  Stage  of  Reaction. — During  this  stage  the  tannic  acid  may  be 
replaced  by  a  solution  of  salt  in  water  (10  or  15  per  cent.)  for  enteroclysis 
(Cantani),  and  it  may  be  well  to  continue  hypodermoclysis  in  some  instances. 
Fui'ther  than  this,  the  treatment  is  essentially  symptomatic.  Food  of  the 
blandest  sort  and  in  small  quantities  must  be  allowed  at  frequent  intervals 
if  we  would  avoid  enteritis  and  other  unfavorable  complications.  Tonic 
remedies  should  be  given  cautiously,  and  rest  and  careful  nursing  insisted 
upon.    Complications  must  be  met  in  accordance  with  general  principles. 

Reference  should  be  made  here  to  the  antitoxin  and  the  vaccine  that 
are  being  used  by  the  Japanese  in  treating  this  disease.  Schurupow's 
serum  has  given  good  re^sults  on  therapeutic  trial. 


YELLOW  FEVER. 

(Febris  Jiava;    Gelfieber,    Ger.) 

Definition. — Yellow  fever  is  an  acute,  highly  infectious  (but  non- 
contagious) endemic  and  epidemic  disease.  It  is  characterized  by  a  shai-p 
period  of  invasion,  followed  by  a  period  of  remission,  and  the  latter  in  turn 
by  a  relapse  and  certain  symptoms  peculiar  to  the  affection  (black  vomit, 
jaundice,  suppression  of  urine). 

Historic  Note. — Yellow  fever  is  endemic  only  within  certain  geo- 
graphic limits,  where  it  also  prevails  epidemically  when  the  conditions 
are  favorable.    According  to  general  belief,  it  first  appeared  in  1647  in  the 


90  INFECTIOUS  DISEASES. 

Barbadoes  (West  Indies).  Subsequently,  it  was  conveyed  along  the  chan- 
nels of  commerce  until  it  became  ■widely  disseminated,  and  chiefly  in  sea- 
port towns.  In  1G99  an  English  vessel  carrying  slaves  transported  the 
disease  to  Mexico  from  the  Atlantic  coast  of  Africa.  Guit6ras  classified 
the  areas  of  infection  thus :  (1)  The  focal  zone,  in  which  the  disease  is 
never  absent,  including  Havana,  Vera  Cruz,  Rio,  and  other  Spanish- 
American  ports.  (2)  Perifocal  zones,  or  regions  of  periodic  epidemics, 
including  the  ports  of  the  tropical  Atlantic  coast  in  America  and  Africa. 
(3)  The  zone  of  accidental  epidemics,  between  the  parallels  of  45°  N.  and 
35°  S.  latitude.  Yellow  fever  was  brought  to  the  United  States  (Boston) 
in  1693,  and  since  then  has  invaded  in  epidemic  form  numerous  sea-coast 
cities,  being  carried  thence  to  a  number  of  inland  towns.  For  example, 
in  1853  the  disease  prevailed  tliroughout  the  Southern  States,  and  since 
then  six  epidemic  outbreaks  (1867,  1873,  1878,  1897, 1898,  1899),  though 
of  lesser  severity,  raged  in  the  same  section.  The  disease  has  been  con- 
veyed to  seaports  in  Great  Britain  and  France,  but  has  never  been  carried 
inland  in  those  countries.  The  belief  that  the  disease  never  originates 
outside  of  certain  territorial  limits  was  advanced  for  the  first  time  by  the 
College  of  Physicians  of  Philadelphia  (1797). 

Pathology. — The  shin  is  jaundiced,  and  often  ecchymotic  spots  are 
observed,  but  the  internal  viscera  show  no  characteristic  lesions  in  cases 
of  average  intensity.  In  severe  forms  congestion,  hemorrhage,  degenera- 
tion, and  necrosis  are  the  changes  noted. 

After  death  the  liver  is  anemic,  as  a  rule,  but  in  the  early  stages  of 
the  disease  it  is  markedly  hyperemic.  Its  color  varies,  ranging  from 
pale  yellow  to  an  orange  hue,  and  punctiform  extravasations  cause 
mottling  of  the  surface.  Its  size  varies  little  from  the  normal.  Paren- 
chymatous degeneration  of  the  hepatic  tissue  is  common,  though  in  places 
it  may  be  entirely  normal.  The  liver  cells  are  swollen,  containing  fat 
and  orranular  matter,  with  indistinctness  or  absence  of  nuclei. 

The  gastro-intestinal  mucosa  is  the  seat  of  acute  catarrh  (in  severe 
types)  and  numerous  minute  hemorrhages,  similar  spots  of  extravasation 
being  found  on  the  various  serous  membranes  of  the  body  (meninges, 
pericardium,  pleura,  etc.).  Hemorrhagic  infarctions  may  be  found  in 
the  various  internal  viscera.  The  black-vomit  material  is  found  in  the 
stomach,  and  less  frequently  also  in  the  smaller  intestines. 

The  spleen  is  dark  and  friable,  but  is  not  enlarged.  The  Sidneys 
show  the  lesions  of  diffuse  nephritis,  the  microscope  revealing  cloudy 
swelling  of  the  epithelium  of  the  tubules,  with  fatty  degeneration  and 
tube-casts.  The  heart-muscle  looks  pale,  and  may  be  the  seat  of  granu- 
lar and  fatty  degeneration.  The  brain  and  its  menitiges  are  hyperemic, 
and  degenerative  changes  occur  in  the  sympathetic  ganglia  (Schmidt). 

Tlie  blood  is  dark,  and  many  of  the  red  corpuscles,  having  disor- 
ganized, set  free  hemoglobin,  as  in  malaria.  Fatty  degeneration  of  the 
walls  of  the  small  blood-vessels  and  the  capillaries  have  been  noted,  and 
these,  by  allowing  filtration  of  blood-serum,  produce  concentration  of  the 
blood.     General  glandular  enlargement  is  often  found. 

Btiology. — Bacteriology. — At  present  writing,  nothing  is  known  of 
the  micro-organism  that  causes  this  disease.  H.  Seidelin,  however,  has 
observed  in  the  red  blood-cells  certain  ring-like  and  ameboid  forms  which 
he  believes  have  an  etiologic  relation  to  the  disease.  The  infective  char- 
acter of  the  complaint  is  shown  by  the  fact  that  it  can  be  produced  by 


YELLOW  FEVER.  91 

the  inoculation  of  a  susceptible  person  with  the  blood  of  a  patient  suffer- 
ing from  the  disease. 

Mode  of  Transmission. — 'I'he  work  of  the  Yell(jw  Fever  Corn- 
mission  of  the  U.  S.  Army  (Drs.  Keed,  Carroll,  Lazear,  Agranionte) 
having  thoroughly  overthrown  the  claims  of  Sanarelli,  that  the  baciHus 
icteroides  is  the  specific  cause  of  yellow  fever,  his  bacillus  is  now 
regarded  as  a  secondary  invader.  In  1881  C.  J.  Finley  '  pointed  out 
that  the  disease  is  transmitted  through  the  agency  of  the  mosquito.  It, 
however,  remained  for  the  commission  mentioned  above  to  furnish  incon- 
testable experimental  proof  that  yellow  fever  is  a  mosquito-borne 
affection.  They  have  shown  that  the  stegomyia  fasciata  is  probably  the 
only  carrier  of  the  infecting  agent.  Twelve  days  after  biting  a  yellow- 
fever  subject  the  bite  of  the  mosquito  will  infect  a  non-immune  person. 
The  insect  is  capable  of  infecting  man  for  a  period  of  several  weeks. 
There  is  some  evidence  that  the  mosquito,  once  infective,  is  capable  of 
transmitting  the  parasite  for  the  balance  of  its  life.  The  mosquitoes, 
however,  are  not  infected  by  biting  the  dead  bodies  of  yellow-fever 
patients,  it  being  only  during  the  first  few  .days  of  the  disease  that 
the  patient's  blood  is  infective  for  the  mosquito,  and  only  the 
female  mosquito  bites.  The  clothing,  vomitus,  urine,  and  feces  are 
non-infectious. 

The  stegomyia  fasciata  has  been  found  as  far  north  as  Charlestown, 
S.  C,  and  southward  to  the  Rio  de  la  Plata,  and  is  extremely  prevalent 
in  Cuba.  The  larvae  only  develop  in  comparatively  clean  water,  and 
seldom  breed  far  outside  a  city's  limits.  Yellow  fever  is  thus  a  domicil- 
iary infection.  They  bite  principally  late  in  the  afternoon,  and  are  not 
capable  of  long  flights  unless  assisted  by  winds.  The  stegomyia  only 
travels  when  it  gets  into  a  car,  box,  or  drawer  instead  of  a  house  ;  it  "  will 
not  voluntarily  leave  a  house,  much  less  cross  a  street "  (White). 

Amonof  predisposing  causes,  season  heads  the  list.  The  disease  pre- 
vails chiefly  in  summer,  being  completely  arrested  by  one,  or  at  most 
two,  severe  frosts.  A';^e  and  race  have  some  degree  of  influence,  children 
being  more  liable  than  adults,  males  than  females,  and  whites  than 
blacks.  The  poison  is  not  transferred  by  fomites.  The  march  of  an 
epidemic  may  be  interrupted  or  even  completely  arrested  by  apparently 
trivial  agencies — e.  g.,  watercourses,  rows  or  clumps  of  shrubbery.  One 
attack  usually  bestows  permanent  immunity/,  and  natives  of  an  infected 
district  are  far  less  liable  to  the  disease  than  newcomers.  Two  attacks, 
however,  have  been  reported  (Boseman,  Libby). 

Clinical  History. — Incubation  Stage. — This  varies,  ranging  from 
two  to  five  or  more  days.  During  the  incubation  symptoms  may  appear, 
such  as  languor,  headache,  anorexia,  but  are  not  common. 

Invasion  Stage. — The  onset  is  abrupt,  an  initial  chill  usually  occurring, 
but  it  is  very  seldom  severe  or  prolonged,  a  reactionary  fever  following: 
promptly  and  the  te?nperafure  rising  to  103°,  104°,  or  even  105°  F. 
(40.5°  C.).  The  temperature  is  apt  to  be  highest  at  the  beginning,  and 
then  declines  by  lysis  with  slight  evening  exacerbations  and  morning 
remissions.  Hyperpyrexia  occasionally  occurs  on  the  first  day  of  the 
illness.  The  chill  and  fever  are  accompanied  by  headache  and  pains  in 
the  loins  and  legs,  often  of  gi'eat  severity,  and  a  little  later,  restlessness, 
^  Annales  dela  Biol.  Academie.  vol.  xviii..  pp.  147-161. 


92  INFECTIOUS  DISEASES. 

saental  confusion,  and  a  delirium  that  is  sometimes  violent  in  character 
may  develop.  In  the  majority  of  instances,  however,  the  mind  remains 
clear.  ')^\\q  pulse  is  accelerated,  hut  not  in  proportion  to  tho  height  of 
the  temperature ;  it  is  full  and  strong  at  the  start,  and  is  observed  to  fall 
Avhile  the  temperature  remains  the  same  or  even  rises.  The  face  is 
flushed,  "with  slight  icteroid  addition.  The  early  manifestation  of  jaun- 
dice is  the  most  characteristic  feature  of  the  facies  (Guiteras).  The  eyes 
are  suffused  and  intolerant  of  light.  The  gums  may  be  SAvollen  and 
s))ongy  ;  later  on  a  red  line  is  seen  at  their  margins  and  they  readily  ooze 
blood.  The  tongue  may  or  may  not  be  coated,  and  nausea  and  vomiting 
may  occur,  the  latter  being  one  of  the  most  characteristic  symptoms  of 
the  disease.  Associated  with  these  symptoms  there  arc  epigastric  oppres- 
sion and  burning  sensations,  with  decided  tenderness.  The  vomitus  may 
be  blood-streaked  or  contain  chocolate-colored  particles,  and  occasionally 
unaltered  blood  is  vomited.  Constipation  is  usually  present,  the  stools 
showing  a  deficiency  of  bile.  The  urine  is  diminished  in  amount,  dark- 
colored,  and  often  contains  a  slight  amount  of  albumin:  this  early  tran- 
sient albuminuria  is  a  very  characteristic  symptom.  The  initial  stage 
may  last  from  six  or  eight  hours  to  two  or  three  days,  or  even  longer, 
and  is  longer  in  the  milder  forms.  With  the  termination  of  this  stage 
there  is  a  marked  remission  of  the  fever  and  other  symptoms,  the  pulse 
becoming  remarkably  slow. 

Stage  of  Remission. — From  this  moment  convalescence  may  begin  and 
proceed  to  full  recovery  without  interruption,  the  happy  event  being  often 
marked  by  critical  discharges.  In  most  instances,  however,  the  patient 
presents  certain  symptoms  and  signs  of  ill-health  during  the  stage  of 
calm  (more  or  less  prostration,  epigastric  distress  with  tenderness,  mental 
dulness  or  even  stupor,  and  a  yellowish  tint  of  skin  and  urine),  which  lasts 
from  a  few  to  twenty-four  hours,  when  another  serious  stage  supervenes. 

Stage  of  Secondary  Fever  or  Collapse. — The  patient  becomes  extremely 
weak,  presenting  the  signs  of  profound  collapse.  The  surface  of  the  body 
is  cool  (extremities  often  positively  cold),  the  skin  in  nearly  all  instances 
assuming  a  yellow  or  bronzed  tinge.  It  is  rarely  absent  during  life,  but 
always  present  after  death.  The  pulse  is  rapid  and  compressible,  and 
soon  vomiting  becomes  distressing.  Hemorrhage  into  the  stomach  occurs, 
the  blood  being  acted  upon  by  the  gastric  secretions,  and  producing  the 
material  which  is  expelled  as  the  characteristic  "-black  vomit.''  Occa- 
sionally unaltered  blood  may  be  vomited ;  the  stools  also  may  be  tarry. 
In  the  worst  cases  hemorrhages  from  other  mucous  surfxces  are  common 
(epistaxis,  hematuria,  metrorrhagia,  etc.),  and  cutaneous  hemorrhages 
also  now  occur.  In  this  stage  the  tongue  becomes  dry,  brown,  or  even 
black  ;  less  frei^uently  it  is  smooth,  red,  and  fissured. 

In  most  cases  the  urine  is  deficient,  containing  albumin  and  casts 
(with  careful  centrifugation),  and  in  rare  instances  there  is  complete 
anuria.  The  latter  may  precede  the  development  of  grave  nervous 
symptoms,  as  convulsions,  or  even  coma,  which  may  be  uremic. 

In  some  instances  the  temperature  rises  during  this  period  (secondary 
fever),  and  in  favorable  cases  terminates  by  lysis,  or  it  may  assume  the 
typhoid  form  and  result  fatally,  and  a  decided  slowing  of  the  pulse  may 
occur,  as  low  as  twenty-four  beats  even.  In  all  cases  that  pursue  a 
favorable  course  convalescence  is  slow  and  gradual,  and  it  may  be  inter- 
rupted by  certain  complications  {e.  g.,  abscesses).      The  duration  of  the 


YELLOW  FEVER.  93 

entire  attack  (composed  of  three  stages)  is  variable,  though  as  a  rule  it 
covers  about  one  week. 

Clinical  Varieties. — Many  different  varieties  have  been  described, 
each  characterized  by  one  or  more  prominent  features,  but  none  seem 
more  justifiable  than  Finlay's '  classification,  in  which  he  distinguishes 
three  forms:  (1)  the  acclimation  fever.,  or  non-albuminuric  yellow  fever  ; 
(2)  the  plain  albuminuric  yellow  fever  ;  (3)  the  7iielano-aU>uminuric  yel- 
low fever,  characterized  by  the  presence  of  blood  or  "black  vomit"  in 
the  stomach  or  intestines.      Relapses  occur,  but  are  rare. 

Diagnosis. — The  symptoms  that  justify  a  diagnosis  in  the  initial 
stage,  provided  an  epidemic  be  prevailing,  are  the  sudden  onset, .severe 
nephralgia,  cephalalgia,  peculiar  facies  and  pulse  (a  fall  in  the  pulse-rate 
while  the  fever  remains  high  or  rising — Faget's  sign),  nausea,  and  vomiting 
of  bile.  In  the  early  stage  intense  capillary  congestion  of  the  surface  of  the 
body  is  diagnostic  and  indicative  of  a  severe  type.  In  the  third  stage  the 
co-existence  of  jaundice,  the  black  vomit,  and  suppression  of  urine,  'vith 
evidences  of  collapse,  make  the  diagnosis  easy.  The  mild  or  rudimentary 
form  offers  the  greatest  difficulty,  since  the  clinical  picture  comprises  only 
slight  fever  which,  at  the  end  of  a  day,  is  followed  by  speedy  convalescence. 

Serum-diagnosis. — Woodson  and  P.  E.  and  J.  J.  Archinard  have 
applied  the  Widal  reaction  (agglutination-test)  in  100  cases,  and  claim  that 
the  serum-diagnosis  of  yellow  fever  is  practicable  and  may  be  used  on  the 
second  day.     A  dilution  of  1  :  40  is  advised. 

Differential  Diagnosis. — Pernicious  malarial  fever  (estivo-autumnal) 
has  not  the  early,  deep  jaundice,  the  slow  pulse,  the  peculiar  temperature- 
curve,  the  intense  capillary  congestion  of  the  surface  of  the  body,  the 
black  vomit,  the  early  albuminuria,  and  the  clear  mind — all  symptoms 
that  mark  yellow  fever.  On  the  other  hand  the  crescentic  or  small  ring- 
shaped  forms  of  the  plasmodium  are  pathognomonic  of  pernicious  malarial 
fever,  as  is  the  effect  of  quinin  upon  the  disease.  Kemp  has  made  a 
microscopic,  spectroscopic,  and  chemical  study  of  the  black  vomit  of  yel- 
low and  malarial  fevers,  and  found  that  the  pigment  was  derived  from  the 
blood,  which  had  been  acted  upon  by  the  gastric  juices.  The  vomitus  in 
malarial  fever,  however,  contains  in  addition  considerable  quantities  of 
bile-pigment  and  bile-salts,  which  are  wanting  in  that  of  yellow  fever. 
Further,  in  the  latter,  the  vomited  matter  is  much  more  highly  acid. 
The  diagnostic  features  of  dengue,  which  has  been  confounded  with  fehris 
jiava,  have  been  contrasted  with  those  of  the  latter  disease  on  p.  140. 

Prognosis. — Different  epidemics  show  widely  different  death-rates, 
and  the  most  potent  factor  is  the  particular  type  of  the  disease  in  indi- 
vidual epidemics.  Some  outbreaks  have  been  characterized  by  the 
lighter  forms,  and  in  such  the  death-rate  has  been  low  (1  per  cent.).  In 
other  epidemics  the  type  has  been  so  virulent  (with  high  temperature)  as 
to  make  the  mortality  list  high — even  to  100  per  cent.  In  general,  mild 
epidemics  give  a  mortality  of  5  to  10  per  cent.,  and  severe  ones  of  30  to 
50  per  cent.      The  death-rate  is  lower  in  private  than  hospital  practice. 

Among  the  gravest  symptoms  are  intense  capillary  congestion,  coming 
on  during  the  first  stage,  suppression  of  urine,  intense  jaundice,  and 
uremic  toxemia.  The  black  vomit  is  not  as  fatal  a  sign  as  the  symptoms 
previously  mentioned. 

It  has  been  noted  that  a  larger  number  of  men,  proportionately,  than 
^  Edinburgh  Medical  Journal,  Edinburgh. 


94  INFECTIOUS  DISEASES. 

■women  and  children   succumb  to  the   disease,    and   that   it  is  less  fatal 
among  negroes  than  among  whites. 

Treatment. — The  measures  that  are  employed  in  yellow  fever  may 
be  considered  under  three  main  heads :  (1)  Prophylaxis  ;  (2)  general 
management  ;   and  (3)  medicinal  measures. 

(1)  Prophylaxis. — Reed  claims  that  the  present  quarantine  laws 
against  yellow  fever  are  needless  and  the  detention  system  absurd.  The 
effective  way  to  prevent  carrying  of  the  fever  poison  is  the  destruction 
of  the  Stegomyia  fasciata — on  vessels  at  sea  as  well  as  in  infected  houses 
and  districts  on  land.  Well  persons  must  be  protected  against  the  bites 
of  the  Stegomyia  by  careful  screening.  It  is  a  twilight  mosquito,  resting 
in  the  middle  of  the  day,  hence  non-immunes  may  visit  infected  localities 
between  9  a.  m.  and  3  p.  m.  with  impunity.  It  is  unnecessary  to  disin- 
fect articles  of  clothing,  bedding,  or  merchandise  supposedly  contaminated 
by  contact  with  those  ill  of  the  disease.  W.  C.  Gorgas  ^  has  shown  that 
in  Havana,  since  attention  has  been  directed  entirely  to  the  mosquito, 
the  minimum  annual  death-rate  from  yellow  fever  has  been  reached.  The 
patient  must  be  isolated  and  carefully  screened. 

"  When  a  non-immune  is  going  to  be  exposed  to  yellow  fever  it  is 
better  to  be  inoculated,  so  that  he  can  be  put  to  bed  and  treated  from  the 
beginning,  than  to  take  it  accidentally "  (Gorgas).  To  immunize  a 
patient  a  single  mosquito  should  be  employed  for  each  inoculation. 

(2)  General  Management. — The  sufferer  from  yellow  fever  must  be  put 
to  bed  at  once,  and  an  abundance  of  fresh  air  (without  exposure  to  strong 
drafts)  must  be  supplied.  The  medicaments  and  the  nourishment  are  to 
be  administered  through  a  tube  or  spout-cup,  so  as  to  obviate  raising  the 
patient's  head.  Body-  and  bed-linen  should  be  kept  scrupulously  clean, 
and  the  patient  must  not  be  allowed  to  leave  his  bed  on  any  account. 
The  diet  should  be  of  the  lightest  sort  and  entirely  liquid,  beginning  with 
peptonized  milk,  koumiss,  or  light  broths. 

(3)  Medicinal  Measures. — At  the  outset  it  is  w^ell  to  gently  stimu- 
late the  various  excretory  organs,  and  mild  laxative  diaphoretics  and 
diuretics  answer  this  purpose.  Hydrotherapy  may  be  employed  to 
maintain  the  nervous  tonicity  and  reduce  the  temperature,  but  when 
the  spontaneous  fall  of  temperature  sets  in  it  must  be  discontinued. 
The  neuralgic  pains,  which  attack  principally  the  head,  loins,  and 
nerve-trunk,  are  to  be  relieved  by  morphin  given  hypodermically ;  and 
for  the  same  symptom  Bemiss  highly  recommends  quinin  by  the  rectum 
(gr.  XX — 1.296).  Intestinal  antiseptics  may  also  be  used  throughout 
the  attack. 

During  the  stage  of  remission  the  powers  of  the  system  are  to  be  fully 
maintained  by  a  suitable  dietary  and  by  tonics  and  stimulants  if  required. 

In  the  last  stage,  supportive  measures  must  not  be  forgotten. 
Rectal  nutrient  enemata  should  be  employed  if  marked  gastric  irrita- 
bility prohibits  feeding  by  the  mouth.  Stimulants  are  demanded,  and 
these  should  also  be  administered  per  rectum  if  not  retained  by  the 
stomach,  or  they  may  in  some  measure  be  administered  hypodermically. 
The  stomach  is,  as  a  rule,  tolerant  of  iced  champagne. 

If  irritability  of  the  stomach  be  present,  ice  and  hydrocyanic  acid 
may  be  tried.  Sodium  bicarbonate  (gr.  x  to  xx — 0.648  to  1.296)  in 
Vichy,  Apollinaris,  or  Seltzer  w^ater  is  a  most  useful  remedy,  and  Stern- 
^  Phila.  Med.  Jour.,  Jan.  4,  1902. 


CEREBROSPINAL  MENINGITIS.  95 

berg  has  used  it  in  combination  with  naercuric  chlorid  with  success  in 
the  following  formula : 

I^.   Sodii  bicarb.,  3iv(16.0); 

Hydrarg.  bichlorid.,  gr.  ss.  (0.032); 

Aquae  purae,  Oj  (480). — M. 

Sig.  For  a  severe  case  two  teaspoonfuls  every  hour,  day  and  night ; 
for  a  mild  case,  every  hour  by  day  and  every  two  hours  by 
night ;  administer  always  ice-cold. 

Perhaps  the  chief  indication  for  the  use  of  sodium  bicarbonate  is 
the  extreme  acidity  of  the  various  secretions,  especially  the  gastric  and 
renal.  Sternberg  contends  that  by  fulfilling  this  indication  we  prevent 
in  great  measure  the  occurrence  of  acute  nephritis  and  suppression  of 
the  urine.  Hemorrhages  and  other  symptoms  must  be  treated  by  the 
usual  means.  During  convalescence  tonics  are  to  be  administered,  and 
the  customary  diet  can  gradually  be  resumed. 

Serum-therapeutics. — Prof.  Sanarelli  records  favorable  results  from 
the  use  of  his  antitoxic  serum.  Morcour  ^  points  out  that  we  need  to  try 
the  serum  only  in  grave  cases,  since  mild  cases  recover  with  simpler 
methods  and  careful  nursing.  Wasdin,  however,  used  Sanarelli's  serum 
in  3  cases  and  noted  no  advantage  over  other  ti*eatment.  Matienzo,^ 
after  a  series  of  experiments  on  guinea-pigs  and  human  beings  with 
American  serum,  concludes :  Intravenous  and  subcutaneous  injections 
produce  general  reaction ;  no  effect  is  produced  upon  the  disease.  The 
reaction  obtained  in  convalescence  proves  that  the  antitoxin  does  not 
produce  the  cure. 


CEREBRO-SPINAL  MENINGITIS. 

[Spotted  Fever ;   Cerebrospinal  Fever.) 

Definition. — An  infectious  disease,  caused  by  the  diplococcus  intra- 
cellularis  meningitidis  (Weichselbaum).  It  is  characterized  anatomically 
by  inflammation  of  the  meninges  of  the  brain  and  spinal  cord,  and 
clinically  by  an  irregular  course,  a  moderate  febrile  movement  with 
somewhat  characteristic  and  profound  nervous  symptoms  (excruciating 
headache,  pain  in  the  back  and  upper  part  of  the  spine,  contraction  of 
the  muscles  of  the  nucha,  hyperesthesia,  delirium,  and  ofttimes  coma). 
The  disease  may  occur  sporadically  or  in  epidemics,  or  may  even  assume 
pandemic  proportions. 

Historic  Note. — Cerebro-spinal  meningitis  was  first  recognized 
and  described  as  late  as  the  beginning  of  the  last  century  (1805)  by 
Viesseux  of  Geneva.  During  the  next  decade  numerous  limited  epi- 
demics were  observed  both  in  Europe  and  the  United  States,  and  subse- 
quently recurring  epidemic  and  pandemic  visitations  were  noted,  though 

^  Proceedings  Third  Pan-American  Medical  Congress,  Feb.  4, 1901. 
2  Med.  News,  Jan.  13,  1900. 


96  lyPECTIOUS  DISEASES. 

at  longer  and  variable  intervals  of  time.  In  nearlv  all  the  larce  cities  in 
this  country  it  has  become  endemic,  and  in  Philadelphia  since  18G3. 

Pathology. — The  cases  that  prove  speedily  fatal  do  not  present 
gross  characteristic  changes,  but  by  the  aid  of  the  microscope  leukocytes 
are  discovered  immediately  around  the  cerebral  vessels,  and  round  cells 
in  the  cortex  of  the  brain.  In  some  cases  the  characteristic  evidences  of 
encephalitis  are  already  noticeable.  On  the  other  hand,  the  cases  in 
which  death  occurs  after  the  disease  has  been  full}'^  developed  show  the 
lesions  of  suppurative  inilanunation  of  the  meninges  of  the  brain.  The 
arteries,  veins,  and  sinuses  are  much  engorged  ;  the  ventricles  are  dis- 
tended with  liquid,  but  the  pia  mater  is  principally  affected,  its  vessels 
being  greatly  enlarged,  and  a  more  or  less  copious  sero-fibrinous  or  sero- 
purulent  exudate  occurring  into  the  meshes  of  its  netAvork.  The  longer 
the  duration  of  the  case  the  more  purulent  is  the  exudation.  The  ven- 
tricles of  the  brain  are  filled  Avith  a  similar  exudation,  and  red  blood- 
globules  may  be  present  at  an  advanced  stage.  The  color  of  the  exu- 
date is  at  first  almost  clear  (being  composed  of  serum) ;  it  then  changes 
to  a  milky  turbidity,  to  a  pale  yellow,  and,  lastly,  takes  on  a  greenish- 
yellow  color  ("leek-green  ").  The  subarachnoid  space  may  be  occupied 
by  a  uniform  layer  composed  of  fibrin  and  pus. 

The  brain-matter  is  congested,  and  sometimes  softened  in  spots,  and 
on  section  the  gray  matter  may  present  punctate  extravasations.  When 
resolution  occurs  recovery  may  be  comi)iete,  but  frequently  the  pia  mater 
remains  thickened.  The  exudation  may  follow  the  auditory  and  optic 
nerves  along  their  lymph-sheaths,  and  pus  has  been  found  in  the  internal 
ear  as  well  as  in  the  chambers  of  the  eye. 

The  membranes  of  the  spinal  cord  manifest  lesions  identical  with 
those  of  the  brain.  They  are  vascular  engorgements,  followed  by  sero- 
fibrinous, and  later  still  by  sero-purulent,  exudation  beneath  the  arach- 
noid. The  changes  are  more  marked  on  the  posterior  than  the  anterior 
surface  of  the  cord,  and  the  exudate  increases  in  amount  in  passing  from 
above  downward,  in  severe  cases  sometimes  assuming  the  form  of  a  sheath 
which  completely  surrounds  the  cord  throughout  its  entire  length.  The 
pia  mater  is  congested,  and  may  be  thickened,  shaggy,  and  in  places 
adherent  to  the  cord,  of  which  the  gray  matter  may  be  the  seat  of  serous 
infiltration,  and  rarely  of  softening.  Barker  describes  certain  changes 
that  occur  in  the  nerve-cells  and  the  ventral  horns  of  the  nucleus 
dorsalis  (Clarkii)  of  the  spinal  cord  in  epidemic  cerebro-spinal  menin- 

The  lungs  may  exhibit  the  changes  peculiar  to  bronchitis  or  pneu- 
monia. In  the  heart  endocarditis  may  be  noted,  though  rarely,  and  both 
the  pleura  and  the  pericardium  may  show  inflammatory  lesions  and  con- 
tain a  serous  or  sero-purulent  exudation.  Hemorrhages  into  the  serous 
membranes  and  into  the  skin  may  take  place.  The  spleen  may  be  en- 
larged, the  increase  in  size  and  the  degree  of  fever  being  })roportional, 
and  the  liver  is  hyperemic.  The  kidneys  are  congested,  and  bacterial 
forms  have  been  found  associated  in  the  latter  with  the  lesions  of  acute 
nephritis  and  hemorrhage — conditions  of  which  they  were  probably  the 
cause. 

Ktiology. — Bacteriology. — The  diplococcus  meningitidis  is  the  spe- 
cific cause  of  epidemic  cerebro-spinal  meningitis.     The  special  organism 


CEREBHO-SPTNAL  MENINdlTLS.  97 

can  be  isolated  from  the  spinal  fluid,  the  meninges  of  tlie  l>rain  and  eoi'd, 
the  blood,  the  joint-lesions,  aiid  the  nasal  mucus. 

The  meningococcus,  like  the  gonococcus,  occupies  a  position  witliin 
the  polynuclear  leukocytes,  but  never  appears  within  the  nucleus  (Park), 
and  like  the  latter  is  biscuit-shaped.  The  bacterium  takes  the  usual 
stains.  It  develops  upon  agar-agar  and  upon  Loeffler's  blood-serum, 
manifesting  characteristics  of  growth  that  simulate  those  of  the  pneu- 
mococcus.  Councilman,  Carl  Frank  el,  Boston,  and  others,  by  refined 
methods,  have,  however,  been  able  to  differentiate  these  organisms. 
Welch  suggests  that  the  meningococcus  and  the  ])neumococcus  are  possibly 
varieties  of  the  same  bacterium,  while  Netter  regards  the  meningococcus 
as  a  degenerate  form  of  the  pneumococcus.  Among  the  associated 
microbes  are  the  pneumococcus,  streptococcus  pyogenes,  staphylococcus 
aureus,  bacillus  coli  communis,  and  the  tubercle  bacillus,  and  any  one  of 
the  latter  is  capable  of  causing  sporadic  cerebro-spinal  meningitis. 

Predisposing  Causes. — (1)  Age. — Most  cases  occur  in  children  and 
young  adults,  though  no  age  enjoys  perfect  immunity.  Of  94  cases  occur- 
ring in  children  up  to  15  years  of  age,  56  were  under  five  years  (Claytor). 

(2)  Climate. — The  disease  is  unknown  in  tropical  climates,  but  has 
occurred  in  all  parts  of  the  temperate  zone,  and  is  most  prevalent  in  the 
more  northerly  portions  of  the  latter. 

(3)  Season  is  not  an  important  factor,  though  the  disease  prevails 
largely  in  winter  and  spring. 

(4)  Unhygienic  Influences. — The  disease  often  appears  in  ill-ventilated 
and  overcrowded  habitations — among  the  poorer  classes,  among  soldiers 
crowded  together  in  barracks,  and  among  prisoners.  Prolonged  march- 
ing, and  excessive  physical  or  mental  exertion,  may  heighten  suscepti- 
bility.    In  certain  epidemics  the  disease  has  raged  exclusively  in  villages. 

Modes  of  Conveyance. — Precisely  how  the  contagion  is  transferred  from 
an  infected  person  to  a  healthy  one  is  not  known,  but  the  disease  is 
probably  contagious.  Hare^  has  recorded  two  cases  in  which  the  infec- 
tion seemed  to  be  transferred  directly  from  the  first  to  the  second.  The 
poison  may  be  conveyed  hj  fomites  in  cases  that  furnish  intensely  viru- 
lent poison.  As  to  the  manner  in  which  the  virus  gains  entrance  to  the 
system,  our  knowledge  is  imperfect,  although  Hunt^  states  that  cerebro- 
spinal meningitis  seems  to  be  an  inhalation  disease.  It  is  certain  that 
this. germ  may  enter  the  meninges  (a)  by  blood  metastasis  ;  (b)  by  direct 
extension  of  an  adjacent  inflammatory  process  (e.  g.,  mastoiditis).  Elser 
and  Hontoon  ^  believe  that  the  disease  may  be  spread  by  meningococcus 
carriers. 

Clinical  History. —  The  period  of  incubation  is  brief,  though  un- 
known. The  prodromal  symptoms  are  variable  in  diff"erent  epidemics. 
Invasion  maybe  sudden,  a  patient  in  vigorous  health  often  being  stricken 
down  as  though  by  a  blow.  In  some  rapidly  fatal  cases  there  is  a  short 
prodromal  period,  during  which  the  patient  complains  of  lassitude,  head- 
ache, rachialgia,  muscle-  and  joint-pains,  and  sometimes  nausea  and 
vomiting.  In  ordinary  forms  the  prodromes  may  last  from  a  few  hours 
to  a  week  or  more,  and  the  patient's  complaint  may  be  limited  to  cervical 
and  occipital  pains  lasting  a  day  or  two  ;  then,  without  any  initial  chill,  ■ 

1  New  York  Med.  Jour.,  Feb.  10, 1906.  2  Boston  Med.  and  Surg.  Jour.,  Xov.  1,  1906. 

3  Journal  of  Medical  Research,  1909,  p.  397. 
7 


98  INFECTIOUS  DISEASES. 

the  invasion-period  supervenes.  In  milder  and  sporadic  cases  the  symp  = 
toms  consist  chiefly  of  languor  and  debility,  headache,  pain  in  the  back 
and  limbs,  vertigo,  vomiting,  and  sometimes  diarrhea. 

Most  cases  begin  ahrKptly,  between  noon  and  midnight.  The  most 
distinctive  and  violent  features  are  chill  (often  severe), /ever  of  a  moder- 
ate grade,  a  full  and  somewhat  accelerated  pulse,  raging  headache,  and 
vomiting.  In  children  the  ushering-in  symptom  may  be  a  convuhion. 
These  phenomena  are  followed  by  pain  in  the  back  and  cervical  por- 
tion of  the  spine — an  early  and  characteristic  symptom.  Attempts  at 
flexion  or  rotation  of  the  head  increase  the  pain  in  the  neck  and  move- 
ments of  the  body  augment  the  spinal  pains.  Later,  the  muscles  in  the 
cervical  region  contract,  at  the  same  time  becoming  rigid,  and  produce  the 
condition  of  opisthotonos.     The  patient  may  be  unable  to  swallow. 

The  temperature  is  but  moderately  elevated.  In  a  certain  percentage 
of  the  cases  it  rapidly  rises  to  104°  or  105°  F.  (40.5°  C),  but  soon  falls 
to  102°  or  103°  F.  (38.8°  or  39.4°  C),  at  which  level  it  is  maintained 
with  irregular  undulations  until  defervescence,  which  takes  place  by 
lysis.  In  fatal  cases  death  is  preceded  by  a  sudden  great  elevation  of 
temperature  to  108°  and  even  1]0°  F.  (43.3°  C).  In  the  very  young 
the  thermometric  range  is  lower  than  in  adults. 

The  jniUe  is  but  slightly  accelerated,  if  at  all,  in  the  early  stages  of 
the  disease.  Later,  in  twenty-four  to  thirty-six  hours,  it  may  in  severe 
cases  leap  to  120  or  even  140,  its  chief  characteristic  being  the  variability 
in  its  rate.  In  the  early  stage  it  is  of  good  volume  and  tension ;  later, 
it  may  be  soft  and  compressible,  and  in  serious  cases  it  becomes  small 
and  feeble.     Polynuclear  leukocytosis,  moderate  or  severe,  is  constant. 

The  respirations,  as  a  rule,  increase  in  frequency  and  are  sometimes 
quite  irregular ;  but  marked  dyspnea,  with  slowing  of  the  respirations, 
may  be  observed  during  the  advanced  stage,  being  due  to  pressure  ex- 
erted by  the  exudation  upon  the  respiratory  center.  Cheyne-Stokes 
breathing  and  sighing  respirations  may  be  present. 

Nervous  S3rmptoms. — The  headache  is  racking  and  often  persistent, 
though  it  is  subject  to  remissions;  it  is  intensified  by  light  and  sounds. 
There  is  vertigo  in  nearly  all  instances.  The  pain  referred  to  the  spine 
may  be  general  or  limited  to  either  the  lumbar  or  cervical  region  (rarely 
the  dorsal),  and  the  general  myalgic  pains  are  often  intense,  especially  in 
the  extremities  and  the  abdominal  region.  With  the  cephalalgia  and 
abdominal  pain  may  be  associated  vomiting.  Hyperesthesia  is  a  promi- 
nent symptom,  the  gentlest  touch  being  extremely  painful ;  and  anesthesia 
may  follow.  Any  voluntary  muscular  movements,  however,  excite  pain. 
In  some  cases  delirium  appears  early,  and  in  others  rather  late,  Avhile  in 
the  worst  types  death  often  occurs  before  delirium  develops.  On  the 
other  hand,  in  a  small  percentage  of  cases,  this  symptom  is  absent  through- 
out the  entire  course,  and  always  its  character  and  intensity  exhibit  a 
remarkable  variety.  It  may  be  mild  or  it  may  take  the  form  merely  of 
incoherent  answers  to  questions.  Active  delirium,  however,  is  common 
and  is  accompanied  by  hallucinations,  during  which  the  patient  shouts 
loudly,  and,  unless  restrained,  gets  out  of  bed.  This  form  of  delirium  oc- 
curs in  paroxysms  that  are  most  apt  to  appear  at  night,  and  in  the  female 
it  is  sometimes  hilarious  or  hysteric.  An  erotic  tendency,  with  priapism 
or    seminal  emissions,  has    been  observed    in  males.     The  "maudlin" 


CEREBBO-SPTNAL  MEN/NO ITfS.  99 

delirium  of  the  drunkard  is  sometimes  seen,  but  sooner  or  later  somnolence 
appears  and  may  deepen  quickly  into  coma,  perhaps  temporary,  though 
more  often  it  continues  until  recovery  or  death.  Vomiting  is  common, 
usually  late  in  the  disease ;  it  is  doubtless  of  cerebral  origin. 

Symptoms  of  motor  irritation  are  common,  twitching  of  single  muscles 
or  groups  often  being  seen,  and  occasionally  muscular  tremors.  Muscular 
contraction  is  an  almost  constant  feature.  After  a  few  days  a  tonic 
spasm  of  the  muscles  of  the  extremities  sets  in,  bending  the  arms  upon  the 
chest,  the  forearm  upon  the  arm,  and  the  thumb  upon  the  palm ;  the 
thigh  is  also  flexed  on  the  abdomen  and  the  leg  on  the  thigh.  The 
opisthotonos  may  be  followed  by  trismus,  which  can  be  considered  a 
mortal  symptom.  Convulsions  do  not  occur  in  adults,  but  are  common 
in  children ;  occasionally  there  is  paralysis  (facial  hemiplegia). 

Organs  of  Special  Sense. — Photophobia  is  a  prominent  symptom,  and 
the  condition  of  the  pupils  is  very  variable.  They  may  be  dilated  or 
contracted  (more  frequently  the  former)  or  remain  normal ;  and  in  the 
majority  of  cases  they  are  unequal  in  size  and  react  poorly  to  light. 

Strabisfnus  is  frequent,  usually  temporary,  though  it  may  recur  during 
the  attack.  Rarely  it  is  permanent.  Conjunctivitis  of  moderate  inten- 
sity and  keratitis  may  occur,  the  former  being  common.  Burville- 
Holmes^  invites  attention  to  anesthesia  of  the  cornea  and  conjunctiva, 
which  occurs  in  about  one-half  of  the  cases.  Ptosis  is  almost  always 
present.  Intense  purulent  irido-ehoroiditis  sometimes  occurs ;  either 
temporary  or  permanent  blindness  and,  rarely,  nystagmus  are  noted. 
Among  optical  sequelae  are  cataract  and  atrophy  of  the  eyeball. 

Deafness  is  common,  there  being  an  early  intolerence  of  sound  and  a 
marked  tinnitus  aurium.  Late  suppurative  inflammation  of  the  middle 
ear,  followed  by  rupture  of  the  tympanum  and  otorrhea,  may  occur.  The 
internal  ear  may  be  similarly  involved,  with  uncertain  gait. 

Cutaneous  symptoms  appear,  some  of  which  possess  considerable  diag- 
nostic worth.  Pallor  and  lividity  of  the  skin  and  visible  mucous  mem- 
branes often  characterize  the  period  of  invasion,  and  shortly  after  the 
onset  herpes  facialis  appears  in  more  than  half  the  cases.  This  symptom 
is  significant  for  diagnosis.  The  separate  lesions  are  extensive,  and  often 
coalescence  of  two  or  more  is  witnessed.  Herpes  facialis  belongs  in  a 
peculiar  sense  to  cerebrospinal  meningitis ;  herpes  labialis  to  malaria, 
and  less  frequently  to  pneumonia  and  meningitis.  A  petechial  eruption 
is  common,  in  the  early  epidemics,  and  more  frequently  in  America  than 
in  Europe.  To  this  symptom  the  disease  owes  the  name,  long  since  given  to 
it,  of  "spotted  fever."  It  may,  however,  be  absent,  and  when  present 
it  is  sometimes  limited  to  a  small  superficial  area,  though  more  fre- 
quently it  is  diffuse.  At  first  the  eruption  may  be  bright  red  (erythe- 
matous), later  becoming  darker,  or  it  may  be  distinctly  petechial  from  the 
start ;  purpuric  spots  of  considerable  size  and  sometimes  large  ecchymoses 
may  appear,  but  these  are  most  common  in  the  more  malignant  types. 
Other  forms  of  eruption  are  also  seen  (sudamina,  urticaria,  ecthyma, 
erythema,  erysipelas,  etc.),  but  are  devoid  of  diagnostic  value.  Giangrene 
of  the  skin  is  occasionally  noticed,  and  in  some  cases  bed-sores  are  liable 
to  arise ;  but  there  is  no  fixed  time  for  the  skin-lesions  of  cerebro-spinal 
fever  to  appear,  and  their  duration  is  exceedingly  variable. 
^Jour.  Amer.  Med.  Assoc,  1908,  ],  280. 


100  INFECTIOUS  DISEASES. 

Of  gastro-intestinal  symptoms  vomiting  is  the  most  common.  It  usu- 
ally lasts  only  tor  a  brief  period  at  the  onset,  though  it  may  recur  later 
at  "longer  or  shorter  intervals,  and  is  of  nervous  origin.  The  appetite 
mav  be  good,  but  in  many  cases  it  is  soon  lost,  the  tongue,  in  a  large  ])ro- 
portion  of  the  .instances,  being  only  slightly  coated.  In  cases  assuming 
the  adynamic  or  typhoid  type  the  tongue  is  apt  to  become  dry  and  of  a 
brown'  color,  with  the  formation  of  sorties.  Under  these  circumstances 
the  abdomen  is  tympanitic  and  the  bowels  relaxed,  and  diarrhea  may  be 
urgent,  resisting  "all  eflbrts  aimed  at  its  relief.  Retraction  of  the  belly 
is  common,  and  constipation  instead  of  diarrhea  is  the  general  rule ;  the 
spleen  may  often  be  felt  a  little  distance  below  the  costal  margin. 

Renal  symptoms  are  not  prominent,  though  the  amount  of  urine  passed 
is  often  above  the  normal  despite  the  febrile  movement.  It  may  be  below, 
though  rarely,  while  in  still  other  cases  it  is  about  normal ;  and  retention 
on  the  one  hand  and  incontinence  on  the  other  have  been  observed. 
AJbumiauria  is  sometimes  met  with,  and  rarely  glycosuria. 

Arthritis  is  not  uncommon,  particularly  in  the  severer  cases. 

Kernig's  Sign. — In  1884  Kernig  first  pointed  out  the  impossibility  of 
obtaining  complete  extension  of  the  leg  on  the  thigh  when  the  patient 
is  sittimi  and  the  thiirli  is  flexed  at  a  right  angle  to  the  trunk.  The 
sign  is  produced  by  irritation  of  the  meninges  of  the  lower  portion  of 
the  spinal  cord  and  of  the  nerve-roots  that  constitute  the  cauda  equina, 
Roglet  thinks  that  one  cause  for  this  sign  is  intraventricular  pressure.^ 
Under  this  irritation,  increased  by  the  stretching  eifect  of  the  sitting 
posture,  the  tonicity  of  the  flexor  muscles  of  the  leg  is  increased,  and  as 
a  consecjuence  complete  extension  of  the  leg  becomes  impossible.  The 
contracture  disaj)pears  when  the  patient  assumes  the  dorsal  decubitus. 
If  the  patient  cannot  be  propped  up  in  bed,  the  thigh  may  be  flexed 
upon  the  abdomen,  when,  if  meningitis  be  present,  complete  extension 
of  the  leg  will  be  prevented  by  contraction  of  the  flexor  muscles.  Head's^ 
statistics,  embracing  156  cases,  show  that  Kernig's  sign  is  present 
in  84  per  cent,  of  the  cases  of  meningitis.  It  is  not  confined  to  cerebro- 
spinal meningitis,  but  is  present  in  all  meningeal  aff'ections.  The  time 
of  its  appearance  is  variable ;  hence,  in  order  to  be  certain  that  the  sign 
is  not  present,  it  should  be  looked  for  repeatedly.  Again,  the  time  of 
its  disappearance  varies ;  it  may  disappear  during  the  preagonal  period. 
The  value  of  the  sign  is  real,  but  its  absence  does  not  justify  the 
exclusion  of  meningitis,  while  it  may  be  present  in  other  diseases  (typhoid, 
tctanuw).  Herrick  ^  points  out  that  from  its  persistence  into  convalescence 
it  may  be  utilized  to  make  a  retrospective  diagnosis. 

Macewens  sign  (vide  Tuberculous  meningitis,  p.  253).  a  hollow  note 
on  percussing  over  the  inferior  frontal  or  parietal  bone,  is  an  indication 
of  fluid  in  the  ventricle,  but  is  not  always  present. 

Brudzinski's  Sign. — On  attempting  to  bend  the  neck  flexure  move- 
ments in  the  ankle,  knee,  and  hip-joints  occur  (identical  reflex).  Another, 
though  less  constant,  sign  is  produced  by  passive  flexion  of  one  leg,  which 
causes  the  fellow  limb  to  draw  up,  and  so  remain  (contralateral  reflex). 

Complications. — Many  of  these  have  already  been  mentioned  in 
the  portrayal  (d'  the  symptoms — e.  g.,  destructive  inflammations  of  the  eye 

1  P.  Roglet,  Gaz.  heb.  de  Med.  el  de  Chir.,  July  15,  1900. 

'St.  Paul  Med.  Jmir.,  Sept.,  1900.  ^  Amer.  Jour.  Med.  Sci.,  July,  1899. 


CEREBRO-SPfNAL   MENTNGTTTS.  101 

and  ear  and  the  paralys(!S  of  the  cranial  ncrvcjs.  The  punilont  inflam- 
mations of  the  serous  sacs  which  were  referred  to  in  discussing  tlie  path- 
ology (pleurisy  and  pericarditis)  are  among  associated  conditions,  and 
secondary  bronchitis  is  common.  Pneimionia  (lobar  and  lobular)  is  a 
frequent  complication.  Endocardial  murmurs  are  common,  but  pericardial 
friction  is  less  so.      Heniorrltmiv;  ne/ihrifis  is  a  rare  com  plication. 

Special  and  Atypical  Forms. — (1)  Mild  or  Rudimentary. — Tn 
this  type  the  characteristic  signs  are  either  undeveloped  or  wanting,  and 
the  diagnosis  is  possible  only  during  the  prevalence  of  epidemics,  which 
furnish  typical  cases.  The  most  constant  and  significant  symptoms  are 
severe  headache,  languor,  vertigo,  nausea,  and  occasionally  vomiting. 
Fever  and  contraction  of  cervical  muscles  are  absent,  as  a  rule.  The 
duration  is  brief,  rai'ely  exceeding  three  or  four  days. 

(2)  The  Abortive  Form. — Here  the  initial  symptoms  are  severe,  but 
after  two  or  three  days  they  rapidly  subside,  leaving  the  patient  conva- 
lescent. The  disease  is  cut  short  by  the  acquisition  of  immunity,  and 
not  as  the  result  of  medical  interference. 

(3)  Intermittent  Form. — In  this  variety  the  symptoms,  however  in- 
tense, remit  or  almost  wholly  intermit  every  day  or  second  dav  ;  these 
remissions  are  followed  by  a  decided  exacerbation  or  recurrence  of  the 
distressing  features  of  the  disease.  Intermissions  often  occur  at  an  ad- 
vanced stage.  There  is  not  observed  the  strict  periodicity  that  is  seen 
in  malaria.      Neither  is  the  malarial  plasmodium  found  in  the  blood. 

(4)  Typhoid  Form. — In  certain  cases  the  special  features  are  character- 
istic of  the  "typhoid  state,"  with  protracted  course. 

(5)  Fulminant  or  Apoplectic  Form. — The  symptoms  characterizing  this 
most  malignant  type  of  the  affection  are  rather  inconstant.  There  may 
be  severe  chill,  loss  of  consciousness,  followed  by  deep  coma  and  death, 
the  whole  course  occupying  the  space  of  a  few  hours  only.  I  saw  two 
such  cases  in  the  same  family :  the  first,  a  girl  of  five  years,  was  stricken 
at  2  p.  M.  and  died  at  9  P.  M. ;  the  other,  a  boy  of  seven  years,  was 
taken  ill  on  the  following  day  about  the  same  hour,  and  died  at  10  p.  m. 
Other  instances  pursue  a  somewhat  slower  course,  though  manifesting  the 
most  striking  malignancy.  These  begin  with  intense  chills,  violent  head- 
ache, vomiting,  early  stupor,  great  prostration,  contraction  of  muscles  of 
the  neck,  moderate  fever,  and  a  feeble,  progressively  slowing  pulse  until 
it  sometimes  reaches  50  or  even  40  beats  per  minute.  The  eruption, 
when  it  appears,  takes  the  form  of  purpura.  This  form  is  most  apt  to  be 
met  with  early  in  an  epidemic,  and  with  few  exceptions  proves  fatal. 

(6)  Schlesinger  ^  states  that  epidemic  cerebrospinal  meningitis  affects  a 
senile  type  in  elderly  subjects,  with  little  tendency  to  fever,  or  opisthotonos. 

Diagnosis. — The  most  important  symptoms  for  diagnosis  are  the 
abrupt  onset ;  intense  pains  (cervico-occipital  and  lumbar) ;  prostration  ; 
vomiting ;  vertigo  ;  somnolence,  alternating  with  local  or  general  tonic  or 
clonic  convulsions ;  delirium  (often  sportive  in  type) ;  tonic  contraction 
of  the  muscles  of  the  neck,  extending  to  the  back  ;  marked  hyperesthesia ; 
a  slow,  followed  by  a  more  rapid,  though  variable,  pulse :  irregular  tem- 
perature-curve ;  and  certain  eruptions  (petechial,  herpetic). 

Lumbar  Puncture. — The  value  of  Quincke's  lumbar  puncture  as  a 
means  of  diagnosis  is  absolute.  It  alone  •  can  render  the  diagnosis 
certain  in  many  cases,  and  is  a  harmless  measure,  if  rigid  asepsis  be 
^Jour.  Amer.  Med.  Assoc,  October  16,  1909. 


102  INFECTIOUS  DISEASES. 

observed.  The  patient  is  placed  upon  the  right  side,  with  the  left  knee 
well  drawn  up ;  a  fine  needle,  three  inches  in  lenrrth.  and  carefully 
guarded  by  the  index  finger  of  the  operator,  is  introduced  between  the 
third  and  fourth  lumbar  vertebra  '•  one-half  inch  to  the  right  of  the 
median  line"  (Mallory  and  Wright),  and  directed  slightly  inward  and 
upward.  The  forefinger  of  the  disengaged  hand  must  be  used  as  a  guide, 
and  the  site  should  be  anesthetized  by  the  application  of  a  local  freezing- 
mixture.  The  needle  should  enter  the  canal  at  a  depth  of  two  or  three 
centimeters  in  children  and  four  to  six  centimeters  in  the  adult.  If  the 
fluid  does  not  flow,  the  dura  has  probably  not  been  penetrated,  and  710 
form  of  suction  upon  the  needle  should  be  attempted ;  the  fluid  should 
be  allowed  to  fall  drop  by  drop  into  a  sterile  test-tube  held  aslant.  From 
five  to  ten  cubic  centimeters  of  the  usually  cloudy  exudate  should  be 
withdrawn  and  subjected  to  a  chemic,  microscopic,  and  bacteriologic  ex- 
amination. Sugar,  which  is  found  normally,  is  absent  from  the  cerebro- 
spinal fluid.  Lorgo  Vinsists  that  lumbar  puncture  must  be  repeated  if 
the  result  of  the  procedure  is  at  first  negative.  The  fluid  is  said  to  be 
clear  in  tuberculous  meningitis.  If  the  presence  of  the  diplococcus  intra- 
cellularis  in  the  nasal  secretion  can  be  shown,  lumbar  puncture  is  unnec- 
essary. The  preci])itin  reaction  permits  one  to  make  a  diagnosis,  and 
sometimes  with  perfectly  clear  cerebro-spinal  fluid  (Vincent  and  Bellot  ^). 

Differential  Diagnosis. — (1)  Tuberculous  Meningitis. — In  this  aff'ection 
there  is  usually  a  tuberculous  history — either  personal  or  family — with 
prodromes  extending  over  many  days  (occasional  vomiting,  unnatural 
peevishness,  constipation),  unlike  the  sudden  onset  of  meningitis.  The 
retraction  of  the  abdomen  is  greater,  while  the  arching  of  the  neck,  the 
general  myalgic  pains,  and  the  hyperesthesia  are  less ;  the  herpetic  and 
petechial  eruptions  are  rare  in  tuberculous  and  common  in  cerebro-spinal 
meningitis.  Cheyne-Stokes  breathing  and  the  well-marked  changes  of 
pulse  belong  peculiarly  to  the  tuberculous  form.  By  the  aid  of  the  oph- 
thalmoscope choroidal  tubercles  may  sometimes  be  detected. 

Hand^  urges  lumbar  puncture,  and  found  polymorphonuclear  leuko- 
cytes in  excess  wherever  tubercle  bacilli  were  absent. 

(2)  Pneumonia. — This  affection  may  be  complicated  with  a  meningitis 
that  afl'ects  chiefly  the  cerebral  cortex.  Hence,  while  there  will  be  motor 
spasm  (more  or  less  localized)  and  tremors,  there  will  also  be  less  retrac- 
tion of  the  head  and  less  myalgic  pain  than  in  cerebro-spinal  meningitis. 
Again,  pneumonia  precedes  the  development  of  the  meningeal  symptoms. 

(3)  Typhoid  Fever. — The  carebral  type  of  this  affection  may  simulate 
closely  meningitis.  In  both  may  be  observed  fever,  delirium,  somno- 
lence, retraction  of  the  neck,  spasm,  tremor,  and  profound  prostration. 
The  mode  of  onset,  however,  is  different,  being  slower  in  typhoid  and 
unaccompanied  by  vomiting,  muscular  spasm,  or  hyperesthesia.  In 
typhoid  there  is  also  the  characteristic  mental  dulness ;  the  fever  ig 
higher,  with  a  typical  fever-curve ;  the  roseate  eruption  and  sero-reaction 
are  characteristic,  and  there  is  greater  enlargement  of  the  spleen. 

Sequelae. — The  leading  sequelae  are  permanent  blindness  (due  to 

optic  neuritis  with  atrophy)  and  deafness,  which  sometimes  terminates  in 

1  Pnh/rlinico,  March,  1901 ;  Saundei-s'  Year-Book,  1902. 
"^  Biillftin  Academie  de  Medecine,  vol.  Ixi,  p.  326. 
3  Pliila.  Med.  Jour.,  Aug.  30,  1902. 


CEREBROSPINAL  MENINOITIS.  103 

deaf-mutism;  and  in  many  cases  headache  ouUasts  the  disease  for  months. 
Chronic  hydrocephalus  and  mental  enfeeblement  are  not  rare  sequels 
(Ziemssen).  Various  local  paralyses  are  observed,  probably  due  to  cer- 
tain peripheral  lesions  (neuritis  and  perineuritis). 

Immunity. — Permanent  immunity  is  rarely  conferred  by  the  occur- 
rence of  cerebro-spinal  meningitis,  relapses  being  common,  and  second 
(recurrent)  attacks  having  been  occasionally  observed. 

Duration  and  Prognosis. — In  very  mild  forms  the  duration  is  from 
one  to  four  or  five  days.  The  most  malignant  type  runs  an  even  shorter 
course,  when,  as  is  the  rule,  it  terminates  fatally.  If  recovery  ensues,  it 
is  after  a  long,  serious,  and  protean  illness.  The  abortive  form  is  neces- 
sarily of  brief  duration.  In  the  ordinary  type  convalescence  usually  sets 
in  at  the  end  of  one  or  two  weeks,  but  a  slow  convalescence,  hindered  by 
numerous  complications  and  sequelae,  is  the  rule. 

Apart  from  the  fulminant  form,  which  nearly  always  proves  fatal,  the 
severity  of  the  infection  may  be  appreciated  by  noting  the  degree  of  fever 
and  the  intensity  of  the  nervous  symptoms,  especially  the  vomiting,  coma, 
headache,  opisthotonos,  character  of  the  respirations,  etc.  Complications 
may  likewise  affect  the  prognosis,  pneumonia,  and  suppurative  inflamma- 
tions of  the  pleura  or  pericardium,  rendering  it  particularly  grave.  In 
children  under  two  years  the  disease  is  very  fatal,  this  period  giving 
the  highest  mortality-rate ;  between  two  and  five  and  after  thirty  years 
it  is  a  more  serious  disease  than  during  young  adult  life.  The  death- 
rate  of  cerebro-spinal  fever  varies  greatly  in  different  epidemics,  ranging 
form  25  per  cent,  in  the  mildest  to  80  per  cent,  in  the  severest. 

Prophylaxis. — Disinfection  of  the  nasopharynx,  the  expectoration, 
conjunctival  secretions,  and  the  urine  is  recommended  with  a  view  to 
destroying  the  specific  poison.  Meningococcus  carriers  must  be  discov- 
ered and  treated.  Isolation  is  to  be  carried  out.  Persons  in  any  manner 
exposed  and  suffering  from  diseased  conditions  of  the  respiratory  appa- 
ratus or  pharynx  should^ receive  prompt  and  active  treatment.  Sophian 
and  Black  claim  that  the  injection  of  dead  meningococci  confers  consid- 
erable immunity. 

General  Management. — The  sick-room  must  be  quiet  and  somewhat 
dark.  All  excitement  is  to  be  avoided ;  the  patient  must  not  be  allowed 
to  leave  his  bed  until  convalescence  is  firmly  established. 

The  diet  should  be  composed  of  nutritious  liquids,  such  as  milk  and 
animal  broths,  etc.,  and  as  soon  as  convalescence  begins  the  dietary  should 
be  increased  by  the  addition  of  semisolid  substances  (rice,  eggs,  milk- 
toast,  etc.),  and,  finally,  the  more  easily  digestible  solids.  The  period 
of  convalescence  may  be  much  abridged  by  systematic  feeding. 

Medicinal  Treatment, — Individual  cases  are  to  be  treated  accord- 
ing to  the  special  indications  presented.  I  regard  it  as  extremely 
improbable  that  any  case  of  this  affection  has  been  benefited  by  vene- 
section. 

Among  medicinal  agents  narcotics  are  the  most  useful.  Morphin 
hypodermically  affords  relief  from  intense  headache,  myalgic  pains,  mus- 
cular contraction,  and  other  nervous  symptoms  in  some  cases.  If  the 
respirations  be  irregular,  atropin  may  be  combined  with  the  opiate  :  and 
if  the  heart  threatens  to  fail,  strychnin  may  be  administered.  Should 
morphin  fail,  the  bromids  and  chloral  (the  latter  in  small  doses)  are  to 
be  employed.  In  young  children  we  must  rely  upon  the  bromids  rather 
than  the  opiates. 


104  lyPECTIOUS  DISEASES. 

Flexner  and  Joblinix'  present  a  report  on  393  patients  treated  with 
Flexner's  curative  i^erlnn.  Of  these.  -\)b,  or  75  per  cent.,  recovered  and 
98,  or  25  jier  cent.,  died.  The  serum  is  injected  directly  into  the  sub- 
arachnoid space  after  the  withdrawal  of  an  equal  amount  of  cerebro-spinal 
fluid  by  means  of  lumbar  puncture.  The  injections  should  be  repeated 
daily  for  three  or  four  days.  When  the  Macewen  percussion-note,  however 
slight,  is  obtained,  Koplik  proceeds  to  puncture.  Cantas  ^  advocates  the 
injectinii:  of  the  serum  into  the  lateral  ventricle.  Wasserman ^  reports 
1<>2  cases  treated  with  antimeninirococcus  seruu)  ;  it  had  a  curative  effect 
when  injected  early  (dose,  5  to  10  c.c.  ie])eated  two  or  three  times  a  day). 
McKenzie  and  Martin  have  introduced  an  autogenous  serum  ;  they  with- 
draw blood-serum  of  a  patient  suffering  from  meningitis  and  inject  it  into 
the  spinal  canal  of  the  same  or  another  meningitis  patient.  Such  a  serum 
is  an  actively  bactericidal  fluid. 

For  the  tonic  contraction  of  the  muscles  and  violent  cerebral  symp- 
toms, cannabis  indica  should  be  tried.  Convulsions  call  for  hot  baths 
(105°  F.)  or  ether  inhalations.  Mercury  has  been,  and  still  is,  advocated 
(mercuric  chlorid,  gr.  -^^ — 0.002,  every  four  hours  to  an  adult;  calomel, 
gr.  yVt^g — 0.005-0.004,  every  four  hours  to  children).  Belladonna  and 
ergot  have  been  employed  in  the  early  stages  to  diminish  the  congestion 
of  the  cerebro-spinal  capillaries. 

Stimulants  are  required  if  signs  of  heart-exhaustion  apjiear.  They 
may  be  freely  exhibited  in  accoi'dance  with  the  customary  rules. 

After  effusion  of  the  exudate  has  taken  place,  the  narcotics  are  to  be 
replaced  by  agents  that  promote  absorption,  as  potassium  iodid. 

The  local  means  are  also  important.  When  tub-baths  are  not  avail- 
able, cold  should  be  used  locally,  since  it  is  both  of  value  and  very  grate- 
ful to  the  patient.  An  ice-bag  is  to  be  put  on  the  head,  and,  if  possible, 
long  ice-bags  placed  along  the  spine.  In  rare  cases  of  sthenic  type  we 
may  employ  small  blisters  at  the  nape  of  the  neck  or  over  the  mastoids ; 
they  are  u.-eful  during  the  stage  of  effusion.  In  the  usual  form  of  the 
disease  it  is  better  to  apply  the  thermocautery  lightly  over  the  mastoid 
region.  A  small  amount  of  blood  may  be  withdrawn  by  means  of  leeches 
or  by  a  few  wet  cups  placed  behind  the  ears.  Quincke's  lumbar  puncture 
and  laminectomy  with  free  drainage  have  been  practised,  and  lumbar 
puncture  should,  if  necessary,  be  repeated,  but  only  in  case  benefit  follows 
first  puncture.  The  principal  effect  is  the  relief  of  the  pressure  upon  the 
central  nervous  system.  In  cases  in  which  lumbar  puncture  only  brought 
2  to  20  c.c.  of  fluid,  Cantas*  obtained  40  to  120  c.c.  from  the  lateral 
ventricle. 

Convalescence  is  prolonged,  and  requires  to  be  diligently  and  judi- 
ciously treated.  We  must  rely  upon  the  generally  accepted  tonics — iron, 
cod-liver  oil,  arsenic,  and  strychnin  ;  the  potassium  iodid  and  the  mer- 
cury also  being  continued  for  their  influence  in  promoting  the  absorption 
of  the  exudate.  Special  attention  is,  however,  to  be  paid  to  the  hygienic 
management  of  this  period.  An  abundance  of  fresh  air,  sunshine,  and 
easily  assimilable  food  must  be  furnished  at  all  hazards,  and  electricity 
and  massage,  judiciously  employed,  will  hasten  recovery. 

»  Jour.  Amer.  Med.  Assoc,  July  25,  190S. 

-  Bulletin  de  I'Acadernie  de  Medeaine,  Paris,  January  .30,  Ixxvi.,  No.  5. 

3  Deutsche  medizinische  Wochenschrift,  .Sept.  26,  11)07. 

*  Loc.  cit. 


LOBAR  PNEUMONIA.  105 

LOBAR  PNEUMONIA. 

[Croupous  or  Fibrinous  Fneumoaia ;  I'neumoidiis ;   Lung  Fever.) 

Definition. — An  acute  infectious  disease  caused  by  the  Micrococcus 
lanceolatus,  which  produces  a  specific  inflammation  of  the  parenchyma  of 
the  lung  and  marked  constitutional  disturbances — chill,  extreme  prostra- 
tion, and  fever  which  terminates  by  crisis.  There  are  different  forms 
of  lobar  pneumonia,  as  primary  lobar  pneumonia,  secondary  lobar 
pneumonia,  and  pneumonia  with  the  formation  of  new  connective 
tissue. 

Pathology. — Usually  the  lesions  are  confined  to  the  whole  of  one 
lobe ;  less  frequently  to  the  whole  of  one  lung,  and  rarely  to  parts  of 
both  lungs.  From  JUrgensen's  analysis  of  6666  cases  the  following 
statement,  showing  the  different  situations  of  the  lesions  and  their  relative 
frequency,  was  taken  :  Right  lung,  about  54  per  cent.  ;  left  lung,  about 
38  per  cent. ;  and  both  lungs,  about  8  per  cent.  In  the  right  lung  the 
lower  lobe  was  involved  in  22  per  cent.,  the  upper  in  12  per  cent.,  the 
middle  in  nearly  2  per  cent.,  and  the  whole  lung  in  about  9  per  cent.  In 
the  left  lung  the  lower  lobe  was  involved  in  about  23  per  cent.,  the  upper 
in  about  7  per  cent.,  and  the  whole  lung  in  about  8  per  cent.  The  dis- 
ease involves  whole  segments  of  the  lungs,  and  these  may  embrace  more 
than  one  lobe. 

The  lesions  of  pneumonia  are  divisible  into  three  stages  :  (a)  Stage  of 
congestion  or  engorgement ;  {b)  Red  hepatization  (consolidation) ;  and 
(c)  Gray  hepatization. 

(a)  Stage  of  Engorgement. — The  part  or  parts  implicated  are  of  a  dark- 
red  color,  and  firmer  to  the  feel,  but  less  resilient  and  crepitant,  than 
normal.  The  cut  section  drips  a  blood-stained  serum,  and  dark  blood 
exudes  from  the  distended  capillaries.  The  air-cells  do  not  collapse, 
though  they  are  not  solid,  since  excised  pieces  float ;  but  the  weight 
of  the  lung-tissue  is  much  increased.  Collapsed  portions  may  be 
observed  which  may  readily  be  insuiBated  from  the  bronchus,  and 
areas  of  extravasation  may  occasionally  be  noted  near  the  pulmonary 
pleura. 

On  microscopic  examination  the  alveolar  epithelium  is  seen  to  be 
swollen,  the  capillaries  greatly  distended,  and  the  air-cells  containing 
alveolar  epithelial  cells,  red  corpuscles^  and  a  few  leukocytes.  Similar 
elements  occupy  the  small  bronchi. 

{b)  Red  Hepatization. — The  affected  tissue  is  solid,  airless,  and  firm, 
resembling,  as  the  term  indicates,  liver-tissue.  It  is  reddish  brown  (ma- 
hogany) in  color,  presenting  a  dry,  mottled  appearance,  and  when,  as  is 
usual,  an  entire  lobe  is  involved,  it  is  more  voluminous  than  normal  and 
its  surface  is  often  furrowed  by  the  impress  of  the  ribs.  Being  airless, 
the  affected  portion  does  not  crepitate,  and  its  weight  and  specific  gravity 
are  increased.  It  cannot  be  inflated  ;  is  extremely  friable,  and  its  lace- 
rated surface  presents  a  finely  granular  aspect,  this  latter  appearance 
being  due  to  the  minute  plugs  of  inflammatory  matter  (fibrin)  Avhich  fill 
the  air-spaces.  The  air-passages  and  small  bronchi  are  distended  with 
similar  material,  and  granular  masses  can  be  removed  from  the  air-cells 
of  a  cut  or  lacerated  surface  by  carefully  scraping  the  latter.     If  death 


106  INFECTIOUS  DISEASES. 

takes  place  during  this  stage,  the  ante-mortem,  dry,  inflammatory  exudate 
soon  softens,  and  may  flow  from  the  cut  section  as  a  grumous,  viscid  fluid ; 
the  consolidated  tissue  sinks  i*apidly  in  water.  The  pulmonary  pleura  is 
covered  with  a  fine  sheet  of  fibrin,  and  in  cases  complicated  by  marked 
pleurisy  the  fibrinous,  inflammatory  exudate  forms  a  thick  coating  upon 
the  pleural  membrane,  and  the  sac  may  contain  liquid  effusion. 

Microscopic  examination  shows  the  air-spaces  filled  with  clotted  fibrin, 
in  whose  meshes  are  held  red  blood-corpuscles,  pus-cells,  and  changed 
alveolar  epithelium.  The  interlobular  connective  tissue  may  be  infiltrated 
with  leukocytes  and  fibrillated  fibrin,  but  the  blood-vessels  in  the  walls 
of  the  alveoli  remain  pervious.  The  pneumococci  (micrococci  lanceolati), 
less  frequently  also  streptococci  and  staphylococci,  are  detectable. 

(6*)  Gray  Hepatization. — In  this  stage  the  fibrinous  exudation  becomes 
decolorized,  the  surface  at  first  resembling  granite  in  color,  and  later 
appearing  uniformly  gray.  Associated  with  this  change,  and  following 
it,  there  is  fatty  and  granular  degeneration  of  the  inflammatory  exudate, 
in  consequence  of  which  the  latter  becomes  moist  and  soft.  The  exudate 
loses  its  granular  character,  while  at  the  same  time  the  friability  of  the 
lung-tissue  is  further  increased,  and  from  the  surface  of  the  cut  section 
there  flows  usually  a  grayish-white  or  yellowish-white  purulent  liquid. 
Not  less  than  one-half  of  the  fatal  cases  die  in  the  early  part  of  this 
stage.     The  pleura  is  usually  covered  with  a  fine  fibrinous  exudation. 

Microscopic  examination  shows  the  air-cells  stuffed  with  leukocytes, 
while  the  other  histologic  elements  (fibrin,  red  blood-cells)  have  disap- 
peared ;  and  with  the  full  development  of  gray  hepatization  resolution 
usually  commences.  The  exudate  is  now  softened  into  a  liquid  material 
with  disintegration  of  cellular  elements,  and  is  absorbed  by  the  lymphatics. 
Resolution  usually  corresponds  in  time  with  the  occurrence  of  the  crisis, 
though  it  may  begin  later.  Pratt  ^  found  larger  phagocytic  cells  in  all 
stages  of  the  disease ;  it  is  likely  that  they  play  an  important  part  in 
resolution.     Among  unfavorable  terminations  are — 

(1)  Purulent  Infiltration. — Here  the  lung-tissue  becomes  very  soft, 
friable,  and  is  bathed  in  purulent  material ;  and  microscopic  observa- 
tion shows  the  pus-cells  densely  infiltrating  the  interalveolar  tissue  and 
filling  the  air-spaces  as  well.  Necrosis  of  the  lung-texture  may  occur, 
producing  abscess. 

(2)  Abscess. — This  is  due  to  subsequent  infection  by  streptococci, 
hence  is  a  complicating  lesion.  The  abscesses  vary  in  size  within  wide 
limits,  most  frequently  being  situated  near  the  base  of  the  lung.  In 
most  instances  the  abscess-cavity  has  a  fistulous  connection  with  a  bron- 
chus, but  occasionally  the  abscesses  become  encapsulated  in  fibrous  tissue, 
their  contents  undergoing  first  caseous,  and  then  calcareous  degeneration. 
When  multiple,  they  sometimes  coalesce,  forming  large  abscesses. 

(3)  Gangrene  may  rarely  follow,  but  is  due  to  a  specific  cause. 

(4)  Induration. — A.  Frankel  states  that  in  a  few  instances  (about  1 
per  cent.)  pneumonia  ends  in  induration,  and  is  found  upon  section  to  lie 
smooth  and  its  tissue  resistant  (xncle  Chronic  Interstitial  Pneumonia). 

(5)  Pneumonia,  particularly  of  the  apex,  may  terminate  in  phthisis. 
Tubercular  infection  commonly  occurs  in  unresolved  pneumonias. 

Changes  in  other  Viscera. — The  heart  often  appears  pale  and  is  flabby, 
1 W.  H.  Welsch's  Fetsebrift,  p.  265. 


LOBAR  PNEUMONrA.  107 

but  upon. microscopic  examination  tlie  muscular  cell-fibors  of  the  or^an 
are  not  found  to  be  degenerated,  except  in  rare,  protracted  cases.  The 
cardiac  chambers,  particularly  the  right,  are  distended  with  firm,  tough 
clots,  which  are  usually  removable  en  masse  from  the  great  vessels  in  the 
form  of  arboreal  casts.  The  blood  tends  to  coagulate,  owing  to  the  fact 
that  its  fibrinous  elements  are  vastly  increased,  although  Dochez  found 
the  coagulation  time  to  be  generally  prolonged.  Flexner  found  that 
coagulation  was  favored  by  auto-agglutination  of  the  red  cells. 

Pericarditis  occurs  in  about  5  pei'  cent,  of  the  cases,  and  is  relatively 
more  frequent  in  right-sided  or  double  pneumonia.  Endocarditis  is  more 
common,  especially  the  ulcerative  form — in  11  out  of  100  autopsies 
(Osier).  With  malignant  endocarditis  the  lesions  of  meningitis  are 
often  combined,  but  as  a  separate  complication  the  latter  is  rare. 

The  spleen  is  congested,  moderately  enlarged,  and  softened,  and  the 
litter  is  likewise  hyperemic  and  somewhat  swollen.  In  the  kidneys  are 
found  the  lesions  of  parenchymatous  inflammation,  and  with  remarkable 
frequency  also  those  of  chronic  interstitial  inflammation.  A  catarrhal 
state  of  the  gastro-intestinal  mucosa  (often  with  jaundice)  is  common  ; 
and  a  frequent  complicating  change  is  croupous  inflammation  of  the  colon. 

When  the  infection  is  caused  by  the  Friedlander's  bacillus  the  dis- 
eased portions  of  the  lung  are  increased  in  volume,  and  multiple  foci 
may  be  formed  throughout  one  lobe  (Kokawa).  The  cut  section  is  char- 
acterized by  a  slippery  sensation  to  touch  owing  to  the  presence  of  a 
large  amount  of  mucus,  especially  in  the  early  stages.  Swelling,  pro- 
liferation, desquamation,  and  necrosis  of  the  epithelium  is  observed. 
The  fibrino-hemorrhagic  exudate  is  not  great,  the  large,  emigrated  leu- 
kocytes, and  the  epithelial  cells  forming  the  principal  constituents  of  the 
exudate  in  the  later  stages.  The  bacilli  are  taken  up  by  the  epithelial 
cells  and  leukocytes,  which  swell  up  and  develop  vacuoles.  Other  infec- 
tions may  be  caused  by  the  pneumobacillus — pleuritis,  endocarditis,  peri- 
carditis, abscesses,  otitis  media,  and  osteomyelitis. 

etiology. — Bacteriology. — The  generally  accepted  specific  cause  of 
pneumonia  is  the  Micrococcus  lanceolatus  of  Frankel.  It  is  a  lance- 
shaped  (slightly  elliptic)  coccus,  united  in  pairs,  when  typical  has  the 
shape  of  two  cartridges  placed  end  to  end,  is  surrounded  by  a  pale 
capsule,  and  is  present  occasionally  in  the  nose,  Eustachian  tubes,  and 
larynx  of  healthy  individuals.  Netter  found  it  in  20  per  cent,  of  the 
specimens  of  buccal  secretion  taken  from  well  persons,  and  "  it  is  the 
migration  of  these  ever-present  germs  into  the  pulmonary  alveoli  which 
causes  pneumonia  "  (Wells).  It  is  present  in  about  90  per  cent,  of  all 
instances  of  pneumonia,  and  in  persons  who  have  had  the  disease  it  is 
detectable  for  many  months  or  even  years.  It  is  generally  present  in 
pure  culture,  but  may  be  associated  with  pyogenic  organisms.  It  is 
probable  that  Friedlander's  bacillus  (discovered  in  1888)  and  other  micro- 
organisms (Eberth's  bacillus,  streptococcus  of  erysipelas,  bacillus  pestis) 
may  also  have  the  power  to  cause  the  disease ;  and  Wassermann  ^  sug- 
gests that  specific  forms  of  pneumonia  may  coexist  in  the  same  indi- 
vidual, as,  for  example,  lobar  pneumonia  and  influenzal  pneumonia. 
The  organism  grows  upon  all  the  culture-media  except  potato,  between 
the  temperatures  of  24°  and  42°  C.  (McFavland).  The  diplococcus 
pneumonicB  (Fig.  10)  can  be  readily  demonstrated  in  the  sputum  by 
^  Deutsch.  med.  Woch.,  Leipzig,  Nov.  23,  1893. 


108  INFECTIOUS  DISEASES. 

treating  a  fixed  cover-slip  preparation  'svith  glacial  acetic  acid  which  is 
allowed  to  drain  off  and  is  rei)lacetl  (without  washing  in  water)  by  anilin 
oil-gentian  violet  solution ;  this  is  to  be  poured  off  and  renewed  two  or 
three  times. 

The  Pnc-umAicoccus  in  Other  Diseases. — It  has  been  found  in  pure 
culture  in  pleuritis  (including  empyema),  pericarditis,  meningitis,  peri- 
tonitis, endocarditis,  synovitis,  bronchopneumonia  (principally  in  adults), 
acute  abscess    and  other  conditions. 

The  mode  of  infection  is  by  inhalation,  although  there  may  be  other 
portals  of  entry.  The  first  eiiects  of  the  germ  are  local — in  the  lung, 
though  it  may  reach  more  distant  organs.  To  the  w^idespread  distribu- 
tion of  the  pneumococcus  is  due,  in  part,  the  septicemic  process  sometimes 
observed.  The  toxins  of  the  mierococcus  lanceolatus  also  become  diffused 
throughout  the  system,  pro<lucing  a  general  disturbance  {toxemiri).  Sec- 
ondary infeetion  with  other  specific  organisms  (streptococci,  staphylo- 
cocci, colon  bacillus)  commonly  occurs  in  the  various  organs  of  the  body. 

Predisposing  Causes. — (1)  Endemic  Influence. — That  endemics  of  pneu- 
monia, often  of  serious  type,  may  occur  in  solitary  buildings  (barracks, 


Fio.  10.— Diplococcus  pneumonia;,  I'roin  tlie  hcarls  bluod  uf  a  rabbit;  X  1000  (Friinkel  and  Pfeiflfer). 

tenement-houses,  institutions,  etc.)  cannot  be  successfully  denied,  and  we 
may  attribute  these  outbreaks  to  defects  in  the  local  sanitary  conditions. 
(2)  Epidemic  Influence. — From  time  to  time  pneumonia  prevails  epi- 
demically. Epidemics  are  caused  by  an  increased  virulence  of  the 
organism.  Pneumonia  may  also  originate  in  the  endemic  form  in  tene- 
ment-houses and  institutions,  and  increase  in  its  scope  until  it  assumes 
an  epidemic  character.  House  epidemics  occur,  and  in  the  winter  of 
1894  I  saw,  with  Dr.  W.  K.  Mattern,  of  Philadelphia,  3  cases  develop 
in  rapid  succession  in  one  family.     A  Sister  of  Charity,  after  nursing 


LOBAR  PNEUMONIA^  109 

two  of  the  patients  faithfully,  also  died  of  the  disease.  It  is  possible  that 
the  house-epidemic  form  may  spread  by  contafjion.  An  instructive  epi- 
demic is  reported  by  W.  B.  Rodman,  who  states  that  118  cases  of  pneu- 
monia, with  25  deaths,  occurred  in  a  prison  population  of  735.  13. 
Robinson  insists  upon  his  view  that  pneumonia  is  contagious. 

(3)  Geographic  Distribution. — Pneumonia  may  be  said  to  be  an  al- 
most universally  distributed  affection.  Climate,  per  ise,  does  not  exercise 
a  notable  influence.  Delafield,  however,  points  out  the  fact  that  in  the 
United  States  the  disease  is  of  more  frequent  occurrence  in  the  South 
than  in  the  North. 

(4)  Season. — Of  5905  cases  collected  by  Seitz  in  Munich,  36.8  per 
cent,  occurred  in  the  spring,  32  per  cent,  in  winter,  15.7  per  cent,  in 
autumn,  and  15.3  per  cent,  in  the  summer.  In  London  most  cases 
appear  between  the  end  of  March  and  the  end  of  June  (Herringhan). 
My  own  analysis  of  the  monthly  mortality  list  covering  the  decade  from 
1894  to  1903  inclusive,  for  Philadelphia,  gave  the  following  numerical 
order:  January,  4,210;  February,  3,717;  March,  3,496;  April,  3,039; 
December,  2,860;  May,  2,238 ;  November,  1,936;  October,  1,269; 
June,  1,165;  July,  913;  September,  826;  August,  800.^  The  period 
of  greatest  frequency  will  be  sometimes  found  to  correspond  in  time 
with  the  period  of  the  greatest  vicissitudes  of  temperature  and  humidity. 
Exposure  to  cold  is  incapable,  jogr  se,  of  giving  rise  to  pneumonia. 

(5)  "  CatcMng  cold  "  is  often  followed  by  pneumonia,  but  frequently 
there  is  no  such  history.  The  so-called  "  cold  "  is  a  predisposing  cause, 
rendering  the  respiratory  passages  more  than  ordinarily  susceptible  to 
pneumonic  infection.  Such  facts  as  these  also  explain  why  pneumonia 
occurs  with  undue  frequency  in  persons  following  certain  occupations. 

(6)  Traumatism. — Following  injuries  and  contusions,  especially  of  the 
chest,  which  lower  the  vital  power  and  resistance  of  the  tissues. 

(7)  Age. — Lobar  pneumonia  is  common  at  all  periods  of  life,  but 
before  two  years  of  age  it  is  comparatively  infrequent.  Between  the 
ages  of  twenty  and  forty  susceptibility  is  increased,  and  again  after  the 
sixtieth  year  of  life  it  augments  rapidly.  McDonald^  reports  a  case  of 
antenatal  pneumonia. 

(8)  Sex. — Males  are  more  commonly  attacked  than  females,  the  dis- 
crepancy in  the  relative  number  of  cases  being  greatest  from  the  twen- 
tieth to  the  fiftieth  years  of  age,  and  being  due  to  the  more  frequent 
abuse  of  alcohol  by  men. 

(9)  Race. — The  negro,  American  Indian,  and  the  Esquimaux  are 
more  susceptible  to  pneumonia  than  the  white  race. 

(10)  Unhygienic  Surroundings. — The  disease  is  more  frequent  among 
the  lower  than  the  higher  classes — a  fact  due  to  the  improved  hygienic 
environment  of  the  latter. 

(11)  Circumstances  Connected  with  Individuals. — The  alcoholic  is  espe- 
cially prone  to  this  disease,  any  or  all  habits  that  tend  to  depress  the 
nervous  system  acting  as  predisposing  causes.  The  increasing  incidence 
of  pneumonia  is  probably  due  in  a  measure  to  the  recognized  increase  in 
frequency  of  the  various  forms  of  degeneration  of  the  viscera,  particu- 
larly of  the  heart  and  kidneys.  Certain  chronic  diseases,  therefore 
(chronic  Bright's  disease,  organic  heart-affections,  carcinoma,  diabetes, 

1  "  Meteorolos^ic  Conditions  in  the  Causation  of  Lobar  Pneumonia,"  AToer.  Med.,  Sept 
1,  1904.  ''  -^British  Med.  Jour.,  Nov.  II,  1911. 


110  INFECTIOUS  DISEASES. 

etc.),  exert  an  influence.     Emigrants  Avould  seem  to  be  more  susceptible 
than  persons  ■who  have  become  accliuiatod. 

(12)  Prior  Attacks. — One  attack  unchMibtedly  leaves  the  system  more 
susceptible  to  tlie  disease,  so  that  repeated  attacks — ten  or  more — may 
occur  in  the  same  individual. 

(lo)  There  has  been  noted  a  marked  increase  in  the  number  of  cases 
of  lobar  pneumonia  during  the  past  two  decades,  due  to  the  prevalence 
of  influenza.  Wells  has  shown  by  statistical  facts  that  the  incidence  of 
the  disease  has  steadily  increased  during  the  last  century. 

Immunity. — The  results  of  the  investigations  of  Behring  and  Kitasato 
with  the  blood-serum  of  animals  which  had  been  immunized  against  tetanus 
and  diphtheria  led  Drs.  G.  and  F.  Klemperer  to  experiment  upon  the  lower 
animals  with  Friinkel's  diplococcus.  They  found  that  the  rabbit  could 
be  rendered  immune  by  intravenous  or  subcutaneous  injections  of  large 
amounts  of  the  fluid  bouillon-cultures  or  of  the  glycerin-extract.  From 
10  to  20  c.c.  of  serum  taken  from  a  non-receptive  animal  were  injected 
into  the  veins  of  an  animal  that  was  suflfering  from  typical  pneumonia 
(artificially  produced),  whereupon  the  symptoms  subsided  rapidly  and  the 
animal  entered  upon  a  speedy  recovery.  The  same  serum,  used  in  a  sim- 
ilar manner  upon  healthy  receptive  animals,  rendered  them  non-receptive. 
Clinical  History. — Prodromes  are  rare,  and  when  present  consist 
of  a  slight  general  indisposition,  lasting  a  day  or  more.  Rarely,  there  is 
cough,  thoracic  oppression,  and  slight  chest-pains  (simple  bronchitis),  that 
may  or  may  not  be  connected  with  the  pneumonic  process.  Here  inva- 
sion maybe  marked  by  sudden,  great  thoracic  oppression  or  by  a  gradual 
development  of  the  local  and  general  symptoms  without  rigor. 

Usually  the  invasion  is  veri/  abrupt,  and  marked  by  a  severe  rigor, 
which  has  a  duration  of  from  half  an  hour  to  an  hour,  during  which 
period  the  patient  feels  most  uncomfortable,  and  is,  indeed,  very  ill. 
The  initial  chill  may  occur  at  any  hour  of  the  day  or  night,  the  fever 
rising  immediately  and  rapidly,  and  the  temperature  often  mounting  to 
104°  F.  (40°  C.)  or  even  higher  in  the  course  of  a  few  hours.  The  skin 
becomes  harsh  and  dry,  the  face  flushed,  and  the  cheek  on  the  side 
aflfected  often  shows  a  circumscribed  deep-red  spot.  Prostration  is  pro- 
nounced, and  headache  and  other  nervous  disturbances  (restlessness, 
delirium)  accompany  and  follow  the  ushering-in  symptoms. 

The  thoracic  symptoms  follow  closely  upon  the  termination  of  the 
chill.  Inspiration,  particularly  if  deep,  causes  a  stabbing  pain  in  the 
affected  side;  the  respirations  are  hurried,  somewhat  jerking  and  shallow 
(panting),  while  the  pain  persists,  and  later  dyspnea  may  become  marked, 
with  accelerated  breathing.  Cough  sets  in  early,  and  is  dry  and  pain- 
ful during  the  first  day  or  even  longer,  and  may  be  attended  with  expec- 
toration, which  generally  presents  a  characteristic  rusty  or  blood-stained 
appearance.  The  physical  signs  rarely  appear  before  the  end  of  the 
first  day,  and  sometimes  as  late  as  the  third  (central  pneumonia) ;  in  the 
latter  form  the  local  symptoms,  as  cough,  dyspnea,  and  sometimes  pain, 
are  either  wanting  or  feebly  expressed  during  the  first  three  or  four  days, 
and  the  clinical  picture  is  composed  of  the  general  features  only. 

Anorexia  is  usually  complete;  thirst  is  excessive,  and  commonly  there 
is  vomiting  at  the  onset,  the  bowels  being  generally  constipated,  though 
diarrhea  may  not  infrequently  be  present.    The  patient  in  most  instances 


LOBAR  PNEUMONIA.  Ill 

lies  upon  the  affected  side  until  the  pain  has  in  great  part  Ruhnided,  and 
then  he  is  apt  to  assume  the  dorsal  position,  exposing  to  full  view  an 
anxious  countenance,  with  a  characteristic  Jiunh  upon  the  cheek,  while 
the  alae  nasi  are  seen  to  dilate  forcibly  during  inspiration.  Yery 
frequently  herpes  on  the  lips  or  nose  appears  about  this  time,  and 
forms  a  valuable  diagnostic  symptom.  The  nocturnal  remissions  are 
slight,  the  temperature  being  of  the  continued  type,  and  the  fever  con- 
tinues high— 104°  to  105°  F.  (40.5°  C.)— for  from  five  to  ten  days,  and 
generally  terminates  by  crisis.  The  pulse  is  somewhat  quickened,  but 
the  pulse-respiration  ratio  is  not  maintained.  The  other  general  features 
last  until  the  crisis  occurs,  or  even  increase  in  severity,  but  do  not  out- 
last this  period ;  many  of  the  local  symptoms,  however,  and  particularly 
pain,  are  greatly  improved  before  the  crisis  is  reached. 

As  will  be  seen  hereafter,  the  general  course  of  pneumonia  is  modi- 
fied by  a  variety  of  interfering  conditions  that  hstve  relation  to  compli- 
cations, individual  circumstances,  severity  of  the  type,  etc.  In  the  in- 
stances in  which  the  crisis  is  reached  convalescence  is  rapidly  established. 
The  crisis  may  be  accompanied  by  special  symptoms,  as  copious  sweat- 
ing or  diarrhea. 

Leading  Symptoms  in  Detail. — Local  or  Respiratory  Symptoms. — In- 
creased frequency  of  the  respirations  is  a  characteristic  symptom,  the  rate 
varying  from  40  to  60  per  minute  in  adults,  and  in  children  from  60  to 
90  or  more.  It  is  panting  in  character,  particularly  when  pneumonia 
occurs  in  old  subjects,  and  both  inspiration  and  expiration  are  brief, 
though  sometimes  separated  by  a  rather  long  pause.  Expiration  is 
usually  accompanied  by  an  audible  "  grunt,"  indicating  great  oppression, 
and  while  actual  dyspnea  is  a  frequent  symptom,  it  may  be  absent  or  as 
the  case  progresses  may  become  either  increased  or  greatly  diminished 
according  to  the  severity  of  the  type. 

The  chief  causes  of  the  rapid  and  labored  breathing  are  the  involve- 
ment of  a  large  portion  of  the  lung,  associated  general  bronchitis,  peri- 
carditis or  extensive  pleurisy,  cardiac  failure,  collateral  congestion  with 
edema,  fever,  and  the  intense  pain  in  the  side. 

The  pulse-respiration  ratio  is  disturbed,  the  relation  now  being  1  to 
2,  or  even  1  to  1.5,  instead  of  1  to  4,  as  in  health  (see  Fig.  11). 

Pain  in  the  affected  side  is  in  most  cases  developed  within  a  few  hours 
after  the  initial  chill,  and  after  lasting  two  or  three  days  gradually  dis- 
appears. It  is  stabbing  in  character,  and  usually  referred  to  the  region 
immediately  below  the  nipple  or  to  the  axilla,  and  rarely  to  other  points 
(abdomen,  flank — the  so-called  abdominal  symptoin).  In  most  instances 
it  is  not  severe  until  greatly  intensified  by  the  cough,  which  always  aggra- 
vates this  symptom,  as  does  deep  inspiration.  The  pain  is  due  to  impli- 
cation of  the  pleura  covering  the  inflamed  lung,  and  may  be  entirely 
absent,  especially  in  the  aged  and  those  showing  marked  toxemia. 

The  cough,  like  the  chest-pain  and  respiration,  is  somewhat  charac- 
teristic, being  frequent,  short,  dry,  and  voluntarily  repressed,  because  it 
is  attended  Avith  increased  suffering.  Yet  there  are  cases  that  run  their 
entire  course  without  cough — e.  g.,  in  the  aged  and  in  drunkards. 

The  Sputum. — At  first  mucoid  and  frothy,  it  soon  becomes  of  a  cha- 
racteristic rusty  color.  It  consists  of  a  frothy,  fluid  mucus  containing 
an  abundance  of  small  viscid  masses  of  a  vellowish-  or  reddish-brown 


112  INFECTIOUS  DISEASES. 

color,  from  admixture  of  blood.  The  chief  peculiarity  of  the  sputum  in 
fully  developed  cases  is  its  viscidift/  and  tenacity/,  often  adhering  to  the 
receptacle  even  thouch  the  latter  be  inverted ;  owincr  to  its  adhesive 
quality  it  is  ejeetod  from  the  mouth  with  considerable  dilhculty  by  the 
patient.  About  the  time  of  the  crisis  the  sputum  usually  becomes  more 
abundant,  distinctly  purulent,  and  its  expulsion  easy,  but  rarely  it  may 
be  absent  after  the  crisis.  In  severe  types  of  the  disease  it  may,  at  the 
outset,  consist  largely  of  pure  blood,  and  in  adynamic  forms  it  is  often 
thinner  and  darker  in  color  (/n-uiu'-juice).  There  are  cases  in  -which 
there  is  an  abundance  of  muco-purulent  expectoration  when  extensive 
associated  bronchitis  occurs,  and,  on  the  other  hand,  instances  are  met 
Avitli  in  which  nothing  is  expectorated  save  a  little  light-colored  mucus. 
In  old  persons  or  in  those  previously  enfeebled  there  may  be  no  expec- 
toration whatsoever.      The  amount  is  therefore  exceedingly  variable. 

Under  the  microscope  the  sputum  is  seen  to  contain  red  blood-cor- 
puscles, alveolar  epithelium,  the  3Iicrococcus  laneeolatus  (usually  Avith 
other  micro-organisms),   pus-corpuscles,   and  small  fibrinous  casts. 

General  Features. — The  Fever. — As  I  have  already  stated,  the  fever 
rises  rapidly  during  the  initial  chill,  so  that  in  eight  to  twelve  hours  the 
temperature  reaches  104°  or  105°  F.  (40.5°  C).  It  then  remains  high 
until  the  crisis,  pursuing  the  continued  type,  with  nocturnal  remissions 
amounting  to  a  degree  or  over,  while  the  daily  fluctuations  correspond 
with  the  normal,  except  that  they  are  now  somewhat  exaggerated.  In 
children  the  rigor  is  almost  always  replaced  by  convulsions.  The  tem- 
perature has  a  lower  average  range  in  persons  previously  debilitated,  in 
old  people,  and  in  drunkards,  than  in  healthy  adults  and  children. 
During  the  febrile  period  there  may  be  observed  a  pronounced  fall  of 
temperature — pseudo-crisis — but  the  temperature  again  rises  to  its  former 
height.  This  may  occur  quite  early,  though  more  often  it  precedes  the 
true  crisis  by  a  day  or  two  ;  and  rarely  it  may  take  place  repeatedly, 
and  the  temperature-curve  bear  a  strong  resemblance  to  the  remittent  or 
even  the  intermittent  type,  regardless  of  any  malarial  infection.  The 
temperature  may  be  unusually  high,  106°  F.*(41.1°  C.)  or  even  107°  F. 
(41.6°  C),  these  striking  elevations  sometimes  preceding  the  crisis  (per- 
turhatio  critica),  and  hyperpyrexia  is  often  the  signal  of  approaching  dis- 
solution. It  is  especially  characteristic  of  pneumonia,  however,  that  the 
fever  terminates  by  crisis ;  hence  a  mere  glance  at  the  temperature- 
chart  may  serve  to  complete  the  diagnosis  in  doubtful  cases  (see  page 
113).  The  crisis  may  occur  anywhere  from  the  end  of  the  third  to  the 
fourteenth  day,  but  in  the  majority  of  instances  it  is  on  the  seventh  or 
the  ninth  day.  The  temperature  usually  falls  during  the  night,  and  the 
drop  is  accompanied  by  copious  perspii-ation,  so  that  bv  the  following 
morning  the  thermometer  is  found  to  register  at  the  normal,  or  more  often 
a  subnormal,  point  (96°-05°  F.— 35°  C). 

The  duration  of  the  period  of  decline  is  usually  from  eight  to  twelve 
hours.  It  may  be  much  shorter,  but  more  commonly  it  is  longer,  or  by 
lysis.  Tlie  latter  mode  of  termination  is  often  due  to  some  complication. 
A  gradual  fall  of  the  temperature  in  this  disease  is  more  common  at 
present  than  formerly.  After  the  crisis  the  temperature  may  remain 
subnormal,  or  there  may  occur  a  slight  postcritical  rise ;  the  respiration 
and  pulse-rate  quickly  return  to  the  normal. 

Circulatory  Symptoms. — The   average  pulse  rate   in  typical   cases  is 


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3 

114  INFECTIOUS  DISEASES. 

about  100  to  108  per  minute,  and  wben  it  exceeds  120  there  is  just  cause 
for  alarm.  The  rate  may  be  increased  either  suddenly  or  gradually,  but 
in  any  event  augmented  frequently  implies  danger.  Cardiac  failure  is 
generally  (lue  to  the  eftect  of  the  pneumotoxin  upon  tlie  heart,  although 
less  commonly  also  either  to  previous  organic  disease  of  the  heart  or  to 
some  complicating  condition  (pericarditis,  collateral  edema),  and  the 
period  of  greatest  liability  is  in  the  advanced  stage  of  the  disease.  A^aso- 
motor  paresis  affecting  the  splanchnic  area  is  also  a  factor  in  causing 
heart-exhaustion.  At  first  the  pulse  is  small,  especially  in  extensive 
consolidation ;  a  little  later,  full  and  bounding.  Dicrotism  may  be 
noticeable,  and  an  irregularity  in  the  volume  and  rhythm  of  the  pulse 
may  be  observed;  it  is  an  unpropitious  sign.  In  the  aged  and  the 
weakly  a  feeble,  frequent  pulse  may  be  present. 

The  blood-pressure  generally  begins  to  fall  after  three  or  four  days, 
and  -when  it  progresses  and  exceeds  25  mm.  Hg.  it  is  significant  and 
calls  for  increased  stimulation.  A  prompt  fall  indicates  approaching  dis- 
solution, as  a  rule.  Brem^  states  that  the  first  sign  of  exhaustion  is 
ahvays  a  fall  of  the  peripheral  tension.  MacKenzie  points  out  that  when 
the  line  of  blood-pressure,  measured  in  mm.  of  Hg.,  falls  below  that  of 
the  pulse-rate,  there  is  danger,  and  vasomotor  stimulants  are  required. 

The  heart-sounds  are  clear,  and  owing  to  increased  tension  in  the. 
pulmonary  vessels  the  pulmonary  second  sound  is  accentuated.  This  is 
the  state  of  things  throughout  in  favorable  cases.  With  failure  of  the 
right  ventricle  (a  not  rare  event)  there  arise  the  signs  of  dilatation  of  this 
chamber  (extension  of  cardiac  dulness  to  the  right,  epigastric  impulse, 
a  low  systolic  murmur,  shortening  of  the  diastole,  or  fetal  heart-sounds, 
cyanosis,  and  indistinctness  of  the  second  pulmonary  sound).  A  soft, 
low-pitched  murmur  may  be  audible  in  the  mitral  and  pulmonary  zones. 

The  blood-appearances  are  somewhat  characteristic.  There  is  a 
leukocytosis  varying  from  10,000  to  40,000  or  more.  The  reseaches 
of  Lacbe^  show  that  leukocytosis  is  of  some  value  in  determining 
between  the  crisis  and  pseudo-crisis,  continuing  in  spite  of  the  fall  of 
temperature,  etc.,  in  pseudo-crisis,  while  it  disappears  with  the  true  crisis. 
Stienon^  finds  that  in  the  febrile  stage  tlie  polynuclear  forms  predom- 
inate, but  as  soon  as  these  diminish  the  eosinophiles  begin  to  increase. 
A  small  percentage  of  myelocytes  may  be  found.  Slight  leukocytosis 
may  indicate  a  mild  infection,  but,  as  a  rule,  it  is  a  bad  prognostic  sign. 
Leukopenia  occurs  in  the  malignant  cases  ;  on  the  other  hand,  leukocy- 
tosis of  high  deiiree,  while  indicating  a  severe  infection,  "  it,  at  the  same 
time,  shows  a  good  reaction."^  Leukocytosis,  however,  may  be  pre- 
vented by  previous  infections  (e.  g.^  typhoid)  and  the  use  of  internal 
antipyretics.  Ludwig  Jehle^  reports  6  cases  of  the  agglutination  of  the 
pneumococcus  by  the  serum  of  pneumonia  patients. 

The  red  corpuscles  and  hemoglobin  remain  little  changed  during  the 
fastigium,  but  show  a  marked  decrease  almost  immediately  after  the 
actual  crisis.^  The  blood-plates  are  also  increased  in  number  (Hayem). 
Da  Costa  has  collected  9  cases  of  phlegmasia  alba  dolens  in  pneumonia. 

1  Johm  Hopkins  Hasp.  Bull.,  1905,  xvi.,  321. 

2  Berliner  klin.  Woch.,  189.3,  Nos.  36  and  37.  ^  la  PrcKse  med.,  13,  1895. 

*  E.  Becker,  Dmtsch.  med.  Work.,  Aug.  30,  1900.         ^  |j^^,„_  j.ii^_  Woch.,  1903,  No.  32. 
®  Sadler,  Fortsckritle  der  Medicin,  1892  ;  Leichtenstein,  Ueber  der  Hiimoglobin-gehalt  des 
Blutes,  etc.,  Leipzig,  1892. 


LOBAR  PNEUMONIA.  115 

Cerebral  Symptoms. — Headache  sets  in  early  and  may  be  a  prominent 
and  persistent  feature.  In  many  cases,  and  particularly  in  children,  the 
disease  is  ushered  in  by  convulsions,  this  symptom  occurrinif  more  often 
in  the  apical  than  in  the  basilar  form  of  pneumonia.  JJelirium  may  come 
on  during  the  acme  of  the  disease  (rarely,  it  may  start  as  an  acute  mania), 
and  may  assume  a  maniacal  form,  but  oftener  in  my  experience  conscious- 
ness has  been  retained.  In  the  drunkard  delirium  tremens  usually  devel- 
ops, and  may  anticipate  the  symptoms  referable  to  the  lungs ;  and  I 
fully  agree  with  Osier  in  stating  that  it  should  be  an  invariable  rule,  if 
fever  be  present,  to  examine  the  lungs  in  delirium  tremens.  These  cases 
may  often  be  appropriately  termed  ^^  walking  pneumonia,"  since  they 
go  about  until  excitement  gives  way  to  a  coma  that  deepens  into  death. 
In  adynamic  forms  a  low,  muttering  delirium  and  coma  are  frequent. 

In  the  so-called  cerebral  pneumonia  the  nervous  phenomena  are  quite 
pronounced,  and  simulate  closely  cases  of  cortical  meningitis.  It  is 
often  associated  with  excessively  high  fever,  except  in  the  aged,  when 
the  cerebral  symptoms  are  also  well  marked,  but  the  fever  is  mod- 
erate. Apical  pneumonias  are  apt  to  assume  the  cerebral  type,  but 
in  my  experience  this  dictum  is  correct  as  relating  to  children  only. 
Double  pneumonias  are  commonly  characterized  by  severe  cerebral 
symptoms. 

The  Cutaneous  Symptoms. — As  stated  before,  herpes  is  common  and  its 
diagnostic  importance  is  considerable.  Naso-labial  herpes  is  but  little 
less  frequent  in  this  disease  than  in  malaria,  being  present  in  about  one- 
third  of  the  cases.  It  usually  comes  out  from  the  second  to  the  fifth 
day  of  the  disease,  and  rarely  may  appear  upon  the  cheek,  lobe  of  the 
ear,  the  genitals,  forearm,  or  upon  the  mucosa  of  the  tongue.  Sweats 
are  not  common  except  at  the  time  of  the  crisis,  when  they  may  be 
copious.  The  deep-red  circumscribed  spot  upon  one  cheek  [mahogany 
flush),  usually  on  the  side  of  the  aifected  lung,  has  already  been  men- 
tioned.    Urticaria  has  been  observed,  though  rarely. 

Digestive  System. — The  mouth  is  dry,  the  tongue  has  a  coating  of  a 
yellowish-white  color,  becoming  dry  and  brown  in  cases  representing  a 
low  form,  and  anorexia  and  thirst  are  present.  Vomiting  is  not  uncom- 
mon at  the  outset,  and  may  be  repeated,  while  constipation  is  the  general 
rule  and  diarrhea  the  frequent  exception.  Sears  and  Larrabee^  in  an 
elaborate  analysis  of  949  cases  found  that  pain  below  the  costal  margin 
was  frequently  present,  and  in  several  cases  appendicitis,  especially  when 
the  pain  was  associated  with  muscle  spasm.  Splenic  enlargement  of 
slight  degree  can  usually  be  detected  on  palpation. 

Urinary  Symptoms. — The  urine  is  febrile,  diminished  in  amount, 
and  high-colored,  the  urea  and  uric  acid  being  greatly  in  excess.  On 
the  other  hand,  the  chlorids  are,  according  to  the  older  authors,  either 
diminished  in  amount  or  absent  during  the  febrile  stage,  presumably  for 
the  reason  that  they  pass  into  the  inflamed  lung-tissue.  They  are  not, 
however,  constantly  absent,  and  sometimes  they  are  not  even  lessened, 
in  pneumonia ;  moreover,  their  disappearance  is  not  peculiar  to  this  dis- 
ease. The  above-mentioned  facts  justify  two  important  inferences  :  (1) 
The  absence  of  chlorids  is  a  symptom  of  little  diagnostic  value  :  and 

1  The  Mfd.  and  Surg.  Reports  of  Boston  City  Hospital,  Twelfth  Series,  Dec.  1,  1901. 


116  jyFECTIOUS  DISEASES. 

(2)  their  reappearance  in  the  urine  tmvard  the  close  of  pneumonia  is  of 
small  prognostic  worth.      Slight  (febrile)  albuminuria  is  common. 

Physical  Signs. — Stage  of  Congestion. — The  density  of  the  lung  is 
increased,  but  the  involved  tissue  is  not  consolidated  and  the  pleura  is 
not  yet  covered  with  fibrin. 

Inspection. — The  movements  of  the  affected  side  (especially  if  the 
base  be  involved)  are  defective,  the  degree  of  expansion  being  much 
diminished.  In  double  pneumonia  the  costal  type  of  breathing,  com- 
bined with  a  vigorous  play  of  the  abdominal  muscles,  is  observed. 

Palpation. — There  is  a  slight  increase  in  the  tactile  fremitus  over  the 
congested  area,  and  defective  expansion  is  noted. 

Percussion. — The  note  may  be  normal,  though  more  often  it  is 
briefer,  higher-pitched,  or  even  distinctly  tympanitic. 

Auscultation. — The  breath-sounds  are  weak,  and  sometimes  become 
broncho-vesicular  upon  deep  inspiration,  while  over  the  unaffected  lung- 
tissue  they  are  exaggerated.  If,  as  often  happens,  inflammatory  prod- 
ucts due  to  associated  bronchitis  occupy  the  small  bronchi,  subcrepitant 
rales  may  be  audible.  The  crepitant  rale,  however,  is  rarely  heard 
until  the   close  of  the  first  stage. 

Stage  of  Consolidation. — Insjyection. — There  is  little  or  no  expansive 
motion  of  the  chest  over  the  affected  area,  while  upon  the  unaffected  side 
it  is  increased.  The  volume  of  the  thorax  on  the  diseased  side  is  increased, 
as  shown  by  mensuration,  but  the  intercostal  depressions  are  not  effaced. 

Palpation  renders  clearly  perceptible  the  defect  or  absence  of  expan- 
sion. Vocal  fremitus  is  usually  much  increased,  though  in  exceptional 
instances  it  is  diminished  or  absent — a  circumstance  which  can,  as  a 
rule,  though  not  invariably,  be  attributed  to  an  associated  pleurisy  with 
more  or  less  effusion.  Frequently  a  friction-rub  is  felt  before  complete 
consolidation  is  established. 

Percussion. — A^arying  degrees  of  dulness  are  obtained  in  this  stage, 
and  before  the  lung-tissue  becomes  thoroughly  solidified  the  note  may 
have  a  tympanitic  quality.  After  complete  consolidation  there  is  usu- 
ally marked  or  absolute  dulness  posteriorly,  unchanged  by  full  inspira- 
tion, while  the  note  may  be  more  or  less  tympanitic  anteriorly,  where 
the  vibrations  are  more  apt  to  reach  the  air  in  the  larger  bronchi.  A 
sense  of  resistance  is  offered  to  the  pleximeter-finger,  but  not  to  the 
same  degree  as  in  the  case  of  a  pleurisy  with  effusion.  When  the  latter 
condition  is  associated  and  in  massive  pneumonia  the  percussion-note 
will  be  flat.  Deadness  is  less  marked  in  old  people  in  whose  ribs  senile 
changes  have  taken  place,  which  render  them  more  resonant,  or  in 
cases  in  Avhich  the  consolidated  areas  occupy  the  central  portions  of  the 
lung.     Above  the  solidified  part  Skodaic  resonance  is  usually  obtainable. 

Auscultation. — Bronchial  or  tubular  breathing  is  heard,  as  a  rule, 
over  the  solidified  lung,  but  it  may  be  absent  in  consequence  of  the 
plugging  of  the  large  bronchi  with  exudate  (so-called  massive  pneu- 
monia). Bronchophony  is  usually  obtainable  over  the  portion  of  the 
lung  affected,  though  this  may  also  be  absent,  and  for  the  same  reason 
as  in  the  case  of  the  bronchial  breathing:  it  sometimes  takes  the  form 
of  egophony.  Subcrepitant  rales,  due  to  associated  bronchitis,  are 
sometimes  heard  with  unusual  distinctness  (ownng  to  the  consolidation), 
and  the  crepitant  rale  at  the  end  of  inspiration  is  best  heard  at  the 
beginning  of  consolidation,  when  the  pleura  receives  its  coat  of  fibrin 


LOBAR  FNEUMONTA.  117 

and  while  the  lung  is  yet  capable  of  sufficient  movemeijt  to  produce  fine 
pleural  friction.     A  distinct  friction-rub  may  also  be  hoard  occasionally. 

Stage  of  G-ray  Hepatization. — With  beginning  resolution  the  solid  con- 
tents of  the  air-cells  liquefy  and  are  removed,  so  that  air  now  re-enters 
the  air-cells  and  permits  a  consequent  increase  in  the  movement  of  the 
lung. 

Inspection. — The  normal  expansile  movement  gradually  returns. 

Palpation. — Tactile  fremitus  progressively  diminishes. 

Percussion. — The  dull  or  tympanitic  quality  of  the  note  is  gradually 
lost,  though  the  fact  must  be  emphasized  that  the  abnormalities  in  the 
note  vanish  more  slowly  than  the  other  abnormal  physical  signs.  .Some 
degree  of  deadness  often  remains  long  after  apparent  recovery. 

Auscultation. — With  increased  movement  of  the  lung  there  may  be  a 
reappearance  of  the  crepitant  rale,  due  to  interplay  of  the  pleural  sur- 
faces, and  the  softened  exudate  in  the  air-cells  gives  rise  to  subcrepitant 
rales,  heard  both  on  inspiration  and  expiration  {rdle  redux),  with  coarser 
rales  over  the  bronchi.  Bronchial  breathing  gradually  gives  place  to 
broncho-vesicular,  and  the  latter  in  turn  to  normal,  breathing. 

The  Pneumococcus  Septicemia. — The  pneumococcus  infection  may 
cause  severe  toxic  features  and  even  speedy  death  without  any,  or 
with  but  little,  involvement  of  the  lung-texture.  The  general  inva- 
sion symptoms,  such  as  the  chill,  high  fever,  and  nervous  symptoms 
which  always  predominate,  however,  are  present  and  persist  until 
death  ends  all.  Death  is  preceded  by  signs  of  cardiac  failure,  by  vaso- 
motor paresis,  or,  more  rarely,  by  coma.  In  some  of  these  cases  localiza- 
tion of  the  morbid  process  may  occur  in  organs  other  than  the  lungs,  as 
the  cerebral  meninges,  the  endocardium,  pericardium,  and  the  pleura. 
An  assured  diagnosis  in  these  atypical  forms  of  the  pneumococcus  infec- 
tion can  be  arrived  at  by  a  bacteriologic  examination  of  the  exudate 
obtained  by  aspiration.  The  pneumococcus  can  also  be  demonstrated  in 
blood-cultures,  provided  that  they  are  made  Avith  large  quantities  of  blood. 

Complications. — Many  of  these  are  due  to  the  primary  infection. 

Pleurisy  is,  of  necessity,  associated  in  all  instances  in  which  the  con- 
solidation reaches  the  pleura.  In  most  cases  the  presence  of  the  diplo- 
cocci  has  been  demonstrated.  Cases  are  met  with  in  which  the  truly 
pneumonic  symptoms  are  overshadowed  by  the  intensity  of  the  pleuritis 
and  to  these  the  term  pleuropneumonia  has  been  applied.  There  is  often 
a  copious  effusion  which  is  exceedingly  rich  in  fibrin — a  circumstance 
which  distinguishes  it  from  other  forms  of  acute  pleurisy.  There  may 
be  the  ordinary  grade  of  pleurisy  on  the  side  of  the  pneumonia,  and  a 
severe  grade  on  the  opposite  side  which  is  apt  to  be  purulent.  Indeed, 
empyema  has  of  late  been  shown  to  be  a  frequent  complication  of 
pneumonia,  and  it  also  occurs  as  a  sequel.  A  condition  that  affects  its 
incidence  is  involvement  of  the  lower  right  lobe.  Lambert  and  Daly^ 
report  5  cases  of  empyema  developing  as  a  complication  in  lobar  pneu- 
monia, which  showed  a  sudden  rise  of  leukocytosis  to  nearly  or  more  than 
double  the  count  of  the  previous  day.  Its  development  is  accompanied 
by  replacement  of  ordinary  dulness  by  flatness  with  great  resistance,  and 
by  the  disappearance  of  rales  and  breath-sounds,  normal  and  abnormal. 
Other  characteristic  features  of  empyema  are  present,  but  if  doubt  sur- 
round the  diagnosis,  the  needle  should  be  introduced. 
^St.  Paul  Med.  Jour.,  Dec,  1902. 


118  INFECTIOUS  DISEASES. 

There  is  a  prompt  rise  of  fever,  the  temperature  leaping  to  103°  or 
104°  F.  (39°  or  40°  C.)  quickly,  after  which  it  is  decidedly  remittent  in 
type,  but  there  are  no  hectic  chills.  Fistulous  connection  Avith  a  bronchus, 
however,  and  the  establishment  of  empyema  necessitatis  are  common 
events,  and  may  ,be  preceded  by  diurnal  chills,  sweats,  etc. 

The  occurrence  o^  septic  phenomena  is  a  certain  indication  of  second- 
arv  infection  by  streptococci.  The  pus  is  rarely  absorbed  and  frequently 
becomes  encysted.  I  saw  one  instance  in  which  the  effusion  measured  8 
liters,  while  ordinarily  the  amount  ranges  from  2  to  5  liters.  Removal 
of  the  effusion  by  aspiration  is  promptly  followed  by  the  disappearance 
of  the  fever,  but  reaccumulation  generally  occurs. 

Finally,  if  defervescence  in  pneumonia  takes  place  by  lysis  or  if  an 
irregular  fever  persists,  a  residual  purulent  or  sero-fibrinous  effusion  may 
be  considered  as  the  likely  cause.  This  latter  complication  is  attended 
by  a  paroxysmal  cough  which  is  excited  by  movement,  and  is  not  usually 
accompanied  by  expectoration. 

Acute  general  broncliitis  may  pre-exist  or  arise  as  a  complication,  and 
often  proves  formidable,  intensifying  the  fever  and  increasing  the  dysp- 
nea, the  tendency  to  heart-failure,  and  the  cyanosis.  The  expectoration 
is  freer  than  in  uncomplicated  pneumonia,  and  over  the  bronchi  moist 
rales  intermingled  with  sibilant  and  sonorous  rales  are  audible. 

Pericarditis. — This  is  an  important  and  serious  complicating  affection. 
According  to  Chathard,  it  is  oftener  synchronous  with  involvement 
of  the  right  than  of  the  left  lung,  hence  arises  as  often  by  a  metastatic 
process  as  by  direct  extension.  It  was  present  in  4.66  per  cent,  of  665 
cases  and  occurred  most  frequently  in  young  adults.  Although  gener- 
ally of  the  plastic  variety,  it  is  not  infrequently  sero-fibrinous,  and  rarely 
the  effusion  is  purulent.  The  diagnosis  can  be  made  here  as  under  other 
conditions  (pericardial  friction  rub,  etc.),  but  the  complication  is  often 
insidious.  The  occurrence  of  increased  dyspnea,  with  or  without  pre- 
cordial pain,  should  serve  as  a  signal  and  lead  to  a  physical  examination. 

Endocarditis. — This  is  somewhat  more  frequent  than  pericarditis. 
Preble  ^  has  well  said  that  endocarditis  should  always  be  suspected  in  a  case 
of  pneumonia,  which  is  followed  by  an  irregular  temperature  not  suffi- 
ciently accounted  for  by  some  other  complication,  such  as  empy- 
ema. Out  of  209  cases  of  malignant  endocarditis  collected  by 
Osier,  54  cases  occurred  in  pneumonia.  Endocarditis  complicates 
pneumonia  in  1  per  cent,  of  all  cases  and  in  5  per  cent,  of  the 
fatal  cases  (Preble).  It  is  generally  of  the  malignant  type  and  may 
attack  any  valve  (the  aortic  leaflets,  however,  being  most  commonly 
affected).  There  are  no  reliable  symptomatic  indications  of  this  condition. 
The  physical  signs  must  be  faithfully  and  systematically  noted.  Fre- 
quently murmurs  are  absent ;  and,  on  the  other  hand,  the  presence  of  a 
murmur  alone  is  by  no  means  diagnostic  of  the  complication.  Brady- 
cardia is  not  uncommon,  but  oftener  the  pulse  is  rapid  and  feeble.  The 
development  of  septic  manifestations,  especially  irregular  fever,  chills, 
and  sweats,  renders  the  case  highly  suspicious,  and  when  in  addition  there 
arises  distinct  evidence  of  embolic  processes  the  diagnosis  becomes  highly 
probable.  If,  now,  the  symptoms  of  meningitis  supervene,  little  doubt 
remains  as  to  the  character  of  the  complications,  since  meningitis  and 
endocarditis  are  often  combined  in  pneumonia. 

^  Amer.  Jour.  Med.  Sci.,  Nov.,  1904. 


LOBAR  PNEUMONIA.  119 

Netter,  Weichselbaum,  and  Bigniirni  have  shown  that  acute  endocar- 
ditis may  be  caused  directly  by  the  diplococcus  of  pneumonia.' 

Chronic  Endocarditis, — J'neumonia  arising  in  the  course  of  chronic  en- 
docarditis is  apt  to  be  attended  by  cardiac  failure,  with  ensuing  venous 
stasis.  The  murmurs  of  chronic  valvulitis  often  dis;ip[)ear  with  the  de- 
velopment of  pneumonia. 

Cardiac  clots  (ante-mortem)  may  form,  but  are  rare.  They  result 
from  weakness  of  the  ventricular  wall,  especially  in  the  right  heart; 
and  are  most  apt  to  arise,  therefore,  in  cases  in  which  the  preagonal  period 
is  much  prolonged.  Venous  thrombosis  is  rarely  seen,  and  embolism  of 
the  larger  arteries  is  a  rare  complication,  the  lesions  and  determining 
factors  being  similar  to  those  in  typhoid  fever.  The  cerebral  embolism, 
causing  aphasia  and  even  hemiplegia,  has  been  observed,  but  seldom. 

Pneumococcus  meningitis  may  be  a  complication  ;  it  differs  only  in  the 
bacteriologic  findings  from  meningococcus  meningitis.  Pneumococcus 
meningitis  may  also  occur  independently  of  lung  involvement. 

The  symptoms  are  not  clearly  defined ;  particularly  is  this  true  when 
it  develops  during  the  invasion-period  and  the  basilar  meninges  are  not 
involved.  The  presence  of  intense  and  persistent  headache,  rigidity  of 
the  nucha,  wild  delirium,  followed  by  stupor,  deepening  into  profound 
coma,  affords  a  basis  for  a  probable  diagnosis.  Its  frequent  association 
in  the  purulent  form  with  ulcerative  endocarditis  has  been  pointed  out 
above.     The  cerebrospinal  fluid  contains  no  sugar  in  this  condition. 

Peripheral  neuritis  is  among  the  rare  complications  of  this  disease. 

Parotitis  is  also  sometimes,  seen,  and  may  cause  a  fatal  termination  of 
the  case.  I  have  seen  two  instances,  however,  in  which  this  was  a  com- 
plication, and  both  ended  in  recovery.  It  is  thought  to  be  associated 
usually  with  endocarditis,  but  not  so  in  my  cases. 

Arthritis. — A  pneumococcic  arthritis  occurs,  but  it  is  rare.  The  joint 
is  occasionally  primarily  involved,  showing  the  importance  of  toxemia 
(Herrick).  It  is  most  prone  to  develop  after  the  crisis,  and  is  associated 
with  meningitis  and  endocarditis.  The  exudate  is  generally  a  thick 
creamy  pus,  less  commonly  sero-fibrinous.  The  changes  may  be  either 
slight  in  the  acute  forms,  or  extensive  and  destructive  of  cartilage  and 
bone,  particularly  in  the  more  chronic  cases.  A  recognition  of  the  con- 
dition demands  exploratory  aspiration  and  bacteriologic  examination. 
The  mortality-rate  is  65  per  cent.  Rheumatism  and  otitis  media  may  be 
rarely  met  also,  particularly  in  children. 

Gastro-intestinal  Complications. — Croupous  gastritis  may  rarely  inter- 
vene. Fussell  ^  calls  attention  to  complicating  acute  dilatation  of  the 
stomach  ;  it  causes  vomiting,  sudden  epigastric  distention  becoming  gen- 
eral, and  collapse,  Avhich  is  an  urgent  symptom.  Croivpous  colitis  is  a 
frequent  concomitant,  sometimes  grave,  giving  rise  to  tympanites  and 
diarrhea. 

Peritonitis  occurs,  but  with  great  rarity. 

Jaundice  may  be  observed  ;  it  is  more  frequent  in  serious  than  in 
mild  forms  of  the  disease.  It  is  rarely  intense,  and  is  most  probably  an 
obstructive  (hepatogenous)  jaundice.  N.  V.  P^trov  has  reported  13  cases 
complicated  with  icterus,  and  in  all  observed  local   lesions  (mainly  catar- 

^  Practitioner,  London,  Aug.,  1894. 
"^Amer.  Jour,  of  the  Med.  Sci,  Dec,  1911. 


120  INFECTIOUS  DISEASES. 

rhal)  of  the  duodenum  and  the  biliarv  canals.  A  catarrhal  or  suppura- 
tive cholecystitis  may  rarely  complicate  lobar  pneumonia.^ 

Acute  nephritis  is  a  complication,  and  its  recognition  is  dependent 
upon  the  discovery  of  albumin  and  casts  in  the  urine.  In  20,107  cases 
of  lobar  pneumonia,  acute  nephritis  occurred  in  208,  or  1.3  per  cent. 
(Norris). 

Clinical  Varieties  and  Anomalous  Types. — (1)  Typhoid  Pneu- 
monia.— This  relates  to  an  adyn;imic,  serious  type  of  the  disease  with 
typhoid  Kjinipfoms,  and  not  to  typhoid  fever.  It  is  often  secondary  to  low 
fevers,  to  septicemia,  diabetes,  and  chronic  nephritis,  and  is  also  the  vari- 
ety met  with  in  drunkards  and  in  persons  previously  enfeebled.  The 
onset  is  somewhat  gradual.  The  physical  signs  may  be  ill  defined,  but 
the  general  features  are  always  striking  and  characteristic.  Prostration  is 
extreme ;  there  are  delirium  and  often  stupor ;  the  temperature  may  or 
may  not  be  high  ;  while  the  respirations  and  pulse  are  almost  always  fre- 
quent. The  skin  is  dry,  and  may  show  a  dusky  tint  or  slight  jaundice. 
The  tongue  is  dry,  often  brown,  and  vomiting  is  common ;  the  sputa  may 
be  rusty  or  decidedly  hemorrhagic.  Splenic  enlargement  is  often  clearly 
perceptible.  When  recovery  ensues  convalescence  is  tedious.  Some  of 
the  cases  belong  in  the  category  of  atypical  pneumonias. 

(2)  Epidemic  Pneumonia. — This  is  often  of  malignant  type.  Tlie 
symptoms  exhibit  noticeable  variations,  according  to  the  special  etiology 
and  to  different  epidemics.  The  pneumonias  of  epideniw  influenza  are 
complicated  with  or  preceded  by  general  bronchitis.  The  heart-power 
often  becomes  exhausted  early,  and  then  follow  congestion  and  edema  of 
the  lungs.     The  physical  signs  are  often  slight. 

The  so-called  serous  pneumonia  often  complicates  influenza;  it  is 
ascribed  to  streptococcus  infection  (streptococcus  pneumonia).  Septic 
phenomena  often  arise,  such  as  irregular  fever  and  sweats.  The  physical 
signs,  for  a  time  indefinite,  when  fully  developed  resemble  those  of  bron- 
chopneumonia. There  may  be  a  tendency  to  migration  from  one  to  the 
other  lung.  There  may  be  a  late-appearing  rusty  expectoration,  and  in 
some  cases  the  sputa  are  mucopurulent  throughout.  The  course  is  often 
protracted,  and  the  fever  may  terminate  by  lysis.  In  two  of  my  cases 
the  pneumococcus  was  detected  in  the  sputum  in  increased  numbers.  It 
is  said  that  in  mixed  infection  the  micrococcus  lanceolatus  is  abundantly 
present.  In  so-called  ''larval  p>neum(>nia''  the  general  symptoms  are 
mild  and  the  local  signs  ill  defined.  The  epidemic  outbreaks  that  occur 
in  institutions,  tenement-houses,  jails,  etc.,  belong  to  this  variety. 

(3)  Latent  Pneumonia. — To  this  class  belong  central  pneumonias. 
The  sputum  is  to  be  stained  and  examined  microscopically,  when  the 
pneumococcus  will  be  found.  The  sputum  is  gummous  and  rusty,  as  a 
rule.  When  pneumonia  arises  in  the  course  of  emphysema  the  dilated 
air-cells  are  not  filled  with  the  exudate  ;  hence  dulness  is  less  marked, 
and  true  tubular  breathing  may  be  absent.  Before  the  crisis  occurs 
consolidation  usually  advances  to  the  periphery.    • 

(4)  Migratory  Pneumonia. — By  this  is  meant  an  extension  of  the  spe- 
cific inflammation  to  other  parts  of  the  lungs.  Such  extension  may  pre- 
vent the  occurrence  of  the  usual  crisis,  and  often  occasions  an  exacerbation 
of  the  general  pneumonic  features. 

1 ''  Cholecystitis  as  a  Complication  of  Lobar  Pneumonia,  with  a  Report  of  Three  Cases, 
and  Remarks  on  Icterus  in  Pneumonia,"  by  tiie  writer. 


LOIIAII    PNEUMONIA.  121 

(5)  Bilious  Pneumonia  ("  Malarial  Pneumonia  "). — In  pneumonia  oc- 
curring in  malarial  subjects  the  initial  chill  is  prolonged  and  tlie  fever 
paroxysmal  or  remittent.      Jnundice  and  vomiting  are  common. 

(6)  In  children,  the  first  symptom  is  often  a  convulsion.  Cerebral 
symptoms  (delirium,  stupor,  coma)  may  appear  early.  The  upper  lobes 
of  the  lungs  are  frequently  involved.  Unless  the  objective  indications 
be  examined  for,  the  disease  is  frequently  overlooked.  The  characteristic 
sputum  is  rarely  seen  in  juvenile  pneumonia.  Crozer  Griffith  reports  8 
cases  in  which  the  pain  suggested  appendicitis. 

(7)  In  old  persons  the  initial  chill  is  often  absent  or-  replaced  by 
moments  of  chilliness.  There  may  be  nausea  and  vomiting.  Prostra- 
tion is  profound ;  there  is  fever,  but  it  does  not  range  high  and  is  irreg- 
ular. Nervous  phenomena,  sometimes  prominent,  are  not  uncommon, 
but  the  local  symptoms  (cough,  expectoration,  and  pain)  are  mild  or 
wholly  absent.  The  physical  signs  are  defective  owing  to  impairment 
of  the  respiratory  movements;  dulness  on  percussion  (with  a  tympanitic 
quality),  tubular  breathing,  and  a  few  subcrepitant  rales  may,  however,  be 
noted.  This  affection  is  a  most  deceptive  one  in  old  people,  the  cases  gener- 
ally ending  fatally  after  an  illness  of  an  apparently  mild  degree  of  intensity. 

(8)  Abortive  pneumonias  last  no  longer  than  twenty-four  or  forty- 
eight  hours.  The  general  features  are  rigor,  high  fever,  and  deferves- 
cence by  crisis  with  profuse  sweating.  The  sputum  is  rarely  characteristic, 
and  the  physical  signs  variable  ;  typical  tubular  breathing  is  rare,  while 
rales  and  pleural  involvement  are  common.  Bechtold^  has  frequently 
observed  this  form  affect  all  the  members  of  a  family. 

(9)  Terminal  Pneumonia. — Many  instances  of  pneumonia  are  dis- 
covered in  the  post-mortem  room.  These  arise  in  advanced  cases  of 
chronic  pulmonary  tuberculosis,  organic  heart  diseases,  chronic  Bright's 
disease,  diabetes,  and  the  like,  and  manifest  no  clinical  symptoms  other 
than  slight  elevation  of  temperature,  an  increase  in  the  respirations,  and 
lung  consolidation.    A  fatal  termination  is  the  rule  in  terminal  pneumonia. 

(10)  Ether-pneumonia. — Opinions  are  divided  as  to  the  frequency  of 
occurrence  of  pneumonia  after  ether-narcosis.  The  aggregate  number  of 
cases  from  all  sources  (57,842)  gives  a  percentage  of  0.07.  My  own 
statistics,  embracing  12,842  cases,  give  a  percentage  of  0.23.^ 

The  principal  causes  are — {a)  Season.  According  to  my  investiga- 
tions, over  80  per  cent,  of  the  cases  occur  during  the  winter  and  spring 
months.  The  patient  is  sometimes  carried  from  a  heated  operating-theatre 
through  a  cold  corridor  to  a  room  or  ward  with  a  lower  temperature.  (6) 
"  Catching  cold,"  or  exposure  as  may  obtain  during  protracted  opera- 
tions, (e)  Bronchitis,  coryza,  and  the  like  present  at  the  time  of  anes- 
thesia, {d)  Dried  secretions  or  incrustations  of  foreign  matter  that  are 
loosened  by  the  ether  and  drawn  into  the  lungs,  (e)  Abdominal  opera- 
tions give  the  highest  percentage  of  cases,  due,  as  my  studies  show,  to  the 
more  protracted  etherization.  Mikulicz  has  shown  that  ether-pneumonia 
following  these  operations  is  caused  by  embolism.  (/)  Graves  ^  believes 
that  most  cases  are  caused  by  the  lighting  up,  or  aggravating  of,  pre- 
existing foci  in  the  lungs. 

The  clinical  features  are  aptly  compared  with  those  of  secondary  pneu- 
monia (vide  p.  130).     The  diagnosis  rests  principally  upon  the  typical 

»  Munch,  med.  Woch.,  No.  44, 1905.       2  "  Ether-pneumonia,"  Univ.  Med.  Mag.,  Aug.,  1898. 
'  Boston  Med.  and  Surg.  Jour.,  Sept.  29,  1910. 


122 


INFECTIO  US  D ISEA  SES. 


physical  signs.  Owing  to  the  extreme  latency  of  the  condition,  and  the 
danger  that  the  symptoms  may  he  regarded  as  being  septic  in  nature,  I 
would  emphasize  the  importance  of  a  physical  examination  of  the  thorax 
upon  the  sudden  accession  o^feve)\  particularly  if  associated  with  thoracic 
pain,  however  slight,  following  an  operation. 

Relapses. — These  are  rare,  and  are  usually  rudimentary.  Recur- 
renres.  liowever.  are  ordinary  (vide  Predisposing  Causes,  p.  110). 

Course  and  Duration. — In  most  instances,  the  crisis  occurs  on  the 
seventh  or  ninth  day,  an<l  resolution  is  completed  about  one  week  later, 
making  the  total  duration  from  twelve  days  to  two  or  three  weeks.  Con- 
valesence,  however,  may  be  delayed  by  complications  or  sequelae,  and 
fatal  cases  are  apt  to  terminate  on  the  seventh,  eighth,  or  tenth  day. 

Sequelae. — [a)  Delayed  Resolution. — The    process    of  resolution    may 


Pig.  12. —Lobar  pneumonia:  1,  unaffected  area  (upper  lobe);  2,  consolidated  area  (middle  lobe); 
3,  resolving  area  (lower  lobe) ;  4,  heart  in  normal  position. 

not  begin  until  the  fourth,  sixth,  or  even  tenth  week.  Usually  deferves- 
cence by  crisis  has  taken  place  long  before  the  physical  signs  indicate 
resolution  ;  the  fever  may,  however,  fall  by  lysis.  When  resolution  occurs 
it  may  lead  to  complete  restoration  of  the  anatomic  entirety  of  the  lung- 
tissue.  Delayed  resolution  is  often  confused  with  certain  sequelae,  especially 
empyema.  Rarely  proliferation  of  the  interstitial  connective  tissue  arises 
in  postponed  resolution,  producing  (Ii)  chronic  interstitial  pneumonia,  (c) 
Abscess;   (d)  gangrene;  and  [e)  tubercular  phthisis  are  also  sequelae. 

Diagnosis. — The  diagnosis  is  determined  by  special  local  and  gen- 
eral symptoms,  together  with  the  physical  signs.  Of  these,  the  abrupt 
onset  with  rigor,  the  course  of  the  fever  with  termination  by  crisis,  the 


LOBAR  PNEUMONIA. 


123 


abnormal  pulse-respiration  ratio,  the  cough,  the  rusty  expectoration,  expi- 
ratory "  grunt,"  leukocytosis,  and  the  signs  of  lobar  consolidation,  are  the 
most  characteristic.  Repeated  physical  examinations  of  the  chest  will  often 
detect  consolidation,  in  the  absence  of  the  accustomed  symptoms.  Again, 
when  in  the  course  of  certain  chronic  affections  (cancer,  ]>right's  disease, 
diabetes,  and  organic  aff"ections  of  the  heart)  fever  is  developed,  physical 
exploration  of  the  thorax  is  imperatively  demanded. 


Fie.  13. 


__ ^:zj 

•Acute  pneumonic  phthisis,  posterior  view :  1 ,  cavity ;  2  and  3,  consolidation ;  4,  infiltra- 
tion ;  the  white  spots  indicate  r^les. 


Differential  Diagnosis. — This  relates  to  {a)  acute  pneumonic  phthisis, 
(h)  pneumo-typhoid,  {c)  meningitis,  {d)  broncho-pneumonia,  {e)  acute 
pleurisy  with  eifusion. 


(a)  Primary  Lobar  Pneumonia. 
There  may  have  been  prior  attacks. 

Sudden,  with  severe  rigor  and  rapid  rise 
of  tempeiuture. 

Fever  of  continued  type,  terminating  by 

crisis. 
No  drenching  sweats,  except   at  time  of 

crisis. 
Hei'pes  common. 
Not  much  emaciation. 
Pulse-respiration  ratio  much  disturbed. 
Sputum  rusty-colored,    viscid,   and  sticky; 

contains  pneumococcus. 

Leukocytosis  present. 

Duration  of  febrile  stage  shorter. 


Acute  Pneumonic  Phthisis. 

Inherited  predisposition  or  previous  tu- 
berculous disease. 

Genei-ally  more  gradual — repeated  fits  of 
chilliness  (rarely  severe  rigor),  often 
following  exposure  oi'  "  cold." 

Fever  of  remittent  type,  often  becoming 
intermittent,  without  crisis. 

Drenching  sweats  present  and  oft  re- 
peated. 

Absent. 

Eapid  emaciation. 

Less  so. 

Sputum  may  be  blood-tinged ;  is  more 
purulent  and  copious,  and  contains  nu- 
merous bacilli  and  yellow  elastic  tissue. 

Relative  lymphocytosis. 

Duration  lonsrer. 


124  INFECTIOUS  DISEASES. 

[a)  Primary  Lobar  Pneumonia.  Acute  Pneumonic  Phthisis. 

Physical  signs,  as  a  rule,  first  referable  First  referable  to  apex. 

to  base  of  lung. 

Usually  limited  to  one  lobe  or  the  lower  Usually  extension  from  apex  to  base. 

segment  of  one  lung. 

Signs  of  consolidation,  followed  by  reso-  Signs  of  consolidation,  followed  by  cavity- 

lution.  formation,  with  large  gurgling  r^les  at 

apex. 

Apex  of  opposite  lung  not  involved.  Apex    of    opposite    side    generally    in- 
vaded. 

Prognosis  not  hopeless.  Hopeless. 

Tuberculous  disease  of  other  organs  does  Often  does, 
not  follow  as  a  rule. 

[h]  Typhoid  pneumonia  must  be  diagnosed  from  p)neumo-typ1ioid.,  and 
the  blood  in  the  two  conditions  may  be  of  service  in  the  discrimination. 
Leukocytosis  usually  exists  in  pneumonia,  and  there  is  hypoleukocytosis 
in  typhoid ;  but  this  fact  is  only  of  value  when  there  is  marked  increase 
or  decrease  of  the  leukocytes,  since  figures  about  normal  may  occur  in 
either  condition.  In  pneumo-typhoid,  after  the  end  of  the  first  week, 
hoAvever,  undoubted  symptoms  of  typhoid  fever  arise,  and  often  before 
this  period  the  Widal  test  will  clear  the  diagnosis.  On  the  other  hand, 
typhoid  pneumonia  is  characterized  especially  by  great  physical  prostra- 
tion, feeble  heart-action,  and  other  symptoms  of  the  typhoid  state. 

{e)  3Ieningitis  is  sometimes  mistaken  for  pneumonia,  and  particularly 
when  the  latter  occurs  in  children.  The  initial  symptom  of  pneumonia 
in  the  very  young  is  often  a  convulsion  ;  whereas,  though  in  meningitis 
this  symptom  is  not  uncommon,  it  is  more  apt  to  manifest  itself  later. 
When  headache  occurs  in  pneumonia  it  is  frontal.  It  is  almost  invari- 
ably complained  of  in  meningitis,  but  is  occipital,  and  is  associated  with 
rigidity  of  the  cervical  muscles.  Before  the  occurrence  of  pressure- 
symptoms  in  the  latter  disease  the  patient  is  very  restless  and  m-^rose; 
his  reflexes  are  exaggerated  and  there  is  marked  hyperesthesia.  The 
temperature-range  is  lower,  more  irregular,  and  there  is  no  crisis,  while 
the  pulse  is  more  variable  and  often  irregular  in  meningitis.  In  pneu- 
monia with  latent  local  symptoms  the  pulse-respiration  ratio  is  greatly 
altered  and  the  type  of  respiration  peculiar  (vide  ante).  The  important 
rule,  to  examine  for  the  physical  signs  in  doubtful  cases,  must  not  be 
neglected,  and  if  the  subject  be  young  the  apex  region  in  particular. 

The  differential  diagnosis  between  pneumonia  and  broncho-pneumonia 
and  pleurisy  with  effusion  will  be  found  on  pages  558  and  592. 

Prognosis. — The  mortality  from  pneumonia  in  hospitals  averages 
about  25  per  cent.  It  is  less  in  private  practice — about  15  per  cent. 
The  death-rate,  however,  is  greatly  modified  by  the  type  of  the  indi- 
vidual epidemic ;  hence  a  precise  statement  as  to  the  percentage  of 
fatal  cases  cannot  be  ventured.  Wells  collected  22o,730  cases,  which 
gave  a  mortality  of  18.1  per  cent. 

The  elements  that  enter  into  a  correct  prognosis  are  in  the  main 
identical  with  those  in  other  acute  infectious  diseases,  and  concern  (1) 
the  severity  of  the  type  of  infection,  (2)  the  presence  or  absence  of 
complications,  and  (3)  circumstances  peculiar  to  the  individual. 

(1)  Severity  of  the  Type  of  Infection. — In  sthenic  cases  this  is  shown 
by  (a)  the  temperature-range,  (b)  the  degree  of  heart-power,  (c)  the  in- 
tensity of  the  nervous  symptoms,  and  to  some  extent  by  {d)  the  size  of 


LOBAR  PNEUMONIA.  125 

the  area  of  lung-induration.  It  is  a  matter  of  common  observation  that 
the  absence  of  leukocytosis  is  indicative  of  a  grave  type.  In  case  the 
diplococcus  be  found  in  the  blood,  the  prognosis  is  by  most  writers  con- 
sidered grave,  and  it  is  to  be  recollected  that  with  the  improved  tech- 
nique of  the  present  day  this  organism  is  readily  isolated,  (a)  The 
Temperature-ranf/e. — A  continued  high  temperature,  as,  for  example, 
105°  F.  (40.5°  C.),  on  two  or  three  consecutive  di»ys  without  material 
remissions,  is  ominous,  (b)  The  Degree  of  Beari-fowcr. — A  steadily 
rising  pulse-rate  after  the  fifth  day  indicates  real  danger,  since  it  points 
indisputably  to  gradual  cardiac  failure.  The  same  thing  is  shown  by  a 
diminution  in  the  intensity  of  the  second  pulmonary  sound ;  it  indicates 
the  giving  out  of  the  right  ventricle,  {c)  The  Intensify  of  the  Nervous 
Symptoms. — Active  delirium  is  not  favorable  at  any  stage,  and  is  partic- 
ularly unfavorable  if  it  develop  early.  When  it  assumes  the  form  of 
delirium  tremens  the  case  has  usually  passed  beyond  the  hope  of  re- 
covery, {d)  The  Size  of  the  Area  of  Lung-induration. — I  have  observed 
that  extension  of  the  consolidation  at  an  advanced  stage  belongs  to 
serious  types.     The  same  may  be  said  of  double  basic  pneumonias. 

Typhoid  pneumonia.,  being  of  low  type,  gives  an  unfavorable  prog- 
nosis, notwithstanding  an  absence  of  high  temperature  and  of  extensive 
inflammation  of  the  lung-texture. 

(2)  Presence  or  Absence  of  Complications. — Cases  in  which  there  is 
involvement  of  a  single  lobe  or  two  lobes,  if  it  occur  on  the  right  side 
and  without  complications,  generally  terminate  in  recovery.  In  nearly 
one-half  of  the  instances  complications  occur,  and  these  greatly  increase 
the  death-rate.  Among  the  most  common  is  pleurisy.,  which,  unless 
accompanied  by  considerable  effusion,  does  not  add  fresh  danger ;  when 
pleurisy  attacks  the  non-affected  side,  however,  it  does.  Empyema, 
following  pneumonia,  generally  terminates  in  recovery  unless  septic 
phenomena  are  superadded.  Extensive  bronchitis  is  a  most  perilous  com- 
plication in  my  judgment.  Pericarditis  decreases  the  chances  for  re- 
covery, but  by  no  means  to  the  same  extent  as  ulcerative  endocarditis. 
Cardiac  clots  may  form,  but  usually  the  patient  is  already  moribund. 
Abscess  of  the  lung  and  gangrene  form  highly  unfavorable  complications. 
Congestio7i  and  edeina  of  the  uninvaded  portions  of  the  lungs  render  the 
outlook  bad,  and  these,  together  with  cyanosis,  are  apt  to  be  dependent 
upon  failure  of  the  right  heart.  Acute  meningitis  is  exceedingly  grave. 
Fenwick,  as  the  result  of  an  analysis  of  10,000  cases,  found  that  the 
quantity  of  albumin  in  the  urine  is  of  considerable  prognostic  value. 
G-astro-intestinal  complications  occurring  at  the  outset  are  unpropitious. 

(3)  Circumstances  Connected  with  the  Individual. — Of  these  age  heads 
the  list,  and  after  the  twentieth  year  the  mortality  increases  progres- 
sively until  the  seventh  decade,  when  it  rises  more  abruptly.  It  has  been 
claimed  that  nine-tenths  of  the  deaths  after  the  seventy-fifth  year  are 
from  lobar  pneumonia.  Under  the  twentieth  year,  according  to  the 
analysis  of  708  cases  at  St.  Thomas's  Hospital  by  Hadden,  H.  W.  G. 
Mackenzie,  and  W.  W.  Ord,  the  mortality  is  3.7  per  cent. 

Sex  has  little  influence.  Napier's  figures  indicate  that  pneumonia  is 
a  more  deadly  disease  in  men  than  in  women.  The  alcoholic  rarely 
escapes  death,   and  adiposity  is  an  unfavorable  condition. 


126  INFECTIOUS  DISEASES. 

Modes  of  Death. — Death  is  due  to  :  (1)  overwork  or  overdistention 
of  the  right  ventricle ;  (2)  from  niechanical  interference  with  respiration 
(rare) ;  (o)  pneumococcus  infection  of  other  organs,  as  the  meninges, 
pleura,  pericardium,  endocardium ;  (4)  pneumococcus  toxemia  and  sep- 
ticemia as  shown  by  the  typhoid  state,  progressive  lieart  weakness,  tym- 
panites, and  diarrhea ;  (o)  vasomotor  paresis  is  often  the  cause  of  death. 
Treatment. — General  Management. — The  patient  should  be  isolated 
in  a  well-aired  apartment.  Fresh  air  constantly  breathed  improves  the 
appetite,  lessens  cough,  diminishes  the  temperature,  pulse-rate,  and 
respiration-rate ;  in  short,  a  less  marked  toxemia  is  observed  than  in 
patients  treated  by  the  more  usual  method.^  Spolverini  ^  points  out  that 
the  pneumococcus  in  the  sputum  may  remain  virulent  from  fifty-five  to  one 
hundred  and  forty  days,  hence  it  is  important  to  sterilize  pneumonic 
sputum.  An  antiseptic  mouth-wa«h  should  be  advised.  In  severe  forms 
the  constant  presence  of  a  physician  is  required.  The  patient  must  be 
kept  at  perfect  rest,  and  not  allowed  to  leave  his  bed  for  at  least  one  week 
after  the  occurrence  of  the  crisis.  The  beneficial  effects  of  rest,  in  the 
fullest  sense  of  the  term,  are  not  appreciated  to  the  extent  they  deserve. 
Perhaps  the  principal  object  is  to  support  the  powers  of  life  until  the 
crisis  is  passed. 

The  diet  should  be  light,  chiefly  liquid,  but  of  the  most  nutritious 
sort.  3filk  should  constitute  the  chief  article  of  diet ;  meat-broths  or 
meat-juices,  egg-white,  and  light  farinaceous  substances  may  also  be  al- 
lowed. The  food,  particularly  the  milk,  is  to  be  administered  at  stated 
brief  intervals  and  in  definite  quantities.  When  resolution  is  delayed 
stronger  forms  of  nourishment  (scraped  meat,  etc.)  may  be  given.  After 
the  crisis  a  gradual  return  may  be  made  to  the  usual  forms  of  solid 
foods.  Page^  and  others  advocate  abstinence  from  practically  all  nour- 
ishment except  ivater.  Alcohol  has  considerable  food-value ;  it  lessens 
waste  and  improves  the  appetite  and  digestion.  To  accomplish  this  ob- 
ject, it  should  be  given  in  small  amounts,  two  or  three  ounces  daily. 

The  medicinal  treatinent  is  that  of  a  toxemia,  although  the  patient 
himself  is  the  main  factor. 

The  use  of  calomel  in  fractional  doses  or  one  of  the  saline  laxatives 
in  the  early  stage  is  an  important  procedure.  Subsequently  the  liver 
and  bowels  must  be  kept  acting  freely,  so  as  to  eliminate  waste  products 
and  toxins,  and  to  obviate  "absorption  of  fermentative  products  from 
the  alimentary  canal  "  (Thornton).  The  action  of  the  kidneys  is  best 
maintained  by  the  regular  use  of  Avater  and  that  of  the  skin  by  sponge- 
baths.  Stockton  advises  stimulation  of  the  eliminative  organs — skin, 
liver,  kidneys — in  senile  pneumonia. 

Cardiac  stimulants  are  often  indicated.  It  is  well  to  begin  their  use 
as  soon  as  the  slightest  tendency  to  cardiac  failure  is  shown.  AVhen  the 
pulse  becomes  more  accelerated  and  feeble,  the  first  sound  of  the  heart 
less  distinct,  and  the  second  pulmonic  sound  loses  its  accentuated  char- 
acter, or  marked  nervous  symptoms  or  adynamia  appear,  then  alcoholics 
must  be  used.  At  first  they  are  to  be  employed  in  moderate  doses  {^ 
ounce — IG.O — of  whisky  or  brandy  every  three  hours),  to  be  increased 

^  Medical  Record,  1906,.  No.  i,  p.  i,  bv  the  writer. 

2  Centralb.  f.  alhj.  Path.  v.  pathol.  Anal.,  July  18,  1900. 

3  Mediccd  kecord,  Dec.  23,  1905. 


LOBAR  PNEUMONIA.  127 

if  the  effect  be  favorable  proportionate  to  the  urgency  of  the  indication. 
In  the  pneumonia  of  drunkards  its  early  use  is  to  be  recommended. 

If  the  alcoholic  stimulants  fail,  other  cardiants  must  bo  administered 
simultaneously.  Of  these,  strychnin  has  been  the  most  serviceable  in  my 
own  hands,  its  mode  of  administration  foHowing  the  same  rules  as  have 
been  mentioned  for  alcohol — at  first  in  inoderate-sized  doses,  to  be  in- 
creased as  occasion  demands.  Should  urgent  need  of  stimulation  arise, 
strychnin  should  be  exhibited  hypodermically.  It  is  my  custom  in 
desperate  cases  to  use  subcutaneously  as  much  as  gr.  ^  (0.004'3)  every 
two  or  three  hours.  As  soon  as  the  condition  of  the  heart  denotes  resto- 
ration of  cardiac  power  the  size  of  the  dose  is  to  be  reduced.  In  no 
other  disease  do  strychnin  and  alcohol  possess  greater  potency  for  good 
than  in  pneumonia ;  they  lessen  the  depressing  effect  of  the  poison.  For 
sudden  heart-failure  ether,  administered  hypodermically,  is  also  very 
efficacious.  In  severe  forms  of  pneumonia  digitalis  is  invaluable  during 
the  advanced  stages;  it  may  be  given  in  doses  ranging  from  5  to  15 
minims  (0.333—0.666)  of  the  tincture  every  third  hour.  In  cases  in 
which  extreme  cardiac  weakness  with  depression  of  respiratory  forces 
supervenes  the  drug  is  to  be  administered  hypodermically  in  the  same 
dosage.  Strychnin  may  be  combined  with  the  digitalis.  The  effect 
upon  the  pulse  and  heart-sounds  should  be  the  criterion  of  sufficiency. 
Lowenstein  states  that  both  camphor  and  caffein  are  far  superior  to  digi- 
talis. S.  West^  sees  most  benefit  from  caffein  citrate  with  nux  vomica. 
Recent  experience  enables  me  to  speak  strongly  in  favor  of  atropin  ad- 
ministered subcutaneously  in  the  threatened  collapse  that  sometimes  at- 
tends the  crisis.  Nitroglycerin  is  especially  indicated  when  the  renal 
secretion  is  scanty  and  the  urine  contains  more  than  the  usual  trace  of 
albumin.  Ammonium,  adrenalin  chlorid,  and  camphor  (gr.  1  to  2 — 
0.027—0.054)  in  sterile  oil,  hypodermatically,  are  also  excellent  stimu- 
lants to  the  feeble  heart  of  pneumonia. 

Peripheral  stimulants,  such  as  cold  or  heat,  either  locally  or  gen- 
erally, may  be  useful  after  the  blood-pressure  falls.  It  is  claimed  by 
some  that  central  stimulation  to  an  over-acting  heart  may  hasten  exhaus- 
tion rather  than  prevent  the  same. 

Saline  injections  are  valuable  in  overcoming  a  falling  blood-pressure 
with  increasing  toxemia,  for  the  purpose  of  filling  the  vessels.  The  hypo- 
dermic method  of  administration  is  preferable.  From  1  to  2  pints 
(strength  0.7)  may  be  injected,  and  allowed  to  flow  under  the  skin  from 
a  rubber  bag ;  and  this  may  be  repeated  at  intervals  of  eight  hours  if 
necessary.  For  an  acute  exacerbation  of  a  chronic  nephritis  in  the  course 
of  pneumonia,  venesection  with  saline  infusion  is  worthy  of  trial. 

Respiratory  Stimulants. — Beginning  cyanosis  is  the  signal  for  the  use 
of  respiratory  stimulants,  of  which  the  best  are  strychnin  and  atropin, 
and  they  should  be  given  hypodermically.  Oxygen,  if  given  freely,  often 
serves  to  tide  over  periods  of  marked  cyanosis.  The  gas  should  be 
inhaled  directly  from  the  cylinder  until  relief  is  afforded,  when  it  may 
be  allowed  to  escape  near  the  patient's  nose,  so  as  to  become  mixed  with 
air.  Stoker  -  advises  the  continuous  use  of  oxygen  from  the  moment  the 
disease  declares  itself. 

1  British  Medical  Journal,  March  11,  1908. 

'  Medical  Press  and  Circular,  1908,  Ixxxvi.,  90. 


128  INFECTIOUS  DISEASES. 

Hydrotherapy. — In  meeting  high  temperature,  marked  nervous  symp- 
toms, dyspnea,  cardiac  Avoakness,  etc.,  hydrotherapy  offers  many  superior 
advantages.  When  the  temperature  is  high,  ice-hags  over  the  chest  and 
abdomen  are  useful.  Tub-baths  have  been  for  the  most  part  omitted  from 
consideration  in  the  treatment  of  lobar  pneumonia,  rest  being  of  the  great- 
est importance.  Cool  sponging,  combined  with  tlie  ice-cap  or  the  wet  pack, 
serve  as  a  substitute  for  the  full  baths  [vide  Local  Measures  infra). 

Abortive  Method  of  Treatment— Petresco  found  hirge  doses  of  digitalis 
(oj-ij — 8.0  of  the  digitalis  leaves  in  an  infusion  daily)  administered  at 
the  onset  to  jugulate  the  <lisease.  Tlis  experience  covered  1192  cases,  and 
showed  a  mortality  range  of  1.22  to  2.6G  per  cent.  This  plan  of  treatment 
aims  to  meet  the  chief  pathogenic  indication  of  pneumonia  by  passing 
through  the  lung-tissue  an  adecjuate  proportion  of  leukocytes,  and  thus 
re-establishing  the  cardiopulmonary  circulation. 

Venesection. — This  is  a  good  measure  in  sthenic  cases  (which  are  not 
uncommon  in  rural  districts),  the  temperature  falling,  the  pain,  the  dysp- 
nea, and  the  nervous  symptoms  being  relieved  and  the  pulse  softened. 
The  bleeding,  however,  must  be  free  and  rapid.  Later  in  th.e  course  of 
pneumonia  venesection  may  be  resorted  to  if  cyanosis  and  the  signs  of 
collateral  pulmonary  edema — due  to  a  failing  heart — arise,  but  at  this 
period  bleedings  rarely  yield  good,  results,  except  in  vigorous  subjects. 

Antiseptic  Method. — This  method  is  based  upon  etiologic  indications. 
The  best  antiseptics  are  carbolic  acid  (TTlj — 0.066,  every  four  hours), 
thymol  (gr.  ij-iij — 0.129-0.194,  every  four  hours),  mercuric  chlorid 
(gr.  Y^-Q — 0.0006,  every  four  hours).  Creasote  carbonate  has  been 
warmly  advocated  by  Wilcox  and  others,  and  it  merits  a  careful  trial. 
It  is  claiiued  that  this  remedy  aborts  a  large  percentage  of  cases  and 
mitigates  almost  all  the  rest;  it  tends  to  nullify  bacterial  activity,  tlius 
inducing  crisis.  Citric  acid,  given  to  diminish  the  coagulability  of  the 
blood,  has  proven  to  be  a  valuable  remedy. 

Antipneumococcus  Serum  and  Serum  obtained  from  Convalescents. 
— Washbourn,  Pane,  Fanoni,  and  others  have  reported  favorable  results 
from  the  use  of  antipneumococcus  serum.  On  the  other  hand,  many 
clinicians  who  have  employed  the  serum  are  skeptical  as  to  its  thera- 
peutic efficiency.  It  seems  to  possess  considerable  protective  power,  as 
shown  by  the  Klemperer  brothers  {vide  p.  110).  I  have  collected  535 
cases  treated  by  serum  therapy — 61  cases  by  diphtheritic  and  474  by 
antipneumococcic  serum — with  85  deaths,  a  mortality  of  18.8  per  cent.* 
The  results  obtained  by  different  observers  are  variable  and  fail  to 
carry  conviction.  The  use  of  killed  cultivations,  or  "  vaccines,"  are 
found  to  be  useful  (Latham  and  others).  Robertson  and  Illman  used 
bacterins  in  20  cases  with  beneficient  results.  Raw  states  that,  while  not 
a  specific  remedy,  they  ought  ahvays  to  be  used  in  cases  of  a  virulent 
type.     The  estimation  of  the  opsonic  index  is  unnecessary. 

Treatment  of  Special  Symptoms. — The  initial  pain,  w^hen  it  is  of  an 
acute,  agonizing  character,  is  relieved  by  the  hypodermic  use  of  mor- 
phin.  This  counteracts  the  shock  produced  by  the  invasion-period,  but 
it  is  to  be  omitted  if  the  bronchi  contain  secretory  products,  since  mor- 
phin  dries  these  and  favors  their  accumulation  rather  than  their  removal. 
Rarely  is  it  necessary  to  continue  this  remedy  after  the  second  day. 

Fever. — The  fever  of  pneumonia  is  a  temporary  affair,  and  instead 
1  Jour.  Amer.  Med.  Assoc,  Dec.  10,  1904,  p.  1777. 


LOBAR  PNEUMONIA.  129 

of  being  hurtful  may  prove  beneficial,  since  it  furthers  tissue-metabolism, 
and  this  aids  in  the  destruction  of  the  specific  poison  of  the  disease. 
While  it  is  true  that  internal  antipyretics  possess  tlie  power  to  reduce 
temperature,  their  use  is  attended  with  dan<^er  from  their  action  ns  cardiac 
depressants;  if  it  be  true,  as  before  stated,  that  pneumonia  usually  kills 
through  the  heart,  it  follows  that  cardiac  power  must  primarily  be  con- 
served.    I  have  abandoned  their  use.     (See  Hydrotherapy,  p.  128.) 

In  cases  in  which  venesection  is  indicated  the  tinctures  of  veratrum 
viride  and  of  aconite  have  been  much  vaunted  as  substitutes.  The  tinc- 
ture of  veratrum  viride  produces  a  good  effect  upon  the  congestion  in  the 
early  stage,  since  it  relaxes  the  arterial  walls,  and  thus  bleeds  tlie  patient 
into  his  own  vessels,  and  "allows  the  return  of  the  blood  to  the  circula- 
tion when  the  stage  of  consolidation  is  reached  "  (H.  C.  Wood).  It  should 
be  discontinued  after  the  second  day  of  the  illness.  The  tincture  of 
aconite,  owing  to  its  depressing  influence  upon  the  heart,  should  not  be 
employed.  The  alkalies  (e.  c/.,  sodium  carbonate)  are  em.ployed  to  neu- 
tralize the  acid  produced  by  the  causative  bacteria.  The  salts  of  the 
organic  acids  will  serve  the  same  purpose  (Brown)  as  potassium  citrate. 

The  nervous  symptoms  are  successfully  met,  as  a  rule,  by  hydrother- 
apy (including  the  ice-cap),  by  the  arterial  stimulants,  and  by  the  use 
of  morphin,  as  before  recommended. 

Cougli  during  the  early  stage  is  controlled  by  the  morphin  needed  to 
combat  the  pain.  In  the  more  advanced  stages,  if  there  be  present 
numerous  moist  rales  and  a  scanty  expectoration,  stimulant  expecto- 
rants (ammonium  muriate,  terebene)  may  be  employed  with  happy 
effect ;  but  ordinarily  they  do  harm  rather  than  good.  Pilocarpin  may 
aid  resolution  when  this  is  delayed  (Reiss) ;  the  heart  must  be  guarded. 

Complications. — The  management  of  the  complications  does  not  diff'er 
from  that  which  is  appropriate  when  they  occur  as  independent  aff'ec- 
tions,  though  all  depressing  measures  must  be  positively  omitted.  I 
Avould  add  that  in  pleuro-pneumonia  aspiration  is  not  well  borne.  Sup- 
purative arthritis  should  be  treated  by  incision  and  drainage.  Among 
measures  to  prevent  ether-pneumonia,  I  would  urge  an  appropriate  toilet 
(a  thorough  cleansing  followed  by  the  topical  use  of  an  efficient  antiseptic 
solution)  of  the  nasopharynx  and  mouth  as  a  routine  practice.  Pneu- 
monia occurring  in  malarial  subjects  demands  the  use  of  quinin. 

Local  Measures. — When  in  doubt  as  to  whether  venesection  should  be 
employed  or  not,  it  must  be  remembered  that  early  local  bloodletting 
(cupping,  leeching)  is  followed  by  relief  from  pain  and  dyspnea,  but 
that  these  measures  should  be  reserved  only  for  robust  persons.  Coun- 
ter-irritation by  means  of  sinapisms  is  useful  at  the  onset,  and  if  pains 
be  severe,  strapping  the  side  affected  gives  much  comfort.  The  cotton 
jacket  has  cex'tain  advantages  in  maintaining  the  free,  local  action  of  the 
skin.  The  topical  use  of  cold  in  the  form  of  ice-bags  has  been  practised  exten- 
sively by  Lees  of  England  and  Mays  of  America  with  brilliant  success.  Other 
hydriatic  measures,  suggested  by  Baruch,  as  cold  compresses,  wrung  out  of 
water  at  a  temperature  of  60°  F.  (15.5°  C),  and  applied  to  the  anterior 
and  posterior  portions  of  the  chest  (the  edges  overlapping  in  the  axilla), 
give  similarly  good  results.  They  should  be  made  of  several  thicknesses 
of  muslin,  held  together  by  basting,  covered  by  flannel,  and  firmly  secured 
by  safety-pins.     A  reapplication  every  half  hour  or  hour  is  advised. 

9 


130  I^'FECTIOUS  DISEASES. 


Secondary  Pneumonia. 


Pathologfy. — The  lesions  are  identical  in  character  with  those  of 
primary  lobar  pneumonia,  but  the  areas  involved  have  not  always  the 
same  regular  distribution.  Congestion  surrounding  the  hepatized  lung- 
tissue  is  not  infrequently  extensive.  We  see,  post-mortem,  a  tendency 
to  commingling  with  small  areas  of  lobular  pneumonia.  Both  the  strep- 
tococcus and  the  micrococcus  lanceolatus  are  frequently  found  on  micro- 
scopic examination. 

Ktiology. — Most  instances  are  secondary  to  the  acute  infectious 
diseases,  and  it  is  probable  that  the  specific  causes  of  certain  of  the 
latter  (Eberth's  bacillus,  Pfeiffer's  bacillus,  etc.)  have  the  power  to  ex- 
cite the  morbid  changes  of  acute  lobar  pneumonia.  Colon-pneumonia, 
due  to  the  bacillus  coli,  is  the  result  of  hematogenous  infection  either 
from  the  intestinal  or  from  the  urogenital  tract.  In  the  majority  of 
instances,  however,  in  which  this  disease  develops  in  the  course  of  the 
acute  infectious  diseases  the  latter  are  to  be  regarded  as  merely  furnish- 
ing an  opportunity  for  infection  by  the  micrococcus  lanceolatus. 

Symptoms. — The  rational  symptoms  are  often  absent.  Close  ob^ 
servation  may,  however,  detect  more  or  less  dyspnea,  cough,  and  in- 
creased fever,  and  rarely  the  attack  is  heralded  by  a  rigor,  followed  by 
fever,  the  pneumonic  type  of  breathing,  pain,  cough,  and  the  character- 
istic expectoration. 

The  physical  signs,  when  carefully  observed,  usually  serve  to  enlighten 
the  physician  as  to  the  nature  of  the  affection.  Hence  it  is  a  natural 
corollary  that  repeated  physical  examination  is  demanded  in  all  cases  in 
which  there  is  danger  of  intervening  lobar  pneumonia. 

Diagnosis. — This  rests  chiefly  upon  the  physical  signs,  which  are 
the  same  as  in  primary  lobar  pneumonia.  Obviously,  when  the  local 
subjective  symptoms  and  the  characteristic  sputa  are  present  a  correct 
diagnosis  is  easily  made.  The  fact  must  be  emphasized  that  broncho- 
pneumonia arises  in  the  course  of  infectious  diseases  far  more  frequently 
than  does  lobar  pneumonia. 

Prognosis. — The  occurrence  of  lobar  pneumonia  as  an  intercurrent 
affection  adds  greatly  to  the  gravity  of  the  primary  disease.  It  is  espe- 
cially dangerous  when  it  appears  as  a  sequel  during  convalescence  from 
acute  infectious  diseases. 

The  treatment  is  similar  to  that  of  primary  lobar  pneumonia, 
though  lees  satisfactory. 


INFLUENZA. 

[La  Grippe:   Epidemic  Catarrhal  Fever.) 

Definition. — Influenza  is  an  acute  contagious  disease,  probably 
caused  by  the  bacillus  of  Pfeiffer.  Its  chief  symptoms  are  due  to  catarrh 
of  the  respiratory  and  digestive  tracts,  together  with  profound  muscular 
and  nervous  prostration,  and  grave  complications  (especially  pneu- 
monia) often  present  themselves.  The  disease  may  be  endemic,  though 
oftener  it  prevails  in  an  epidemic  or  pandemic  form. 


INFLUENZA.  131 

Historic  Note. — Every  quarter  of  the  globe  has  been  the  scene 

of  visitations  of  epidemic  influenza.  More  rapidly  than  any  otlier  dis- 
ease belonging  to  the  same  class  does  it  traverse  a  region  of  country. 
As  a  rule,  influenza  develops  into  epidemic  proportions  in  the  East, 
whence  it  spreads  with  unparalleled  rapidity  in  a  westerly  direction. 
The  first  epidemic  of  the  disease  in  the  United  States  appeared  in 
1647,  and  was  subsequently  described  ;  and,  though  it  has  since  then 
frequently  prevailed,  the  outbreaks  have  not  observed  any  regular  pe- 
riodicity. The  last  true  pandemic  of  the  affection  originated  in  Bok- 
hara in  May,  1889,  reached  St.  Petersburg  in  the  following  October, 
Paris  in  November,  and  London  in  turn  early  in  December.  In  Amer- 
ica the  cases  began  to  appear  about  the  middle  of  December,  and  rap- 
idly multiplied  into  an  explosive  epidemic,  which  reached  its  maximum 
in  January,  1890.  Influenza  reappeared  in  epidemic  form,  though  less 
extensively,  during  April  and  a  part  of  May,  1891,  and  again  in  a 
briefer  and  lighter  form  in  the  winter  of  1891—92.  During  the  winter 
of  1892—93  only  a  few  sporadic  cases  occurred.  Subsequently,  it  pre- 
vailed in  an  epidemic  form  annually  for  seven  successive  years  in  limited 
sections  of  this  country.  During  the  early  part  of  1901,  and  again  in 
the  winter  of  1902-03.  pandemic  visitations  of  the  disease  occurred  in 
the   United   States. 

Pathology. — There  are  no  special  anatomic  lesions  that  charac- 
terize the  disease.  In  the  rare  instances  in  which  death  occurs  in  uncom- 
plicated cases  the  catarrhal  changes  of  the  respiratory  and  gastro- 
intestinal mucosa  disappear  after  death.  In  the  abdominal  type  of  the 
affection  there  may  be  enlargement  of  the  glands  of  Peyer  and  of  the 
solitary  follicles.  Among  the  fatal  complications  are  pneumonia  (either 
lobular  or  lobar),  serofibrinous  pleurisy,  empyema,  purulent  pericarditis, 
nephritis,  and  rarely  cerebrospinal  meningitis  and  acute  hemorrhagic 
encephalitis.  All  of  these,  however,  may  rarely  be  of  influenzal 
origin. 

Ktiology. — Bacteriology. — Early  in  the  year  1892  Pfeiffer  dis- 
covered the  influenza  bacillus.  It  is  of  about  the  same  breadth  as  the 
bacillus  of  mouth-septicemia,  and  only  one-half  the  length  of  the  latter. 
When  stained  by  the  aid  of  gentle  heat  with  Ziehl's  carbol-fuchsin,  one 
part ;  water,  nine  parts,  or  Loefiler's  methylene-blue,  it  may  be  observed 
as  a  small  dumb-bell,  having  knobbed  ends  connected  by  a  rod-like  shaft. 
These  bacilli  are  obtained  from  the  sputum  and  nasal  secretions.  Pfeiffer 
has  shown  that  they  may  penetrate  the  peribronchial  tissue  and  pass  out 
to  the  pleura.  They  have  also  been  found  in  the  blood  and  other  tissues. 
This  bacillus  can  be  cultivated  only  in  media  containing  hemoglobin,  and 
when  inoculated  into  rabbits  it  causes  symptoms  resembling  those  of 
influenza.  While  the  bacillus  of  Pfeiffer  is  generally  supposed  to  be  the 
sole  pathogenic  agent,  this  has  not  as  yet  been  proved.  The  organism 
probably  causes  an  intoxication  and  not  an  infection.  Influenza  is  a 
common  secondary  infection.,  especially  in  childhood,  and  may  occur  in 
measles,  diphtheria,  scarlet  fever,  and  other  infections. 

Modes  of  Conveyance. — A  specific  germ  that  is  propagated  with  the 
unusual  rapidity  that  marks  the  bacillus  of  Pfeiffer  must  be  air-borne. 


132  ISFECTIOUS  DISEASES. 

Pepper  suggests  that  the  micro-organism  may  be  ahnost  universally 
distributed,  and  that  under  certain  extraordinary  atmospheric  or  telluric 
conditions  it  acquires  a  degree  of  virulence  that  renders  all  subject  to  its 
attack.  Influenza  is  communicable  by  contayion,  and  evidence  is  abun- 
dant to  show  that  it  may  be  transferred  by  fomites.  In  some  epidemics 
the  disease  travels  slowly,  and  follows  principally  the  lines  of  ordinary 
human  and  commercial  intercourse. 

Manner  of  Invasion. — The  contagion  probably  enters  the  sys- 
tem witli  the  inspired  air  through  the  respiratory  tract.  Some  con- 
tend that  the  infection  atrium  is  the  alimentary  canal,  while  others 
believe  that  the  ]irimary  point  of  infection  may  be  the  conjunc- 
tiva. 

Predisposing  Causes. — All  persons  are  liable  to  tlie  contagion.  Af/e 
has  slight  influence,  the  period  of  greatest  susceptibility  being  from  the 
twentieth  to  the  thirtieth  year.  The  very  young  are  lea^Jt  susceptible, 
and  during  an  epidemic  are  apt  to  be  aff"ected  last,  while  old  persons  are 
frequent  sufferers.  Subjects  whose  vitality  is  lowered  by  neuropathic 
heredity  or  chronic  maladies  are  among  the  first  to  suffer  during  an 
epidemic. 

Immunity. — A  primary  attack  of  influenza  does  not  bestow  immu- 
nity, since  relapses  are  very  common,  in  10  per  cent,  of  the  cases 
(Turney).  Many  persons,  too,  suffer  from  the  disease  with  the  reap- 
pearance of  fresh  epidemics,  so  that  two,  three,  four,  or  even  more  attacks 
may  be  observed  in  the  same  individual  (recurrejices).  Recent  investi- 
gations have  shown  that  a  decided  antagonism  exists  between  influenza 
and  malaria.^  Epidemic  influenza  increases  susceptibility  to  pneumonia 
and  probably  also  to  typhoid  fever  and  appendicitis. 

Clinical  History. — General  Symptomatology  and  Course. — The  in- 
cubation period  is  (]uite  brief,  rarely  exceeding  two  or  three  days.  The 
O'iiset  is  generally  sudden,  with  either  a  severe  rigor  or  repeated  slight 
shiverings,  accompanied  by  a  rapid  elevation  of  temperature  which  may 
touch  10-4°  or  105°  F.  (40.5°  C),  intense  headache,  distressing  myalgic 
pains,  and  great  prostration.  The  primary  fever,  however,  varies 
greatly  in  severity,  as  does  also  the  character  of  the  symptoms — both 
local  and  general.  Profound  prostration  characterizes  the  vast  majority 
of  instances  during  the  invasion  period.  Depression  of  spirits,  restless- 
ness, insomnia  (more  rarely  undue  somnolence),  and  frequently  delirium 
are  among  the  prominent  nervous  phenomena. 

Mare  Modes  of  Invasion. — The  infection  may  set  in  (a)  by  vertigo, 
(b)  by  apoplectic  features,  (c)  by  bilious  vomiting,  (d)  by  an  abrupt  and 
profound  prostration.     Nose-bleed  sometimes  occurs. 

The  most  striking  symptom  is  pain,  which  in  many  cases  is  refer- 
able chiefly  to  the  forehead,  temples,  occiput,  eyeballs,  and  root  of  the 
nose.  General  neuro-muscular  pains  are  often  present.  The  principal 
seat  of  the  pain  is  commonly  the  lumbar  spine  (rachialgia).  I  have  fre- 
quently noted  cutaneous  hyperesthesia.  The  pains  may  take  the  form 
of  neuralgia  of  individual  nerves  or  of  pleurodynic  stitches,  or  there  are 

^"A  Statistical  .Study  of  Influenza;  its  Potency  to  Lessen  the  Receptivity  of  tlie 
Body  for  Maliiria,  as  well  a.i  to  Increase  tlie  Receptivity  for  Pneumonia  and,  probably, 
Typhoid  Fever,"  by  the  writer. — Philaddpliia  Hospital  lieporl,  3895,  vol.  iv. 


INFLUENZA.  133 

localized  areas  of  burning,  boring  muscular  pain.  The  temperature 
may,  as  before  intimated,  mount  quite  high  at  the  beginning,  and  if  so 
it  usually  remits  during  the  first  night.  It  subseijuently  pursues  a 
comparatively  low  range.  The  temperature-curve  is  markedly  irregular, 
and  often  terminates  by  an  apparent  crisis.  The  puhe  is  small,  feeble, 
running,  irregular,  and  even  intermittent,  and  I  have  sometimes  ob- 
served it  to  be  unusually  slow.  The  depressing  effects  of  the  poison  upon 
the  heart  often  reach  a  dangerous  degree.  No  leukocytosis  is  present  as 
a  rule.  An  occasional  mild  leukocytosis  (10,000—15,000),  however,  is 
noted  in  uncomplicated  cases.  In  many  cases  dyspnea  is  a  rather  con- 
spicuous symptom,  occurring  independently  of  pulmonary  complications. 
The  same  is  true  of  cyanosis.      Sweating  may  be  troublesome. 

Clinical  Types. — Different  types  have  been  described  based  on  the 
differences  in  the  local  manifestations  and  the  varying  degrees  of 
toxemia.  Influenza  is  remarkably  protean  in  its  features,  and  the 
enumerated  types  quickly  and  frequently  merge  into  one  another. 
(a)  Respiratory  Type. — Local  catarrhal  symptoms  usually  develop  in  the 
course  of  one  or  two  days.  They  are,  as  a  rule,  evidenced  first  by 
a  suffusion  of  the  conjunctivae,  with  excessive  lacrymation,  frequent 
sneezing,  and  slight  pharyngitis.  A  little  later,  in  most  instances, 
hoarseness  and  cough  come  on,  the  latter  being  hard,  racking,  parox- 
ysmal in  character,  and  resembling  whooping-cough.  The  cough  and 
other  local  symptoms  are  due  to  an  intense,  dry  laryngo-tracheal  irritation. 
In  most  instances  the  expectoration  is  scanty,  and  in  these  the  physical 
signs  are  very  generally  negative.  In  a  smaller  proportion  of  the  cases 
there  is  considerable  expectoration,  and  the  physical  signs  of  ordinary 
bronchitis  are  manifested,  (h)  Gfastro-intestinal  Type. — The  catarrhal 
symptoms  may  center  in  the  digestive  system,  most  frequently  in  chil- 
dren. In  such,  vomiting  comes  on  early  and  is  apt  to  be  repeated  at 
longer  or  shorter  intervals.  There  is  diarrhoea,  more  or  less  urgent,  with 
sharp  abdominal  pain,  as  a  rule,  (c)  The  cardiac  group  of  symptoms 
that  occasionally  supervenes  comprises  heart-failure  and  distress,  with  a 
rapid,  feeble  pulse  (a  toxic  form),  (c)  The  nervous  or  typhoid  (toxic) 
type  presents  a  continued  fever,  with  the  signs  of  the  typhoid  state. 
Two  classes  of  nervous  symptoms  are  seen — "comatose  and  delirious" 
(Bury).  Patients  may  be  seized  with  intense  headache,  or  an  epileptic  or 
apoplectic  fit,  or  there  may  be  local  paralysis  or  hemiplegia.  Muscular 
rigidity,  especially  of  the  neck,  is  far  from  uncommon,  (e)  The  7-heu~ 
matoid  type  manifests  itself  by  violent  pains  in  the  muscles  all  over  the 
body.  There  is  no  visible  change  in  either  the  joints  or  the  nerve- 
trunks.  (/)  Huchard  ^  calls  attention  to  apyretic  forms,  in  which  there 
may  be  marked  pulmonary  congestion  or  actual  lobar  pneumonia  without 
fever,  without  expectoration,  and  often  without  cough,  [g)  There  are 
ambulatory  forms  which  are  important  because  they  tend  to  spread  the 
affection.  (Ji)  Franke  describes  a  chronic  form  assuming  the  guise  of 
catarrhal  affections  of  the  respiratory  and  gastro-intestinal  paaeages. 
The  raspberry  tongue  is  characteristic  of  chronic  influenza. 

I/cading  Features  and  Complications. — (1)  Pulmonary. — 
Severe  bronchitis,  particularly  affecting  the  capillary  tubes  and  leading 
to  bronchopneumonia,  is  a  common  and  very  serious  complication.  As  a 
1  Bull  Acad,  de  Med.,  Feb.  17,  1900. 


134  INFECTIOUS  DISEASES. 

secondary  result  we  are  apt  to  observe  the  development  of  collateral  pul- 
monary edema,  "with  its  usual  fatal  termination;  and  while  this  compli- 
cation is  prone  to  develop  in  the  so-called  thoracic  type  of  influenza,  it  is 
by  no  means  limited  to  this  cdass  of  cases.  I  have  observed  broncho- 
pneumonia in  cases  in  which  the  physical  signs  of  bronchitis  were  not 
presented  prior  to  its  onset.  It  may  originate  apparently  in  the  profound 
prostration  of  the  nervous  system — a  condition  which  also  annuls  in 
great  part  the  phagocytic  action  of  the  leukocytes.  As  a  rule,  both 
broncho-  and  croupous  pneumonia  may  be  definitely  traced  to  exposure. 

The  nature  of  the  c<mdition  is  variable,  and  may  at  times  be  ascribed 
to  coyigestive  collapse  and  other  conditions,  rather  than  to  the  ordinary 
type  of  bronchopneumonia.  Congestion  associated  tvith  edema  of  the 
lungs  occurs  as  a  complication  of  influenza.  Enlargement  of  the 
bronchial  glands  may  also  be  noted,  and  the  recognition  of  this  con- 
dition may  be  aided  by  percussion  over  the  upper  four  dorsal  vertebrae, 
where  dulness  will  be  obtained  [vide  Streptococcus-pneumonia,  p.  120). 

Lobar  pneumonia  is  also  a  frequent  and  very  fatal  complication.  It 
may  arise  early  and  in  rare  instances  insidiously,  but  it  is  much  more 
apt  to  manifest  itself  after  influenza  has  about  exhausted  its  force  upon 
the  vital  organs  or  during  the  early  part  of  convalescence.  The  symp- 
toms of  invasion — severe  chill,  high  temperature,  followed  by  the  usual 
])hysical  signs — are  sudden  in  their  onset  and  lead  rapidly  to  an  ex- 
tremely serious  condition.  When  lobar  pneumonia  develops  early  in  the 
course  of  influenza  (a  rare  event),  its  symptoms  are  modified,  the  prelimi- 
nary chill  and  pain  in  the  side  being  often  absent,  and  more  frequently 
still  the  characteristic  crepitant  nile.  Subcrepitant  niles,  however,  are 
audible,  and  the  dyspnea  is  out  of  proportion  to  the  area  of  lung-tissue 
involved.  Most  of  these  features  may  also  be  observed  in  connection 
with  the  pneumonia  that  appears  during  convalescence.  Marked  leuko- 
cytosis is  present  as  a  rule.     (See  Apyretic  Varieties,  p.  133.) 

Plastic  pleurisy  is  commonly  an  associated  condition,  especially  in 
cases  of  lobular  or  lobar  pneumonia.  Other  forms  of  pleurisy  also  occur, 
though  less  frequently  (sero-fibrinous  and  empyema).  Gangrene  and 
abscess  of  the  lungs  may  arise  as  terminal  complications. 

Cardiac  Complications. — Heart-failure  often  manifests  itself,  and  may 
prove  fatal,  though  rarely.  Purulent  pericarditis  is  a  rare  complication, 
and  is  often  secondary  to  pleurisy  or  pneumonia,  while  attacks  of  angina, 
which  usually  interchange  with  simple  weak  heart  (often  associated  with 
arrhythmia),  have  been  noted  in  certain  epidemics  (Curtin  and  Watson). 

Gastro-intestinal  System. — There  may  be  severe  gastro-enteritis  (par- 
ticularly in  children),  with  frequent  vomiting  and  purging  and  abdom- 
inal pains,  and,  more  rarely,  hemorrhages  occur  from  the  stomach  and 
bowel  {vide  Gastro-intestinal  Type).  Catarrhal  jaundice  may  appear. 
Appendicular  inflammation  may  be  induced  by  influenza. 

Nervous  System. — The  most  frequent  symptom  is  perineuritis,  Avhich 
probably  causes  much  of  the  patient's  sufferings.  A  soporose  or  even 
comatose  condition  may  be  observed.  Delirium  of  a  most  active  form 
sometimes  appears,  and  particularly  when  certain  other  complications 
have  arisen  (pneumonia,  pericarditis).  Cerebro-spinal  meningitis  occa- 
sionally occurs.  I  have  observed  symptoms  identical  with  those  of  men- 
ingitis appearing  suddenly,  and  in  the  course  of  a  day  or  two  disappear- 


INFLUENZA.  135 

ing  just  as  suddenly.  In  addition  to  these  syrnptoTDs,  we  should  have  tlie 
existence  of  suppuration  elsewhere  in  the  body  (otitis,  puruh;nt  pericar- 
ditis) or  of  pneumonia.  Davis  holds  that  in  a  large  percentage  (78  per 
cent.)  of  patients  dying  of  influenzal  meningitis,  broncho-pneumonia  oc- 
curs. A  positive  diagnosis  demands  the  finding  of  the  specific  organism 
by  means  of  lumbar  puncture.  Jundell  found  inflnen/a  bacilli  in  about 
10  per  cent,  of  200  cases  in  which  a  symptomatic  diugnosis  liad  been 
made.  Cerebral  abscesses  have  also  been  noted  (Bristowe).  Kerr  has 
reported  disseminated  lesions  of  the  central  nervous  system  following  in- 
fluenza. The  severer  nervous  features  and  complications  are  mostly  ob- 
served in  the  typhoid  type  of  the  disease. 

Grenito-urinary  Tract. — Renal  congestion,  and  even  acute  nephritis, 
may  appear  as  a  complication.  A  case  of  cystitis  with  hematuria  has 
also  been  reported  (Comby  and  Le  Gendre). 

The  diagnosis  of  influenza  except  in  ill-defined,  sporadic  cases 
rarely  presents  difiiculty.  Usuall}'',  the  march  of  the  epidemic,  the  abrupt 
onset,  with  alternating  flashes  of  heat  and  chilliness,  the  brevity  of  the 
febrile  stage,  headache,  sore  eye-balls,  rachialgia,  and  a  prostration  out 
of  proportion  to  the  catarrhal  manifestations,  form  a  conclusive  assem- 
blage of  symptoms.  In  all  cases,  more  particularly  the  obscure  forms,  the 
sputa,  if  there  be  any,  should  be  studied  microscopically.  The  bacillus 
of  Pfeiff'er  may  be  conveniently  stained  with  a  solution  of  fuchsin-rubin 
(gr.  0.01  in  100.0  aqua  destillata).  Franke  invites  attention  to  the  band- 
like redness  of  the  half-arches  as  a  diagnostic  criterion. 

(a)  Olimatic  catarrhal  affections  are  sometimes  hard  to  discriminate 
from  sporadic  cases  of  influenza.  The  former  are  usually  attributed  to 
sudden  and  great  vicissitudes  of  temperature  or  exposure  to  strong  drafts 
of  air,  while  the  latter  come  on  independently  of  such  agencies.  Again, 
in  influenza  the  general  features  (nervous  symptoms  and  debility)  out- 
weigh the  local  (catarrhal  manifestations).  Leiehtenstern  speaks  of 
pseudo-influenza,  or  catarrhal  fever  (influenza  nostras),  believing  that  it 
bears  the  same  relation  to  true  influenza  as  does  cholera  nostras  to  Asiatic 
cholera.     Its  cause  is  unknown. 

(b)  Typhoid  fever  in  its  early  stages  is  often  simulated  by  influenza 
with  intestinal  symptoms.  Influenza,  however,  gives  the  history  of  the 
prevalence  of  an  epidemic,  begins  suddenly,  does  not  show  the  typical 
temperature-curve  of  typhoid,  may  present  splenic  enlargement — but  not 
to  the  same  extent  as  typhoid — has  no  characteristic  eruption,  and  does 
not  give  the  characteristic  sero-reaction.  Again,  the  PfeiS"er  bacillus 
may  be  discovered  in  the  nasal  and  bronchial  secretions  in  influenza. 

(c)  Pneumonia  has  quite  frequently  been  mistaken  for  influenza,  and 
especially  when  the  thoracic  symptoms  in  the  latter  have  been  unusually 
distinct.  As  already  stated,  lobar  pneumonia  may  early  complicate  in- 
fluenza in  rare  instances ;  but  pneumonia  is  generally  unilateral,  while 
the  lung-involvement  in  influenza  is  generally  bilateral.  In  the  fonner 
the  physical  signs  indicative  of  consolidation  are  present ;  in  the  latter 
(unassociated  with  pneumonia)  those  suggestive  of  congestive  edema  (im- 
paired resonance,  stationary  subcrepitant  rales).  The  general  features 
also  present  dissimilarities.  Thus  the  nervous  depression  and  the  my- 
algic  and  neuralgic  pains  are  more  marked  in  influenza,  while  the  pul8«- 
respiration  ratio  is  less  disturbed  than  in  pneumonia. 


136  INFECTIOUS  DISEASES. 

(d)  Cerebrospinal  meningitis  may  manifest  features  that  are  almost 
identical  with  those  characteristic  of  influenza.  Thus  during  certain 
t'pidemics  "grippe"  patients  may  be  stricken  as  by  a  blow;  they  suffer 
from  intense  headache — occipital  and  frontal — racliialgia,  fever  prostra- 
tion, delirium,  and  stiffness  of  the  muscles,  with  slight  retraction  of  the 
head.  There  may  be  convulsions  and  vomiting  at  the  outset.  Here  the 
history  with  reference  to  the  character  of  the  prevailing  epidemic  and 
the  attendant  circumstances  must  be  carefully  considered,  but  an  abso- 
lute diagnosis  is  sometimes  impossible  unless  a  laboratory  investigation 
of  the  discharges  or  lumbar  puncture  be  made. 

(r)  Small-pox,  in  the  pre-emptive  stage,  may  be  confounded  with  in- 
fluenza, but  the  latter  is  soon  diagnosticated  by  (juick  response  to  therapy 
and  sweating,  relieving  the  symptoms  in  twenty-four  to  thirty-six  hours, 
whereas  small-pox  is  resistant  to  all  treatment,  the  appearance  of  the  rash 
only  1)ringing  amelioration  of  the  symptoms. 

Sequelce. — Among  the  sequelae  are  phthisis,  chronic  bronchitis, 
abscess  and  gangrene  of  the  lungs  (the  latter  two  being  rare),  tachy- 
cardia, and  angina  pectoris.  Chronic  gastro-intestinal  catarrh,  chronic 
nephritis,  and  less  frequently  cystitis,  may  also  be  mentioned.  Latent 
forms  of  tuberculosis  and  chronic  nepliritis  are  often  kindled  into  active 
and  progressive  affections  by  intercurrent  influenza. 

Among  nervous  sequelae,  which  are  both  numerous  and  important,  are 
to  be  noted  especially  insomnia,  neuralgia,  migraine,  melancholia,  with 
tendency  to  self-murder,  meningitis,  acute  ascending  myelitis,  peripheral 
neuritis,  and  perineuritis.  The  organs  of  special  sense  manifest  a  great 
variety  of  sequelae,  such  as  otitis  media,  otitis  interna,  mastoid  abscess, 
conjunctivitis,  keratitis,  iritis,  irido-choroiditis,  acute  glaucoma,  etc. 

Prognosis. — The  prognosis  is,  on  the  whole,  good.  Almost  all 
fatalities  are  due  to  complications,  especially  pyieumonia^  and,  less  fre- 
quently, pulmonary  congestion  and  edema,  pleurisy,  pericarditis,  and 
cerebro-spinal  meningitis.      The  comatose  type  is  often  fatal. 

The  circumstances  connected  with  the  individual  case  often  affect  the 
outcome.  Thus  influenza  runs  a  more  severe  course,  and  hence  offers  a 
correspondingly  more  serious  prognosis,  in  those  enfeebled  on  account 
of  previous  chronic  disease  (phthisis,  valvular  disease  of  the  heart, 
emphysema,  nephritis)  and  in  the  young  and  the  old  than  at  other 
periods  of  life.  During  severe  epidemics  of  influenza  the  mortality-list 
in  most  chronic  diseases  is  considerably  augmented.  Though  epidemics 
vary  as  regards  the  mortality,  the  general  average  death-rate  is  a  little 
under  1  per  cent.  In  some  epidemics  it  may  reach  2  per  cent.,  while 
in  others  it  may  be  less  than  |^  of  1  per  cent. 

Duration. — The  duration  of  the  attack  is  brief,  though  subject  to 
variations.  In  mild  forms  it  is  from  two  to  four  days,  in  the  severe 
from  seven  to  ten  days ;  but  complications  and  previous  infirmities  may 
prolong  the  attack.  The  duration  of  ptarticidar  epidemics  rarely  exceeds 
from  four  to  six  weeks.      Convalescence  is  usually  protracted. 

Treatment. — Prophylaxis. — Drugs  which  have  been  counselled  for- 
their  preventive  effect  (quinin,  salicin)  are  devoid  of  value.      Those  who 
are   at  either  extreme  of  life  or  who  are  enfeebled  by  chronic  organic 
disease,  should   be  most  carefully  protected    by  proper  wearing  ap))arel, 
and  should  not  be  carelessly  exposed  to  unfavorable  weather  conditions. 


INFLUENZA.  137 

The  inmates  of  hospitals  and  prisons  have  been  known  to  escape  the 
disease.  Isolation  should,  therefore,  be  carried  out  in  hospitnls,  and,  when- 
ever practicable,  in  private  families,  especially  when  the  disease  appears 
in  households  in  which  there  are  young  children  and  aged  persons.  E. 
W.  White  has  reported  an  epidemic  of  influenza  that  was  successfully 
aborted  by  strict  isolation  of  the  patients.  Disinfection  of  the  catarrhal 
discharges,  particularly  the  bronchial,  which,  as  a  rule,  abound  in  the 
bacilli  of  Pfeiffer,  is  necessary.  I  must  also  insist  upon  disinfection  of 
the  naso-pharynx  and  mouth  cavity. 

Treatment  of  the  Attack. — The  cases  may  be  grouped  under  three 
heads : 

[a)  Mild  or  Rudimentary  Form. — The  cases  belonging  to  this  type  re- 
quire careful  hygienic  management.  However  light  the  attack,  the 
patient  should  remain  in-doors  and,  if  prostrated,  in  bed  for  a  period  of 
two  or  three  days.  The  diet  should  be  light  and  nutritious  (milk,  eggs, 
rice,  gruels,  fresh  vegetables.  Stewed  fruit),  and  cooling  drinks  are  to  be 
preferred  to  hot  ones,  among  the  former  lemonade  or  cold  oatmeal-water 
with  lemon,  and  effervescent  mineral  Avaters  (Apollinaris,  lithia,  Seltzer), 
being  the  best.  The  bow^els  should  be  moved  regularly,  avoiding,  how- 
ever, active  purgation.  The  use  of  light  wines  is  not  objectionable  if 
desired  by  the  patient.  In  all  cases  of  influenza,  even  of  the  mildest 
grade,  I  prescribe  moderate  doses  of  quinin  (gr.iv — 0.2592,  three  or 
four  times  daily),  and  if  there  be  much  headache  combined  with  it,  Dover's 
powder  and  monobromate  of  camphor  (of  the  first  tAvo,  gr.  iij — 0.194, 
each,  and  of  the  last  gr.  j — 0.0648,  in  capsule),  the  dose  to  be  repeated 
at  intervals  of  three  or  four  hours.  To  overcome  the  languor  and  debility 
I  have  found  nothing  so  successful  as  strychnin. 

(5)  Cases  of  Medium  Severity. — General  Management. — This  class  of 
influenza  patients  betake  themselves  to  bed,  and  should  be  kept  there 
till  convalescence  is  well  advanced.  During  the  febrile  period  the  diet 
must  be  light,  liquid,  yet  nutritious,  and  the  food  should  be  given  every 
two  or  three  hours.  Although  the  patient  has  no  desire  for  food,  he 
should  be  urged  to  take  it  regularly.     Moderate  stimulation  is  also  useful. 

The  medicinal  treatment  is,  for  the  most  part,  simple  and  sympto- 
matic. Calomel  in  moderate  doses  (gr.  j  every  third  or  fourth  hour) 
should  be  a  remedy  of  choice  for  a  day  at  least.  An  efiicient  diapho- 
retic, given  within  six  or  eight  hours  from  the  time  of  onset,  may  abort 
the  attack.  The  neuralgia  and  myalgia  may  be  relieved  by  the  use  of 
quinin,  Dover's  powder,  and  ergot ;  but  if  the  pain  be  intense,  mor- 
phin  administered  subcutaneously  may  be  required.  The  temperature 
is  somewhat  reduced  by  these  remedies,  and  especially  by  the  quinin 
and  Dover's  powder,  the  latter  acting  as  a  diaphoretic.  In  addition,  I 
am  in  the  habit  of  ordering  cool  sponge-baths  at  intervals  of  two  or  three 
hours  if  the  temperature  be  about  102°  F.  (38.8°  C).  If  not  controlled 
in  this  manner,  we  may  combine  with  quinin  some  antiseptic,  such  as 
salicylic  acid  or  salol.  I  have  sometimes  found  it  necessary  to  add  to 
the  foregoing  small  doses  of  phenacetin  (gr.  ij — 0.129).  Sleeplessness 
may  demand  hypnotics,  such  as  sulfonal,  chloralamid,  opium,  and 
trional.  It  is  necessary  to  utter  a  warning  against  the  free  use  of  coal- 
tar  products,  since  they  induce  heart-failure. 

The  local  catarrhal  conditions  (coryza,  laryngo-bronchial  irritation. 


138  INFECTIOUS  DISEASES, 

true  bronchitis,  etc.)  must  be  treated  according  to  the  special  indications 
presented  in  individual  cases.  For  the  coryza  inunctions  of  animal  fats 
over  the  forehead  and  bridge  of  the  nose  are  useful.  A  flannel  cap  may- 
be worn  if  agreeable  to  the  patient.  Steam  inhalations  through  the 
nares  and  mouth  often  act  beneficially,  both  upon  the  coryza  and 
laryngo-bronchi'al  irritation.  For  the  latter  common  condition  the  fol- 
lovfing  foi'mula  will  be  found  serviceable : 

^.   Codeinse  sulph.,  gr.  iv  (0.259); 

Aramon.  chloridi,  .^v         (20.0); 

Syr.  prun.  virgin.,  f.^ij      (60.0); 

Spts.  junip.  comp.,      q.  s.  ad  fsiv      (120.0). — M. 
Sig.   One  teaspoonful  every  two  or  three  hours. 

If  this  prescription  fail  to  mitigate  the  cough,  we  may  resort  to  morphin 
hypodermically  in  small  doses.  The  bronchitis  may  sometimes  be  con- 
trolled by  the  use  of  sodium  bcnzoate,  .^ij  (gm.  viij)  in  aq.  month,  pip., 
5iv  (gm.  120),  of  which  a  tablespoonful  may  be  taken  every  two  or  three 
hours.  In  the  later  stages,  particularly  if  bronchitis  be  associated  Avith 
free  secretions,  the  oil  of  eucalyptus  (TTLiij  to  v — 0.199  to  0.333),  in  cap- 
sule, eveiT  four  hours,  has  in  my  experience  proved  useful.  To  obviate 
pulmonary  complications  I  have  found  strychnin  (gr.  -^^ — 0.0021),  com- 
bined with  the  extract  of  gentian  (gr.  j — 0.063),  useful.  Chest-pains 
may  be  relieved  by  the  use  of  turpentine  stupes  and  sinapisms. 

(c)  Severe  Forms. — The  general  management  is  similar  to  that  recom- 
mended in  cases  of  medium  severity,  excepting  that  freer  stimulation  is 
usually  demanded.  The  medicinal  treatment  must  also  be  more  active 
than  in  the  previous  form,  and  often  is  heroic.  Especially  must  quinin 
be  given  and  continued,  since  it  not  only  serves  to  reduce  the  tempera- 
ture somewhat,  but  also  to  sustain  the  vital  forces,  to  control  the  nervous 
symptoms,  and  lessen  the  tendency  to  inflammatory  complications.  Flex- 
ner^  recommends  the  daily  injection  for  three  or  four  days  by  means  of 
lumbar  puncture,  of  the  immune  serum  of  the  influenza  bacillus  in  com- 
plicating meningitis.  Should  there  be  sudden  cardiac  failure,  it  must  be 
promptly  met  by  cardiac  stimulants  (strychnin,  camphor,  ether,  digitalis) 
given  hypodermically.  In  addition  to  alcoholic  stimulants,  the  aromatic 
spirits  of  ammonia  is  usually  borne  well,  and  should  be  administered. 
The  various  inflammatory  complications  must  be  treated  as  under  other 
circumstances. 

The  Convalescence. — The  greatest  injury  to  patients  at  this  period 
comes  from  going  out  too  early.  Usually  the  temperature  is  subnormal 
for  several  days — a  circumstance  due  to  the  weakness  of  the  patient — 
and  so  long  as  this  condition  obtains  the  patient  is  highly  susceptible  to 
a  chill.  Hence  it  is  a  good  rule  not  to  allow  exposure  to  the  external 
atmosphere  until  the  temperature  has  been  normal  for  several  days. 
The  diet  should  now  be  more  liberal,  and  tonics,  such  as  gentian,  iron, 
and  quinin,  may  be  administered  and  continued  until  complete  res- 
toration of  the  patient's  health  has  taken  place.  In  every  way  pos- 
sible exposure  to  reinfection  during  the  period  of  convalescence  is  to  be 
avoided.  The  sequelae  must  be  treated  according  to  general  rules. 
1  Jour.  Amer.  Med.  Assoc,  1911,  Ivii.,  16. 


DENGUE.  139 

DENGUE. 

( Break-bone  I'ever. ) 

Definition. — An  acute  infectious  disease  occurring  epidemically 
in  tropical  and  subtropical  countries.  Its  chief  symptoms  are — a  double 
febrile  paroxysm  (separated  by  an  interval),  arthritic  and  muscular  pains, 
and  a  skin-eruption  in  about  one-half  the  cases. 

Historic  Note. — The  disease  was  prevalent  in  Java  as  early  as 
1779,  in  India  in  1824,  and  later  in  the  West  Indies,  Spain,  and  in 
some  of  the  southern  American  States.  Mild  epidemics  have  visited 
Philadelphia,  New  York,  and  Boston  (during  warm  weather),  but,  as  a 
rule,  it  has  not  traversed  regions  beyond  32°  N.  latitude. 

Its  pathology  has  not  been  studied,  death  being  the  rarest  of  events. 

Htiology. — McLaughlin,  of  Texas,  has  isolated  from  the  blood  and 
cultivated  a  micrococcus.  H.  Graham^  has  discovered  an  ameboid  form 
resembling  the  plasmodium  malarice,  but  having  a  longer  life-cycle. 

Predisposing  Factors. — Its  prevalence  is  favored  by  the  summer  sea- 
son, and  to  a  slight  extent  by  faulty  hygienic  conditions.  On  the  other 
hand,  age,  race,  sex,  and  social  status  are  all  without  effect,  most  persons 
being  susceptible,  a  fact  that  accounts  for  its  marvellously  rapid  diffusion. 
As  a  rule,  susceptibility  is  exhausted  by  one  attack.  The  epidemics 
spread  along  lines  of  travel  by  land  and  sea.  Graham's  experiments  in 
Beirut  indicate  that  dengue  is  not  contagious,  but  culex  fatigans  may 
carry  the  infection  from  one  person  to  another.  Altitude  is  said  to  ex- 
ercise an  inhibitory  influence. 

Clinical  History. — There  is  a  period  of  incubation  that  lasts  from 
one  to  four  days  and  exhibits  no  prodromes. 

Invasion  then  is  abrupt.,  with  a  slight  chill ;  fever  follows,  the  tempera- 
ture reaching  its  maximum— 103°  to  106°  F.  (39.4°  to  41°  C.)  or  over— 
at  the  end  of  the  first  or  on  the  second  day,  and  is  accompanied  by  head- 
ache and  by  muscular  and  arthritic  pains.  The  patient's  sufferings  are 
intense,  the  pains  being  described  as  "breaking" — a  peculiarity  to 
which  the  disease  owes  the  popular  name  of  ^'■break-bone  fever."  The 
painful  joints  are  neither  swollen  nor  tender,  as  a  rule.  Jones  reports 
an  epidemic  in  which  severe  pain  was  absent.  The  respiration  and  pulse 
are  much  quickened ;  there  is  anorexia  and  slight  nausea.  Febrile  albu- 
minuria is  rare,  delirium  and  mental  torpor  also ;  but  prostratioji  may 
become  marked,  and  an  erythematous  eruption  (initial  rash)  commonly 
appears.  DeBrun^  noted  the  symptoms  during  the  epidemic  at  Beirut 
(1892),  and  states  that  the  eruption  is  roseolar,  morbilliform,  scarlatinous, 
or  papular.  He  distinguished  three  groups  of  cases  :  1.  With  high  fever 
and  marked  associated  symptoms,  and  with  eruption.  2.  Fever  absent, 
the  symptoms  mild,  with  eruption.  3.  The  eruption  the  only  symptom. 
The  eruption  may  appear  early,  but  has  no  fixed  time,  is  evanescent  in 
mild  cases,  and  is  never  constant  in  character.  It  is  attended  with 
burning  and  itching,  and  DeBrun  noted  desquamation.  Hemori^hages 
from  the  various  organs  (nose,  gums,  stomach,  bowels,  lungs,  kidneys, 
etc.)  may  occur,  and  reach  even  a  dangerous  extent.  The  lymphatic 
glands  are  often  swollen ;  the  mucosae  of  the  nose  and  throat  are  hyper- 
emic ;  the  eyes  are  congested  and  the  face  flushed.  The  disease  is  char- 
acterized by  well-marked  leukopenia. 

1  Medical  Eecm-d,  Feb.  8,  1902.  2  ^^v.  de  Med.,  No.  6,  1894. 


140  lyFECTIOUS  DISEASES. 

The  initial  fever  lasts  three  or  four  days,  and  ends  ^Yith  a  deep  remis- 
sion accouiiianied  by  sweating.  All  the  symptoms  now  vanish  save  a 
slight  soreness  and  stifi'ness,  but  after  two  or  three  days  the  characteristic 
symptoms  (including  a  roseolar  eruption)  reappear.  This  terminal  erup- 
tion is  rubeolar,  commencing  on  the  palms  and  backs  of  the  hands,  and 
extending  upward.  It  is  circular,  dusky  red,  and  sometimes  slightly 
elevated.  It  extends  quickly  to  other  parts,  being  best  seen  on  the  back, 
chest,  upper  arms,  and  thighs.  The  spots  disappear  on  pressure,  and 
never  or  rarely  become  petechial  (Manson).  The  secoiid  febrile  paroxysm 
is  usually  milder  and  shorter  than  the  first. 

The  duration  of  the  disease  is  from  seven  to  ten  days,  the  attack 
being  followed  by  a  slow  convalescence,  which  may  be  interrupted  by  a 
relapse.  The  slowness  of  the  recovery  is  due  to  persistence  of  the  pains, 
mental  depression,  and  marked  })hysical  prostration. 

Complications. — Meningitis  has  been  rarely  noted.  Convulsions 
sometimes  occur  in  children,  and  severe  catarrhal  inflammations  of  cer- 
tain mucosiie  (bronchial,  gastric)  may  develop.  Insomnia  is  common. 
Hyperpyrexia  and  pericarditis  occur,  though  exceptionally. 

Diagnosis. — The  diagnosis  of  the  epidemic  form  of  the  disease  is  an 
easy  one  after  observation  of  the  first  few  cases,  but  it  is  difficidt  to  dis- 
criminate sporadic  cases  from  rhcumafism.  The  course  of  the  fever, 
however,  diifers  in  the  two  diseases,  while  the  eruption  belongs  to  the 
former  alone.  Influenza  may  reseuible  dengue.  Influenza  occurs  in 
the  cold  season,  and  herpes  is  usually  the  only  eruption  ;  the  joints  are 
rarely  involved ;  there  is  no  recurrence  of  the  fever,  and  serious  compli- 
cations are  more  frequent.  The  discovery  of  the  bacillus  of  influenza  is 
decisive,  and  the  existence  of  an  epidemic  of  either  condition  suggests 
the  true  nature  of  the  disease.  Scarlet  fever  has  an  erythematous  erup- 
tion, but  the  fever  is  continuous,  angina  is  present,  and  the  arthritic 
symptoms  are  wanting.  As  a  rule,  dengue  prevails  only  in  tropical  and 
subtropical  countries. 

Yelloiv  fever  has  been  mistaken  for  dengue,  and  the  two  affections 
may  prevail  together,  as  in  the  Galveston  epidemic  of  18U7.  The  diff'er- 
ential  diagnosis  is  difficult,  as  there  are  points  of  similarity — time  of 
appearance,  geographic  distribution,  and  the  character  of  the  febrile  par- 
oxysm.   To  show  contrast,  howevei',  I  have  arranged  the  following  table: 

Dengue.  Yellow  Fever. 

Affects  all  races.  Foreigners  more  especially. 

Facies  characteristic  ;  face  flushed.  Mucous  membranes  injected. 

Irregular  rise  of  fever,  followed  byre-  The  temperature  rises  regularly.     Dura- 
mission,  then  a  second  moderate  rise.  tion  of  fever  72  hours. 
Duration  5  to  9  days. 

The  pulse  keeps  pace  with  the  fever.  Pulse  falls  while  the  fever  is  rising. 

Eruption  frequent  (terminal  rubeola).  Eruption  quite  rare. 

Vomiting  rare.  Vomiting  frequent. 

Urine  never  contains  albumin  (?).  Urine  early  albuminous. 

Jaundice  absent.  .Jaundice  present  and  early  appearing. 

Hemorrhages  from  mucous  outlets,  gen-  Hemorrhages      common      and     .severe, 
erally  slight,  and  black  vomit  rare.  Black  vomit  an  alarming   symptom. 

Muscular  and  joint  pains  present.  Absent. 

Prognosis  favorable.  Often  fatal. 

Serum-diagnosis  valueless.     There  is  a  Serum-diagnosis  present  in  66  per  cent, 
well-marked  leukopenia.  of  cases;  no  leukopenia. 

Second  attacks  common.  No  second  attacks. 


THE  PLAGUE.  141 

The  prognosis  is,  with  rare  exceptions,  favorable,  dangers  arising 
only  in  the  serious  forms,  jiarticularlj  those  showing  hemorrhages. 

Treatment. — Indications:  (a)  to  harbor  the  patient's  strength,  and 
(h)  to  meet  certain  leading  symptoms.  The  first  is  to  be  met  by  enjoin- 
ing rest  in  bed,  by  a  generous  diet,  and  by  the  use  of  stimulants  and 
tonics  during  convalescence.  The  fever  ujay  demand  treatment,  and 
and  when  this  is  high,  hydrotherapy  is  indicated.  For  the  intolerable 
pains  morphin  is  to  be  administered  hypodermically.  Efforts  to  destroy 
the  culex  fatigans  should  be  instituted.     Isolation  should  be  practised. 


THE  PLAGUE. 

{Bubonic  Plague  ;  Black  Death.) 

Definition. — A  specific  contagious  disease,  occurring  chiefly  in  unsan- 
itary surroundings  and  characterized  by  high  fever  and  cutaneous  symptoms 
(petechige,  etc.).     Its  course  is  severe  and  rapid,  and  it  occurs  in  epidemics. 

Historic  Summary. — An  Oriental  disease,  the  plague,  has  long 
been  endemic  in  certain  portions  of  India.  Most  European  countries  have 
in  the  past  been  visited  by  epidemics  of  the  malady,  and  among  the  most 
famous  was  the  truly  pandemic  prevalence  of  "  black  death  "  in  Europe 
during  the  fourteenth  century.  Another  virulent  outbreak  occurred  in 
London  in  1665,  destroying  more  than  70,000  persons.  In  May,  1894,  a 
severe  epidemic  prevailed  in  Canton  and  Hong-Kong,  to  which  cities  it 
had  been  imported  from  Northern  India.  In  September,  1896,  the 
plague  appeared  in  Bombay  and  the  Bombay  Presidency.  Since  then 
the  plague  has  show^n  periods  of  decrease  followed  by  others  of  decided 
increase,  and  the  total  plague-statistics  for  the  Bombay  Presidency  from 
September,  1896,  to  January  13,  1899,  are  214,197  cases  and  169,240 
deaths.  In  the  autumn  of  1899,  2  cases  Avere  brought  to  the  New  York 
harbor,  and  on  March  6,  1900,  it  appeared  in  the  Chinese  quarters  of 
San  Francisco,  and  31  cases  were  officially  reported  between  that  date 
and  February  13, 1901.  It  has  reached  several  European  ports — Oporto, 
Hamburg,  Glasgow,  London.  W.  J.  Simpson^  has  given  a  graphic  ac- 
count of  the  history  and  distribution  of  the  plague. 

Btiology. — Bacteriology. — During  the  epidemic  at  Hong-Kong,  Kita- 
sato  and  Yersin,  working  independently  (1894),  discovered  the  special  or- 
ganism of  the  plague  (bacillus  pestis  huhonicce).  It  stains  deeply  at  the 
ends,  giving  the  appearance  of  a  pair  of  micrococci,  but  is  really  a  short 
rod-bacillus  with  rounded  ends.  Pure  cultures  can  be  made,  and  when 
animals  (mice,  rats,  guinea-pigs,  rabbits)  are  inoculated  with  these  the 
symptoms  of  the  disease  are  produced. 

Predisposing  Causes. — These  are  (a)  unhygienic  conditions,  and  (h) 
seasons.  Broca  states  that  epidemics  of  pneumonic  plague  occur  in  win- 
ter, and  those  of  bubonic  form  in  summer. 

Inside  the  body  the  bacillus  has  been  found  in  the  lungs  (plague- 
pneumonia — where  it  is  often  combined  with  the  pneumococcus  and 
staphylococcus),  in  the  enlarged  glands,  in  the  pus  from  the  buboes  and 
the  blood.  Outside  the  body,  among  infected  materials  are  dust  from 
sputum,  plague-infected  flies,  fleas,  the  excreta,  food,  and  soil. 
1  ".t  Treatise  on  the  Plague,"  1905. 


142  lyFECTIOUS  DISEASES. 

Modes  of  Transmission  and  Entrance  into  the  Body. — According  to 
Kitasato,  the  bacillus  enters  either  through  the  digestive  (rare)  or  respira- 
tory tract  or  the  skin  (<?.  (/.,  abrasions  of  the  feet).  The  point  of  infec- 
tion is  usually  a  gland  or  group  of  glands  (Flexner)  causing  the  primary 
bubo.  The  bubonic  pest  is  spread  by  two  principal  factors — the  rat  and 
man  (Simond).  "  In  most  outbreaks  of  human  plague  rats  had  the  disease 
both  before  and  during  the  epidemic  (Clemow).  The  rat  is  the  carrier 
from  house  to  house,  although  man  is  the  chief  factor  in  the  spread  of  the 
disease,  the  agent  of  transport  for  long  distances.  Flies,  fleas,  ants,  and 
other  insects  may  act  as  carriers  from  rat  to  man.  The  rat  flea  carries  the 
contagion  from  one  rat  to  another.  Kuttalls  studies  indicate  that  trans- 
mission of  the  poison  by  stinging  insects  is  extremely  rare.  Certain  ani- 
mals besides  rats  (mice,  tarabagans,  dogs,  cats,  rabbits,  pigs,  horses)  may 
become  infected  and  transmit  the  disease  to  healthy  animals.  INIcCoy 
and  others  have  found  the  ])lague  bacillus,  pathogenic  for  rats  and  guinea- 
pigs,  in  the  ground  squirrel.  Yersin  established  the  contagion  of  plague 
by  keeping  inoculated  rats  and  healthy  mice  in  the  same  place  (Payne, 
in  AUbutt's  S^/stem).  The  disease  is  commonly  transmitted  by  foci  of 
the  infection  (houses,  ships),  by  fomites,  and  possibly  by  plague-infected 
food  and  immune  carriers. 

Clinical  History. — Varieties. — The  classification  is  based  on  the 
particular  system  of  the  body  principally  invaded  as  folloAvs  :  (a)  Bubonic 
(glandular);  [b)  septicemic  (circulatory);  (a)  pneumonic.  Formerly  tAvo 
distinct  forms,  (1)  pestis  minor,  or  larval  plague,  and  (2)  pestis  major,  or 
the  severe  epidemic  form,  were  recognized. 

Incubation. — This  lasts  from  two  to  five  or,  rarely,  eight  days.  In 
malignant  epidemics  it  may  be  but  three  or  four  hours.  Prodromatamay 
be  observed  for  from  twelve  to  twenty-four  hours  ;  they  are  intense  head- 
ache, vertigo,  and  an  unsteady  gait.      The  physiognomy  is  stupid. 

(a)  Bubonic  Type. — This  type  corresponds  to  the  so-called  pestis  minor 
(see  ante),  often  a  forerunner  of  severe  epidemics.  It  is  characterized  by 
swelling  of  the  lymphatics,  lasting  about  a  fortnight,  with  slight  general 
disturbance,  as  a  rule.  The  bubonic,  however,  may  merge  into  the  sep- 
ticemic or  pneumonic  forms.  Such  symptoms  as  halting  speech,  stagger- 
ing gait,  great  prostration,  a  peculiar  physiognomy,  and  more  or  less 
lymphatic  involvement  are  common  to  all  varieties. 

{b)  Septicemic  Type. — Invasion  may  be  abrupt ;  less  commonly  it  is 
preceded  by  the  prodromes  mentioned  above  ;  and  rarely,  bilious  vomit- 
ing or  hematemesis  are  the  ushering-in  symptoms.  A  prolonged  rigor  or 
repeated  shiverings  occur.  The  temperature  does  not  rise  to  a  high  level 
(100°  F.),  owing  to  profound  prostration,  and  the  pulse  becomes  rapid 
and  thread-like,  although  variable  in  force  and  character.  Delirium  or 
coma  tends  to  supervene.  Debility  may  now  be  extreme,  and  the  patient 
may  die  in  the  initial  period.  More  commonly  this  threatened  collapse 
is  survived,  and  then  (second  to  the  fifth  day)  the  most  characteristic 
feature  almost  always  appears — secondary  buboes  or  inflammation  of  the 
lymph-glands,  most  commonly  the  inguinal,  but  also  the  axillary  and 
cervical.  The  latter  enlarge  and  are  painful.  Resolution  may  occur,  or 
they  may  remain  unchanged,  particularly  in  fatal  cases.  Suppuration 
may  also  occur,  and  rarely  gangrene,  forming  the  so-called  carbuncle.^ 
Petechiae  and  the  hemorrhagic  diathesis,  as  shown  by  bleedings  from  the 
1  Saunders'  Year-Booh,  1902,  p.  378. 


THE  PLAGUE.  143 

lungs,  stomach,  and  intestines,  arise  in  the  worst  forms.  In  this  variety 
blood  obtained  by  puncture  of  spleen,  liver,  and  other  organs  sliows  the 
microbe  in  pure  culture. 

((?)  Pneumonic  Type. — Pneumonic  plague,  where  primary  localization 
of  the  disease  in  lungs  occurs,  commences  with  a  rigor,  malaise,  head- 
ache, nausea,  vomiting,  and  pains  in  the  limbs.  Fever,  varying  in 
range  from  102°  to  105°  F.,  hurried  breathing  with  oppression,  cough, 
and  blood-tinged  sputum,  soon  appear.  The  physical  signs,  especially 
the  stethosco-pic,  may  be  those  of  bronchopneumonia.  The  local  symp- 
toms grow  worse,  cyanosis,  delirium,  and  later  coma  supervene,  while 
the  heart's  action  fails  and  death  occurs  on  the  third,  fourth,  or  fifth 
day  of  the  illness.  In  cases  which  recover  or  become  more  protracted, 
buboes  may  appear,  and  rarely  these  develop  early  in  plague  pneumonia. 

(t^)  An  intestinal  type,  with  marked  hematemesis,  bloody  diarrhea,  and 
abdominal  pains,  also  occurs. 

(e)  Abortive  Type  {Pestis  Ambulans). — Certain  epidemics  are  distin- 
guishable by  the  larger  proportion  of  mild  cases  (Manson).  The  patient  may 
be  so  little  inconvenienced  as  to  be  able  to  be  about  throughout  the  illness. 

Plague  pneumonia  may  also  be  secondary  to,  or  symptomatic  of,  other 
types,  the  microbe  having  reached  the  lung  metastatically,  or  possibly  has 
been  inhaled  into  the  lungs.  This  form  likewise  simulates  lobular  pneu- 
monia in  its  clinical  features,  and  a  pure  growth  of  the  plague  bacillus 
can  be  obtained  on  making  cultures  from  the  sputum. 

Sequelae. — Paralyses  of  various  kinds,  myocardial  weakness,  and 
recurring  suppuration  of  buboes  are  the  principal  sequels  of  the  disease. 

Relapses  rarely  occur,  and  are  dangerous. 

Diagnosis. — The  diagnosis  can  be  made  with  ease  and  certainty 
when  the  disease  occurs  in  endemic  centers,  but  when  it  occurs  else- 
where its  recognition  offers  some  difficulty.  The  bubonic  type  is  easily 
recognized,  as  a  rule.  On  the  other  hand,  to  differentiate  between  prim- 
ary plague  pneumonia  and  ordinary  lobar  or  bronchopneumonia  is 
puzzling.     A  certain  diagnosis  rests  upon  bacteriologic  evidence  alone. 

Prognosis  and  Mortality. — The  death-rate  is  high,  ranging  from 
40  per  cent,  (rare)  to  80  or  even  90  per  cent.  Among,  favorable  indica- 
tions is  suppuration  of  the  buboes.  On  the  other  hand,  a  rapid  disap- 
pearance of  a  group  of  swollen  glands  is  a  bad  augury.  Additional 
unfavorable  indications  are  plague-pneumonia,  intense  toxic  features, 
with  cardiac  dilatation,  purpuric  spots  ("  tokens"),  and  hemorrhages. 

Treatment. — Prophylaxis. — The  precautions  to  be  taken  by  the 
individual  relate  to  the  abandoning  of  all  unsanitary  habits,  the  isolation 
of  the  sick,  and  the  avoidance  of  prolonged  contact  with  infected  patients 
or  dwellings.  Personal  cleanliness  and  freedom  from  abrasion  of  the 
lower  extremities  are  important  prophylactic  measures  (White).  It 
would  seem  that  doctors  and  even  nurses  and  attendants  in  w^ell-ordered 
and  properly  ventilated  hospitals  rarely  take  the  plague. 

The  prophylaxis  of  the  public  embraces — (a)  Isolation  of  the  sick 
and  thorough  disinfection  of  the  sick-room,  the  bed  and  bed-linen,  the 
vomitus,  and  the  stools.  Kitasato  advocates  steaming  the  bed  at  212° 
F.  (100°  C.)  for  one  hour,  or  exposure  for  a  few  hours  to  sunlight,  and 
the  burning  of  all  infected  articles.  "After  recovery  the  patient  is  to 
be  kept  in  isolation  for  at  least  one  month."  Cases  of  pestis  arnbulans 
must  be  found  and  treated  on  account  of  their  bearing  on  the  spread  of 


144  INFECTIOUS  DISEASES. 

the  graver  tvpe?;.  The  infected  houses  are  to  be  thoroughly  (lisinfected, 
and  a  pure  water-supply  ju'ocured.  [h)  Protective  inoculation  or  treat- 
ment ijv  '•  vaccination  "  ut"  healthy  persons  seems  efficient.  llafFkine' 
states  that  at  llubli  the  difi'erence  in  mortality  of  those  inoculated  and 
of  those  uniuoculated  averaged  from  80  to  90  per  cent.  The  dose  was 
'2.5  c.c.  The  experiments  of  Strong  and  Teague  indicate  that  prophy- 
lactic inoculation  does  not  protect  against  ])neumonic  infection  in  man. 
Calmette  recommends  Yersin's  antiplague  serum  for  prophylactic  pur- 
poses in  preference  to  Haffkines  vaccine.  Strong  advocates  the  injec- 
tion of  attenuated  living  cultures  of  Bacillus  pestis  as  a  method  of  im- 
munization. Buchanan-  advocates  the  keeping  of  cats  to  destroy  the 
root  of  the  trouble — the  rats. 

Treatment  of  the  Attacks. — The  diet  should  be  liquid  and  nourishing, 
while  free  stimulation  is  demanded  from  the  onset.  JJediciues  are  used 
to  combat  symptoms  as  they  arise.  Delirium  and  pain  are  to  be  met  by 
morphin  or  hyoscin,  and  high  temperature  by  hydrotherapy. 

Local  Treatment. — Cantlie  does  not  believe  in  local  measures  before 
suppuration  occurs.  On  the  other  hand,  Nesfield  notes  that  early  incis- 
ion into  a  plague  gland  produces  an  immediate  improvement  in  the 
patient's  condition.^ 

Serum-therapy. — Anti-plague  serum  exercises  a  specific  action  (Yer- 
sin).  Of  26  cases  treated.  2  died — a  mortality  of  7.6  per  cent.  Cal- 
mette^ states  that  serum  injection  provokes  rapid  destruction  of  the 
bacilli  by  phagocytosis.  As  a  curative  dose,  20  c.c.  must  be  injected 
intravenously,  and  repeated  in  twenty-four  hours  if  there  be  fever  still. 
Choksys  concludes  that  in  the  Yersin-Roux  antiplague  serum  we  pos- 
sess an  efficacious  remedy,  especially  if  used  during  the  first  few  or  even 
twenty-four  hours,  serious  complications  being  averted. 


ERYSIPELAS. 

{St.  Anthony  s  Fire.) 

Definition. — A  specific,  acute  contagious  disease,  characterized  by 
a  special  inflammation  of  the  skin  and  subcutaneous  tissues,  with  a  ten- 
dency to  spread,  high  fever,  moderate  prostration,  a  disposition  to  mixed 
infection,  and  an  average  duration  of  fourteen  days.  It  usually  occurs 
as  an  endemic  disease,  though  also  in  epidemic  form. 

Patholog^T-. — Erysipelas  is  a  specific  inflammation  involving  the 
skin,  subcutaneous  and  less  commonly  the  mucous  surfaces.  When 
inflammation  extends  to  the  subcutaneous  connective  tissue  there  follows, 
as  a  rule,  suppuration.  The  specific  cocci  are  found  in  the  superficial 
lymph-vessels  and  spaces  of  the  affected  skin.  Beyond  the  border  of 
the  inflamed  region  they  occupy  chiefly  the  lymph- vessels,  where  they  are 
finally  overpowered  by  the  phagocytic  leukocytes.  Microscopic  examina- 
tion reveals  the  changes  of  simple  inflammation.  Pericarditis,  endocar- 
ditis (rarely  malignant  endocarditis),  pleuritis,  and  nephritis  may  be  noted. 

Ktiology. — Bacteriology. — The  specific  cause  of  the  disease  is  the 
streptocuccus  eryhipclatis  uf  Fehleisen,  which  is  identical  with  the 
ordinary    pus-producing    streptococcus.       Petruschky    has    shown    that 

1  Pnc.  Roy.  Soc,  vol.  Ixv.,  No.  418.  ^British  Med.  Jour.,  May  30,  1908. 

«  I'he  Lancet,  London,  Nov.  4,  1911.  *  Lancet,  1454,  Nov.  17,  1900. 


ERYSIPELAS.  H5 

streptococci  derived  froTn  non-erysipclatous  moibid  processes  in  man 
were  capable  of  producin;^  a  typical  erysipelas.  'J'he  streptococcus  of 
erysipelas  is  a  saprophytic  organism  ;  it  assumes  the  form  of  a  serpent  or 
chain,  is  small,  and  thrives  on  all  kinds  of  culture-media.  Its  favorite 
situations  are  the  lymph-vessels  of  the  skin  and  the  cutaneous  connective 
tissue.  It  is  especially  abundant  near  to  the  advancing  border  of 
the  erysipelatous  area,  but  is  rarely  found  in  the  blood-vessels,  and  in 
blood-serum  it  is  caused  to  disappear  by  the  action  of  the  phagocy- 
tes; yet  in  exceptional  cases  intra-uterine  infection  has  occurred.  (}.  E. 
Pfahler^  found  a  diplococcus  in  8  cases.  Erysipelatous  inflammation  can 
also  be  produced  experimentally  by  the  staphylococcus. 

Predisposing  Causes. — (1)  Season. — In  a  paper  on  "  Seasonal  Influences 
in  Erysipelas,  with  Statistics,"^  I  have  shown,  as  the  result  of  an  analysis 
of  2010  cases  collected  from  diff"erent  sources  that  the  various  seasons  of 
the  year  exercise  a  potent  influence  upon  the  frequency  of  this  aff"ection. 
Thus  month  by  month  the  cases  increase,  in  slightly  varying  ratio,  from 
August  to  April,  the  latter  month  giving  the  greatest  number,  and  then 
there  is  a  rapid  decrease  from  April  to  August,  when  we  find  the  smallest 
number.  Again,  one-half  of  all  the  cases  occur  during  the  months  of 
February,  March,  April,  and  May,  and  15.9  per  cent,  during  the  month 
of  April  alone.  It  was  found  that  a  low  barometer  and  mean  relative 
humidity  invariably  correspond  with  the  annual  period  in  which  the 
greatest  number  of  cases  occur,  and  that  the  highest  percentage  of  rela- 
tive humidity  corresponds  with  the  months  affording  the  fewest  cases. 

(2)  Age. — From  the  notes  of  1894  cases  I  found  that  in  25.8  per  cent; 
the  age  of  the  patient  was  between  twenty  and  thirty  years.  After  fifty 
years  the  cases  decrease  rapidly,  and  more  than  15  per  cent,  occur  before 
the  age  of  twenty.     The  great  liability  of  newly-born  infants  is  well  known. 

(3)  Sex. — This  factor  was  noted  in  1767  cases,  and  a  marked  prepon- 
derance of  the  male  over  the  female  sex  was  noted  (about  3  to  2). 

(4)  Previous  Attacks. — Of  450  cases,  there  had  been  previous  attacks 
m  39  (8.6  per  cent.),  in  one  instance  four,  and  in  another  seven,  while 
second  and  third  recurrences  were  not  uncommon. 

(5)  Family  predisposition  exercises  a  slight  though  decided  influence. 

(6)  Certain  Antecedent  Aflfections. — Dr.  M.  Booth  Miller  examined 
the  history  of  301  cases,  and  found  that  acute  coryza  preceded  the  attack 
in  13  instances.  Slight  lesions  of  the  Schneiderian  mucous  membrane 
may  be  assumed  to  exist  in  such  instances.  That  certain  chronic  diseases 
(chronic  Bright's,  phthisis,  organic  heart  disease,  chronic  alcoholism, 
cirrhosis  of  the  liver)  augment  a  receptivity  to  the  complaint  has  also 
been  brought  to  light  by  my  researches. 

(7)  Slight  Injuries,  Abrasions,  etc. — Erysipelas  will  not  develop  on  a 
surface  which  does  not  present  a  break,  but  with  this  present  may  do  so 
though  the  latter  be  so  trivial  as  to  escape  observation.  Slight  abrasions 
and  fissures,  either  in  the  mucous  membrane  of  the  nose  or  in  the  skin  of 
the  face  or  ear,  as  well  as  all  forms  of  slight  injuries,  are  liable  to  furnish 
a  highway  for  the  organism.  Yet  in  643  out  of  the  2010  cases  men- 
tioned above,  previous  lesions  were  noted  in  but  13.  Women  who  have 
been  recently  delivered  and  persons  subjected  to  sui-gical  operations  are 
peculiarly  liable,  and  any  deep-seated  focus  of  irritation  (necrotic  bone, 
chronic  abscess,  appendicitis)  may  give  rise  to  erysipelas. 

^  PhilcL  Med.  Jour.,  January  13,  1900.  ^  Proc.  of  the  Amer.  Climatalog.  Assoc,  1893^ 

10 


146  lyFECTIOVS  DISEASES. 

(8)  Antihygienic  Surroundings. — These  doubtless  predispose  to  the  affec- 
tion, as  lias  boon  shown  by  tlio  prevalence  of  erysipelas  in  hospitals  and 
institutions  in  Avhich  the  sanitary  arrangements  were  markedly  faulty. 

Jlodes  of  Conveyance  of  the  Contagion. — The  latter  may  be  air-borne 
for  short  distances  at  least.  It  has  been  collected  from  the  air  of  rooms 
and  wards  occupied  by  erysipelas  patients.  It  may  be  transferred  for  a 
longer  or  shorter  distance  by  fomites,  by  instruments,  unclean  hands, 
etc.  The  infecting  microbe  is  inoculated  through  small  and  even  in- 
visible lesions  of  the  skin  about  the  nose  and  mouth  (spontaneous  or  facial 
erysipelas).      It  is  possible  for  intravascular  infection  to  occur. 

Clinical  History. — I  shall  discuss  only  idiopathic  erysipelas,  the 
traumatic  variety  fallmjj  within  the  domain  of  surgical  treatises. 

Incubation. — This  is  somewhat  varied,  though  it  ranges  usually  from 
seven  to  fourteen  days.  The  prodromal  si/mptoms  are.  for  the  most  part, 
general  in  character,  consisting  in  headache,  restlessness,  cough  and  sore 
throat,  anorexia,  and  slight  or  moderate  pyrexia.  These  endure  for  a 
very  variable  period — from  a  few  hours  to  several  days. 

Invasion  Stage. — The  symptoms  are  (1)  local  and  (2)  general. 

(1)  At  first  the  affected  part  feels  hot,  tense,  painful,  and  is  tender  to 
the  touch.  A  circumscribed  area  becomes  red,  swollen,  firm,  and  shining, 
and  simultaneously  the  subjective  symptoms  (pain,  heat,  etc.)  become 
aggravated.  The  point  of  election  is  usually  on  the  nose,  but  it  may  be 
on  the  ear,  the  face,  or  elsewhere  about  the  head.  The  inflamed,  swollen 
zone  spreads,  chiefly  in  the  direction  of  one  or  the  other  side  of  the  head. 
Separating  the  diseased  from  the  unaffected  skin  there  is  a  sharp  line  of 
demarcation — an  elevated  brawny  ridge  ;  this  ridge  presents  a  "  zigzag 
irregularity  of  outline,  like  the  burned  edges  of  a  sheet  of  paper"  (Warren). 
While  the  inflammation  is  advancing  there  may  be  noted,  beyond  the 
border  of  the  latter,  little  red  streaks  and  spots  that  grow  in  area  till  at 
last  they  become  confluent.  Any  natural  prominence  or  fold  in  the  in- 
tegument may  prevent  extension  of  the  inflammation  [e.  g..  nasolabial 
folds).  In  cases  of  average  severity  the  face  is  much  swollen,  the  eyes 
closed  on  account  of  tumefaction  of  the  eyelids,  the  ears  greatly  enlarged 
(better  marked  on  one  side  than  the  other),  the  scalp  swollen  and  tender, 
and  the  facial  lineaments  often  changed  beyond  recognition.  Tenderness 
to  pressure  is  a  constant  feature.  In  a  minority  of  the  cases  the  inflam- 
matory process  extends  from  the  head  to  the  arms,  to  the  trunk,  and  even 
to  the  lower  extremities  {erysipelas  migrans),  and  in  such  instances  the 
face  may  be  healed  while  the  disease  is  yet  extending.  When  the  disease 
is  arrested  the  peripheral  ridge  ceases  to  extend  and  grows  pale. 

The  epidermal  layer  may  become  elevated  over  circumscribed  areas, 
giving  rise  to  larger  or  smaller  vesicles  or  bullae  (erysipelas  vesiculosum). 
Suppuration  may  attack  these  large  vesicles,  whereupon  they  fill  with 
pus  {erysipelas  pustulosum).  From  intense  infiltration  the  part  or  parts 
may  become  gangrenous — erysipelas  gangrcenosum.  Enlargement  of  the 
cerebral  lymph-glands  is  common.  Desquamation  follows  erysipelas, 
and  the  complexion  is  more  delicate  than  before  the  attack. 

(2)  Ckneral  Symptoms. — With  the  onset  of  the  attack  the  patient  is 
seized  with  repeated  fits  of  chilliness ;  less  commonly,  a  severe  rigor 
occurs.     Immediately,  and  more  rapidly  than  before,  the  temperature 


ERYSIPELAS.  147 

rises  to  a  height  of  104°  or  105°  F.  (40°-40.5°  C.)  on  the  evening  of 
the  first  day.  As  a  rule,  the  temperature  reaches  its  niaxiniurn  (10.5'^  to 
107°  F. — 40.5°  to  41.6°  C.)  on  the  third  evening.  Marked  nocturnal 
remissions  of  temperature  (2°  to  5°  F. — 1.1°  to  2.7°  C)  after  a  few 
days  of  continued  fever  are  the  rule.  At  the  end  of  a  week  the  tempera- 
ture declines  rapidly  to  normal,  /.  e.,  by  crisis.  Sometimes,  however,  the 
course  of  the  fever  is  prolonged  and  defervescence  may  he  less  critical 
(lysis).  In  erysipelas  migrans  a  long  and  decidedly  irregular  tempera- 
ture-curve is  presented,  and  the  same  remark  applies  Avhen  complications 
are  present.  Czyhlarz*  reports  29  afebrile  erysipelas  cases,  all  in  women. 
The  pulse  is  frequent,  of  good  volume,  and  soft.  I  have  been  able  to 
confirm  the  observations  of  Da  Costa,  Striimpell,  and  others,  that  the 
cutaneous  inflammation  in  erysipelas  may  advance  to  a  slight  extent  even 
after  the  temperature  has  returned  to  the  normal  grade. 

The  tongue  is  furred,  the  anorexia  intensified,  and  nausea  and  vomit- 
ing occur.  The  bowels  are  usually  constipated,  though  I  have  observed 
instances  in  which  marked  diarrhea  developed  at  a  late  stage.  The 
inflammation  may  extend  to  the  mucous  membrane  of  the  throat  and 
larynx,  causing  swelling  and  edema  of  the  parts.  It  may  also  involve 
the  serous  membranes,  though  rarely.  The  nervous  symptovis  are  intense 
headache  and  restlessness,  with  some  mental  aberration  at  night.  Actual 
nocturnal  delirium  appears  in  the  severer  forms,  and  in  drunkards  de- 
lirium tremens  may  suddenly  develop.  The  urine  presents  the  usual 
febrile  characters.  Commonly  it  contains  a  little  albumin,  and  rarely 
acute  nephritis  occurs  as  a  complication.  Urobilinuria,  the  expression 
of  an  acute  parenchymatous  hepatitis,  was  present  in  9  cases  reported 
by  Hildebrandt.  A  polymorphonuclear  leukocytosis,  parallel  with  the 
severity  of  the  infection,  occurs  in  erysipelas.  The  blood,  however,  must 
come  from  the  warmed  finger  (Chantemesse  and  Ray^). 

There  is  a  direct  correspondence  between  the  intensity  of  the  local 
and  constitutional  disturbances  in  this  disease.  Often  in  severe  forms 
(such  as  are  apt  to  arise  in  old,  much  enfeebled,  or  intemperate  persons) 
of  facial  erysipelas  the  typhoid  (adynamic)  condition  is  developed. 

Complications  and  Varieties. — An  analysis  of  1674  cases  of 
erysipelas  with  particular  reference  to  complications  gave  an  interesting 
series  of  results.  Some  are  given  here  in  the  order  of  frequency  of  oc- 
currence :  Abscess,  105  ;  rheumatism,  20 ;  delirium  tremens,  10  ;  lobar 
pneumonia,  active  delirium,  phlebitis,  pleurisy,  each  7  ;  acute  nephritis, 
6  ;  synovitis  and  diarrhea,  each  5 ;  tonsillitis,  3 ;  catarrhal  pneumonia, 
otitis  media,  edema  of  the  larynx,  acute  bronchitis,  each  2}  Some  of 
these  conditions  are  septic  in  nature  and  due  to  the  primary  infection. 

The  fact  that  acute  articular  rheumatism  is  a  relatively  frequent  com- 
plication of  erysipelas  is  worthy  of  special  notice,  for  the  reason  that  the 
attention  of  the  profession  has  not  hitherto  been  called  to  it.  The  symp- 
toms of  rheumatism  usually  come  on  several  days  after  the  onset  of  ery- 
sipelas. In  a  few  instances  pneumonia  appeared  early,  being  due  most 
probably  to  special  localizations  of  the  specific  streptococcus.     To  such 

1  Berliner  klinische  JVochenschrift,  Sept.  11,  1911. 
^  Presse  mSd.  Jn\j  I,  1899  ;  Saunders'  Year  Book  for  1901. 

'"The  Complicating  Cbnclitions,  Associated  Diseases,  and  Mortality-rate  in  Erysip- 
elas," by  the  author:  The  Int.  Med.  Mag.  for  Oct.,  1893. 


148  INFECTIOUS  DISEASES. 

cases  the  term  "  pneumo-erysipeliis  "  may  be  appropriately  ajjplied.  The 
cases — '1  ill  number — in  Avhieh  acute  nepliritis  developed  during  the  first 
few  days  of  the  attack  should  in  like  manner  be  termed  "  nephro-erysipe- 
la*;."     Meninijitis  was  present  in  a  single  instance  only. 

Three  other  forms — namely,  fhlegmonous  or  cellulo-eutaneous,  rela/>s- 
ing  erysipelas,  and  erysipelas  neonatorum — should  be  mentioned.  The 
first  exhibits  an  inflammation  of  the  subcutaneous  tissue,  which  tends  to 
suppurate.  Relapsing  erysipelas  constitutes  the  chronic  form  of  the  dis- 
ease, recurring  at  intervals,  and  usually  in  the  same  locality.  It  is  com- 
monly due  to  some  deep-seated  focus  of  suppuration.  Erysipelas  neona- 
torum is  the  result  of  infection  of  the  stump  of  the  umbilical  cord.  From 
the  navel  the  inflammation  spreads  to  the  thighs  and  genitals.  As  a  rule, 
there  is  fever,  followed  in  a  few  days  by  fatal  collapse. 

Sequelae. — The  hair  often  falls,  but  it  is  usually  replaced  by  a  fresh 
crop.  Otitis  media  and  chronic  nephritis  may  date  from  an  attack  of 
erysipelas.  Per  contra^  erysipelas  is  reputed  to  be  curative  of  certain 
afi"ections  (eczema,  lupus,  carcinoma,  sarcoma). 

Out  of  476  cases  collected  by  me  relapses  occurred  in  54  (11.3  per 
cent.),  and   in   1    of  these  instances  5  relapses  occurred;   in  2  others,  4.* 

The  diagnosis  is  made  with  ease  after  the  eruption  has  fully  devel- 
oped, and  its  appearance,  seat,  and  behavior,  particularly  the  manner 
of  extension  of  the  brawny,  ridge-like  edge  (best  marked  on  the  fore- 
head), are  the  features  that  distinguish  it  from  every  other  disease.  A 
bacteriologic  diagnosis  is  often  possible,  the  streptococcus  being  found 
in  the  pus  and  secretions  from  the  naso-pharynx. 

Differential  Diagnosis. — Erythema  produces  superficial  redness,  but 
is  not  attended  with  heat,  swelling,  or  fever.  Urticaria  assumes  the 
form  of  pale-red  circular  wheals,  which  cause  marked  itching  and 
appear  in  successive  crops,  often  disappearing  in  the  course  of  a  few 
hours.  Acute  eczema  of  the  face,  when  intense,  may  resemble  erysipe- 
las ;  but  it  lacks  the  peculiar  border  and  mode  of  progression  so  charac- 
teristic of  the  latter  disease.  Again,  eczema  produces  troublesome  itch- 
ing, and  the  swelling  is  less  than  in  erysipelas.  Chronic  erythematous 
eczema  is  met  with  later  in  life,  is  without  fever,  without  any  considerable 
swelling  or  pain,  and  excites  intense  itching.  Eczema  nodosum  is  char- 
acterized by  its  nodosities  near  the  joints. 

Course  and  Duration. — In  my  own  experience,  based  upon  1880 
cases, ^  the  average  duration  (including  the  prodromal  stage  and  period 
of  convalescence)  in  persons  under  forty  years  of  age  is  fourteen  days. 
The  course  of  the  disease  is  much  lengthened  by  complications,  the  pre- 
existence  of  chronic  affections,  and  by  age  (after  the  fiftieth  year). 

The  prognosis  is  favorable,  and  it  is  rare  for  erysipelas  to  assume  a 
malignant  type.  Perhaps  the  chief  dangers  lie  in  certain  complications, 
especially  extensive  suppuration,  pneumonia,  acute  nephritis,  delirium 
tremens,  etc.  Acute  articular  rheumatism  is  comparatively  harmless ; 
but  previous  debility,  especially  if  dependent  upon  chronic  diseases,  as 
syphilis,  chronic  rheuuiatisra,  gout,  tuberculosis,  organic  disease  of  the 
heart,  and  the  like,  increases  the  percentage  of  deaths  considerably. 
Again,  age  has  a  positive  influence  upon  the  mortality,  which  it  augments 
moderately  after  the  forty-fifth  year,  and  most  decidedly  after  the  sixtieth 

^  Journal  of  the  Ameri/-an  Medical  Association,  .July  2-,  189.3,  by  the  writer. 
2  "  Points  in  the  Etiology  and  Clinical  History  of  Erysipelas,"  by  the  writer:  Journal 
of  the  Am.  Med.  Assoc,  July  22,  1893. 


ERYSIPELAS.  149 

year.  Of  2663  deaths  duo  to  erysipcdas  (United  States  Census  Jleport), 
the  death-rate  per  1()0,0()0  inhabitants  was  as  follows:  under  5  years, 
31.34 ;  5  to  15  years,  0.81  ;  15  to  45  years,  2.80 ;  45  to  65  years,  8.88; 
65  and  over,  38.55  (Wm.  L.  llodrnan).     Death  is  due  to  exhaustion. 

The  mortality-rate  is  low,  as  shown  by  the  results  of  my  own  collective 
investigations  into  the  subject.  I  found  the  general  average  death-rate 
to  be  5.6  per  cent.,  while  in  cases  from  private  practice  it  was  4  per  cent. 
In  persons  over  seventy  years  it  was  46  per  cent.  The  traumatic  cases 
gave  a  mortality  of  14.5  per  cent. 

Treatment. — The  treatment  of  erysipelas  falls  naturally  into  four 
subdivisions:  {1) Dietetic;  {'I)  Constitutional ;  (S) Local;  {^)Proj)hylactic. 

(1)  Dietetic, — Proper  attention  to  the  diet  is  of  the  first  importance.  It 
must  be  generous  and  composed  of  highly  nutritious  articles,  and  if  the 
temperature  be  high,  only  liquid  forms  of  nourishment  should  be  admin- 
istered in  definite  quantities  and  at  stated,  brief  intervals.  Rectal 
alimentation  should  be  resorted  to  if  the  stomach  rejects  a  suitable  diet- 
ary. Lack  of  attention  to  the  patient's  diet  during  the  primary  attack 
tends  to  increase  the  frequency  of  relapse.  In  persons  over  fifty  years 
of  age,  and  in  those  in  whom  the  vital  processes  have  been  lowered  on 
account  of  previous  chronic  diseases,  correct  alimenation  is  of  paramount 
importance,  often  abridging  the  course  of  the  afi"ection. 

(2)  Constitutional  Treatment. — When,  despite  an  appropriate  diet,  the 
pulse  becomes  very  rapid  and  feeble,  the  heart's  first  sound  indistinct,  and 
the  tongue  dry,  indications  for  the  use  of  stimulants  exist.  Alcohol  may 
be  given  with  a  comparatively  free  hand,  12  to  16  ounces  (360.0-480.0) 
of  whisky  daily  in  divided  portions.  Strychnin  gives  prompt  results, 
and  digitalis  may  be  used  in  severe  cases.  In  marked  gastric  irritability 
champagne  is  to  be  preferred.  The  eliminative  organs,  especially  the 
kidneys,  are  to  be  stimulated,  so  as  to  rid  the  economy  of  the  bacillary 
toxins. 

The  tincture  of  the  chlorid  of  iron  was  first  extensively  used  in  this 
disease  by  English  authorities,  and  was  formerly  regarded  by  most  clin- 
icians as  a  truly  specific  remedy.  In  74  cases  of  erysipelas  which  were 
treated  by  this  remedy  alone,  the  average  quantity  being  1  dram  (4.0)  daily 
in  divided  doses,  in  the  Pennsylvania  Hospital  by  Drs.  Lewis,  DaCosta, 
Longstreth,  Meigs,  and  others,  the  death-rate  was  4  per  cent.^  Other 
preparations  of  iron,  however,  are  equally  efficacious.  Quinin  is  a  valu- 
able remedy  in  erysipelas,  and  during  the  past  twelve  years  I  have  em- 
ployed it  in  not  less  than  30  cases,  confining  its  use  to  instances  in  which 
the  temperature  touched  103°  F.  (39.4°  C),  and,  with  a  single  exception, 
in  uncomplicated  cases  (22  in  number)  the  nocturnal  remissions  were  de- 
cidedly greater.  In  every  instance  iron  in  ^ome  form  was  administered 
simultaneously.     Numerous  antiseptic  remedies  have  been  recommended. 

Antistreptococcus  Serum. — Andrd,  Robinson,  Cox,  Anderson,  and 
others  have  reported  instances  of  its  successful  use.  The  serum  is 
injected  subcutaneously ;  its  influence  endures  over  several  days,  but  it  is 
important  that  the  injections  are  repeated  at  forty-eight-hour  intervals. 
Marmorek's  serum  (care  being  taken  that  it  is  not  too  old)  is  to  be  pre- 
ferred. G.  H.  Sherman  reports  uniformly  good  results  from  the  use  of 
stock  vaccines  (streptococcic),  especially  when  used  early  in  the  course  of 
the  disease.  The  dose  is  20,000,000  for  the  adult,  and  where  local  im- 
^  "  The  Treatment  of  Erysipelas,"  by  the  writer,  Therapeutic  Gazette,  July  16,  1S94. 


150  INFECTIOUS  DISEASES. 

provement  with  the  rctluctioii  of  teiiipevaturc  does  not  occur,  this  should 
be  repeated  at  the  end  of  twenty-four  liours. 

Certain  si/)npto)n8  demand  internal  medication.  When  the  fever  is 
high,  its  reduction  is  best  accomplished  by  means  of  cold  spongings  com- 
bined -with  the  ice-cap,  or  cold  or  gradually  cofded  baths.  Guaiacol  applied 
externally  has  recently  been  employed  for  the  same  purpose. 

For  nvirked  nervous  phenomena,  such  as  pain,  sleeplessness,  and  active 
delirium,  hyosein  hydrobromate  (gr.  ^H — ().0()06)  has  been  tried  hypo- 
dermically  at  the  Medieo-Chirurgical,  Pennsylvania,  and  Philadelphia 
hospitals,  and  has  given  promise  of  being  a  valuable  remedy.  It  should 
not  be  employed  when  the  heart-power  is  deficient.  For  the  same  indi- 
cation we  may  utilize  the  following :  Sodium  bromid,  gr.  v  (0.324)  every 
two  houi-s,  or  gr.  xx-xxx  (1.296-1.944)  at  night;  morphin,  gr.  ^  (0.008). 
and  chloral,  gr.  x  (0.648),  in  combination  every  half-hour  for  three  doses; 
potassium  bromid,  gr.  x  (0.646),  and  tincture  of  cannabis  indica,  TTtx 
(0.666),  in  combination,  and  morphin,  gr.  -^  (0.0108),  hypodermically. 

The  treatment  of  the  various  complications  must  be  conducted  in 
accordance  with  general  principles  applicable  to  each. 

3.  Local  measures  have  always  held  a  prominent  place  in  the  treatment 
of  erysipelas.  In  my  paper  previously  cited  those  most  frequently  used 
were  elm  (37  cases) ;  lead-water  and  laudanum  (20  cases)  ;  carbolic  acid 
(1  :  40),  injected  subcutaneously  (18  cases) :  zinc  oxid  (14  cases) ;  mer- 
curic chlorid  solution  (14  cases) ;  ichthyol  ointment  with  lanolin  (8  cases), 
etc.     P.  Ph.  Smolitcheff,^ 

!^.  Tr.  iodi,  25.0  grams ; 

01.  camphor, 

Ichthyoli,  da  12.5  grams. — M. 

Sig.  For  external  use.  Shake  before  applying. 

Many  of  these  preparations  were  prescribed  for  their  eifect  in  excluding 
the  air — a  leading  indication.  This  I  am  in  the  habit  of  meeting  by  the 
use  of  carbolized  vaselin  or  cool  carbolized  oil.  IchthyolcoUodion 
(strength  10  to  50  per  cent.),  painted  over  the  erysipelatous  area  and 
also  over  the  surrounding  healthy  skin  for  2  or  3  cm,  has  been  advocated. 

Tucker^  recommends  the  application  of  a  saturated  solution  of  mag- 
nesium sulphate  in  water.  This  is  applied  in  facial  cases  on  a  mask  con- 
sisting of  from  fifteen  to  twenty  thicknesses  of  ordinary  gauze,  of  suffi- 
cient size  to  extend  beyond  the  area  involved,  with  a  small  opening  to 
permit  breathing,  but  none  for  the  eyes.  After  thorough  saturation  with 
the  solution,  the  mask  is  applied  and  covered  with  oiled  silk  or  wax 
paper ;  it  is  wetted  often  enough  to  assure  a  moist  dressing — usually 
every  second  hour.  The  dressing  should  not  be  removed  oftener  than 
once  in  twelve  hours  to  permit  an  inspection  of  the  parts. 

A  knowledge  of  the  microbic  nature  of  erysipelas  has  led  to  the  local 
application  of  numerous  antiseptic  remedies.  Mention  has  been  made  of 
the  method  of  injecting  carbolic  acid.  Here  the  aim  is  to  check  the 
spread  of  the  inflammatory  process  by  inserting  the  needle  at  numerous 
points  just  beyond  the  inflamed  border.  The  method  (introduced  by 
Heuter)  has  been  much  practised  by  Henry  at  the  Philadelphia  Hospital, 
and  is  especially  applicable  in  erysipelas  migrans.  In  the  statistics  before 
given  a  solution  of  mercuric   chlorid  (1  :  4000)  was  used  locally  in  14 

1  Medical  News,  Nov.  14, 1903.  '  Therapeutic  Gazette,  June  15,  1908. 


DrPIITHERIA.  151 

instances,  to  which  I  can  add  the  results  of  12  others  at  the  Medico- 
Chirurgical  Hospital  and  in  private  practice.  In  a  few  cases  it  was 
injected  beneath  the  skin,  as  in  the  case  of  the  carbolic  acid.  More 
recently  it  has  been  recommended  to  scarify  the  affected  part  and  follow 
with  the  application  of  a  solution  of  mercuric  chlorid.  In  view  of  the 
fact  that  the  streptococcus  is  found  chiefly  in  the  more  superficial  chan- 
nels of  the  corium,  it  follows  that  it  may  be  attacked  directly  by  the 
mercuric  chlorid  solution  when  the  latter  is  used  after  scarification  ;  and 
this  method  of  treatment  is  at  once  most  promising  and  rational.  G.  L. 
Curtis  ^  advises  sodium  sulphate,  which  acts  by  depriving  the  germs  of 
oxygen,  as  a  local  application.  MacLennan  advocates  a  saturated  solution 
of  picric  acid  as  a  local  remedy. 

(4)  Prophylaxis  embraces  isolation  and  care  of  the  skin  of  the  whole 
body.  Bathing  with  a  boric-acid  wash  (3  per  cent.),  at  intervals  of 
several  hours,  so  as  to  disinfect  the  desquamating  epidermis,  removes  a 
source  of  danger.  It  is  probable  that  relapses  are  sometimes  due  to 
autoinfection.  Frequent  change  of  the  body-linen  is  to  be  advised  and 
removal  to  another  room  during  convalescence  may  prevent  a  relapse. 
Admission  of  erysipelatous  patients  to  hospitals  should  be  refused, 
except  such  institutions  be  provided  with  an  isolation  building. 


DIPHTHERIA. 

{Diphtheritis  ;  Angina  Maligna ;   Croup.) 

Definition. — xln  acute,  contagious  disease  caused  by  the  Klebs- 
Loffler  bacillus,  and  characterized,  anatomically,  by  a  croupous-diph- 
theritic  faucitis,  less  commonly  rhinitis  and  laryngitis.  Clinically,  it  is 
characterized  by  irregular  fever,  prostration,  and  albuminuria ;  also  by 
the  secondary  development  of  toxemia,  and  often  cardiac  failure.  It  is 
commonly  followed  by  peculiar  paralyses.  In  large  municipalities  it 
behaves  endemically,  and  from  time  to  time  epidemically.  The  disease, 
however,  is  less  prevalent  than  formerly. 

Pseudo-diphtheria. — There  are  forms  of  inflammation  occurring  most 
frequently  in  the  pharynx  and  adjacent  air-passages  (and  also  in  many 
other  parts  of  the  body)  that  are  attended  with  the  formation  of  a 
pseudo-membrane,  and  are  not  caused  by  the  Klebs-Loffler  bacillus. 
These  cases  have  been  studied  exhaustively  by  Prudden  and  others,  who 
have  usually  found  the  streptococcus.  The  latter,  however,  has  been 
found  in  the  inflamed  mucous  surfaces  met  with  in  erysipelas,  scarlatina, 
and  measles.     Vincent's  angina  is  a  form  of  pseudodiphtheria. 

Pathology. — The  true  diphtheritic  inflammation  has  for  its  chief 
pathologic  peculiarity  the  production  of  a  fibrinous  exudate.  When  the 
inflammation  is  superficial  and  of  a  mild  grade,  a  croupous  membrane  is 
produced  which  can  be  easily  removed  from  the  mucosa,  which  it  covers. 
In  the  severer  types  of  the  aff"ection,  however,  the  fibrinous  membrane 
infiltrates  all  the  layers  of  the  mucosa,  which  undergoes  necrosis  more  or 
less  nearly  complete.  In  the  severest  forms  the  submucous  layer  may 
also  become  necrotic.  It  is  to  be  borne  in  mind  that  the  production  of 
the  fibrinous  exudate  in  diphtheria  is  always  preceded  by  coagulation- 
1  Med.  Record,  April  20.  1901. 


152  INFECTIOUS  DISEASES. 

necrosis  of  the  epitholhim.  The  membrane-formation  is  accompanied  by 
changes  in  the  underlying  tissue  which  represent  a  combination  of  degen- 
eration and  exudation  (Councilman.  Mallory,  and  Pearce).  The  mucous 
membrane  surrounding  the  exudate  is  hy))eremic,  more  or  less  edematous, 
and  the  seat  of  muco-purulent  secretions. 

The  Pseudo-membrane. — Its  composition  comprises  fibrin,  pus,  disin- 
tegrated leukocytes,  flakes  of  necrosed  epithelium,  bacilli,  and  sometimes 
red  blood-corpuscles.  The  fibrin  has  two  main  sources :  (a)  '*  The 
fibrinogen  of  the  inflaunnatory  matter."  which  transudes  through  the 
capillary  walls;  and  {b)  Disintegrated,  migratory  leukocytes,  which  form 
branching  fibrillae.  Weigert  holds  that  the  inflammatory  exudation  is 
coagulated  by  a  ferment  derived  from  the  disintegrated  leukocytes. 

The  Klebs-Loffler  bacilli  are  found  in  the  meshes  of  the  fibrilhe,  in 
the  granular  fibrin,  and  on  the  adjacent  mucous  membrane;  they  are 
never  found  ffrowinsr  in  living  tissue,  but  always  in  necrotic  tissue.  Fre- 
quently  other  micro-organisms  are  associated  (streptococci,  staphylococci, 
etc.).  The  membrane  presents  a  grayish-white  color ;  it  is  thick,  firm, 
and  adherent,  so  that  its  removal  entire  cannot  be  effected  without  great 
diflSculty,  and  without,  as  a  rule,  injury  to  the  surface,  as  shown  by  bleed- 
ing, etc.  The  character  of  the  pseudo-membrane  is  affected  by  the 
nature  of  the  underlying  structure  ;  thus  in  the  pharynx  it  is  firmer  and 
less  easily  separable  than  in  the  larynx  and  trachea,  where  a  distinct 
basement-membrane  is  found  (Flexner).  As  the  membrane  becomes  older 
its  color  is  apt  to  grow  darker,  becoming  yellow  or  even  dark  brown.  It 
sometimes  becomes  gangrenous,  and  softens  or  disintegrates,  with  the 
production  of  a  very  offensive  brownish,  semiliquid  excretion.  The 
advancing  edge  of  the  false  membrane  is  usually  thin.  On  the  other 
hand,  when  the  process  has  become  arrested  the  edge  is  apt  to  look  raised 
or  wrinkled,  and  later  it  may  be  distinctly  curled  up. 

The  membrane  may  extend  downward  into  the  ramifications  of  the 
bronchi.  In  such  cases  there  is  apt  to  be  a  lobular  pneumonia,  but  the 
lung  may  be  invaded  by  the  bacillus  without  any  clinical  indications. 
Lung-infection,  due  to  the  streptococci  and  (less  commonly)  the  pneumo- 
cocci,  is  common.  A  generalized  bronchitis  extending  to  the  smaller 
bronchi  is  common  from  the  irritation  of  aspirated  substances.  In  rare  cases 
the  membrane  has  spread  into  the  esophagus  and  even  into  the  stomach. 

After  separation  of  a  croupous  membrane  repair  consists  merely  in  a 
restoration  of  the  epithelial  layer — a  process  which  is  initiated  by  the 
fragments  of  epithelium  that  remain  along  the  edges  of  the  diseased 
area,  and  proceeds  centrally.  On  the  other  hand,  in  true  diphtheria, 
with  necrosis  (more  or  less  complete)  of  the  mucosa,  sloughing  occurs,  and 
the  missing  structures  are  replaced  by  cicatricial  tissues. 

The  Heart. — The  muscular  structure  and  the  nervous  mechanism 
suffer  most.  The  histologic  changes  may  be  of  the  parenchymatous  va- 
riety, but  only  in  mild  instances ;  whereas  in  severer  cases  fatty  degen- 
eration is  conspicuous.  In  still  other  cases  the  chief  pathologic  charac- 
teristic is  an  interstitial  myocarditis,  and  rarely  the  lesions  of  peri- 
carditis and  endocarditis  have  been  noted.  The  heart  is  by  no  means 
always  involved. 

The  spleen  is  commonly  enlarged,  though  not  to  an  excessive  degree. 
The  blood  is  dark,  its  coagulability  is  greatly  diminished,  and  Canon  and 
Frosch  have  in  a  few  cases  found  the  bacilli  in  the  blood  of  those  dying 


DIPIITIJERTA.  163 

of  diphtheria.  The  red  corpuscles  are  somewhat  decreased  in  number 
during  the  course  of  the  disease,  whikj  the  white  corpuscles  are  increased. 
Bouchut  and  Dulinsay  consider  the  grade  of  leukocytosis  of  prognostic 
value,  and  claim  that  it  varies  directly  with  the  severity.  Grawitz  has 
determined  in  numerous  cases  a  higher  specific  gravity  of  the  blood 
during  diphtheria.  The  lymphatic  glands  of  the  neck  become  swollen,  as 
a  rule,  and  are  often  greatly  enlarged,  but  they  show  little  tendency  to 
suppurate.  In  pronouncedly  septic  cases  in  which  a  mixed  infection  is 
found  by  culture  a  good  deal  of  tumefaction  of  tbe  neck  occurs,  this 
sometimes  even  obliterating  the  normal  contour  from  jaw  to  clavicle. 

The  Kidneys. — The  kidneys  show  degenerative  changes,  the  usual 
kidney-lesion  being  a  hyperemic  swelling  with  edema  of  the  interstitial 
tissues,  and  often  hemorrhagic  spots  in  the  cortex.  Sometimes  there  is 
a  marked  glomerulo-nephritis,  and  rarely  a  diffuse  granular  degeneration 
of  the  epithelium.  Minute  areas  of  necrosis  have  been  observed  in  the 
internal  organs,  in  which  fibrin  has  been  found  deposited  (Oertel).  Welch 
and  Flexner  have  produced,  by  artificial  inoculation  upon  guinea-pigs, 
kittens,  and  rabbits,  foci  of  cell-death  in  the  lymph-glands  throughout 
the  body,  in  the  spleen,  liver,  lungs,  heart,  and  intestinal  mucosa.  When 
the  dose  is  small  and  the  animal  lives  several  weeks,  paralysis  may  develop. 

The  nerves,  in  cases  of  paralysis,  have  shown  parenchymatous  and 
interstitial  inflammatory  lesions.  In  paralysis  of  throat-muscles  (i.  g., 
those  near  the  locality  of  the  pseudo-membranous  inflammation)  the  latter 
show  also  round-cell  infiltration  and  fatty  degeneration  of  the  fibers.  The 
nerve-fibers  of  the  central  nervous  system  may  also  show  fatty  degener- 
ative changes.  In  fatal  cases  lesions  have  been  found  to  engage  either 
the  meninges,  the  cerebro-spinal  substance,  or  the  nerves. 

l^tiology. — True  diphtheria  is  caused  by  the  Klebs-Loffler  bacillus, 
and  all  cases  of  supposed  diphtheria  in  which  the  bacillus  is  absent  are 
to  be  regarded  as  non-diphtheritic.  The  etiologic  is,  therefore,  quite  dif- 
ferent from  the  pathologic  significance  of  this  term.  Recent  researches  have 
removed  all  doubt  as  to  the  specific  nature  of  the  Klebs-Loffler  bacillus. 

Bacteriology. — The  bacillus  diphtherias  nearly  equals  in  length  that 
of  the  bacillus  tuberculosis,  and  is  twice  the  diameter  of  the  latter.  It 
has  rounded  extremities,  which  are  also  frequently  bulbous,  giving  it  the 
appearance  of  a  dumb-bell.  At  times  one  end  only  is  clubbed,  or, 
more  rarely,  one  or  both  ends  appear  pointed.  The  bacilli  are  immobile, 
do  not  form  spores,  and  stain  readily,  the  best  agent  being  alkaline 
methyl-blue.  Their  manner  of  taking  the  stain  is  important.  The 
bacilli  show  alternating  segments  of  darker  and  lighter  stained  areas. 
and  often  minute  dots  showing  a  most  intense  and  deep  staining.  They 
grow  on  most  culture-media,  but  for  clinical  purposes  Loffler's  blood- 
serum  is  important  (3  parts  blood-serum  and  1  part  neutral  or  slightly 
alkaline  nutritive  bouillon,  containing  1  per  cent,  of  glucose).  Inocu- 
lated on  this,  they  outgrow  all  other  organisms  that  may  be  present,  and 
within  eight  hours  or  less  show  numerous  spots,  one-half  to  one  millimeter 
in  diameter,  which  have  a  dull  surface  and  a  dense  white  or  somewhat 
yellowish  color.  There  are  usually  present  also  smaller  points  which 
have  different  appearances  and  which  are  colonies  of  other  organisms. 
The  former  are  the  colonies  of  the  bacillus  diphtherise,  and  from  these 
microscopic  preparations  and  (by  further  cultivation)  pure  cultures  can 
be  obtained.      The  bacilli  are  semi-anaerobic,  and  thrive  at  the  temper- 


154  INFECTIOUS  DISEASES. 

ature  of  the  human  body  ;  a  temperature  of  122°-136.5°  F.  (50°- 
58°  C.)  causes  their  destruction  in  ten  minutes. 

Pseudo-diphtheria  Bacillus  or  Bacillus  Xerosis. — From  many  cases, 
often  showinj];  no  lesions,  an  organism  may  be  obtained  that  is  identical  in 
appearance,  manner  of  culture,  growth,  etc.  with  the  bacillus  diphtheritie, 
but  inoculation  with  it  causes  no  lesions.  The  works  of  Abbott,  Roux, 
Yersin,  and  others  seem  to  show  that  this  is  an  attenuated  form  of  the 
true  bacillus,  and  varying  grades  of  pathogenicity  may  be  found  between 
the  two.  The  distinction  from  the  pathogenic  bacillus  can  only  be  made 
by  determining  the  lack  of  infection  after  inoculation. 

Site  of  Infection. — In  the  human  family  the  seat  of  election  of  the 
bacillus  diphtheriiB  is  usually  the  faucial  mucosa,  and  less  frequently 
other  mucous  surfaces  and  abraded  skin.  The  bacilli  do  not  penetrate 
the  mucosa,  and  hence  do  not  find  their  way  into  the  lymphatic  or  cir- 
culatory system,  but  remain  at  or  very  near  the  site  of  the  local  changes. 

The  Toxins. — Toxins  are  absorbed  from  the  diseased  spots  by  the 
lymphatics  and  blood-vessels,  and  produce  the  general  phenomena  in  un- 
complicated cases.  They  have  been  isolated  from  artificial  cultivations 
of  the  microbe,  and  when  inoculated  the  chief  ptomain  of  the  Klebs- 
LoflBer  bacillus  so  modifies  the  solids  and  liquids  of  the  body  as  to  render 
the  subject  immune  (Behring).  Another,  however,  if  employed  in  like 
manner,  produces  dangerous  and  even  fatal  symptoms  (convulsions, 
paralysis,  etc.). 

It  is  certain  that  the  bacillus  can  maintain  an  existence  for  months 
outside  of  the  body,  though  its  usual  habitat  is  unknown  unless  it  be 
the  organic  constituents  of  the  superficial  soil.  The  virulence  of  its 
products  is  modified  by  many  individual  conditions,  and  chief  among 
these  is  a  healthy  and  intact  condition  of  the  mucous  membranes,  which 
greatly  reduces  the  susceptibility  to  the  disease. 

Associated  Microbes. — With  the  Klebs-Ldffler  bacillus  are  frequently 
found  other  microbes,  especially  streptococci  and  staphylococci.  These 
pass  beyond  the  site  of  local  infection,  reaching  the  internal  viscera  and 
other  structures,  and,  as  will  be  seen  hereafter,  give  rise  to  the  serious 
septic  element  of  the  disease.  VY.  Bloch  and  P.  Sommerfield,^  in  studies 
on  the  pathogenicity  of  the  Lbffler  bacillus,  have  verified  the  accepted 
statement  with  reference  to  the  germ,  their  article  being  a  good  exposi- 
tion of  the  present  status  of  the  bacteriology  of  diphtheria.  From  a 
study  of  436  cases,  the  authors  state  that  the  Loftier  bacillus  was  never 
found  in  culture,  but  always  associated  with  other  bacteria,  among  which 
streptococci  played  the  greatest  part.  The  two  doctrines  concerning  the 
relation  of  streptococci  to  septic  diphtheria  are  given,  the  one  being 
that  the  streptococci  increase  the  virulence  of  the  diphtheria  bacillus 
and  cause  sepsis  by  gaining  access  to  the  circulation  ;  the  other  is  that 
the  diphtheria  toxin,  l)y  its  eff"ect  on  the  organism,  prepares  the  way  for 
an  invasion  by  streptococci.     The  pneumococcus  ma\'  be  found. 

Modes  of  Infection. — When  the  bacillus  leaves  tlie  body  of  the  sick 
it  is  contained  in  particles  or  shreds  of  the  diphtheritic  membrane  or  in 
the  expired  air.  Infection  may  then  occur  (a)  By  direct  contact  with  the 
shreds  of  membrane  thrown  oft" — e.  g.,  when  the  latter  are  ejected  by 
coughing  and  lodge  upon  the  conjunctivae  or  faucial  mucosa  of  bystand- 
ers. The  deadly  poison  is  sometimes  transferred  to  the  physician  and 
•  Arch.  J.  Kinder.,  Bd.  li.,  Ileft  2. 


DIPITTTTERTA.  155 

attendants,  with  resulting  infection,  from  the  sucking  of  tracheotomy 
tubes,  (h)  By  inhaling  the.  air  surrounding  tlie  patient  (contagion).  In- 
fection by  contagion,  however,  does  not  extend  beyond  a  radius  of  a  few 
feet  from  the  patient,  (c)  A  very  leading  matter  of  conveyance  of  the 
bacillus  from  the  sick  to  the  healthy  is  by  fofnifes.  The  contagion  ad- 
heres tenaciously  to  a  great  variety  of  objects  (toys,  clothing,  library 
books,  letters,  slates  and  drinking-cnps  in  the  public  schools,  etc.),  iind 
in  this  way  the  germs  of  diphtlieria  have  been  transferred  over  great  dis- 
tances and  have  given  rise  to  the  disease  long  after.  The  latter  fact  ren- 
ders it  difficult  to  trace  certain  cases  to  previous  ones,  to  which  they  in- 
variably owe  their  origin,  (d)  Sewer  gas^  per  se,  is  to  he  regarded  as 
non-pathogenic,  or  at  least  so  far  as  this  affection  is  concerned  (Laws). 
It  may,  however,  become  a  carrier  of  diphtheritic  poison,  (e)  ]Joni.ei>tic 
animals  may  be  occasional  carriers,  especially  cats.  (/)  Tlie  disease  is 
kept  alive  in  a  community  largely  by  virulent  organisms  in  immune  per- 
sons ("  healthy  carriers" — 13.3  percent. — Sobernheim).  Rarely,  "latent 
carriers,"  who  conceal  the  bacillus  for  a  time  before  they  show  the  clini- 
cal evidences  of  diphtheria,  may  convey  the  disease. 

Our  knowledge  as  to  how  the  infection  occurs  is  incomplete.  \Ve 
know  definitely  the  usual  point  of  local  infection  in  man,  and  also  that  a 
catarrhal  mucosa  or  an  open  lesion  of  a  mucous  surface  invites  infection. 
It  is  not  certain,  however,  that  even  a  slight  lesion  of  the  mucous  surface 
is  essential  to  infection.  Some  writers  claim  still  that  the  Klebs-Loffler 
bacillus  may  enter  the  blood  through  the  respiratory  system  and  give  rise 
to  primary  constitutional  symptoms,  the  local  manifestations  in  the  throat 
being  secondary. 

Predisposing  Factors. — (1)  Age. — This  is  the  most  important  factor, 
diphtheria  being,  in  the  main,  a  disease  of  childhood.  Most  cases  occur 
between  the  second  and  seventh  years,  while  the  receptivity  diminishes 
rapidly  after  the  tenth  year.  Instances  have,  however,  been  observed 
up  to  the  fiftieth  or  even  the  sixtieth  year.  During  the  first  year  of 
life  also  it  is  rare.  (2)  Sex. — This  is  without  appreciable  influence. 
(3)  Season. — Cases  are  more  numerous  in  winter  and  spring  than  at  other 
seasons.  (4)  Climate. — Diphtheria  is  met  with  less  frequently  in  tropical 
than  in  temperate  and  cold  climates.  Humidity  favors  the  propagation 
of  the  diphtheria  germ,  and  hence  damp  cellars  also  promote  the  spread 
of  the  disease.  (5)  Unhygienic  Conditions. — Unfavorable  sanitary  sur- 
roundings tend  to  lower  vital.ity,  thus  increasing  the  susceptibility  to  the 
specific  virus.  Most  epidemic  outbreaks  have  held  more  or  less  intimate 
relationship  with  decomposing  organic  matter,  defective  drainage  and 
sewage,  cesspools,  etc.,  though  it  is  to  be  especially  remembered  that  the 
disease  often  prevails  in  sparsely-settled  rural  districts. 

Immunity. — A  single  attack  does  not  confer  perfect  immunity. 
Second  and  third  attacks  not  infrequently  occur  in  the  same  individual. 

Symptoms. — Incubation. — The  duration  of  this  period  is  from  two 
to  seven  or  ten  days,  and  in  a  small  percentage  of  the  cases  it  may  be 
longer.  In  virulent  epidemics  and  when  the  disease  is  produced  experi- 
mentally the  incubation-stage  is  short — from  twelve  hours  to  two  or 
three  days.  The  prodromal  indications  of  diphtheria  are  not  strikingly 
characteristic.  They  may  either  be  acute  in  character  or  very  mild ; 
but  usually  the  child  will  complain  of  feeling  weary  and  indisposed  to 


156  lyFECTious  DrsEASf:s. 

plav.  of  sensations  of  chilliness,  and  of  ))ain  in  the  head,  back,  and  limbs. 
In  youn>:  children  the  onset  of  diphtheria  may  be  marked  bv  connihions. 
There  is  nothinij  in  this  early  stage  of  the  disease  to  distinguish  it  from 
simple  ])haryngitis  or  tonsillitis.  There  may  be  some  fever,  not  very 
high — an  elevation  of  one  or  two  degrees  at  most.  The  urine  contains  a 
small  amount  of  albumin.  R.  Koch  found  diphtheria  bacilli  in  the  urine 
of  2  out  of  26  diphtheria  patients.  The  child  often  complains  of  discom- 
fort in  swallowing,  and  on  examination  the  fauces  will  be  found  to  be  red- 
dened, and  in  a  short  time  the  exudate  will  be  found  on  the  tonsils  or 
soft  ]ialatc.      This  is  tlic  usual  type  of  simple  tonsillar  diphtheria. 

Pharyngeal  Diphtheria. — The  symptoms  are  nsuallj  slower  of  develop- 
ment  than  in  tonsillitis.  The  child  is  sluggish,  looks  heavy-e3^ed.  languid, 
and  pale  for  several  days.  The  fever  may  not  rise  above  101°  or  102° 
F.  (38.8°  C.)..  On  examining  the  throat,  however,  it  is  found  to  be 
swollen  and  red,  and  if  Uvidity  is  more  pronounced  than  the  swelling, 
it  suggests  the  true  nature  of  the  disease.  The  membrane  begins  on 
the  tonsils  in  the  form  of  small  patches  of  yellow  exudate,  resembling  the 
thick,  cheesy  plugs  of  inspissated  dead  epithelium  and  secretion  which 
issue  from  the  mouths  of  the  follicles  of  the  tonsils  during  the  course  of 
acute  or  chronic  tonsillitis.  Quite  early  this  exudate  is  easily  removable. 
The  membrane  spreads  from  the  tonsils  to  the  soft  palate  and  half  arches 
within  a  few  days,  and  it  may  also  appear  on  the  pharyngeal  wall.  During 
this  stage  the  throat  may  become  much  swollen  and  the  tonsils  greatly 
enlarged,  frequently  meeting  in  the  median  line.  The  glands  immedi- 
ately beneath  the  angle  of  the  lower  jaw  on  one  or  usually  both  sides 
become  hard,  painful,  and  slightly  enlarged;  the  swelling  of  these  glands 
is  not  great  in  mild  forms,  although  their  presence,  in  association  Avith 
the  foregoing  symptoms,  is  an  almost  infallible  indication  of  the  disease. 
The  child,  as  a  rule,  shows  grave  constitutional  symptoms  for  a  few  days 
and  albuminuria  is  present.  Acetonuria  is  common  in  the  severer  forms 
of  the  disease.  The  temperature  is  not  characteristic,  as  a  rule  not  being 
high,  and  the  pulse  is  rapid  and  weak,  being  out  of  proportion  to  the 
general  indications  of  the  disease.  The  blood-pressure  is  below  normal 
in  about  one-third  of  the  cases  (Rolleston),  and  the  degrees  of  depression 
bear  a  direct  relation  to  the  severity  of  the  infection.  In  mild  cases  the 
symptoms  abate  by  the  end  of  the  first  week,  and  the  pseudo-membrane 
separates,  leaving  a  red,  inflamed  surface  behind.  The  child  is  pros- 
trated for  a  number  of  weeks,  and  in  abo.ut  20  per  cent,  of  the  cases 
neuritis,  with  its  accompanying  paralysis,  occurs.  Simple  leukocytosis 
is  present  in  diphtheria,  although  this  symptom  may  be  absent  in  mild 
cases. 

Variations  in  3Ianifestation. — Diphtheria  may  exhibit  variations  as 
regards  the  s6at  of  attack  and  the  severity  of  the  poisoning.  In  some 
epidemics  the  Klebs-Loffler  bacillus  seems  to  be  more  active,  or  more 
virulent,  than  in  others.  The  severity  of  the  attack  does  not  seem  to 
depend  on  the  amount  of  the  pseudo-membrane,  but  rather,  according  to 
Rotch,  upon  three  factors  :  (1)  the  virulence  of  the  bacteria  ;  (2)  the  local 
resistance  ;  and  (.3)  the  general  resistance.  The  mucous  membrane  of 
any  part  of  the  body  (lips,  tongue,  conjunct! vib,  vulva,  or  glans  penis) 
may  be  the  seat  of  the  membranous  growth. 

Malignant  Diphtheria. — The  symptoms  are  severe  from  the  com- 
mencement.     There  are  one  or  at  most  two  days  of  slight  illness,  and 


DIPHTHERIA.  157 

then  alarming  symptoms  manifest  tlicmselves,  cardiac  failure  possibly 
setting  in  without  a  specially  severe  local  lesion.  Vomitinf^  and  hujh 
fever,  resembling  tbe  onset  of  scarlet  fever,  may  initiate  the  attack  ; 
and  within  a  few  hours  we  may  find  extensive  swelling  at  the  angles  of 
the  jaws,  of  stony  hardness,  an  offensive  bloody  discharge  coming  from 
the  nostrils,  accompanied  with  difficulty  in  opening  the  mouth.  If  the 
throat  is  examined,  there  will  be  found  extensive  swelling  of  the  tonsils, 
even  to  meeting,  the  uvula  and  soft  palate  being  edematous  and  covei'ed 
with  much  sloughy-looking  membrane.  The  temperature  in  severe  cases 
soon  reaches  a  point  between  103°  and  104°  F.  (40°  C),  while  the  heart- 
beats become  exceedingly  feeble.  In  a  day  or  two  the  cellulitis  extends, 
the  face  becomes  edematous,  the  skin  pits  all  over  the  face,  neck,  sternum, 
and  chest-walls.  The  patient  becomes  drowsy,  cyanotic,  and  an  erythem- 
atous rash  may  appear  about  the  face,  neck,  and  chest,  while  a  purpuric 
rash  is  not  infrequent.  Death  occurs  in  such  cases  within  one  week  from 
toxemia.  Cases  of  diphtheria  septicemia  have  been  recorded  in  the  liter- 
ature by  Mahler^  and  others. 

Nasal  Diphtheria. — In  all  severe  cases  of  pharyngeal  diphtheria  the 
inflammatory  process  is  likely  to  extend  to  the  nasal  mucous  membrane. 
In  some  cases  the  nasal  mucous  membrane  is  found  to  be  the  first  in- 
volved ;  the  exudate  may  spread  to  the  tonsils,  involving  the  back  of  the 
soft  palate  and  pharynx  as  well.  In  many  cases  of  nasal  diphtheria  no 
membrane  may  be  found  during  life ;  there  may  be  only  a  purulent  dis- 
charge with  blood,  the  presence  of  which  in  the  nasal  passage  obstructs 
breathing,  giving  rise  to  a  bubbling  sound,  and  rendering  sleep  trouble- 
some and  noisy.  Cases  have  also  been  reported  of  formation  of  pseudo- 
membrane  in  the  nose  with  mild  general  symptoms,  and  from  which  or- 
ganisms identical  with  diphtheria  bacilli  were  obtained  by  culture.  Some- 
times the  cases  have  recurring  mild  attacks  of  pseudo-membranous  in- 
flammation of  the  nose,  while  the  bacilli  may  be  constantly  present.  It  is 
probable  that  these  cases  may  give  rise  to  infections  of  like  nature,  and 
even  of  true  diphtheria.  In  nasal  diphtheria  the  symptoms  are  quite  as 
severe  as  in  faucial  diphtheria,  and  in  cases  in  which  the  soft  palate  and 
tonsils  are  also  involved  the  general  symptoms,  the  depression,  and  also 
the  albuminuria  are  apt  to  be  well  marked.  In  all  cases  of  corvza  with 
fever  we  should  be  guarded  as  to  opinion,  especially  if  an  epidemic  of 
diphtheria  is  prevalent  at  the  time.  The  diphtheritic  inflammation  may 
spread  from  the  nose  to  the  conjunctivae,  with  the  formation  of  a  false 
membrane,  and  much  purulent  discharge  may  escape  .from  the  eyes,  the 
lids  of  which  may  be  greatly  swollen.  In  this  place  it  is  well  to  remem- 
ber that  in  measles  we  sometimes  have  a  form  of  membranous  exudation 
occurring  on  the  nasal  mucous  membrane,  and  as  a  primary  disease — 
"rhinitis  fibrinosis  " — which  is  not  always  diphtheria.  This  disorder 
runs  a  favorable  course,  the  membrane  being  less  adherent  than  in  diph- 
theria. Ravenel  has  collected  77  cases,  and  in  33  out  of  41  cases  exam- 
ined bacteriologically  the  Klebs-Lofiler  bacillus  was  found.  Constitutional 
symptoms  were  either  slight  or  wanting. 

Wound-diphtheria. — The   bacillus  wnll  not  live  on  normal  skin,  but 
when  the  skin  is  cut  or  bruised,  as  after  blistering   or  an  eczematous 
condition,  and  when  a    moist,  raw  surface  is  present,   this    germ  freely 
^Berliner  klinische  Wochenschrift,  1907 ,  xliv.,  1499. 


158  INFECTIOUS  DISEASES. 

flourishes.  Granulations  also  form  a  favorable  soil.  The  diphtheritic 
germs  may  be  introduced  into  the  system  durint;;  an  operation,  sucii  as  an 
excision  of  the  tonsils,  or  even  a  vaginal  examination  ;  and  in  newborn 
infants  the  granulating  surface  left  after  sloughing  of  the  cord  may  be- 
come the  seat  of  diphtheritic  inflammation. 

Laryngeal  Diphtheria  or  Membranous  Croup. — The  exudate  may  appear 
first  on  the  mucous  membrane  of  the  larynx,  and  in  these  cases  the  mucous 
membrane  of  the  nose  and  pharynx  may  never  give  evidence  of  a  false 
membrane.  A  close  inspection  of  the  posterior  aspect  of  the  palate  and 
tonsils,  however,  may  reveal  a  slight  primary  membranous  formation  in 
these  situations.  In  laryngeal  cases  the  first  symptom  is  a  cough  of  a 
harsh,  metallic,  ringing  character,  and  never  to  be  forgotten  when  once 
heard.  The  temperature  may  be  slightly  above  normal,  or  even,  in  many 
cases,  normal.  The  toxic  absorption  is  slight,  on  account  of  the  locality 
affected,  and  the  constitutional  symptoms  are  usually  mild.  The  local 
8i/mptoms,  however,  are  very  alarming,  and  result  from  laryngeal  obstruc- 
tion, there  being  marked  dyspnea  with  retraction  of  the  intercostal  and 
supraclavicular  spaces,  and  later  of  the  epigastrium  and  lower  chest,  with 
an  increasing  cyanosis.  The  child  is  soon  restless,  is  forced  to  sit  up  to 
breathe,  and  for  the  same  reason  bends  forward  with  its  head  thrown 
back.  In  these  extreme  cases  unless  relief  is  soon  gained  the  child  dies 
of  suffocation.  In  many  instances  a  slower  form  of  suffocation  may  result 
from  the  extension  of  the  membrane  downward  to  the  bronchi. 

Complications. — Local  complications  may  be  mentioned — e.  g., 
hemorrhage  from  the  nose  and  throat  in  the  more  severe  ulcerative  cases. 
Skin-rashes  are  not  unusual,  especially  diffuse  erythema. 

Broncho-pneumonia  is  the  most  serious  pulmonary  complication  of 
diphtheria.  It  is  is  not  produced  by  the  Klebs-Loffler  bacillus  as  a  rule, 
but  by  the  streptococcus  or  pneumococcus.  Broncho-pneumonia  usually 
terminates  laryngeal  cases  that  have  been  operated  upon. 

Albuminuria  is  a  constant  symptom  (not  a  complication)  of  the  dis- 
ease (vide  supra),  and  is  almost  as  certain  in  establishing  a  diagnosis  of 
true  diphtheria  as  a  bacteriologic  examination.  It  is  met  with  in  both 
mild  and  severe  cases,  and  the  greater  the  amount  of  albumin  the  more 
severe  the  case.  Acute  nephritis  not  infrequently  complicates  diph- 
theria ;  it  is  usually  not  accompanied  by  edema  or  anasarca.  It  may  set 
in  with  suppression  of  urine. 

Dysphagia  may,  by  its  constant  existence  throughout  the  disease,  pro- 
duce a  profound  impression  on  the  general  nutrition.  Involvement  of  the 
conjunctivce  is  a  rare  but  grave  complication. 

Otitis  media  occurs  frequently,  and  may  be  a  troublesome  complica- 
tion as  well  as  a  sequel.  Snow^  reports  a  case  of  diphtheria  complicated 
with  Escherich's  pseudo-tetanus. 

The  most  frequent  sequelae  are  anemia,  chronic  naso-pharyngeal  ca- 
tarrh, and  peripheral  neuritis  and  its  associated  paralysis. 

Anemia  may  so  prolong  convalescence  as  to  expose  the  child  to  some 
intercurrent  disorder.  The  chronic  naso-pharyngeal  catarrh  may  be 
marked  and  offer  a  favorable  ground  for  new  diphtheritic  invasion. 
Paralyses — e.  g.,  palatal  and  cardiac — may  appear  in  the  first  and  sec- 
ond weeks  of  the  disease.  Other  forms  of  paralysis  occur  later.  Par- 
*  Amer,  Jour.  Med.  Sciences,  Dec,  1902. 


DIPHTHERIA.  ]  59 

alysis  usually  is  first  seen  when  the  child  attempts  to  swallow,  and  the 
food,  especially  if  liquid,  is  regurgitated  tli rough  the  nose.  This  is 
due  to  a  paralysis  of  the  muscles  of  the  soft  palate,  which  also  produces 
a  peculiar  alteration  of  the  voice.  The  paralysis  may  take  a  general 
form,  such  as  is  seen  in  multiple  neuritis,  the  lower  extremities  heing 
affected  and  the  knee-jerk  absent.  It  may  extend  to  the  external  ocular 
muscles  and  cause  squint,  to  the  ciliary  muscles  and  cause  dimness  of 
vision  from  unequal  accommodation,  or  to  the  muscles  of  the  trunk  in 
general,  producing  widespread  paralysis.  The  child,  unable  to  hold  any- 
thing, may  stagger  about  as  if  intoxicated,  so  much  so  as  to  suggest  the 
existence  of  a  cerebral  tumor.  The  disturbance  of  vision  and  the  absence 
of  the  patellar  tendon  reflex  has  in  adults  led  to  a  mistaken  diagnosis 
of  locomotor  ataxia.  Loss  of  taste,  deafness,  and  a  disturbance  of  sensa- 
tion are  not  infrequent.  Thus,  paralysis  is  to  diphtheria  what  dropsy  is 
to  scarlet  fever — a  proof  positive  of  the  disease.  T^o  make  one  step  more, 
in  many  sudden  deaths  occurring  in  early  diphtheria,  we  must  recognize 
paralysis  of  the  heart  outside  of  all  toxic  influence.  In  these  cases 
there  occurs  sudden  disturbance  of  the  vagus,  which  may  be  the  seat  of 
degenerative  changes  in  some  instances  at  least.  The  prognosis  in  post- 
diphtheritic paralysis  after  the  third  week  is  favorable,  while  the  cardiac, 
pharyngeal,  and  diaphragmatic  palsies  beginning  before  the  third  week 
are  serious.  Myocardial  weakness  tends  to  supervene  as  a  sequel.  It  is 
evidenced  by  the  sudden  accession  of  pallor,  nausea,  sometimes  by  vomit- 
ing, and  also  by  weak  heart-sounds  and  a  feeble,  broken,  irregular  pulse, 
etc.,  and  usually  leads  to  a  fatal  termination. 

Diagpaosis. — The  diagnoses  of  a  pharyngeal  diphtheria  is  not  difiicult 
if  an  epidemic  be  prevailing.  The  false  membrane  on  the  fauces  and  the 
presence  of  albumin  in  the  urine  give  us  a  practically  certain  diagnosis. 
The  only  unequivocal  evidence  of  the  disease,  however,  is  the  finding  of 
the  Klebs-Loffler  bacillus  in  the  membrane. 

An  immediate  recognition  of  the  disease  is  often  possible  from  a 
smear-preparation  of  the  exudate  from  the  throat  (see  Fig.  14),  the 
Klebs-LofBer  bacilli  being  present  in  sufl5cient  numbers  to  be  readily 
distinguished  by  the  microscopist.  Park,  who  has  had  a  rare  experience 
with  this  affection,  makes  the  following  statement :  "  In  cases  in  which  the 
disease  is  confined  to  the  larynx  or  bronchi,  surprisingly  accurate  results 
can  be  obtained  from  cultures,  and  although,  in  a  certain  proportion  of 
cases,  no  diphtheria  bacilli  will  be  found  in  the  first,  yet  they  will  be 
abundantly  present  in  later  cultures.  We  believe,  therefore,  that  abso- 
lute reliance  for  a  diagnosis  cannot  be  placed  upon  a  single  culture  from 
the  pharynx  in  purely  laryngeal  cases."  When  a  bacteriologic  examina- 
tion cannot  be  made  the  practitioner  must  regard  as  suspicious  all  forms 
of  throat  affections  in  children,  and  carry  out  measures  of  isolation  and 
disinfection.  In  this  way  alone  can  serious  errors  be  avoided.  Mistakes 
usually  occur  in  the  lighter  types,  many  of  which  are  in  reality  due  to 
the  Klebs-Loffler  bacillus  (Osier). 

Differential  Diagnosis. — From  follicular  tonsillitis  we  differentiate 
diphtheria  by  the  seat  of  the  membrane,  that  of  the  former  being  in  the 
tonsils,  while  diphtheritic  membrane  is  over  the  tonsils  and  over  the  soft 
palate.  Moreover,  in  follicular  tonsillitis  the  fever  is  high,  the  onset  is 
sudden,  and  it    is   usually  associated  with  gastric  disturbance.     Albu- 


160 


INFECTIOUS  DISEASES. 


minuria  is  gentM'ally  present  in  diphtheria,  while  it  is  present  in  folHc- 
uhvr  tonsillitis  in  exceptional  cases  only.  Moreover,  mild  cases  may 
not  present  albuminuria,  or  fail  to  sliow  the  presence  of  albumin  until 
later  in  the  disease.  The  histories  of  the  two  cases  are  quite  different. 
(For  differential  diagnosis  between  diphtheria  and  follicular  tonsillitis, 
see  also  Table,  p.  756.)  In  many  instances  of  so-called  diphtheroid 
lesions  the  membrane  is  formed  only  by  streptococcus  pyogenes  {iiietn- 
hranuus  (inyina),  and  these  cases  are  sometimes  of  an  intense  grade. 

Croupous  or  7}umbra)nnis  aiu/itia  (a  st7-eptococcus  infection)  may  offer 
some  dithculty  ;  yet  in  this  disease  there  is  no  tendency  to  sj»read  to  tiie 
nasal  mucous  membrane  or  to  the  larynx  ;  there  is  a  diminished  glandular 
enlargement :  there  is  no  albumin,  and  the  onset  is  more  sudden. 

In  Vincent,  s  angina  there  is  an  absence  of  the  formation  on  the  surface 
of  the  mucosa  of  a  thick  false  membrane;  it  is  an  ulceromembranous 
process.  There  is  a  deep  and  often  widespread  necrosis  of  the  mucosa  of 
the  palate  and  tonsil.  Bacteriologic  examination  shows  the  presence  of  a 
large  number  of  atypic  bacilli,  Avhich  are  often  associated  with  a  spiril- 
lum. According  to  H.  W.  Bruce  ^  there  is  an  absence  of  the  diphtheria 
bacillus. 


Fig.  14.— 1,  A  tube  of  blood-serum ;  2,  a  sterilized  cotton  swab  in  test-tube. 
Rub  the  swab  gently  but  freely  against  the  visible  exudate,  and  without  laying  it  down,  after 
withdrawing  the  cotton  plug  from  the  culture-tube,  insert  it  into  the  latter,  and  rub  that  portion 
which  has  touched  the  exudate  gently  but  thoroughly  over  the  surface  of  the  blood-serum  with- 
out breaking  its  surface.  Now  replace  the  swab  in  its  own  tube,  plug  both  tubes,  and  place  thcui 
in  the  box  provided  by  the  health  officials.  This  is  to  be  sent  to  the  bacteriologic  expert.  In 
laryngeal  diphtheria  the  swab  is  to  be  passed  far  back  and  rubbed  freely  against  the  mucous 
membrane  of  the  pharynx  and  tonsils. 


Diphtheria  frequently  is  associated  with  a  rash,  rendering  it  difficult 
to  distinguish  the  condition  from  scarlet  fever ;  but  in  diphtheria  the 
rash  is  more  truly  an  erythema,  while  in  scarlet  fever  it  consists  of  slightly 
raised  points  between  which  there  may  be  an  erythematous  condition. 
The  rapid  pulse  of  scarlatina  is  of  assistance  in  the  discrimination.  The 
glandular  swelling  and  sloughy  condition  of  the  throat,  however,  closely 
resemble  diphtheria,  and  a  positive  diagnosis  without  a  bacteriologic  ex- 
amination is  often  impossible. 

Prognosis. — Formerly  diphtheria  was  at  the  same  time  the  most 
prevalent  and  most  fatal  of  the  acute  infections,  the  mortality  being  30 
to  40  per  cent.,  although  variable  in  different  epidemics.  The  case- 
mortality  from  diphtheria  has  been  very  materially  reduced  since  the 
introduction  and  wide  use  of  antitoxin — certainly  over  50  per  cent.  The 
remarkable  diminution  in  the  death-rate  from  laryngeal  diphtheria  has 
coincided  precisely  with  the  use  of  antitoxin.  Of  especially  unfavorable 
prof^nosis  are  those  cases  that  show  large  quantities  of  albumin  in  the 
urine,  cervical  glandular  enlargement,  excessive  na.sal  discharge,  rapid 

^Lancet,  3 n\j  16,  1904. 


DIPHTHFJRIA.  161 

extension  of  the  exudate,  a  necrotic  membrane,  vomiting,  and  partial  or 
complete  suppression  of  the  urine.  A  sudden  Ml  of  temperature  to  a 
subnormal  level  and  an  irregular  pulse,  or  bradycardia,  are  a  bad  augury. 
Recovery  from  a  severe  attack  in  which  there  are  extreme  depression  and 
much  albumin  is  unusual  in  a  child  under  six  years  of  age,  though  re- 
covery may  take  place  in  apparently  hopeless  cases.  The  results  of 
Morse's  extensive  observations  are  opposed  to  those  of  Bouchot  and 
Dulinsay,  who  claim  that  the  degree  of  leukocytosis  is  of  prognostic 
value.  The  cases  of  neuritis  invariably  recover.  The  child  is  liable  to 
suffer  from  the  effects  of  the  disease  for  years  after  apparent  recovery. 

The  causes  of  death,  in  their  order,  are  as  follows  :  membranous  croup 
or  laryngeal  stenosis ;  septic  infection,  which  may  be  a  slow  death  ;  sud- 
den heart-failure — paralysis  of  the  heart ;  bronchopneumonia,  following 
tracheotomy  or  occurring  during  an  advanced  stage. 

Treatment. — Prophylaxis. — The  best  preventive  measures  against 
diphtheria  are  a  clean  nose  and  mouth.  The  slightest  appearance  of  a 
coryza  must  be  overcome  at  once  by  the  use  of  a  mild  antiseptic  wash ; 
all  accumulations  of  crusts,  dust,  dried  blood,  etc.,  should  be  removed 
from  the  nose  twice  daily,  especially  in  children  attending  school  or  during 
the  prevalence  of  an  epidemic.  The  child  should  be  early  taught  to 
employ  a  small  antiseptic  gargle  as  a  daily  routine,  using  a  weak  solution 
of  hydrogen  dioxid  or  listerine.  The  teeth  should  be  carefully  cleaned 
daily,  and  all  decaying  teeth  should  be  filled  or  removed.  Since  domes- 
tic animals,  especially  cats  and  dogs,  may  communicate  the  disease,  they 
should  be  excluded  from  the  sick  room. 

All  cases  of  sore  throat  should  be  examined  for  the  Klebs-Lojffler  bacil- 
lus, and,  if  it  is  found,  the  individual  should  be  isolated  ;  and  all  cases  of 
diphtheria  should  be  kept  isolated  until  cultures  taken  from  the  throat 
or  nose  fail  to  indicate  the  presence  of  the  specific  germ.  This  is  espe- 
cially true  in  schools  and  asylums.  Moreover,  all  persons  exposed  to 
this  disease,  and  those  caring  for  diphtheritic  patients,  should  receive  im- 
munizing doses  of  antitoxin.  Dzerjgowsky  recommends  the  subcutaneous 
use  of  minute  doses  of  toxin  with  a  view  to  establishing  active  immunity. 
Bacteriologic  examination  of  the  throats  of  school-children  is  of  the  great- 
est aid  in  controlling  epidemics.  The  fact  that  the  Klebs-Lofiler  bacilli 
when  found  in  healthy  throats  may  not  be  active  is  no  argument  against 
isolation  and  antitoxin  injections,  because  if  the  same  germs  were  to  find 
a  broken  or  catarrhal  membrane  they  Avould  rapidly  develop. 

An  unrecognized  feature  in  the  prophylactic  treatment  of  the  disease 
is  seen  in  the  uncertain  period  of  convalescence.  It  frequently  happens 
that  long  after  all  membrane  has  disappeared  active  bacilli  may  still  cling 
to  the  throat.  The  persistence  of  the  bacilli  may  be  accounted  for  at 
times  by  assuming  that  the  accessory  sinuses  of  the  nose  may  be  involved. 
This  condition  may  also  continue  for  from  two  to  six  months,  and  even 
longer  in  deeply  fissured  tonsils ;  and  the  disease  may  be  communicated 
by  such  throats  in  the  act  of  kissing  young  children  or  adults  with  sensi- 
tive throats  or  with  a  broken  buccal  mucous  membrane.  For  this  reason 
the  indiscriminate  kissing  of  young  children  on  the  lips  should  be  inter- 
dicted by  the  physician.  Hewlett  and  Nankwell  advise  the  use  of  endo- 
toxin as  an  aid  to  the  antitoxin  treatment  with  a  view  to  reducing  the 
number  of  these  diphtheria  carriers. 
11 


1G2  INFECTIOUS  DISEASES. 

Insufficient  attention  to  isolation  and  disinfection  of  the  milder  caaes 
explains  the  occurrence  of  many  house-epidemics.  The  physician  must, 
durin^y  his  visits,  wear  a  surgeon's  apron  or  linen  duster  which  has  been 
steeped  in  a  mercuric  chlorid  solution  and  allowed  to  dry.  His  hands 
and  face  should  be  washed  in  a  similar  solution  on  leaving  the  room. 

Treatment  of  the  Attack. — The  treatment  falls  naturally  under  several 
departments  :  [a)  the  hygienic  measures  to  limit  the  diffusion  of  the  dis- 
ease ;  (/')  the  local  management  of  the  throat  to  destroy  early  the  toxic 
germs;  (f)  medication  to  antagonize  the  effect  of  the  toxins,  and  event- 
ually to  overcome  the  complications  and  sequela'. 

(a)  Hygienic  Treatment. — The  patient  should  be  in  a  room  well  ex- 
posed to  sunliiiht  and  fresh  air,  and  superfluous  furniture  and  hangings 
should  be  promptly  removed.  No  stationary  washstand  should  be 
allowed  in  the  room,  and  Goodhart  well  says  that  many  cases  seem  to 
have  their  origin  in  the  proximity  to  foul-smelling  drains.  Even  in  mild 
cases  the  patient  should  be  kept  in  bed  throughout  the  attack.  White 
and  Smith,  from  a  study  of  the  heart  complications  in  946  cases  of  diph- 
theria, believe  that  the  presence  of  murmurs  and  a  slight  degree  of 
irregularity  are  no  contraindications  to  getting  out  of  bed  at  the  end  of 
two  weeks,  if  the  first  sound  is  strong  and  the  heart  is  not  dilated. 
Patients  who  have  been  severely  ill,  or  ill  several  days  without  treatment, 
should  not  be  allowed  out  of  bed  before  five  weeks.  The  general  comfort 
of  the  patient  is  enhanced  by  two  daily  sponge-baths  of  tepid  salt-water 
or  of  alcohol  and  water. 

Feeding. — Nursing  infants  may  be  fed  on  breast-milk  obtained  by  a 
breast-pump,  but  should  not  be  placed  at  the  mother's  breast  (Holt). 
The  feedings  should  be  regular,  yet  lighter  in  quality  and  quantity  than 
in  health,  remembering  the  fact  that  gastric  disturbance  is  closely  asso- 
ciated with  diphtheria.  The  rule  must  be  to  pay  every  possible  attention 
to  the  feeding.  Milk  in  some  form  being  our  main  dependence,  it  should 
usually  be  diluted,  and  for  young  children  partially  if  not  wholly  peptonized. 
The  greatest  difficulty  comes  in  the  latter  part  of  the  disease,  when  the 
child  is  septic  and  most  likely  has  a  strong  objection  to  being  disturbed. 
At  this  time  vomiting  is  most  easily  provoked  and  swallowing  is  rendered 
very  difficult  on  account  of  the  swelling  and  pain.  We  must  not  neglect 
the  feeding  even  if  it  does  cause  discomfort,  and  here  forced  feeding  by 
means  of  gavage  is  most  valuable.  Gavage  is  likely  to  be  more  success- 
ful with  children  under  three  years  than  rectal  alimentation.  In  older 
children  who  object  to  the  tube  through  the  mouth,  it  may  be  passed 
through  the  nose  with  little  difficulty,  and  gavage  by  this  route,  even  in 
intubated  cases,  will  be  extremely  satisfactory.  Concentrated  broths, 
meat-juice,  and  even  milk-punch  or  raAV  eggs,  may  be  given  in  this  way. 
(b)  Medicinal. — Alcohol  no  longer  holds  a  debatable  ground  in  the 
treatment  of  dij)htheria ;  it  is  the  most  powerful  drug  in  our  possession 
to  offset  the  ravages  of  the  disease  on  the  nervous  centers  and  for  the 
control  of  the  circulation.  Stimulation  should  be  commenced  as  soon  as 
there  is  a  reasonable  certainty  as  to  the  correctness  of  the  diagnosis,  and 
by  commencing  early  Avith  whiskey  or  brandy  we  may  prevent  the  depress- 
ing effects  of  the  poison  of  diphtheria  as  seen  in  the  pulse  and  general 
condition  of  the  child.  The  indications  for  the  free  use  of  alcohol  are 
marked  prostration,  feeble  pulse,  and  a  weak  first  sound  of  the  heart.     The 


DIPHTHERIA.  163 

quantity  must  be  adjusted  to  the  age  and  gastric  condition  of  the  child, 
and  usually  one  ounce  (32.0)  of  good  whiskey  or  brandy,  well  diluted,  in 
twenty-four  hours  is  sufficient  for  a  child  four  years  old.  In  very  bad 
cases  five  or  six  times  this  quantity  may  be  given,  the  only  limit  being 
the  tolerance  of  the  stomach.  The  stimulants  should  be  mingled  witli 
the  food,  as  the  child  may  rebel  against  taking  both  food  and  stimu- 
lants. 

Strychnin  stands  next  to  alcohol  in  importance  in  the  treatment  of 
diphtheria,  and  usually  it  is  given  in  too  small  doses.  For  a  child  four 
years  old  gr.  -^^  (0.0021)  may  be  given  every  six  to  eight  hours,  and  may 
be  administered  in  little  tablets  by  the  mouth  or  hypodermically. 

Digitalis  does  not  hold  an  important  place  in  the  heart-weakness  of 
diphtheria,  and  yet  it  is  strongly  indicated  on  theoretic  grounds.  Clinic- 
ally, it  has  been  found  to  have  an  unfavorable  action  on  the  stomach 
before  its  good  influence  can  be  had  on  the  heart  itself.  The  same  may 
be  said  of  camphor  and  ammonium  carbonate.  The  aromatic  spirits  of 
ammonia  is  valuable  for  rapid  eff"ects  in  syncopal  attacks.  In  cases  of 
threatened  heart-paralysis  occurring  late  in  the  disease  Holt  has  found 
nothing  so  valuable  as  morphin  employed  hypodermically,  the  drug  being 
given  in  full  doses  and  repeated  every  two  hours,  keeping  the  child  under 
its  influence  for  some  days.  In  cases  of  diphtheria  in  which  a  murmur 
and  slight  arrhythmia  develop,  efforts  at  treatment  should  be  concen- 
trated on  the  general  condition. 

Internal  medication  should  be  minimized.  Symptoms,  as  vomiting  or 
diarrhea,  are  to  be  met  with  sufficient  therapy  only  for  their  control. 

{c)  Local  Treatment. — For  the  direct  attack  upon  the  membrane  in  the 
throat  nearly  all  the  remedies  of  the  Pharmacopeia  have  been  used. 
Gargling,  swabbing,  painting,  spraying,  and  washing  the  throat,  all  have 
their  advocates.  Since  the  acceptance  of  the  antitoxin  treatment  medi- 
cal opinion  has  suffered  a  decided  change  as  to  the  importance  of  local 
measures.  The  very  best  local  application  for  pharyngeal  or  nasal  diph- 
theria consists  of  hydrogen  dioxid,  diluted  one-sixth,  and  used  both  as 
a  gargle  and  spray  as  most  convenient ;  this  is  usually  sufficient  in  the 
early  stage.  Norikove  ^  advises  for  infants  who  cannot  use  a  gargle  the 
administration  of  peroxid  internally  by  the  following  formula  :  hydrogen 
dioxid,  5  to  7  c.c.  ;  distilled  water,  85  c.c.  ;  syrupus  simplex,  15  c.c.  I 
have  found  a  solution  of  mercuric  chlorid,  1  :  1000,  with  an  equal  part  of 
hydrogen  dioxid,  used  as  a  spray,  an  excellent  disinfectant  and  deter- 
gent. The  tincture  of  iron  and  glycerin  (one  part  of  the  former  to  two 
parts  of  the  latter)  is  a  valuable  local  remedy  ;  it  should  be  applied  by 
means  of  a  swab.  The  object  of  local  treatment  is  a  more  thorough 
cleanliness.  To  avoid  new  lesions  in  making  applications,  the  spray  alone 
should  be  used,  and  for  the  nose  boric-acid  solutions  or  hydrogen  dioxid, 
1  :  10,  will  be  most  serviceable.  Fackenheim's  experience  with  a  local 
spray  of  pyocyaneus  convinced  him  that  it  is  a  valuable  adjuvant  to  the 
serum  treatment ;  it  hastens  the  disappearance  of  the  throat  lesions  and 
improves  the  general  health.  In  this  work  the  utmost  tact  and  kindness 
must  be  maintained,  for  it  is  truly  pitiable  to  force  a  struggling  child. 
Warm,  weak  solutions,  most  thoroughly  applied  by  means  of  the  fountain- 
syringe,  often  have  a  better  effect  than  the  more  frequent  use  of  the 
hand-syringe  or  spray  in  cases  of  nasal  diphtheria.  Rendu  advises  in- 
1  La  Medicine,  Oct.  8,  1902. 


164 


INFECTIO  US  nrSEA  SES. 


halation  of  hot  air  as  a  siipi)lementarv  measure  by  exposing  patients  to  a 
teuipcrature  of  176°  F.  for  five  minutes  at  a  time. 

In  laryngeal  diphtheria  the  child  should  inhale  an  atmosphere  laden 
with  the  vapor  of  slaking  lime,  or,  Aviienever  practicable,  an  atmosphere 
saturated  with, Lij tiler "s  solution  (menthol  10  grams,  dissolved  in  sufficient 
toluol  to  make  36  c.c,  liq.  ferri  sesquichlorid,  4  c.c,  absolute  alcohol, 
60  CO.).  J.  Cordin  warmly  recommends  mercurial  fumigation  for  the 
relief  of  lai-yngeal  stenosis.  The  development  of  the  signs  of  actual 
stenosis,  as  shown  by  stridulous  breathing,  cyanosis,  etc.,  furnishes  an 
indication  for  either  intubation  or  tracheotomy.  According  to  my 
observations,  the  results  of  intubation  have  been  quite  favorable,  and 
I  would  strongly  recommend  a  trial  of  this  procedure  before  resorting 


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FiG.  15. — Temperature-chart  of  a  case  of  diphtheria. 


to  tracheotomy  (see  temperature-cliai-t,  Fig.  15).  To  obviate  the  neces- 
sity for  reintubation,  vapor  inhalations  have  been  successful  in  my  hands. 

((i)  External  Applications. — External  applications  to  the  throat  have  no 
effect  on  the  course  of  the  disease.  They  are  useful,  however,  in  relieving 
the  pain  and  the  swelling  in  the  lymph-glands.  Careful  massage  of  the 
neck  with  campiiorated  oil,  as  hot  as  the  skin  will  tolerate,  is  very  sooth- 
ing ;  and  soap  liniment  may  be  used  in  the  same  way,  or,  if  much  pain 
exists,  chloroform  liniment  may  be  substituted.  Poulticing  for  the  relief 
of  pain  is  not  desirable,  as  it  seems  to  favor  suppuration.  In  older  chil- 
dren the  ice-collar  has  been  used  with  good  effect,  and  it  soon  brings 
grateful  relief  from  the  tension  and  subdues  inflammation.  Levinson 
recommends  early  lancing  of  su))purating  glands  to  prevent  a  general 
septicemia.  All  manipulations  about  the  child,  however,  should  be  car- 
ried on  as  L'^ently  as  possible. 

Serum-therapy ;  the  Antitoxin  Treatment. — This  has  now  passed  be- 
yond the  stage  of  experimentation.  The  general  average  mortality  of 
diphtheria   has   been   reduced   by   means  of  the   antitoxin   treatment   to 


DIPHTHERIA.  165 

about  10  per  cent.,  and  the  greatest  decrease  has  been  shown  to  have 
occurred  in  children  under  six  years  of  age.  No  physician  shouhl  be 
guilty  of  failure  to  employ  the  serum  in  any  case  of  diphtheria.  The 
studies  of  Bchring,  Koux,  Kitasato,  and  others,  published  in  1890,  have 
demonstrated  that  the  use  of  the  blood-serum  of  the  lower  animals,  arti- 
ficially rendered  imnmne  against  diphtheria,  has  a  powerful  healing  influ- 
ence upon  diphtheria  that  has  been  contagiously  or  spontaneously  acquired 
by  man.  The  principle  was  first  shown  to  be  true  of  tetanus,  and,  late 
in  1892,  Behring  further  showed  that  the  blood  of  an  immunized  animal 
had  the  power  both  of  protecting  and  of  curing  susceptible  animals  which 
had  been  inoculated  either  with  the  toxins  or  the  bacilli  of  diphtheria. 
In  preparing  the  blood-serum  it  is  desirable  to  have  a  uniform  strength 
or  standard.  One-tenth  of  one  cubic  centimeter  of  what  Behring  calls 
his  normal  serum  will  countei'act  ten  times  the  minimum  of  diphtheria 
poison,  fatal  for  a  guinea-pig  weighing  three  hundred  grams.  One  cubic 
centimeter  of  this  normal  serum  he  calls  an  antitoxin  unit.  The  serum 
prepared  by  his  method  is  labelled  in  three  strengths :  No.  I.  is  sixty 
times  the  strength  of  the  normal  serum  ;  No.  II.  is  one  hundred  times  as 
strong ;  No.  III.  is  one  hundred  and  forty  times  as  strong. 

Dosage. — To  a  child  of  two  years  or  over  not  less  than  2000 
to  4000  units  should  be  administered  at  the  first  dose;  hence  solution 
No.  I.  is  rarely  employed  at  the  present  day.  Should  a  favorable  result 
not  be  attained,  then,  on  the  following  day,  a  similar  dose  should  be 
repeated,  and  a  third  dose  if  necessary.  Massive  doses  should  be  em- 
ployed at  the  outset  in  severe  cases,  in  laryngeal  diphtheria,  and  in 
advanced  cases.  The  sites  to  be  selected  for  injection  are  various.  In 
very  young  children  either  the  buttock  or  thigh  is  to  be  preferred,  while 
in  older  children  the  flanks  or  subscapular  spaces  may  be  chosen  as  well. 
The  injections  should  be  made  deeply  into  the  subcutaneous  cellular 
tissue,  and  the  swelling  which  results  should  not  be  rubbed.  It  is  to  be 
emphasized  that  the  best  results  are  obtained  from  early  injections.  In 
laryngeal  cases  intubation  should  be  combined  with  the  serum  treatment 
in  suitable  cases.  The  early  use  of  antitoxin  in  this  disease  has  greatly 
diminished  the  proportion  of  cases  in  which  the  usual  complications,  par- 
ticularly paralysis,  occurred  previously. 

In  fortunate  cases  the  influence  of  the  serum  soon  becomes  apparent. 
Within  twenty-four  hours  the  faucial  SAvelling  diminishes,  the  membrane 
exfoliates,  the  temperature  falls,  the  pulse  becomes  slower  and  stronger, 
and  the  general  condition  of  the  patient  quickly  improves.  In  cases  of 
moderate  severity  and  when  injections  are  employed  early  the  improve- 
ment in  the  throat  and  the  constitutional  symptoms  is  very  decided ;  and 
the  earlier  the  case  comes  under  treatment  the  better  are  the  results.  There 
are,  however,  some  cases  of  great  severity  in  which  the  antitoxin  has  been 
used  early,  yet  has  not  shown  any  benefit.  Kronig  ^  has  found  that  incising 
the  hard,  swollen  process  enhances  the  efiiciency  of  the  diphtheria  antitoxin. 

A  danger  in  serum-therapy  may  be  the  development  of  local  abscesses, 
which,  if  full  antiseptic  precautions  be  taken,  must  be  rare  indeed.  I 
have  escaped  them  altogether.  Certain  skin  eruptions  have  been  observed 
after  injections,  mostly  urticarial,  though  sometimes  scarlatiniform.  The 
latter  form  has  given  rise  to  apprehensions  of  scarlatina.  Widerhofer 
had  one  case  which  was  isolated  as  measlee,  but  never  developed  any 
^  Jour,  of  the  Amer.  Med.  Assoc,  August  8,  1908. 


166  INFECTIOUS  DISEASES. 

symptoms  other  than  the  suggestive  eruption.  Rarely,  joint-pains  and 
swellings,  with  general  prostration,  supervene.  Abnormal  sensitiveness 
to  horse-serum  is  found  in  certain  persons,  <'•</.,  coachmen  and  asthmatics. 
Two  fatal  cases  have  been  reported — one  '  that  of  a  healthy  boy,  five  years 
old,  the  result  of  an  injection  of  Behring's  fresh  serum  as  a  preventive, 
dying  within  five  minutes  ;  tlie  other  occurred  in  Berlin.'^ 

For  establishing  immunity  in  subjects  exposed  to  infection  the  injec- 
tion of  60  units  (1  cubic  centimeter  of  tiie  No.  I.  serum)  aff'ords  pro- 
tection. In  order  to  arrest  the  development  of  the  disease  during  the 
period  of  incubation  100  units  (1  cubic  centimeter  of  No.  II.  serum)  is 
probably  sufficient-  Rolleston  urges  rest  in  bed  from  three  weeks  after 
a  mild  angina  to  seven  or  eight  weeks  after  a  severe  attack — as  a  pro- 
phylaxis against  palsies.  Adrenalin  and  strychnin  have  their  advocates 
for  the  same  purpose-  Finally,  for  the  serious  circulatory  disturbances 
which  arise  either  during  or  after  diphtheria,  absolute  rest  and  general 
management  accomplish  more  than  drugs. 


SEPTICEMIA. 


Definition. — Septicemia  is  a  systemic  infection  due  to  a  microbic 
invasion  of  the  blood  and  tissues,  with  or  without  a  detectable  seat  of 
infection.  Sapremia  is  a  toxemia  of  saprophytic  origin  (poisoning 
with  chemical  products),  while  septic  intoxication  is  an  afi'ection  due  to 
the  absorption  of  poisons  from  foci  of  suppuration.  Mixed  infections 
are  common,  hence  it  is  clinically  impossible  to  difiTerentiate  cases  of 
pure  sapremia,  septic  intoxication,  and  septicemia  in  most  instances. 

Pathology. — After  death  the  body  putrefies  early.  The  macro- 
scopic changes  in  the  viscera  are  often  wanting.  The  muscles  present  a 
brownish  color-tint.  The  pia  mater  is  generally  congested,  and,  together 
with  the  nerve-centers,  may  be  the  seat  of  ecchymoses.  The  blood  is 
dark  ("  tar-like  ") ;  its  coagulability  is  diminished  and,  microscopically, 
it  shows  micrococci  and  bacilli.  The  organisms,  however,  are  not  so  con- 
stantly found  in  the  circulating  blood  as  in  the  septicemia  of  mice  or 
rabbits.  The  spleen  is  somewhat  softened  and  its  lymphoid  elements 
more  distinct.     Ecchymoses  are  found  in  the  serous  membranes. 

In  protracted  septicemia  more  marked  alterations  exist,  and  among 
them  may  be  briefly  enumerated  the  following :  endocarditis  (rarely 
ulcerative);  gastro-intestinal  catarrh  (of  the  duodenum  and  rectum  in 
particular)  with  punctiform  extravasations ;  enlargement  of  the  lym- 
phatics and  spleen,  with  softening  of  the  latter ;  cloudy  swelling  of  the 
liver  (rarely  the  so-called  emphysema  of  the  organ  due  to  putrefaction) ; 
edema  and  catarrhal  inflammation  of  the  uriniferous  tubules ;  congestion, 
sometimes  associated  with  edema  of  the  lungs ;  and  inflammation  of  the 
pleura,  pericardium,  and  peritoneum,  with  ecchymoses. 

Microscopically,  the  internal  organs  show  numerous  small  foci  of  in- 
flammation, some  of  which  may  be  the  seat  of  "  coagulation-necrosis." 
Bacteria  are  found  in  abundance  in  various  situations,  such  as  the  exu- 
dations, the  capillaries  of  the  inflammatory  foci,  and  renal  glomeruli. 

Htiologfy. — Bacteriology. — Septicemia    may  be    due    to   micrococci, 

•  Jour,  of  the  Amer.  Med.  Assoc,  April  4,  1896.  "  Med.  News,  April  18,  1896. 


SPJrTlCJ'JMfA.  167 

which  Koch  has  shown  to  be  considerably  smaller  than  pus-cocci,  though 
no  one  form  of  bacterium  has  been  found  constantly  present  to  the  exclu- 
sion of  all  others.  Besser,  as  the  result  of  careful  experiments,  concludes 
that  septicema  is  caused  solely  by  streptococci,  while  Rosen  bach  and 
others  have  found  both  staphylococci  and  streptococci.  In  typhoid  fever, 
pneumonia,  gonorrhea,  puerperal  fever,  and  the  like  septicemia  may  be 
due  to  the  organism  causing  the  primary  lesion.  For  example,  Rosenow 
found  the  pneumococcus  in  77  of  83  cases  of  pneumonia  in  which  blood 
cultures  were  made.  Doubtless  in  many  instances  of  human  septicemia 
the  clinical  manifestations  are  due  partly  to  bacterial  poisoning  and 
partly  to  septic  intoxication  with  the  poisons  (ptomains)  developed  by 
the  organisms,  and  the  ptomains  probably  kill  the  patient  before  the 
bacteria  can  propagate  themselves  throughout  the  system.  Laboratory 
experiments  teach  us  that  in  the  lower  animals  septicemia  can  be  pro- 
duced both  by  chemical  poisons  and  by  bacterial  infection,  and  these 
two  types  are  observed  in  human  beings.  With  reference  to  the  bac- 
terial form,  Warren'  states  :  "  Whether  this  process  is  caused  solely  by 
the  multiplication  of  bacteria,  or  is  dependent  in  part  upon  the  liberation 
of  intensely  powerful  poisons,  or  is  due  to  some  ferment-like  substance 
capable  of  reproducing  itself,  like  the  poison  of  the  serpent,  as  are  diph- 
theria and  tetanus,  much  more  extensive  studies  upon  the  human  subject 
will  be  necessary  to  enable  us  to  say.'' 

Modes  of  Infection  and  Introduction  of  the  Poison  into  the  System. — (1) 
Wounds,  either  surgical  or  the  result  of  injury,  with  which  we  have 
nothing  further  to  do  in  this  work. 

(2)  Through  the  uterus,  following  labor,  miscarriage,  or  abortion. 
Generally  in  these  cases  there  are  accompanying  local  changes,  but  in  a 
few  the  poison  appears  to  pass  the  unguarded  portals  of  the  organ,  while 
the  latter  exhibits  nothing  abnormal. 

(3)  The  cases  in  which  the  poison  gains  entrance  into  the  body 
without  obvious  wounds  or  raw  surfaces  are  relatively  more  common. 
When  the  skin  is  quite  natural,  septic  infection  or  intoxication  can- 
not occur,  but  the  slightest  abrasion  or  cut,  bed-sore,  etc.  may  serve 
as  a  gate  of  admission.  These  slight  lesions  "  may  be  almost  com- 
pletely healed  by  the  time  the  severe  symptoms  of  the  disease  are 
developed  "  (Striimpell). 

(4)  Mucous  membranes  often  admit  the  virus,  being  less  protective  in 
nature  than  the  skin.  The  numerous  bacteria — benign  and  pathogenic 
— that  are  constantly  present  in  the  intestinal  canal  may  also  find  in 
local  lesions  (as  in  typhoid  fever,  dysentery,  etc.),  or  catarrhal  inflam- 
mation even,  points  of  lodgement  and  cause  a  systemic  infection.  To 
this  category  belongs  that  form  of  septic  infection  which  follows  gonor- 
rhea. The  so-called  cases  of  "  spontaneous  septicemia "  are  also  usu- 
ally occasioned  by  absorption  from  the  mucous  surfaces. 

Rheumatic  or  septic  manifestations  often  follow  attacks  of  tonsillitis, 
and  it  is  probable  that  the  tonsils  are  more  frequently  points  of  en- 
trance for  the  organism  than  has  hitherto  been  supposed  (Wade,  Ban- 
natyne). 

(5)  "  Sepsis  Intestinalis." — This  special  form  of  poisoning  is  caused 
by  canned  meats,  ice  cream,  sausages,  and  cheese.      Vaughan,  to  whom 

^  &t/rgiccd  Pathology  and  Therapeutics,  p.  340. 


168  INFECTIOUS  DISEASES. 

we  are  indebted  for  the  first  description  of  "  sepsis  intestinalis,"  found 
in  cheese  a  ptomain  which  he  named  ti/)-otoxicon,  and  which  he  regarded 
as  the  axjtive  agent  in  this  group  of  poisoning  cases.  The  symptoms  are 
due,  according  to  his  .statement,  to  poisoning  by  chemical  substances, 
being  instances  of  sapre/uid  :  but  it  may  yet  be  found  that  the  intes- 
tinal micro-organisms  play  a  more  or  less  prominent  part  in  the 
process. 

(6)  Ogston  ^  recognizes  as  one  of  the  mildest  forms  of  sapremia  the 
sickness  and  nausea  produced  by  a  bad  smell,  which,  he  claims,  is  but 
a  ptomain  of  putridity  that  may,  under  certain  contingencies,  produce 
serious  symptoms.  On  the  other  hand,  persons  who  are  habitually  ex- 
posed to  bad  odors  (workers  in  sewers,  in  the  dissecting-room,  etc.)  may 
acquire  a  considerable  degree  of  immunity  against  poisoning  of  this 
sort.  The  fever  in  these  cases  corresponds  in  severity  to  the  dose  of 
the  poison. 

(7)  Septicemia  may  be  associated  with  or  follow  osteomyelitis. 
Clinical  History. — (1)  Symptoms  of  Sapremia. — The  fact  that  this 

form  m  ly  occur  wirJKiut  bacterial  infection,  either  local  or  general,  must 
be  emphasized,  but  more  frequently  there  will  be  either  local  infection  or 
putrefactive  changes  with  the  production  of  a  grave  general  condition 
due  to  the  absorption  of  the  poisonous  chemical  products.  In  certain 
other  acute  infectious  diseases  (diphtheria,  tetanus,  t3"phoid  fever,  ery- 
sipelas, etc.)  the  general  symptoms  are  similarly  engendered.  Perhaps 
the  most  typical  examples  of  sapremia  seen  by  the  physician  are  those 
due  to  tyrotoxicon  and  the  unaccustomed  inhalation  of  foul  odors. 
At  the  beginning  a  chill  may  occur,  but  this  is  more  generally  wanting. 
In  ^^  sepsis  intesti nails"  marked  local  symptoms  may  initiate  the  attack, 
as  nausea,  vomiting,  colicky  pains,  diarrhea,  etc.,  and  in  all  forms  there 
is  fever,  the  temperature  often  rising  rapidly  to  101°  or  103°  F.  (38.3°- 
39.4°  G.)  and  sometimes  higher.  Prostration  and  anemia,  particularly 
the  latter,  may  be  prominent  symptoms.  3Iicroscopio  examination  of 
the  blood  shows  leukocytosis,  and  always  a  marked  reduction  in  the 
number  of  red  corpuscles.      The   hemoglobin,  too,  may  be  reduced. 

Sapremia  following  childbirth  is  a  most  typical  sub-variety,  and, 
apart  from  the  special  history,  the  symptoms  are  much  the  same  as  those 
detailed  above.  It  is  the  form  most  amenable  to  treatment,  the  removal 
of  the  cause  being  followed  by  a  rapid  disappearance  of  all  symp- 
toms. 

(2)  Symptoms  of  True  Septicemia. — There  is  an  incubation-])er\od  which 
is  of  variable  duration,  though  usually  averaging  several  days.  The 
07i8et  is  more  gradual  than  in  the  previous  variety,  although  often  marked 
by  a  chill.  Accession  of  fever  following  surgical  procedures,  with  head- 
ache, anorexui,  prostration,  sometimes  vomiting  and  diarrhea,  and  espe- 
cially dulness  occasionally  amounting  to  mild  stupor,  announce  the 
affection :  these  symptoms  should  also  excite  suspicion  in  the  absence 
of  obvious  causal  factors.  They  become  intensified,  and  now  the  attack 
may  closely  simulate  certain  other  infectious  diseases  (typhoid  fever, 
acute  miliary  tuberculosis,  ulcerative  endocarditis,  etc.),  the  clinical 
picture  as  outlined  presenting  nothing  characteristic.  There  are,  how- 
ever, more  or  less  distinctive  features,  which  will  be  considered  seriatim. 

(a)  The  Fever. — This  is  usually  of  the  continued  type,  and  tends  ta 
'  Warren,  loe.  cit,,  p.  342. 


SEPTICEMIA.  169 

increase  in  degree,  fatal  cases  often  terminating  in  hyperpyrexia.  At 
the  beginning  the  temperature  may  rise  quite  rapidly,  and  in  some  cases 
it  may  even  be  subnormal.  Deep  morning  remissions  may  be  ob- 
served, and  the  initial  chill  may  be  repeated. 

{h)  The  Circulatory  System. — The  pulse  is  frequent,  and  near  the  end 
becomes  very  weak.  In  subacute  cases  characteristic  lesions  (endocar- 
ditis in  particular)  may  develop,  but  are  difficult  of  recognition,  since 
they  do  not,  as  a  rule,  give  rise  to  audible  murmurs  or  other  physical 
signs.  In  other  instances  soft  murmurs  may  be  heard,  but  it  is  indeed 
hard  to  discriminate  these  from  functional  sounds.  Moderate  leukocy- 
tosis (principally  of  polymorphonuclear  variety)  is  observed,  and  the 
presence  of  micrococci  in  the  blood  during  life  has  been  demonstrated. 
A  more  or  less  severe  secondary  anemia  is  present.  In  toxic  states 
associated  with  suppuration,  iodophilia  occurs  (Cabot). 

[c)  Grastro-intestinal  System. — The  spleen  may  Ijecome  perceptibly 
enlarged  and  gastro-enteritis  is  usually  present,  either  in  an  acute  form 
with  vomiting  and  frequent  serous  discharges  or,  more  often,  merely  with 
a  diarrhea  of  moderate  intensity  (septic  diarrhea). 

{d)  Cutaneous  Symptoms. — Punctiform  hemorrhages  into  the  skin  are 
of  prime  importance  in  the  diagnosis.  Occasionally  more  extensive 
ecchymoses  appear,  scarlatinal  eruptions  also  showing  themselves,  but 
these  are  less  characteristic.  Among  rare  appearances,  herpes,  roseola, 
edematous  inflammations,  and  faint  jaundice  may  be  observed. 

{e)  Renal  Symptoms. — The  lesions  consititute  the  so-called  "  septic 
nephritis,"  the  urine  often  containing  a  fair  amount  of  albumin,  epi- 
thelium, tube-casts,  and  red  and  white  corpuscles. 

Diagnosis. — (a)  Sapremia  can  be  distinguished  by  the  history,  the 
immediate  appearance  of  the  symptoms,  their  character,  and  by  the 
prompt  effect  of  the  removal  of  the  cause.  The  diagnosis  requires  a 
careful  seai-ch  for  etiologic  factors,  though  without  the  latter  we  can 
sometimes  arrive  at  a  correct  conclusion  by  a  process  of  exclusion, 

(h)  True  Septicemia. — Here  the  existence  of  an  incubation  period,  the 
continued  fever,  mental  apathy,  faint  jaundice,  splenic  enlargement, 
and  the  characteristics  of  septic  nephritis,  all  combine  to  form  a  well- 
defined  group  of  phenomena.  A  careful  blood-examination  should  be 
made  for  micrococci,  etc.,  and  cultures  should  be  undertaken  in  spon- 
taneous septicemia  and  associated  forms  (e.  g.  septico-pyemia).  The 
surgeon  should  look  to  the  condition  of  the  wound  if  one  is  present. 

Course  and  Prognosis. — The  course  may  be  brief,  virulent  at- 
tacks sometimes  terminating  fatally  within  forty-eight  hours,  this  being 
especially  true  of  sapremia  when  the  dose  of  the  poison  is  large.  The 
gravity  of  the  case  in  the  latter  form  is  in  direct  proportion  to  the 
amount  of  virus  in  the  system,  the  outlook  being  good  when  the  cause  is 
removable,  in  true  septicemia,  however,  the  progression  tending  steadily 
to  the  end.  The  mildest  types  may  rarely  terminate  favorably,  but  the 
eifects  are  not  dependent  upon  the  dose,  and  the  minutest  quantity  may 
lead  to  specific  results  in  their  fullest  intensity.  Septicemia  of  chronic- 
course  is  somewhat  milder. 

Treatment. — Of  first  importance  is  the  removal  of  the  cause,  and 
small  wounds  should  be  excised  and  the  parts  freely  cauterized.  The 
physician  must  support  the  patient's  strength  by  a  suitable  dietary  and 
by  the  judicious  use  of  cardiac  stimulants;  the  former  should  consist 


170  INFECTIOUS  DISEASES. 

mainly  of  liquids  (milk,  egg-white,  meat-juice),  and  the  latter  of  alco- 
holics, together  with  strychnin  and  ammonia.  Of  medicines,  internal 
antiseptics  (mercuric  chlorid,  creasote,  etc.)  richly  deserve  a  trial.  The 
fever  calls  for  hydrotherapy.  Quinine  in  large  doses  (gr.  x  every  four 
hours)  should  he  given,  if  well  tolerated  hy  the  patient.  To  meet  the 
renal  conditions  the  free  use  of  water,  together  with  the  least  irritating 
of  tiie  diuretics,  is  to  be  advised.  A  powerful  agency  in  eliminating  the 
microorganisms  and  their  toxic  products  is  found  in  normal  salt  solution, 
which  may  be  administered  by  hypodermoclysis  ("  washing  the  blood  "). 
Not  less  than  from  one  to  several  pints  of  this  fluid  are  to  be  used  daily. 
In  the  inoperable  cases  antistreptococcus  serum,  although  of  uncertain 
value,  should  be  employed.  If  the  blood-pressure  is  persistently  low, 
adrenalin  is  valuable  when  sloivly  administered  intravenously  in  the  pro- 
portion of  five  minims  of  the  1 :  1000  solution  to  a  pint  of  warm  saline 
solution  (Sajous).  At  first  1000  units  of  Marmorek's  serum  should  be 
injected  daily,  later  at  longer  intervals.  Pearce  states  that  polyvalent 
sera  appear  to  give  most  favorable  results. 


PYEMIA. 


Definition. — A  disease  of  the  blood  invariably  associated  Avith  sec- 
ondary abscesses,  and  due  to  an  absorption  of  pyogenic  organisms. 

Pathology. — The  cadaver  does  not  undergo  putrefaction  as  early  as 
in  septicemia.  Briefly  considered,  the  pathologic  lesions  that  fall  within 
the  physician's  province  arrange  themselves  under  the  following  heads : 

(1)  Thrombosis  and  Embolism. — At  first  the  veins  leading  to  and  from 
the  seat  of  the  local  changes  from  which  pyemia  arises  contain  thrombi 
■which  mav  soften  into  a  puriform  material.  Thrombi  are  also  found  in 
the  lungs  (a  circulating  embolus  first  finding  lodgment  in  the  pulmonary 
artery  or  its  branches),  liver,  kidneys,  spleen,  and  the  cortical  substance 
of  the  brain.  Freah.  emboli  may  be  formed  in  the  circulating  blood. 
Suppurative  phlebitis  is  almost  constantly  present. 

(2)  Abscesses. — These  so-called  metastatic  abscesses  are  set  up  by 
septic  eml)oli  or  result  from  the  thrombi  (chiefly  pulmonary  and  portal), 
and  are  found  in  the  lungs,  liver,  spleen,  and  kidneys.  They  are  not 
large,  but  may  coalesce  and  form  cavities  of  the  size  of  an  apple.  An 
original  focus  of  suppuration  may  be  the  bronchial  glands.  The  kidneys 
are  the  chief  organs  of  elimination  in  this  disease,  and  hence  it  happens 
that  numerous  clumps  of  micrococci  (infarctions),  producing  miliary 
abscesses,  are  frequently  seen  in  the  regions  of  the  Malpighian  bodies. 
There  are  many  other,*though  rarer,  seats  of  abscesses,  as  tlie  muscles, 
submucous  and  subcutaneous  tissues,  bones,  the  parotid  gland,  ovaries, 
and  testicles. 

(3)  Lesions  of  the  Skin  and  of  Mucous  and  Serous  Membranes. — At 
the  post-mortem  examination  hemorrhagic  extravasations  and  pustules 
are  often  visible  in  the  skin.  The  mucous  membrane  of  the  alimentary 
tract  is  rarely  affected,  differing  in  this  point  from  septicemia,  though 
occasionally  ulcers  may  be  noted,  and  most  commonly  in  the  stomach 
near  the  pyloric  orifice  (in  puerperal  cases)  and  in  the  large  bowel.  Prob- 
ably they  are  always  secondary  to  the  submucous  miliary  abscesses.     The 


PYEMIA.  171 

serous  membranes  (pleura,  pericardium,  meninges  of  the  brain,  nynovial 
membranes)  may  be  the  seat  of  purulent  inflammation  and  of  hemor- 
rhagic extravasations. 

(4)  Cardiac  Lesions. — Ulcerative  endocarditis  forms  the  chief  morbid 
lesion  (vide  Ulcerative  Endocarditis).  Myocardial  foci  of  suppuration 
may  be  present. 

D^tiology. — Bacteriology. — Experimental  investigationis  have  shown 
conclusively  that  the  organisms  usually  responsible  for  this  condition  are 
the  staphylococcus  and  the  streptococcus.  Whether  the  former  or  the 
latter  be  the  agent  of  infection  in  the  given  case  depends  chiefly 
upon  the  condition  of  the  tissues  at  the  starting-point,  especially  with 
reference  to  the  character  of  the  local  defensive  processes  ;  also,  though 
to  a  lesser  extent,  the  degree  of  virulence  of  the  micrococci. 

Other  important  pus-producing  organisms  are  the  gonococcus,  pneu- 
mococcus,  Friedlainder's  bacillus,  bacillus  pyocyaneus,  bacterium  coli 
communis,  and  micrococcus  tetragenus.  Pyemia  may  be  caused  by  any 
wound  or  inflammation  in  which  the  pyogenic  organisms  are  present. 

Paths  of  Infection  of  the  Body. — (a)  Almost  always  the  entrance  is  by 
the  blood-vessels,  the  special  varieties  of  bacteria  that  cause  pyemia 
reaching  the  veins  and  producing  thrombo-phlebitis.  Less  frequently 
they  reach  the  arteries  and  produce  thrombo-arteritis.  From  the  former 
condition  emboli  may  be  disseminated  throughout  the  system,  while  from 
the  latter  the  emboli  are  arrested  in  the  neighboring  capillaries  to  which 
the  tributaries  of  the  vessel  lead.  Bacteria  independently  of  emboli  may 
be  found  wandering  in  the  blood-stream. 

(b)  The  lymphatic  system,  but  here  the  bacteria  meet  with  greater 
forces  opposing  their  attempts  to  spread  than  in  the  blood-vessels,  and 
hence  it  is  a  much  rarer  mode  of  propagation. 

(c)  In  spontaneous  pyem,ia,  in  which  there  is  no  wound  to  act  as  an 
infection  atrium,  we  must  presuppose  the  existence  of  either  a  trivial 
lesion,  as  in  "  spontaneous  septicemia,"  or  an  area  of  lessened  resistance. 
The  latter  may  be  produced  by  inflammation,  by  a  contusion,  and  in 
other  ways,  and  all  that  seems  necessary  is  a  lowering  of  the  tone  of 
the  general  system  (Warren).  I  am  certain  that  ulcerative  endocarditis 
is  not  frequently  the  starting  point,  but  is  usually  secondary  to  foci  of 
inflammation  elsewhere.  The  appendix  is  often  the  primary  or  original 
focus  in  this  category  of  cases,  micrococci  localizing  themselves  here  in 
consequence  of  a  preceding  disturbance  of  the  circulation  or  catarrhal 
inflammation.  I  recollect  one  case  in  which  no  original  abscess  was 
found  at  the  post-mortem. 

Predisposing  Causes. — {a)  Epidemic  Influence. — It  has  been  proved 
by  abundant  experience  that  certain  seasons  are  characterized  by  epi- 
demic outbreaks  of  the  disease. 

(h)  Cases  have  sometimes  been  noticeably  more  frequent  in  the  early 
months  of  the  year  (February  and  March)  than  in  other  seasons. 

(c)  Age  and  Sex. — Males  are  more  frequently  aff'ected  than  females, 
and  most  cases  occur  about  the  middle  period  of  life  or  at  the  time  of 
greatest  danger  from  traumatism. 

Clinical  History. — Incuhation. — The  disease  sets  in  within  the  first 
week  after  the  reception  of  the  wound  or  operation.  The  wound  looks 
unhealthy,  and  phlebitis  of  the  eff'erent  veins  is  noted. 


172  mFECTIOUS  DISEASES. 

A  most  conspicuous  symptom,  and  usually  the  first,  is  the  chill:  it 
mav,  however,  he  preceded  for  a  variahle  time  hy  ferer  of  a  continued 
or  intermittent  type.  The  fever  of  pyemia  is  of  the  suppurative  type. 
Profoand  prostration  develops  early ;  the  skin  presents  an  icteroid 
appearance ;  and  gastro-intestinal  symptoms  may  appear,  but  are  not 
prominent.  The  signs  of  abscess  of  the  lung,  liver,  and  other  organs 
may  develop  in  some  cases,  while  in  others  the  whole  clinical  picture 
is  colored  hy  the  ill-defined  characters  of  ulcerative  endocarditis. 

(a)  The  Chill. — This  may  be  mild,  though  oftener  it  is  (juite  severe. 
It  is  repeated  throughout  the  course  of  the  disease  at  somewhat  irregular 
intervals,  and  rarely  it  may  recur  several  times  on  the  same  day.  Chills 
are  must  apt  to  occur  during  the  daytime. 

(^)  The  Fever. — A  rapid  rise  of  temperature  accompanies  the  chill. 
The  fever-curve  is  of  the  irregularly  intermittent  or  profoundly  remit- 
tent type,  Avith  intervening  period,  showing  slight  or  marked  variations, 
and  as  decided  deviations  may  occur  within  a  short  space  of  time,  a 
two-hour  record  should  be  kept.  The  temperature  rarely  falls  to  the 
normal  level :  it  may  do  so,  however,  and  remain  there  for  one  or  two 
days.  To  explain  the  peculiarities  of  the  curve  in  this  disease  v/e  need 
only  recall  the  great  variety  of  pathologic  processes  before  noted. 
With  the  sharp  fall  of  temperature  siveating  occurs  and  leaves  the 
patient  more  or  less  exhausted,  though  only  temporarily  so  as  a  rule. 

(c)  Respiratory  System. — Symptoms  referable  to  the  organs  of  respi- 
ration appear  early.  The  pulmonary  abscesses  are  usually  latent,  but 
may  give  rise  to  dyspnea,  cough,  and  occasionally  a  purulent  expectora- 
tion. Pain  is  present  if  they  are  superficially  located,  and  under  such 
circumstances  the  physical  signs  of  cavity  or  of  pleural  effusion  may  be 
noted.  The  signs  of  pneumonia  at  one  or  both  bases  may  also  develop, 
the  expectoration  now  becoming  rusty. 

{d)  Splenic  and  Hepatic  Symptoms. — The  foci  of  suppuration  in  the 
liver  are  difficult  of  recognition  unless  they  become  large  as  the  result 
of  coalescence  and  are  superficially  located  (see  article  Hepatic  Abscess). 
Splenic  infarction  may  also  be  safely  diagnosed  if  there  are  })ain  and 
great  tenderness  (due  to  localized  peritonitis)  in  the  left  hypochondrium, 
with  progressive  enlargement  of  the  organ.  In  one  case  I  detected 
distinctly  crepitant  sounds  over  the  site  of  the  spleen  during  life. 

(g)  Cardio-vascular  Symptoms.— The  pulse  at  first  is  accelerated,  but 
moderately  full  and  regular;  later  it  becomes  feeble,  rapid  (running),  or 
even  uncountable.  Frequently  cases  in  which  ulcerative  endocarditis 
develops  are  apparently  of  spontaneous  origin.  (  Vide  Endocarditis  in 
the  section  on  Diseases  of  the  Heart.)  Among  the  blood-appearances 
during  life  are  leukocytosis  and  a  rather  marked  reduction  in  the  red 
corpuscles.  Avith  moderate  poikilocytosis.  lodophilia  is  a  frequent  finding. 
Nucleated  erythrocytes  may  be  present.  The  blood-plaques  are  increased. . 
Purulent  pericarditis  may  occur. 

(/)  Cutaneous  Symptoms. — The  most  prominent  is  a  mild  yet  decided 
grade  of  jaundice,  that  is  hepatogenous  (?)  in  nature.  Sweating  has 
already  been  alluded  to  as  a  symptom,  both  during  and  after  the  febrile 
paroxysms.  The  skin  finally  shrinks  from  emaciation.  Skin-eruptions 
are  common,  particularly  erythema,  purpura,  pustules,  pallor,  and  the 
general  surface  is  often  decidedly  hyper  esthetic. 


PYEMIA.  1 73 

(g)  Genito-urinary  Symptoms. — The  urine  is  concentrated  and  urates 
are  copiously  deposited.  There  is  albuminuria,  which  may  be  due  to  the 
pathologic  changes  or  may  be  asctibable  to  the  fever,  ^j'lie  microscope 
discloses  the  presence  of  tube-casts,  micrococci,  pus-  and  (more  rarely) 
blood-corpuscles.     Peptone  has  been  found  in  the  urine. 

(h)  Nervous  Symptoms. — The  mind  generally  remains  unclouded  until 
an  advanced  stage  is  reached;  then  delirium  sets  in,  and  is  followed  by 
a  terminal  coma.  Metastatic  purulent  meningitis,  with  its  usual 
symptoms  (hemiplegia,  strabismus,  ptosis,  deafness,  etc.),  may  appear. 

(^')  Symptoms  may  be  presented  by  the  joints  and  bones.  Metastatic 
arthritis,  usually  suppurative,  is  a  not  unusual  concomitant,  and  in  some 
cases  it  is  combined  with  similar  involvement  of  the  long  bones.  An 
acute  osteomyelitis  may  be  the  only  ascertainable  source  of  the  pyemia. 

Septico-pyemia. — By  this  term  is  meant  the  combined  presence  of 
suppuration  and  a  general  intoxication  (septicemia).  The  symptoms  of 
pyemia  (recurrent  chills,  copious  sweats,  metastatic  abscesses,  and  early 
nervous  symptoms  dominate  the  scene  in  the  majority  of  the  cases. 
Some  of  these  instances  pursue  a  comparatively  mild,  chronic  course. 

Differential  Diagnosis. — The  disease  is  often  confounded  with  malarial 
intermittent  fever  {vide  p.  356),  acute  miliary  tuberculosis,  malignant 
endocarditis,  and,  more  rarely,  typhoid  fever.  Malignant  endocarditis, 
the  secondary  condition,  is,  however,  pyemic  in  nature.  Typhoid  fever 
is  distinguishable  by  the  Widal  reaction,  characteristic  eruption,  and 
course.  A  few  points  of  contrast,  by  means  of  which  septicemia  and 
pyemia  may  be  differentiated,  are  tabulated  below : 

Pyemia.  Septicemia. 

Always  associated  with  suppuration.  Suppuration    may    be    absent,    but    there 

may  be  a  sloughing  wound. 

Multiple  chills.  A  single  chill,  as  a  rule. 

Irregularly  intermittent  fever-curve.  Continued  type  of  curve. 

Profuse      sweats     accompanying      febrile  Absent. 

attacks. 

Rapid    emaciation  and    profound    prostra-  Less  marked. 

tion. 

Sensorium  is  rarely  affected.  Sensorium  seldom  normal. 

Hyperesthesia.  Absent. 

Slight  jaundice.  Less  marked  (very  faint). 

Metastatic  abscesses.  Absent. 

Prognosis. — Pyemia  may  kill  after  an  illness  lasting  but  a  few 
days.  On  the  other  hand,  it  may  become  more  or  less  protracted,  so 
that  a  chronic  form  has  been  distinguished.  In  this  variety  the  symp- 
toms are  milder  in  character,  and  recovery  may  rarely  ensue. 

Treatment. — So  far  as  the  physician's  province  extends,  the  treat- 
ment is  identical  with  that  of  septicemia.  For  the  sweating  the  best 
agents  are  aromatic  sulphuric  acid  and  atropin  ;  the  latter  may  be  given 
with  agaricin  (atropin,  gr.  -j-^-g — 0.0005  ;  agaricin.  gr.  ^  to  \ — 0.008  to 
0.016),  at  bedtime.  Prompt  surgical  interference  must  be  resorted  to 
not  only  with  a  view  to  asepsis  of  the  primary  wound,  but  also  to 
evacuating  the  primary  and  all  secondary  foci  of  suppuration.  Recently 
puerperal  pyemia  has  been  successfully  treated  in  this  way.  The  use  of 
antistreptococcic  serum  has  led  to  immediate  improvement.  The  employ- 
ment of  normal  saline  solution  by  the  method  of  hypodermoclysis  aids  in 
eliminating  the  peccant  material. 


174  INFECTIOUS  DISEASES. 

ACUTE  ARTICULAR  RHEUMATISM. 

{Rheumatic  Fever.) 

Definition.- — An  acute  febrile  disease,  probably  due  to  a  diplococcus. 
It  would  seem  to  be  a  general  infection,  the  commonest  seat  of  the  princi- 
pal lesion  being  the  joints,  '*  but  also  involving  the  heart,  both  endocar- 
dium, pericardium,  and  muscle,  occasionally  the  meninges  and  other 
structures  "  (Webster).  Hueter  first  advanced  the  germ-theory  to  account 
for  the  disease,  and,  although  the  specific  causal  agent  has  not  as  yet 
been  discovered,  this  view  is  the  only  one  that  offers  a  satisfactory  ex- 
planation for  the  production  of  the  lesions,  the  acute  onset,  the  clinical 
course,  and  the  complications  of  the  disease.  The  frequent  involvement 
of  the  joints  in  many  diseases  belonging  to  the  acute  infections  may 
properly  be  regarded  as  supporting  this  theory.  Striimpel  points  out 
the  fact  that  in  Leipsic,  where  articular  rheumatism  is  one  of  the  most 
frequent  of  acute  diseases,  at  certain  times  there  are  only  a  few  cases, 
while  at  others  there  is  a  striking  increase  in  the  number. 

Pathologfy. — The  disease  does  not  show  peculiar  lesions,  and, 
although  the  joints  are  the  chief  seats  of  invasion,  still  in  many  instances 
and  even  in  aggravated  cases,  the  changes  presented  are  slight  or  alto- 
gether wanting.  Usually  the  synovial  membranes  of  the  affected  joints 
are  injected  and  swollen,  and  their  surfaces  may  be  more  or  less  coated 
with  fibrin.  The  effusion,  which  in  a  majority  of  instances  has  been 
found  sterile,  is  mainly  serous,  but  contains  fibrin  and  often  leukocytes, 
and  occupies  the  joints.  A  similar  exudate  infiltrates  the  periarticular 
tissues.  The  tendinous  sheaths  may  also  be  inflamed  ;  the  cartilages 
in  protracted  cases  may  become  eroded ;  and  rarely  a  purulent  exudate 
may  be  seen. 

Fatal  cases,  except  when  death  is  due  to  hyperpyrexia,  usually  show 
the  changes  peculiar  to  endocarditis,  pericarditis,  or  myocarditis,  and 
less  frequently  those  of  pneumonia,  meningitis,  or  pleuritis.  The  fibrin- 
factors  of  the  blood  are  augmented. 

Ktiology. — Bacteriology. — Guttmann,  Collin,  and  Sahli  have  found 
the  staphylococcus  in  the  articular  exudate  of  patients  suffering  from 
complicated  or  recurrent  cases  of  acute  articular  rheumatism,  and  Sahli 
is  inclined  to  include  the  disease  in  the  group  caused  by  this  organism. 
Netter,  however,  has  found  the  streptococcus,  and  Lang  a  peculiar 
bacillus.  Singer  has  examined  92  cases  bacteriologically  and  discovered 
staphylococci  or  streptococci  in  the  majority  of  these  cases,  and  also 
post-mortem ;  they  probably  complicate  acute  rheumatism.  Pierre 
Achalme  ^  has  described  an  organism  which  he  found  in  the  blood 
(Thiroloix  Anhahnii)  of  cases  of  rheumatism  with  cerebral  complications. 
It  is  a  bacillus  somewhat  resembling  that  of  anthrax  ;  it  is  readily  stained 
with  anilin  dyes  and  by  Grams  method,  and  is  anaerobic.  When  in- 
oculated into  guinea-pigs,  it  causes  inflammation  of  the  serous  membranes 
characteristic  of  rheumatism.  Trebouletand  Coyon^  suggest  that  Achal- 
me's  bacillus  is  associated  with  only  the  severe  forms  of  rheumatism, 
and  they  have  found  it  in  some  other  cases  associated  with  a  diplococcus, 
which  latter  was  found  in  all  other  cases  of  rheumatism  examined.  The 
'  Ann.  Pa.<(mr  Tnsl.,  Nov.  1897.         *  Bull,  de  la  Soc.  meil.  des  Hop.,  Dec.  24,  1897. 


ACUTE  ARTICULAR  RHEUMATISM.  175 

diplococcus  was  facultative,  anaerobic,  and  stained  by  Gram's  method. 
The  weight  of  authority,  liowever,  is  in  favor  of  tlic  view  that  a  diplo- 
coccus [Diplococcus  rheumatieus)  is  the  principal  specific  cause  {vi/h 
supra).  Streptococci  of  all  bacteria  have  been  most  frequently  found 
(Park)  occurring  as  diplococci  or  short  chains.  The  definitive  cause  of 
acute  articular  rheumatism,  however,  is  still  suh  judice.  In  certain  cases 
reported  there  was  evidence  of  direct  contagion. 

Predisposing  Causes. — (1)  An  infective  lesion  (septic  wounds,  attacks 
of  angina,  etc.)  that  has  preceded  for  some  time  the  appearance  of  the 
pain  and  articular  manifestations  may  often  be  found,  and  this  may  be 
conceived  to  form  a  portal  of  entry  for  micro-organisms  (Sacaze).  The 
frequency  with  which  an  attack  of  tonsillitis  precedes  the  development 
of  acute  articular  rheumatism  almost  indicates  a  pathologic  relation 
between  the  two  diseases  (Cheadle,  Wade,  Gerhardt,  Packard).  (2) 
Seasons. — The  months  of  February,  March,  and  April  furnish  the 
largest  percentage  of  cases,  though  the  disease  is  also  quite  prevalent  in 
the  remaining  cold  months ;  on  the  other  hand,  the  disease  may  some- 
times prevail  in  summer.  Edlefsen  and  Newsholme  have  shown  that  the 
incidence  is  greatest  when  the  ground-water  is  low.  (3)  "  Catching 
cold  "  was  formerly  classed  among  exciting  causes,  but  abrupt  changes 
of  temperature  merely  predispose  to  the  disease.  (4)  Climate. — Rheuma- 
tism is  most  prevalent  in  temperate  latitudes,  being  rare  both  in  the  cold 
and  tropical  zones.  It  is  essentially  an  urban  disease  (Poynton).  (5) 
Occupation  is  of  importance,  especially  if  it  entail  oft-repeated  or  pro- 
longed exposure  to  the  influence  of  wet  and  cold  or  to  severe  changes  of 
temperature.  Hence  those  who  follow  certain  vocations  are  attacked 
with  great  frequency — e.  g.,  coachmen,  laborers,  sailors,  and  servant-girls. 
(6)  Age. — Primary  attacks  are  most  common  from  fifteen  to  thirty-five 
years  of  age.  Gut  of  655  cases,  80  per  cent,  occurred  between  the  twen- 
tieth and  fortieth  years  (Whipham).  Cases  are  also  rather  num.erous  be- 
tween ten  and  fifteen  years,  and  I  have  met  with  4  under  the  former  age. 
Sucklings  rarely  suffer.  (7)  Sex. — Acute  articular  rheumatism  is  some- 
what more  common  in  men  than  in  women,  possibly  owing  to  the  fact 
that  the  former  sex  more  often  follows  predisposing  occupations.  (8) 
Her editay-y  influence  plays  a  causative  role.  (9)  Conditions  of  ill  health, 
particularly  digestive  and  hepatic  disturbances,  seem  to  exert  a  slight 
effect.  Preceding  or  accompanying  the  attack  an  infectious  sore  throat 
was  noticed  in  53  of  288  cases.  (10)  Chronic  endocarditis  renders  its 
victims  very  prone  to  attacks  of  acute  articular  rheumatism,  and  some 
contend  that  the  two  diseases  are  etiologically  one  and  the  same.  (11) 
Choreic  children  often  develop  rheumatism.  Batton  analyzed  115  cases ; 
he  found  that  within  three  years  11.3  per  cent,  of  the  children  developed 
the  disease,  and  after  five  years  this  total  was  increased  to  20  per  cent. 
(12)  Endemic  and  Epidemic  Influence. — In  certain  localities  the  disease 
is  endemic,  and  epidemic  incidence  has  been  noted  by  McCIymont,  News- 
holme,  and  others.     House  epidemics  have  also  been  observed. 

An  attack  of  acute  articular  rheumatism  is  not  protective  in  char- 
acter, but  increases  susceptibility.  Of  288  cases,  45  per  cent,  of  the 
patients  had  had  one  or  more  previous  attacks  (Thlis).  In  this  respect 
the  disease  resembles  certain  other  infectious  diseases  (pneumonia,  eiy- 
sipelas,  etc.). 

Clinical   History. — Of  the   incubation-period   nothing   is  known, 


176  INFECTIOUS  DISEASES. 

thouizh  prodromat'i.  both  local  and  general,  may  be  observed.  There 
may  be  malaise,  .slight  fever,  angina,  laryngitis,  etc.,  and  last  from  a  few 
hours  to  a  day  or  two.  The  invasio7i  is  usually  abrupt,  with  fever  and 
synovitis,  aft'ecting  one  or  oftener  several  joints,  and  a  chill  or  a  series 
of  chilly  sensations  may  accompany  or  precede  the  rise  of  temperature. 
The  involved  joints  are  tender,  often  red  and  swollen,  and  e.xliibit  the 
local  signs  of  a  rapidly  developed  inflammation.  Pain  is  a  most  promi- 
nent symptom.  The  medium-sized  or  larger  joints  (knee,  ankle,  and 
wrist)  are  first  involved,  and  especially  those  of  the  inferior  extremities ; 
next  the  shoulder-,  elbow-,  and  hip-joints ;  and  lastly  the  lingers,  toes, 
and  intervertebral  articulations.  Quite  unusual  articulations  may  become 
implicated  (vi\h'  infra).  One  of  the  chief  peculiarities  of  the  disease  is 
in  the  fact  that  the  joints  that  are  affected  are  not  all  the  seat  of  anatomic 
changes  simultaneously,  but  that  the  process  migrates  from  one  joint  to 
another  from  day  to  day,  and  often  crosses  from  one  side  of  the  body  to 
the  other.  Sometimes  this  occurs  at  longer  intervals.  Hence  the  number 
of  joints  involved  at  one  and  the  same  time  may  be  either  few  or  many. 

In  cases  of  average  severity  the  general  features  are  subordinate  to 
the  local  symptoms.  The  fever  is  usually  moderate,  the  temperature 
not  exceeding  103°  F.  (39.4°  C),  and  the  temperature-curve  is  of  the 
irregularly  remittent  type,  corresponding  in  severity  with  the  joint- 
symptoms.  Defervescence  is  by  lysis.  The  skin  is  bathed  in  a  copi- 
ous perspiration  Avhich  is  not  dependent  upon  a  previous  fall  of  temper- 
ature.    Nervous  symptoms  are  rarely  observed. 

The  general  course  of  the  disease  exhibits  wide  variations,  both  as  to 
duration  and  intensity  of  symptoms,  especially  in  children.  It  may  not 
outlast  several  days,  appearing  with  mild  symptoms  ;  on  the  other  hand, 
cases  sometimes  persist  for  six  to  eight  weeks.  The  latter  instances  are 
apt  to  show  brief  non-febrile  periods,  alternated  with  marked  paroxysms, 
and  similar  cycles  may  be  repeated.  When  the  symptoms  are  distinct 
from  the  start  the  course  may  be  briefer  than  when  the  features  are  of 
Tuild  character.  As  will  be  seen  hereafter,  the  disease  frequently  mani- 
fests complications,  especially  cardiac. 

Leading  Symptoms  and  Complications  in  Detail. — (1)  Joints  and  Sur- 
rounding Structures. — As  I  have  stated,  pain  is  much  complained  of, 
and  is  greatly  augmented  by  motion  and  by  pressure  of  any  sort.  It 
may  be  out  of  all  proportion  to  the  degree  of  the  anatomic  changes. 
The  joints  affected  are  generally  swollen  (most  markedly  in  the  knees), 
and  the  swelling  is  due  partly  to  effusion  into  the  joint  and  partly  to 
inflammatory  edema  of  the  periarticular  structures.  The  sheaths  of  the 
tendons,  the  bursae,  and  often  the  adjacent  muscles  and  fascife  exhibit 
inflammatory  changes ;  hence  it  is  usual  to  see  an  extension  of  the  swell- 
ing for  a  variable  distance  from  the  joint,  the  backs  of  the  hands  often 
showing  this  to  a  marked  extent.  The  skin  may  present  a  pink  or  rose- 
colored  blush  over  circumscribed  areas  or  taking  the  form  of  streaks. 

In  even  viild  cases  there  are  usually  two,  three,  or  more  joints  in- 
volved, though  it  often  happens  that  one  bears  the  brunt  of  the  disease, 
little  complaint  being  made  of  others  less  severely  implicated.  Hence 
it  shoulil  be  a  golden  rule  to  examine  carefully  all  the  joints  at  each 
visit.  Involvement  of  a  single  articulation  {monarticular  rheumatism) 
does  sometimes  occur,  but  the  diagnosis  of  these  cases  offers  great  difl'i- 


ACUTE  ARTICULAR  RHEUMATISM.  177 

culties.  On  the  other  hand,  an  existing  polyarticular  rheumatism 
may  hecome  centered  in  a  single  joint  and  there  linger  with  great 
obstinacy. 

In  severe  cases  numerous  joints  may  be  invaded,  with  an  involve- 
ment of  the  joints  of  the  symphyses,  of  the  jaw,  of  the  ribs,  and  the 
sterno-clavicular  articulations.  Under  these  circumstances  the  patient 
assumes  a  dorsal  decubitus,  and  seeks  to  relieve  his  excruciating  pain 
by  holding  his  limbs  in  a  semiflexed  position  and  absolutely  motionless. 
If  now  ;in  attempt  be  made  to  change  his  posture,  he  complains  pit- 
eously  of  darting  pains  in  the  affected  joints.  The  fugacity  of  rheumatic 
arthritis  has  already  been  alluded  to. 

The  inflammation,  however  intense,  may  quickly  subside  in  one  joint, 
while  at  the  same  time  an  acute  disturbance  appears  in  another.  Usu- 
ally resolution  is  complete,  no  trace  being  left  of  former  inflammation, 
though  the  disease  may  recur  in  the  joints  primarily  involved.  Suppu- 
rative arthritis  may  supervene,  though  rarely,  and  its  occurrence  points 
indisputably  to  mixed  infection.  This  complication  may  lead  to  anky- 
losis— a  sequela  which  does  not  belong  to  pure  rheumatism. 

(2)  The  Cardio-vascular  Symptoms. — The  pulse  is  quickened  to  100 
beats  per  minute  or  over,  but  is  soft  and  full,  and  when  complications 
arise  it  shows  special  characteristics  which  are  described  in  appropriate 
sections  of  this  work.  In  rare  instances  it  is  very  rapid,  feeble,  and 
irregular,  apart  from  cardiac  involvement.  The  results  of  a  careful 
blood-count  show  a  high  grade  of  syynptomatio  anemia,  which  may 
develop  Avith  marvellous  suddenness.  Moderate  leukocytosis  is  also 
present.     Diplococci  have  been  found  in  the  blood  in  severe  cases. 

Great  importance  attaches  to  the  cardiac  affections  that  so  frequently 
accompany  this  disease.  They  may  arise  in  any  case,  even  the  mildest, 
or  at  any  stage  of  the  disease,  and  hence  the  conscientious  physician 
cannot  afford  to  neglect  the  matter  of  closely  and  regularly  examining 
the  heart.  It  must  be  recollected  that  no  special  symptoms  announce 
the  development  of  cardiac  disease.  At  first  we  may  note  an  increase 
in  the  febrile  movement,  more  or  less  palpitation,  sometimes  dyspnea, 
and  precordial  pains,  which  often  do  not  amount  to  more  than  a  sense 
of  soreness.  There  may  also  be  attacks  of  angina  pectoris  of  appar- 
ently purely  nervous  origin  (Striimpell). 

(a)  The  most  frequent  cardiac  manifestation  is  acute  endocarditis, 
which  is  present  in  25  to  30  per  cent,  of  the  cases.  We  are,  however, 
sadly  in  need  of  reliable  statistics  upon  this  point.  It  usually  takes  the 
form  of  simple  (verrucose)  endocarditis,  and  affects  most  frequently  the 
mitral  valves.  But,  though  usually  indicated  by  an  apical  systolic  mur- 
mur, it  is  hard  indeed  to  eliminate  the  functional  murmurs  that  may 
also  develop  in  the  course  of  this  disease.  Unless  combined  with  the 
symptoms  detailed  above,  the  presence  of  a  blowing  systolic  murmur 
does  not  afford  trustworthy  evidence  of  the  existence  of  acute  endo- 
carditis. I  have  witnessed  two  instances  in  which  endocarditis  preceded 
the  arthritic  manifestations.  Church  and  Cheadle  ^  state  that  "  in  a  large 
majority  of  cases,  if  no  endocardial  murmur  is  present  during  the  first  ten 
days  of  an  attack,  the  endocardium  escapes."  While  it  rarely  endan- 
gers life  and  may  leave  no  trace,  in  the  majority  of  instances  the  acute 

^  AUbut€s  System  of  Medicine,  vol.  iv.,  p.  15. 
12 


178  INFECTIOUS  DISEASES. 

endocarditis  does  not  undergo  complete  resolution,  but  leads  to  sclerotic 
chanires  and  terminates  in  incurable  chronic  valvular  disease. 

[b)  Next  in  the  order  of  freijuency  is  jJcricanUtis,  which  may  or  may 
not  be  combined  with  the  former.  In  many  cases  the  efi'usion  consists 
of  organizable  lymph  (often  large  in  amount) ;  less  commonly  it  is  sero- 
fibrinous and  rarely  becomes  purulent  or  blood-stained.  It  is  distin- 
guished by  its  pathognomonic  friction-sound,  though  also  by  other  char- 
acteristic signs  (vide  Pericarditis). 

[c)  Myocarditis  is  often  present  to  a  slight  extent  in  rheumatic  endo- 
carditis and  pericarditis  when  these  occur  independently  of  each  other, 
but  to  a  more  marked  degree  when  endo-pericarditis  exists.  Hence  it  is 
less  common  than  either  endocarditis  or  pericarditis.  The  changes  and 
symptoms  occasioned  will  be  discussed  under  Myocarditis.  Here  it  should 
be  pointed  out  that  the  condition  weakens  the  cardiac  walls  and  leads  to 
dilatation  of  the  ventricles  (usually  the  left).  Lees  holds  that  dilatation 
of  the  left  ventricle  (greater  or  less)  is  always  present  and  one  of  the 
earliest  symptoms. 

If  we  consider  rheumatism  an  infectious  malady,  we  can  readily  un- 
derstand why  the  local  manifestations  should  appear  not  only  at  the  dif- 
ferent articulations,  but  also  in  the  cardiac  structures  and  other  viscera. 

(3)  The  Skin. — Rheumatism  produces  copious  perspiration.  The 
sweat  emits  a  sour  odor  and  gives  at  first  an  ucid  reaction,  though 
later  it  may  be  neutral,  and  rarely  alkaline.  The  temperature-curve  in 
most  cases  is  not  materially  influenced  by  the  sweats.  Occasionally  the 
drops  in  temperature  and  the  free  sweats  are  concurrent,  but  the  latter 
symptom  is  apt  to  persist  despite  the  oscillations  in  the  temperature. 
Sudamina  appear,  often  in  extensive  crops.  Among  other  skin,  erup- 
tions less  frequently  observed  are  forms  of  erythema  (especially  ^^ 
nodosum)  and  urticaria,  which  latter  may  be  associated  with  purpura 
{urticaria  licemorrhagica).  The  association  of  the  latter  condition  with 
polyarthritis  is  known  as  peliosis  rheumatica,  though,  according  to  some 
writers,  this  is  not  rheumatic  in  nature.  Cutaneous  ecchymoses,  and 
even  extensive  hemorrhacres  into  the  skin  and  from  the  mucous  mem- 
branes — a  general  hemorrhagic  diathesis — mav  also  be  encountered. 

Subcutaneous  Rheumatic  Nodules. — In  1881,  Barlow  and  Warner 
called  attention  to  the  fact  that  during  and  after  acute  articular  rheu- 
matism, particularly  in  children  and  young  adults,  small  subcutaneous 
nodosities  attached  to  the  tendons  and  fasciae  may  in  exceptional  in- 
stances be  observed.  These  small  nodules  are  rather  firm,  movable,  and 
usually  painless.  The  skin  over  them  is  simply  elevated,  with  no  traces 
of  inflammarory  action.  They  are  most  frequently  found  at  certain 
points  of  election  (fingers,  wrists,  edge  of  the  patella,  malleoli,  and  over 
the  back  of  the  elbow),  though  also  seen  less  frequently  elsewhere ; 
they  may  disappear  and  after  a  brief  interval  reappear.  On  micro- 
scopic examination  it  is  seen  that  round  and  spindle-shaped  cells  enter 
into  their  composition.  Riess  believes  them  to  be  of  embolic  origin. 
I  met  with  one  fatal  case  of  the  sort  Avhich  occurred  in  a  male  aged  forty- 
two  years,  in  which  acute  articular  rheumatism  was  also  complicated  with 
endo-pericarditis  and  pneumonia.  Most  of  the  nodosities  were  of  the 
size  of  a  bitter  almond.  Cheadle  considers  that  the  eruption  of  large 
nodules  signifies  persistent  and  uncontrollable  cardiac  disease. 


ACUTE  ARTICULAR  RHEUMATISM.  179 

(4)  The  Fever. — The  fact  that  the  fever  fluctuates  materially  in  this 
affection  has  already  been  noted.  It  remains  to  be  pointed  out  that  if 
suppuration  occur  as  a  complication,  the  fever  may  be  of  the  hectic 
variety ;  also  that  rarely  hyperpyrexia  is  suddenly  developed,  and  with 
it  marked  cerebral  symptoms  (restlessness,  delirium,  and  soniotimes  con- 
vulsions, finally  merging  into  stupor)  are,  as  a  rule,  though  not  neces- 
sarily, associated.  This  serious  condition  commonly  develops  about  the 
beginning  of  the  second  week.  In  my  case  cited  above,  it  began  on  the 
sixth  day.  Delirium  usually  comes  on  either  shortly  before  or  after  the 
acute  development  of  the  hyperpyrexia.  The  pulse  becomes  excessively 
rapid  and  feeble  and  physical  prostration  extreme.  The  temperature 
may  rise  rapidly  with  slight  interruptions  until  it  touches  108°  or  109° 
F.  (42.7°  C),  and  as  the  fever  reaches  its  maximum  death  usually  ensues. 
The  temperature  may  continue  to  rise  after  death.  The  cause  of  "hyper- 
pyretic  rheumatism"  is  not  definitely  knoAvn.  It  has  been  claimed  that 
the  intemperate  are  most  apt  to  be  attacked,  but  this  belief  is  not  cor- 
roborated by  many  clinicians.  In  a  case  of  my  own,  however,  in  which 
pericarditis  with  hyperpyrexia  occurred,  the  patient  was  an  "alcoholic." 
The  symptoms  are  probably  due  to  an  intense  concentration  of  the  poison 
upon  the  nerve-,  and  especially  upon  the  thermal,  centers. 

(5)  The  Muscular  and  Nervous  Symptoms. — It  has  been  stated  that 
the  adjacent  muscles  and  fascise  may  exhibit  inflammatory  changes. 
They  may  also  show  more  or  less  swelling,  and  are  often  very  tender  to 
the  touch,  while  in  long-continued  cases  muscular  atrophy  ensues.  The 
cause  of  this  change  is  not  clear,  but  the  most  likely  view  is  that  it  re- 
sults not  so  much  from  disuse  of  the  muscles  (the  old  theory),  as  from 
some  trophic  disturbance  due  either  to  the  arthritis,  or  peripheral  neur- 
itis, or,  to  some  extent  at  least,  from  extension  of  the  rheumatic  inflam- 
mation from  the  nearest  articulation. 

Mention  has  been  made  of  the  grave  nervous  symptoms  that  are  at- 
tendant upon  hyperpyrexia,  but,  independently  of  the  latter  condition, 
nervous  phenomena  may  be  present.  There  may  be  restlessness  and 
sleeplessness  (due  to  pain),  but  active  delirium  is  exceptional  in  uncom- 
plicated cases,  and  it  is  usually  associated  with  a  temperature  of  104°  F. 
(40°  C.)  or  higher.  In  adynamic  types,  which  are  rare,  low  muttering 
delirium  merging  into  stupor,  and  even  coma,  may  be  observed.  Active 
mental  symptoms  are  sometimes  due  to  cerebral  embolism  secondary  to 
acute  endocarditis.  When  pericarditis  is  a  complication,  wild  delirium, 
with  or  without  hyperpyrexia,  or  the  low  muttering  variety  with  stupor, 
is  not  unusual.  The  drunkard  may  develop  delirium  tremens.  Coma., 
leading  quickly  to  a  fatal  result,  may  develop  without  other  previous  or 
associated  nervous  symptoms,  and  DaCosta  has  reported  cases  in  which 
a  fatal  coma  was  probably  due  to  uremia.  Rarely  coma  develops  during 
the  period  of  convalescence.  Convulsions  may  be  noted  generally  pre- 
ceding the  coma,  though  rarely  as  an  independent  symptom.  Melan- 
cholia may  arise  in  the  course  of  the  disease,  but  more  frequently  at  its 
close.     Meningitis  must  be  numbered  among  the  rarest  of  complications. 

Chorea  is  a  not  infrequent  sequel  of  this  disease  in  children,  and 
more  rarely  is  associated  with  it.  Of  554  cases  analyzed  by  Osier,  in 
only  88  were  chorea  and  rheumatism  associated.  These  instances  may 
or  may  not  be  accompanied  by  acute  endocarditis. 


180  lyFECTIOUS  DISEASES. 

(6)  Pulmonary  Symptoms. — Pleurisii  occurs,  and  is  generally  excited 
by,  an  extcnsivm  ut"  iiillauimatiou  from  tlie  pericardium  and  pleura.  The 
inflamuiatory  process  may  be  propa>rated  through  the  diaphragm  to  tlie 
peritoneum.  Bronchitis  is  sometimt-s  present,  but  is  rarely  a  part  of  the 
rheumatic  morbid  ])rocess ;  it  is  secondary,  and  is  ofieu  occasioned  by 
the  co-operation  of  the  factors  that  are  at  work  in  every  disease  in  which 
enforced  recumbency  and  great  prostration  coexist.  Bfonclio-j>neu7n<niia 
may  be  produced.  Lobar  pneumonia  rarely  occurs,  and  is  confined  to 
aggravated  cases,  but  pidmonary  congestion  is  occasionally  seen,  and 
may  prove  fatal.  Pulmonary  complications  also  develop  secondary  to 
pericarditis,  and  espeeially  to  endo-pcricarditis. 

(7)  The  Renal  Symptoms, — The  urine  is  diminished  in  amount,  is 
high-colored,  and  of  high  acidity  and  density.  The  standing  specimen 
deposits  urates.  As  in  other  infectious  diseases,  there  is  commoidy 
present  a  slight  febrile  albuminui'ia.  but  aeute  nephritis  is  extremely 
rare.     The  chlorids  are  sometimes  diminished,  but  rarely  absent. 

(8)  The  spleen  is  slightly  enlarged  in  some  cases.  The  saliva  often 
has  an  atid  reaction.  (9)  Inflammation  of  the  parotid  (/hmd  (rheumatic) 
was  met  with  in  3  cases  by  Courtois-Suffit  and  IJeaufume. 

Clinical  Peculiarities  of  Acute  Articular  Rheumatism  in  Children. — The 
arthritic  symjitoms  in  children  are  in  abeyance,  while  endocarditis  and 
pericarditis  are  predominant,  and  these  cardiac  conditions  may  appear 
before  the  joint-lesions  are  observed.  Endocarditis  follows  the  joint- 
lesions  twice  as  freijuently  in  children  as  in  adults.  Parsons  lays  stie^ss 
upon  reduplication  of  the  cardiac  second  sound,  audible  at  the  apex  only, 
as  an  indication  of  the  development  of  endocarditis.  This  sign  is  to  be 
distinguished  from  reduplication  heard  at  the  base — e.  </.,  in  Bright's 
disease.  Acid  sweats  are  slight  in  children.  Rheumatic  tonsillitis  is 
common,  and  may  precede,  accompany,  or  follow  attacks  of  rheumatism 
in  children.  Erythema  is  a  frequent  concomitant,  and  is  often  mistaken 
for  scarlatina.  The  febrile  movement  is  brief  and  hyperpyrexia  less  fre- 
quent than  in  the  adult.  The  nervous  features  are  more  marked,  notably 
chorea,  which  Poynton  ^  has  emphasized  as  a  symptom  of  rheumatism. 
Out  of  217  cases  of  chorea,  he  found  obvious  heart  disease  in  122. 
Bareno^  reports  an  instance  in  a  newborn  infant. 

Diagnosis. — The  acute  development  as  a  primary  aifection  of  poly- 
arthritis with  fever,  early  tonsillitis,  sudden  anemia,  moderate  leukocy- 
tosis, and  fresh  cardiac  murmurs,  is  a  symptom-complex  on  which  an 
assured  diagnosis  can  be  usually  based. 

Differential  Diagnosis. — Pyemia  must  be  carefully  separated.  In 
pyemia,  however,  the  general  condition  is  graver,  fever  precedes  the 
local  manifestations,  and  the  fever-curve  is  irregularly  intermitting. 
Rigors  also  occur  in  pyemia  at  varying  intervals,  accompanied  by  a  steep 
elevation  of  temperature — symptoms  that  are  absent  in  rheumatism. 
Afrain,  suppurative  processes  in  the  various  viscera  and  skin  and  slight 
jaundice  appear  in  pyemia.  Rheumatic  symptoms  fluctuate  greatly,  while 
the  pyemic  do  not. 

The  multiple  swelling  of  the  joints  which  develops  after  childbirth  is 
t^  be  regarded  as  septic  in  nature.  In  these  cases  arthritis  leads  rapidly 
to  suppuration,  with  more  or  less  destruction  of  the  joints.      Gout  will 

»  Brilifsh  Jounxil  of  ChiUlren's  Diseases,  Feb.,  ix.,  No.  08. 
^Archives  of  Fediatrics,  Jan.,  1902,  p.  27. 


ACUTE  ARTICULAR   RHEUMATISM.  181 

be  distinguished  from  rheiiniatism  in  connection  with  tlie  consideration 
of  the  former  disease  (^oide  p.  432). 

Monarticular  rheumatism  is  with  difBculty  differentiated  from  a  group 
of  aifections  which  simulate  it  closely.  (1)  The  so-called  yonorrkeal  rheu- 
matism often  affects  a  single  joint,  especially  the  knee;  but  in  tljis  dis- 
ease there  is  usually  a  definite  history  of  recent  infection,  and  the  local 
features  (pain,  swelling,  etc.),  unlike  true  rheumatism,  are  far  more  pro- 
nounced than  the  general.  The  course  of  gonorrheal  arthritis  is  longer 
in  duration,  and  is  generally  connected  only  with  a  single  joint  from  the 
start ;  while  acute  articular  rheumatism  almost  always  begins  as  a  poly- 
arthritis, with  subsequent  fixation  in  one  articulation.  Cardiac  com- 
plications are  rare  in  the  former  disease. 

(2)  Acute  osteomyelitis  is  generally  single,  and  is  sometimes  mistaken 
for  rheumatism,  from  which  it  differs,  however,  in  the  localization  of  the 
lesions  in  a  single  joint  from  the  start,  the  greater  prominence  of  the 
local  symptoms,  and  in  the  implication  of  the  epiphyses  and  the  shaft 
of  the  affected  bone  rather  than  the  joint,  and  in  the  graver  general 
symptoms  from  the  time  of  onset. 

(3)  There  is  a  liability  to  mistake  the  acute  arthritis  of  infants  for 
rheumatism.  This  attacks  by  preference  the  hip  or  knee,  and  is  puru- 
lent inflammation  due  to  pyemia  (Townsend),  hence  having  no  relation 
to  the  disease  under  consideration. 

(4)  Tubercular  arthritis,  particularly  in  children,  has  been  confounded 
with  rheumatic  monarthritis.  The  former  is  less  indurating,  the  swelling 
presented  is  less  symmetric,  the  pain  is  greatest  in  the  joint  itself,  and 
the  course  is  far  less  acute  than  that  of  the  latter. 

(5)  In  the  course  of  the  hemon-hagic  diseases,  scurvy,  purpura,  and 
hemophilia,  effusion  into  the  joints,  either  hemorrhagic  or  serous  in 
nature,  occurs  with  great  frequency  and  is  associated  with  rheumatic 
pains.  The  differential  diagnosis  rests  upon  the  tendency  to  hemorrhage, 
and  in  scurvy  on  the  lesions  of  the  gums.  The  absence  of  fever  is  usually 
decisive;  unfortunately,  it  may  be  present  in  these  joint-affections. 

(6)  Glanders,  at  the  onset,  may  be  mistaken  for  rheumatism. 
Prognosis. — Recovery  is  the  general  rule.     As  in  other  infectious 

diseases,  the  chief  danger  springs  from  the  great  intensity  of  the  type  of 
infection,  as  manifested  in  hyperpyrexia  with  grave  nervous  symptoms, 
the  development  of  the  general  hemorrhagic  diathesis,  etc. — happily  rare 
occurrences  in  this  disease.  Certain  complications,  such  as  pericarditis, 
endopericarditis  (especially  common  in  childhood),  pneumonia,  etc.,  may 
render  rheumatism  grave  or  even  hopeless,  and  rarely  the  endocarditis 
that  complicates  the  disease  is  of  the  ulcerative  variety  and  leads  to  fatal 
pyemia.     Pulmonary  embolism  may  occur  and  cause  death. 

The  influence  of  personal  factors  may  impede  recovery,  such  as  intem- 
perate habits,  great  obesity,  the  existence  of  previous  organic  disease  of 
the  heart,  or  Bright's  disease,  etc. 

Treatment. — (1)  Sanitary  Environment,  Diet,  and  Stimulants. — The 
sick  room  should  be  well  ventilated,  and  its  temperature  maintained  at 
65°  to  70°  F.  (18.3°-21°  C),  but  draughts  should  be  avoided.  The 
patient  should  be  lightly  dressed  in  flannels  and  covered  with  a  sheet  of 
the  same  material.  The  diet  should  be  liquid  and  nourishing,  milk 
being  the  best  food-article.     Farinaceous  matter,  milk  and  Seltzer  water, 


182  ISFECTIOUS  DISEASES. 

buttermilk,  egg-white,  may  be  employed  if  milk  cannot  be  taken  in  ade- 
quate amount.  1  begin  the  use  of  easily  digested  proteins  soon  after 
defervescence  has  occurred,  but  have  immediate  recourse  to  the  earlier 
liquid  or  soft  diet  upon  the  return  of  pain  and  fever.  An  ordinary  die- 
tary is  to  be  gradually  resumed.  iStiinulants  may  be  employed  if  indi- 
cations for  their  use  are  present.  The  prompt  treatment  of  tonsillitis 
among  children  and  young  adults  is  important  prophylactically. 

(2)  Internal  Therapeutics. — The  bowels  should  be  opened  early  with 
calomel,  followt'd  l)y  salines.  There  has  been  of  late  a  surprising  una- 
nimity among  clinicians  in  commending  the  use  of  the  salicylates  in  the 
treatment  of  this  disease — more  so  than  at  any  previous  time  since  their 
introduction.  They  are  employed  in  most  of  the  larger  hospitals,  both 
in  Europe  and  America.  Differences,  however,  relating  to  the  mode  of 
administration  and  the  particular  salt  to  be  selected  still  exist.  Wood  ^ 
ftivors  ammonium  salicylate,  for  the  reasons  that  it  is  freely  soluble,  is 
rapidly  absorbed,  and  when  given  in  sufficient  amount  quickly  produces 
the  symptoms  that  mark  salicylic  action,  while,  in  addition,  it  is  less 
depressing  than  the  other  salts  of  salicylic  acid.  It  is  best  given  in  milk 
and  is  usually  well  borne.  My  experience  with  this  salt  in  acute  articu- 
lar rheumatism,  though  as  yet  somewhat  limited,  has  been  satisfactory. 
Until  the  present  time  sodium  salicylate  has  met  with  more  general  favor 
than  any  other  single  salt  of  salicylic  acid.  The  pure  acid  is  also  used, 
though  not  to  any  great  extent  at  the  present  day.  The  amount  given 
in  twenty-four  hours  should  not  exceed  2  drams  (8.0),  while  often  1^ 
drams  (6.0)  of  the  sodium  or  ammonium  salicylate  is  sufficient.  My 
method  is  to  give  gr.  x  (0.648)  every  two  hours  during  the  first  day,  or 
until  the  pain  or  other  local  features  have  largely  disappeared ;  then  the 
remedy  is  given  at  longer  intervals,  but  not  omitted  entirely.  If  it  be 
given  in  solution  with  an  excess  of  alkali,  it  is  least  irritating  to  the 
gastric  mucosa.  In  this  manner  fresh  exacerbations  are  most  probably 
averted.  If  the  latter  occur,  however,  larger  doses  must  be  instituted, 
so  as  to  cut  them  short.  Some  recommend  that  the  medicine  be  stopped 
as  soon  as  the  pain  has  been  controlled.  The  hypodermic  method  of 
giving  salicylates  will  prove  of  advantage  in  those  patients  who  cannot 
take  them  by  mouth.  Lassere  recommends  methyl  salicylate  to  relieve 
the  pain.  Some  prefer  salol  to  either  the  pure  acid  or  the  salicylates  ;  in 
my  experience,  however,  the  use  of  this  drug  has  not  been  followed  by  good 
results.  Doubtless  the  reason  for  this  lies  in  the  f\ict  that  salicylic  acid  can 
neither  be  introduced  into  the  system  in  sufficient  amount  nor  rapidly 
enough  in  the  form  of  salol. 

Kinnicutt  has  recommended  the  employment  of  the  oil  of  winter- 
green,  a  salicylic  compound  which  does  not  generally  produce  the  un- 
pleasant toxic  symptoms  so  apt  to  be  excited  by  the  salicylates  or  sali- 
cylic acid.  The  dose  is  TTLx-xx  (0.60-1.25),  given  in  capsules  or  in 
milk,  to  be  repeated  every  two  hours.  Salicin  (gr.  x — 0.648,  every  hour, 
increased  to  gr.  xv — 0.972)  is  sometimes  efficacious  and  invariably  agrees; 
it  is  to  be  preferred  to  the  salicylates  in  w^eakly  individuals.  Salophen, 
in  daily  doses  of  1  dram  (gr.  xv — 0.972,  every  four  hours),  may  be  sub- 
stituted for  .sodium  salicylate  if  the  latter  produces  gastric  disturbances 
after  a  few  days'  treatment;  it  is  almost  specific  in  its  eff'ects.  Salophen 
1  University  Medical  Magazine,  Jan.,  1895. 


ACUTE  ARTICULAR  RHEUMATISM.  183 

passes  through  the  stomach  unchanged,  to  split  into  salicylic  acid  and 
acetylparalidophenol  in  the  intestines.  Sodium  salicylate  enemata  (3J — 
4.0 — of  the  salicylate  and  ITLx — 0.60 — of  the  tincture  of  opium  in  each 
injection)  may  be  of  advantage  in  certain  cases.  The  remedy  is  slowly 
absorbed  from  the  rectal  mucosa. 

The  treatment  with  the  salicylates  or  salicylic  acid  mitigates  the  fever, 
relieves  the  pain,  and  shortens  the  stay  in  bed  by  a  few  days,  but  does 
not  curtail  convalescence.  The  statistics  of  Williams  go  to  show  that 
the  salicylic  treatment  also  tends  to  protect  against  the  development  of 
cardiac  complications,  though  it  does  not  seem  to  influence  the  course  of 
the  complications  once  they  are  established.  In  my  experience  the 
alkaline  treatment  operates  to  obviate  the  occurrence  of  the  heart-com- 
plications and  shortens  the  period  of  convalescence,  but  exerts  slight,  if 
any,  influence  upon  the  fever-curve  and  pain.  These  facts  led  me  long 
since  to  use,  in  addition  to  salicylates,  an  alkaline  remedy,  such  as  sodium 
bicarbonate,  potassium  citrate,  etc.,  in  sufficient  doses  to  render,  and  then 
maintain,  the  urine  of  slightly  alkaline  reaction. 

There  are  a  few  other  remedies  that  should  be  referred  to,  and, 
although  more  or  less  serviceable,  they  are  without  specific  influence. 
Among  these  is  antipyrin,  but  safer  and  equally  efficacious  remedies  have 
replaced  this  drug.  Potassium  iodid  and  the  pi'eparations  of  colchicum 
belong  to  this  category  ;  their  eff"ects  are  most  beneficial  in  cases  that 
drag  on  after  the  acute  stage  is  over.  Good  results  have  been  reported 
from  the  use  of  aspirin  (gr.  vij-xv — 0.466-0.972,  thrice  daily)  in  both 
acute  and  chronic  rheumatism.  Stengel  has  noted  improvement  from 
the  use  of  antistreptococcic  serum  in  three  cases  of  protracted  recurring 
rheumatism.  Menzer  has  successfully  treated  a  number  of  cases  with  a 
serum  made  from  streptococci  of  human  origin.  It  is  also  indicated  in 
cases  showing  a  pyemic  temperature  (Chipman).  Wolverton  advises  a 
mixed  streptococcus  and  staphylococcus  (aureus  and  alhus)  vaccine. 

(3)  Local  Measures. — These  occupy  a  subordinate  place  in  the  man- 
agement of  acute  articular  rheumatism.  Their  number  is  legion,  but 
only  a  few  of  the  more  valuable  can  be  adduced  here.  In  mild  cases 
the  affected  joints  should  be  wrapped  in  cotton  batting  or  in  flannel.  If 
the  pain  is  severe  despite  the  use  of  the  salicylates  internally,  fomen- 
tations as  hot  as  can  be  borne  or  hot  cloths  lightly  wrung  out  of  Fuller's 
lotion  (sodium  carbonate,  3vj — 24.0  ;  laudanum,  5J — 30.0  ;  glycerin, 
iij — 60.0  ;  and  water,  gix — 270.0)  are  beneficial.  As  salicylic  acid  is 
absorbed  through  the  skin,  it  may  be  used  in  the  following  formula : 

^.  Acid,  salicyl., 

Lanolini,  da.  siij  (11.65)  ; 

01.  terebinthinae,  Siij  (11.25); 

Adipis,  3iij  (11-65). 

M.  et  ft.  ung. 
Sig.  Rub  over  the  affected  joints  and  follow  by  wrapping  in  cotton. 

Methyl  salicylate,  by  local  application,  is  of  service.  It  is  put  on 
the  skin  over  the  aff'ected  joints  drop  by  drop,  and  the  joint  then 
enveloped  in  gutta-percha  tissue  and  a  flannel  bandage  applied  to  it. 
Cold  compresses  and  the   ice-bag  to  the  joints  have  been  strongly  ad- 


184  JXFECTIOUS  DISEASES. 

vised,  particularly  by  German  authors.  The  affected  joints  should  be 
kept  at  perfect  rest,  and  this  is  best  accomplished  either  by  paddeti  splints 
and  a  roller  bandage  or  plaster  casts.  Blisters  near  the  joints  involved 
and  the  light  application  of  the  I'aquelin  thermo-cautery  are  sometimes 
serviceable.  Taylor^  has  successfully  employed  currents  of  hot  aii-, 
applied  by  means  of  an  instrument  (electro-thermogen). 

The  treatment  of  the  coinplications  will  be  considered  under  their 
appi'opriate  headings.  Should,  however,  hyperpyrexia  occur  during  the 
progress  of  the  affection,  it  is  to  be  relieved  by  cold  affusions,  since  large 
doses  of  internal  antipyretics  are  of  themselves  dangerous.  It  may  also 
be  stated  that  the  cardiac  complications — endocarditis,  pericarditis,  and 
endo-pericarditis — rarely  require  special  remedies.  If  marked  cardiac 
asthenia  appears,  as  indicated  by  the  feeble  first  sound,  the  salicylates 
may  be  replaced  by  salicin,  which  is  less  depressing  in  its  eff'ect  upon 
the  heart.  Cardiac  stimulants  may  be  rcc^uired.  A  copious  pericardial 
effusion  calls  for  paracentesis  {vide  Sero-fibrinous  Pericarditis).  Giirich- 
succeeded  in  curing  98  out  of  125  patients  with  articular  rheumatism  by 
tonsillectomy. 

During  convalescence  the  patient  should  not  be  allowed  to  get  out  of 
bed  too  early.  My  own  rule  has  been  to  keep  him  in  bed  for  a  week 
after  the  temperature  has  returned  to  the  normal  and  after  the  pain  has 
disappeared,  except  it  be  during  the  hot  season.  These  ])recautions  are 
taken  to  avoid  the  occurrence  of  relapses.  After  the  patient  goes  into 
the  open  air  he  should  be  told  to  avoid  cold,  and  wet  in  particular. 
During  this  period  iron  is  to  be  employed  until  the  blood-examination 
fails  to  show  anything  abnormal.  For  the  stiffness  and  swelling  that 
sometimes  persist,  or  disappear  very  slowly  after  the  acute  attack, 
massage  and  the  application  of  hot  water  or  warm  baths  seem  to  yield 
the  best  results. 


SUBACUTE   ARTICULAR    RHEUMATISM. 

This  is,  as  a  rule,  a  sequela  of  acute  rheumatism,  and  may  occur, 
though  rarely,  in  persons  who  have  not  had  a  previous  acute  attack.  Both 
the  local  and  general  features  are  of  a  mild  type,  but  the  course  is  apt 
to  be  prolonged  into  two,  three,  or  more  months.  Usually  the  local 
symptoms  are  confined  to  one  or  two  of  the  larger  joints,  with  little 
swelling  or  redness,  and  the  pain  is  slight  except  on  movement.  The 
temperature  rarely  exceeds  101°  F.  (38.3°  C),  and  at  times  may  be 
practically  normal.  Though  the  course  is  prolonged,  the  joints  usually 
return  to  their  normal  state ;  occasionally,  however,  the  disease  becomes 
chronic.  As  in  the  acute  form,  so  in  the  subacute,  anemia  becomes  well 
marked  and  cardiac  complications  are  not  uncommon,  particularly  when 
the  disease  occurs  in  children. 

The  treatment  embraces,  in  addition  to  the  usual  antirheumatics, 
the  use  of  iron,  quinin,  cod-liver  oil,  and,  when  practicable,  a  change  to 
a  warm  climate.  The  affected  joints  demand  hot  applications  and 
massage. 

I  Lancet,  Nov.  26,  1898.  '  Milnchener  med.  Wochen.,  Feb.  8,  1910,  Ivii.,  No.  6. 


GONORRHEAL  ARTHRfTIS.  185 

GONORRHEAL    ARTHRITIS. 

Definition. — A  se])tic  synovitis  caused  by  the  gonococcus.  It  has 
no  connection  with  true  rlieumatisni.  It  usually  manifests  itself  toward 
the  close  of  an  attack  of  gonorrhea,  but  it  may  develop  during  the  active 
stage  of  the  disease  or  at  any  period  during  the  course  of  gleet. 

Pathology. — The  signs  of  ordinary  synovitis  are  generally  found 
in  the  affected  joints,  though,  not  rarely,  the  inflammatory  process  is 
periarticular  {gonorrheal  tenosynovitis).  In  these  cases  the  inflamma- 
tion may  travel  along  the  sheaths  of  the  tendons  for  a  considerable  dis- 
tance. Synovial  eff'usion  may  occur,  and  rarely  may  be  purulent,  this 
being  most  frequent  in  gonorrheal  inflammation  affecting  the  -wrist  and 
hand.  Gonococci  have  been  found  in  the  effusion,  and  it  is  now  thought 
by  many  writers  (Finger,  Councilman,  and  others)  that  the  gonococcus 
may  be  the  only  infective  agent  concerned  in  the  morbid  process.  Others 
contend  that  the  metastatic  inflammation  of  the  joints  is  due  to  the  pres- 
ence of  pyogenic  cocci.  The  disease  is  present  in  2  per  cent,  of  all  cases 
of  gonorrhea  in  males,  and  rarely  occurs  in  females  (Gaither)  ;  it  mny  fol- 
low any  urethral  discharge  or  may  be  associated  with  menstruation  or 
leukorrhea.  C.  Lucas  has  collected  23  cases  of  gonorrheal  rheumatism 
in  infantile  subjects  of  ophthalmia. 

Clinical  Symptoms. — Two  leading  varieties,  acute  and  chronic, 
are  encountered,  (i)  Acute  Gonorrheal  Arthritis. — This  may  be  very 
mild,  amounting  merely  to  slight  fugitive  pains  about  one  or  more  joints, 
without  swelling  or  redness  [arthralgic  form).  The  typical,  acute  form, 
however,  presents  the  symptoms  of  a  severe  fibrinous  or  sero-fibrinous 
inflammation  of  a  single  joint,  developing  quickly.  The  pain  is  often 
violent;  there  is  swelling  of  the  joint  with  extension  along  the  course 
of  the  tendons,  and  the  condition  is  obstinate.  Unless  pus  be  present 
(a  rare  event)  the  constitutional  features  do  not  correspond  in  severity 
with  the  local.  There  are  many  instances  in  which  the  complaint  begins 
as  a.  polyarthritis,  with  subsequent  concentration  upon  one  or  two  of  the 
larger  articulations,  especially  the  knees  or  ankles.  Fibrinous  ankylosis 
usually  remains  as  the  resulting  condition.  In  infants,  however,  this 
condition  is  transitory,  as  a  rule. 

Complications  and  G-onorrheal  Septicemia  and  Pyemia. — Aaite  endocar- 
ditis may  be  of  gonorrheal  origin,  and  undoubted  instances  are  common. 
In  the  inflammatory  products  of  this  condition  Hering  has  found  the 
gonococci,  as  has  also  Councilman,  in  the  heart-muscles  (gonorrheal 
myocarditis).  Rarely,  gonorrheal  endocarditis  assumes  the  ulcerative  or 
malignant  form.  As  the  result  of  invasion  of  the  blood  by  the  gonococci, 
suppurative  arthritis  may  develop  and  form  a  part  of  gonorrheal  septice- 
mia. Instances  of  severe,  rapidly  fatal  general  infection  in  gonorrhea 
are  probably  always  associated  with  foci  of  suppuration  in  the  urinary 
tract  (Osier).  Among  the  widespread  complications,  emholic,  septic  pneu- 
monia, and  iritis,  deserve  special  mention. 

(2)  Chronic  Gfonorrheal  Arthritis. — This  occurs  {a)  as  a  serous  eff'u- 
sion {hydrarthrosis),  and  {h)  as  a  chronic  inflammation  of  the  articular 
and  periarticular  structures  (synovial  membranes,  bursa,  periosteum, 
and  tendons  with  their  sheaths).  The  former  is  usually  monarticular, 
settling  with  especial  frequency  in  the  knees,  and  may  be  wholly  pain- 
less.     The  latter  is  more  or  less  painful — causes  dense  swelling  of  the 


186  INFECTIOUS  DISEASES. 

joint,  and  frequently  of  the  structures  for  some  little  distance  above  and 
below  the  latter.  Both  forms  lead  to  great  restriction  of  motion.  The 
OS  calcis  may  be  the  seat  of  gonorrheal  periosteal  inilammation  with  or 
without  exostosis.     It  is  sometimes  called  the  painful  heel  of  gonorrhea. 

The  diagnosis  cannot  be  determined  apart  from  the  history  of 
urethral  infection,  or  the  detection  of  the  gonococci  in  the  blood  or  the 
joint-eft'usion.  For  diagnostic  purposes,  Irons  uses  a  "gonococci"  of 
killed  bacteria,  suspended  in  glycerin,  making  inoculations  after  the 
method  of  von  Pirquot,  with  a  control.  A  papule  is  formed  in  a  few 
hours,  with  surrounding  hyperemia,  disappearing  by  the  third  day.  The 
reaction  is  classed  as  positive  when  over  5  mm.  in  diameter.  The  acute 
form  is  distinguished  from  acute  articular  rheumatism  by  the  more 
intense  pain,  the  extent  to  which  the  peri-articular  tissues  are  involved, 
and  the  negative  character  of  the  general  symptoms.  The  chronic  variety 
must  be  discriminated  from  chronic  synovitis  due  to  other  causes,  and 
this  often  proves  a  difficult  task. 

Treatment. — I  have  never  seen  the  slightest  benefit  from  internal 
medication  in  gonorrheal  arthritis,  except  possibly  from  the  use  of  mer- 
cury. J.  C.  Wilson '  has  obtained  excellent  results  from  massive  doses 
Tl^x-lx — 0.60-3.75  t.  d.)  of  the  syrup  of  iodid  of  iron.  There  is  much 
evidence  at  hand  to  show  that  chronic  gonorrheal  arthritis  is  favorably 
influenced  by  the  injection  of  gonococcus  vaccine.  Fuller  ^  reports  good 
results  from  seminal  vesiculotomy. 

Local  measures,  however,  are  of  paramount  importance.  Absolute 
rest  to  the  part  is  indicated,  and  the  limb  should  be  placed  upon  a  splint ; 
then  after  making  an  appropriate  anodyne  application  (ungt.  ichthyol. 
or  ungt.  belladonnie),  it  should  be  bandaged  as  firmly  as  possible.  In 
other  instances  complete  immobilization  in  plaster-of-Paris  dressing 
gives  good  results.  In  acute  cases  the  patient  should  be  anesthetized,  and 
after  the  procedure,  if  pam  be  great,  a  hypodermic  injection  of  morphin 
may  be  given.  Dry  heat,  either  sand-bags  or  the  heating  apparatus 
(oven),  is  useful.  In  chronic  forms  the  aim  should  be  to  remove  the 
effusion  and  swelling,  and  to  restore  the  natural  motility.  For  the  latter 
two  indications  massage  and  passive  movements  are  best.  Hydrar- 
throsis may  also  be  diminished  by  the  use  of  the  thermo-cautery,  at  in- 
tervals, and  blisters.  Willard  urges  removal  of  the  infecting  micro- 
organism by  arthrotomy  and  free  irrigation  with  antibacillary  fluids. 


VARIOLA. 

(Small-pox. ) 

Definition. — Variola  is  an  acute  contagious  disease,  characterized 
by  its  sudden  onset  and  severe  period  of  invasion,  followed  by  a  remis- 
sion of  the  fever  and  an  eruption  of  papules,  which  pass  through  the 
stages  of  vesicle,  pustule,  and  scab.  The  stage  of  pustulation  is  accom- 
panied by  secondary  fever.  Variola  runs  a  variable  course,  but  on  the 
whole  has  become  milder  far  in  character  in  recent  years. 

Historic    Note. — Smallpox    has    existed    from    the    earliest    anti- 

^  Jacobi's  FesLschnft,  1900. 

2  Medical  Record,  New  York,  June  15,  1912. 


VARIOLA.  187 

quity  in  India,  Africa,  China,  and  other  Eastern  countries.  During 
the  thirteenth  century  (1241)  it  entered  Enghuid,  in  the  early  part  of 
the  fourteenth  Ireland,  and  in  the  latter  part  of  the  fifteenth  Germany. 
In  1507  it  was  imported  to  America,  and  first  appeared  in  the  West 
Indies;  a  little  later  (1520)  the  Spanish  troops  conveyed  the  disease  to 
Mexico,  where  it  destroyed  not  less  than  three  and  a  half  millions  of 
people.  It  was  brought  to  the  United  States  from  Europe  in  1649,  and. 
gained  it  first  foothold  in  Boston,  whence  it  progressed  at  intervals  in  a 
westerly  direction  to  the  western  coast-line.  During  the  Spanish-Cuban 
war  the  disease  was  transferred  from  Cuba  to  the  Southern  States,  after- 
ward spreading  to  many  of  the  Northern  and  Western  States.  In  the 
United  States,  for  the  years  1903  and  1904,  there  occurred  42,590  cases, 
Avith  1,642  deaths,  and  25,106  cases  with  1,118  deaths  respectively 
(Wyman).  Variola  exhibits  great  variability  in  intensity  in  different 
epidemics. 

Pathology. — The  eruption  of  small-pox  consists  in  an  inflammatory 
cellular  infiltration  of  the  rete  mucosum,  and  has  four  successive  stages — 
(1)  Papular,  (2)    Vesicular,  (3)  Pustular,  (4)  Scab. 

(1)  The  Papule. — At  first  there  is  a  hyperemia  of  the  papillae  of  the 
skin  appearing  as  small  red  spots.  These  soon  become  round,  discrete 
patches  that  may  be  rolled  like  shot  under  the  skin,  and  then  become 
elevated,  owing  to  the  increase  in  the  cells  in  the  rete  mucosum. 

(2)  The  vesicle  appears  at  the  apex  of  the  papule,  and  results  from  a 
circumscribed  elevation  of  the  superficial  layer  of  the  epidermis  in  con- 
sequence of  the  mechanical  pressure  exerted  by  the  fluid  exudate,  which 
is  excited  by  peripheral  inflammation.  The  vesicle  is  not  unicellular, 
but  is  loculated  (fibrinous  reticuli),  and  contains  serum,  leukocytes, 
fibrin-filaments,  etc.  If  a  section  of  a  vesicle  be  made  early  through  the 
deeper  layers  of  the  rete  mucosum,  an  area  of  coagulation  necrosis  is 
observed,  due  to  the  presence  of  micrococci  (Weigert).  The  vesicle  shows 
central  umbilication,  which  corresponds  with  the  necrotic  area. 

(3)  The  pustule  is  formed  by  the  filling  of  the  reticuli  with  leukocytes. 
Cellular  infiltration  and  swelling  of  the  true  skin  beneath  the  pustule 
occur,  as  a  rule,  as  the  result  of  diapedesis.  Moreover,  suppuration 
may  involve  the  cutis  vera,  and  as  a  consequence  scarring  results.  In 
hemorrhagic  small-pox  the  reticuli  are  occupied  by  an  abundance  of  red 
corpuscles  which  have  passed  in  from  the  adjacent  blood-vessels,  and 
may  infiltrate  the  upper  as  well  as  the  deeper  layers  of  the  epidermis 
surrounding  the  vesicles  or  pustules.  The  pustules  may  dry  up,  but 
commonly  rupture,  and  in  either  case  the  result  is  (4)  scabbing. 

Recently  Councilman,  McGrath  and  Brinckerhofi"  have  described  the 
specific  lesion  as  a  focal  degeneration  of  the  stratified  epithelium,  accom- 
panied by  serous  exudation  and  the  formation  of  a  reticulum. 

The  eruption  has  run  an  atypical  and  even  abortive  course  in  the 
cases  occurring  in  recent  years.  An  early  maturation  of  the  papules 
has  been  observed ;  in  many  cases  they  became  solid,  conical  elevations 
with  a  small  vesicle  at  the  summit.  W.  M.  Welch  ^  states  that  the 
lesions  seemed  to  involve  only  the  outer  epidermis. 

The  mucosa  of  the  mouth,  pharynx,  and,  rarely,  the  esophagus  and 
the  rectum  may  be  the  seat  of  a  variolus  eruption,  and  the  plaques  of 
Peyer  may  be  somewhat  swollen.  The  eruption  also  appears  in  the 
1  Phila.  Med.  Jour.,  Nov.  18,  1899. 


188  lyFKCTiors  diseases. 

larynx,  the  tracliea,  bronchi,  conjunctivio  and  nasal  nniciisa.  where  ulcers 
rather  than  true  pustule.s  are  seen. 

Hemorrhagic  sraall-]iox  presents  extravasations  occurring  in  the 
serous  and  raucous  membranes,  the  connective  tissue,  the  parenchyma 
of  the  various  viscera,  and  also,  though  much  less  freijuently,  in  the 
nerve-sheaths,  bone-marrow,  lilood-vessel  walls,  and  the  muscles.  In 
this  form  the  spleen  is  firm  (Ponfi(dc,  Osier),  and  the  liver  is  sometimes 
enlarged  and  the  subject  of  fatty  degeneration.  Hemorrhagic  infarction 
of  rhe  lung  occurred  in  5  out  of  7  cases  examined  by  Usler. 

Secondary  Lesions. — The  catarrhal  inflammation  of  the  larynx  may 
extend  in  depth  till  it  touches  the  perichondrium  of  the  cartilages  (peri- 
chondritis), and  a  croupous  exudate  in  the  larynx  may  often  coexist 
with  edema.  Lesions  are  ])resent  in  the  lungs,  some  of  them  frequently 
(general  bronchitis,  bronchopneumonia),  and  others  rarely  (hypostatic 
congestion,  lobar  pneumonia),  and  pleuritis  may  be  observed.  Cloudy 
swelling,  diffuse  inflammation,  and  sometimes  fatty  degeneration  of  the 
liver  have  been  noted ;  the  spleen  is  enlarged  and  pulpy  as  a  rule.  The 
heart  may  show  myocardial  alterations — chiefly  parenchymatous  and 
fatty — and  rarely  endocarditis  and  pericarditis  occur.  The  kidneys 
show  cloudy  swelling,  an  acute  degeneration  of  the  epithelium,  more 
marked  than  in  other  infections,  occurs.  "An  acute  glomerulo-nephritis 
■was  found  in  5  cases  out  of  54  "  (Councilman).  Weigert  found  that 
at  the  commencement  of  the  stage  of  suppuration  the  microscope  revealed 
"small-pox  cylindric  masses  "  in  the  various  viscera  (coagulation  necrosis). 

Ktiology. — Bacteriology. — The  recent  investigations  of  Councilman 
and  his  associates  have  resulted  in  the  discovery  of  a  protozoon  in  the 
epithelial  cells  of  the  lesions.  There  are  tw^o  cycles  of  development, 
intracellular  and  intranuclear,  the  latter  only  occurring  in  small-pox. 
Transmission  of  these  organisms  by  the  dried  epithelial  scales  may  be  re- 
sponsible for  the  spread  of  the  disease.  These  findings  have  been  con- 
firmed by  Calkins  and  Howard  and  Perkins  of  Cleveland.  M.  Funck  ' 
found  protozoa  (probably  the  same  organisms  previously  described  by 
Pfeiifer)  in  all  vaccinia  pustules  examined.  They  are  usually  from 
1//  to  3;/  in  diameter,  and  larger  cyst-like  bodies  filled  with  spores  also 
occur.  Iskigami  ^  has  also  discovered  protozoon-like  bodies  in  the  epi- 
thelial scales  of  the  vaccine  pustules,  lymph,  etc.  Haushalter  and 
Etienne^  consider  the  hemorrhagic  symptoms  in  small-pox  due  to  sccond- 
arv  infection  with  the  streptococcus,  since  they  have  found  this  organism 
in  the  blood  of  those  dead  of  hemorrhagic  variola.  Widal  and  l^abrazes 
have  also  noted  the  streptococcus  in  autopsies  upon  small-pox  cases. 

Predisposing  Causes. — The  receptivity  for  variola  is  wellnigh  universal, 
and  among  the  few  who  have  enjoyed  immunity  were  three  distinguished 
physicians — Diemerbroeck,  Boerhaave,  and  Morgagni.  It  may  be  said 
that  one  attack  confers  permanent  immunity,  but  exceptionally  a  second 
or  even  a  third  may  occur.  Vaccination,  also,  if  successful,  affords  future 
protection  against  variola,  but  to  this  rule  exceptions  are  not  infrequent. 

Age. — All  periods  of  life  are  liable  to  the  disease,  but  the  very  young 
are  affected  in  a  relatively  larger  proportion  than  older  persons.  During 
the  entire  puerperal  stage  there  is  an  increased  liability  to  the  disease. 

1  Deutsch.  Med.  Woch.,  Feb.  23,  1901. 

'  Jour.  Amer.  Med.  Askoc,  Dec.  6,  1902 ;  cited  from  Sei-1.  Kwai  CTokio)  xxi. 

'  Saunders'  Year-Book  for  1899. 


VARIOLA.  189 

It  rarely  affects  the  fetus  in  utcro,  and  most  babes  oven,'whf>  are  exposed 
to  the  virus  at  the  time  of  birth,  will  not  take  the  disease  if  immediately 
and  successfully  vaccinated. 

Sex  is  without  influence. 

Season. — In  temperate  climates,  most  cases  occur  during  the  winter 
months.  On  the  other  hand,  in  tropical  countries  it  is  said  that  the 
worst  cases  occur  during  the  hottest  months. 

Ra,ce. — Among  uncivilized  peoples  variola  spreads  with  frightful  ra- 
pidity, the  negro  and  other  very  dark  races  being  affected  in  lai-ger  num- 
bers and  more  severely  than  whites,  since  they  are  not  so  generally  vac- 
cinated.     A  dread  of  the  infection  predisposes  to  its  occurrence. 

The  Contagion ;  where  Found ;  Modes  of  Conveyance  and  of  Infection. — 
One  case  of  variola  is  prima  facie  evidence  of  the  existence  of  another, 
the  poison  having  been  transferred.  The  specific  poison  exists  in  the 
blood  and  in  the  secretions  and  excretions  (most  probably),  but  mainly  in 
the  pustules  and  dry  scabs  and  in  exhalations  from  the  lungs  and  skin. 
The  contagion  is  conveyed  principally  from  the  sick  to  the  healthy  by  the 
dust-like  particles  of  the  dried  scabs. 

Modes  of  Infection. — (a)  Inoculation  with  either  the  blood  or  the 
contents  of  the  eruption  or  the  dissolved  dry  scabs  is  followed  by  variola. 
(6)  Contact  with,  or  proximity  to,  a  patient  suffering  from  small-pox  is 
very  apt  to  convey  the  poison,  with  resulting  variola  in  the  person  thus 
exposed.  To  what  distance  the  contagion  can  be  conveyed  through  the 
air  is  not  known,  but  it  is  probably  considerable ;  and  all  authors  are 
agreed  that  it  is  one  of  the  most  infective  diseases  with  which  we  are 
acquainted.  It  is  contagious  from  the  earliest  active  stage  to  the  end 
of  convalescence,  and  possibly  even  during  the  stage  of  incubation. 
(c)  Transmission  hj  fo7nites  is  common,  the  poison  adhering  to  clothes, 
body-  or  bed-linen,  etc.,  and  evidence  is  not  wanting  to  show  that  the 
poison  is  highly  tenacious  of  pathogenic  power.  Its  vitality  is  retained 
after  death,  and  the  room  occupied  by  a  patient,  the  bedding,  and  the 
articles  of  furniture  all  serve  to  convey  the  disease  unless  thorough  dis- 
infection be  enforced.  The  infection  atrium  for  the  poison  into  the  sys- 
tem is  probably  the  respiratory  tract. 

Clinical  History. — Incubation. — This  stage  varies  with  the  mode 
of  communication  of  the  poison.  If  following  inoculation,  the  symp- 
toms appear  in  six  or  seven  days  ;  when  originating  from  infection,  usually 
in  twelve  days,  though  this  stage  may  be  either  lengthened  by  a  day  or 
two  or  shortened  to  an  equal  extent.  During  a  portion  of  this  period 
complaint  may  be  made  of  certain  ill-defined  symptoms,  but  these  are 
usually  absent.  Invasion  is  sudden  and  accompanied  by  characteristic 
signs.  These  are — a  severe  rigor,  liigli  fever.,  headache.,  and  intensf  linn- 
bar  pai7is.  Instead  of  the  usual  severe  rigor,  repeated  chills.  extendin<r 
over  twelve  to  twenty-four  hours,  may  occur.  The  symptoms  of  the 
onset  have  been  milder  in  the  recent  outbreaks,  although  similar  in 
character  to  the  severer  types  of  former  epidemics.  During  the  pre- 
liminary fever  the  respirations  are  accelerated,  the  pulse  becoming 
decidedly  more  rapid,  and  there  may  be  generalized  bronchitis.  The 
tongue  is  coated  and  slight  pharyngitis  may  exist.  There  are  anorexia, 
general  vomiting,  and  constipation  or  rarely  diarrhea.  Eestlessness, 
delirium,  and  stupor  are  the  principal  nervous  symj)toms  observed.  Infec- 
tive albuminuria  is  common.     In  the  female  menstruation  is  apt  to  occur. 


190  IXFECTIOUS  DISEASES. 

The  physical  signs  referable  to  tlie  lungs  are  few,  and  consist  of  a 
few  dry  and.  later,  moist  rales,  heard  on  auscultation.  Palpation 
detects  splenic  enlargement.  From  the  second  day  the  so-called  initial 
rashes  may  appear :  (a)  the  diffuse  scai-latinous  eruption,  which  in  no 
way  differs  from  ordinary  scarlatina ;  (b)  the  measly  eruption,  which 
may  be  diffuse  and  present  a  striking  similarity  to  that  of  measles. 
Either  associated  with  these  or  occurring  independently  there  may  be  a 
hemorrhagic  eruption  (usually  purpura),  the  petechiae  coming  out  by 
natural  selection,  mainly  upon  the  hypogastric  region  or  the  inner  sur- 
faces of  the  thighs  and  in  the  axillae  (Simon).  The  initial  rashes  occur 
in  a  considerable  proportion  of  cases  (10-15  per  cent.).  The  stage  of 
invasion  lasts  three  days  as  a  rule.  The  temperature  then  declines 
rapidly,  while  at  the  same  time  the  true  variolous  eruption  appears  upon 
the  skin  and  mucous  surfaces.  It  develops  first  upon  the  face,  par- 
ticularly upon  the  forehead  and  the  hairy  scalp,  and  spreads  in  a  down- 
ward direction  till  it  reaches  the  legs,  where  it  last  appears.  The  skin 
in  the  femoral  triangle  rarely  shows  the  true  variolous  eruption.  Each 
pock  passes  through  the  various  stages  noted  in  the  pathologic  descrip- 
tion— viz.,  papule,  vesicle,  pustule,  and  scab  ;  and  when  the  stage  of 
pustulation  has  been  reached  a  secondary  fever  develops.  During  the 
following  remission  of  fever  the  headache,  lumbar  pains,  etc.,  subside. 
The  fever  of  suppuration  which  then  succeeds  is  accompanied  once 
more  by  marked  constitutional  disturbances,  particularly  nervous  de- 
rangements (wild  delirium,  etc.),  and  at  this  time  complications  are  also 
apt  to  develop.  On  the  eighth  or  ninth  day  of  the  eruption  (the  tAvelfth 
or  thirteenth  day  of  the  disease)  the  pustules  begin  to  dry  up,  forming 
yellow  crusts ;  the  redness  and  swelling  of  the  skin  subside ;  and  two  or 
three  days  later  the  scabs  loosen  and  are  thrown  off.  During  this  stage 
the  fever  again  declines  in  company  with  the  constitutional  symptoms, 
and  convalescence  ensues.  As  previously  stated,  when  suppuration  in- 
volves the  true  skin  scars  are  the  inevitable  result.  The  hair  drops  off 
sometimes,  even  to  the  extent  of  total  alopecia,  but  is  generally  renewed. 

The  general  course  described  above  is  that  of  an  average  case,  but  the 
cases  met  with  in  the  recent  epidemic  appearances  in  numerous  sections 
of  this  country  have  been  unusually  mild,  and  also  manifested  strange 
features  ;  and  to  these  the  terms  "  modified  "  and  "  mitigated  "  small-pox 
may  be  appropriately  applied.  Although  not  all  cases  were  equally  mild, 
many  of  them  were  practically  ambulatory,  since  they  would  not  remain 
in  bed  after  the  eruption  appeared,  and  this  was  also  true  of  those  un- 
protected by  previous  vaccination.  There  was  little  or  no  secondary 
fever  and  desiccation  was  rapid.  Says  W.  M.  Welch,^  whose  experience 
is  unparalleled  :  "  I  must  say  I  have  never  seen  cases  present,  uniformly, 
so  mild  a  type  as  during  the  present  year  (1899),  nor  have  I  been  able  to 
find  in  the  vast  amount  of  literature  published  on  the  subject  any  account 
of  a  similarly  mild  epidemic  in  this  or  any  other  country."  During  the 
last  two  years  the  disease  has  resumed  a  more  typical  course,  both  as  to 
symptomatology  and  severity  of  type. 

Leading  Symptoms  and  Complications. — {a)  Eruption. — The  eruption 
in  the  more  typical  cases  appears  at  the  end  of  the  third  or  on  the 
fourth  day,  coming  out  first  upon  the  forehead,  particularly  along  the 
border  of  the  hairy  scalp,  and  spreading  in  a  downward  direction  in 

^  Loc.  cii. 


I'l.ATK  1. 


Variola  (Royer). 


VARIOLA. 


191 


regular  progression.  It  appears  in  the  form  of  slightly  elevated  rnacuUe, 
which  are  at  first  of  a  pale  red  color,  and  later  assume  a  darker  red 
hue,  resembling  small  fleabites.  These  increase  in  size  during  the 
next  forty-eight  hours,  at  the  end  of  which  period  they  are  developed 
into  (1)  papules.  The  change  of  character  is  accompanied  by  intense 
itching  and  burning  of  the  skin-surface.  To  the  feel  they  are  papular, 
like  shot  under  the  skin.  The  eruption  is  always  most  abundant 
upon  the  face  and  scalp,  while  the  hands  and  fingers  are  the  next  most 
favored  seats.  At  the  end  of  the  third  day  (the  sixth  day  of  the  disease) 
the  conical  apices  of  the  papules  contain  liquid,  forming  thus  (2)  vesicles. 
The  latter  increase  in  size  till  the  entire  papule  is  converted,  at  the  same 
time  acquiring  more  and  more  decidedly  a  central  umbilication.  Punc- 
turing a  vesicle  does  cause  it  to  collapse,  but  allows  only  a  small  por- 
tion of  its  liquid  contents  to  escape,  owing  to  its  reticulated  character. 
As  the  vesicle  increases  in  size  its  contents  become  opaque,  and  in  three 
days  more,  or  about  the  sixth  of  the  eruption,  the  vesicles  become  (3) 
pustules.  Umbilication  now  disappears,  and  the  pustule  looks  full  and 
well  rounded,  and  is  surrounded  by  a  red  border  or  "  halo."  If  the 
pocks  be  close  set,  as  on  the  face,  wrists,  and  fingers,  the  intervening 
skin  is  inflamed  and  swollen  and  the  itching  and  burning  become  almost 
intolerable.     The  pustules  may  coalesce  along  their  edges,  and  thus  the 


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Fig.  16.— Temperature-chart  of  a  case  of  variola,  from  a  patient  in  the  Municipal  Hospital,  Phila- 
delphia.   A.  F ,  aged  three  years ;  not  vaccinated. 

eruption  becomes  confluent.  The  eyes  are  closed  as  the  result  of  swell- 
ing and  tumefaction  of  the  face,  and  the  hands  and  feet  assume  a  rounded, 
ball-like  appearance.  The  face,  as  a  whole,  is  markedly  misshapen  and 
is  ultimately  disfigured.  When  the  pus  is  not  liberated  (a  comparatively 
rare  event),  its  desiccation  begins  on  the  ninth  day  (the  twelfth  day  of 
the  affection);  if  the  pustule  is  ruptured  earlier  (as  when  confluence 
occurs,  it  begins  at  an  earlier  day.  (4)  The  scabs  now  form,  and  remain 
until  about  the  twelfth  day  of  the  eruption,  and  when  pits  or  scars  result 
they  gradually  fade  until  they  remain  as  permanent  whitish  spots. 

The  eruption  upon  the  mucous  membrane  develops  simultaneously 
with  that  of  the  skin,  and  among  favorite  surfaces  for  its  appearance 
are  the  mouth,  tongue,  soft  palate,  and  pharynx  (causing  dyspha- 
gia),  the  nasal  chambers  (causing  coryza),  the  larynx  (causing  hoarse- 


192  lyFECTIOUS  DISEASES. 

ness),  the  trachea  and  bronchi  (causing  brcoichitis).  This  mucous  efflo- 
rescence does  not  proceed  to  the  development  of  pustules,  but  forms 
ordinary  ulcers  as  a  consequence  of  early  maceration  of  the  superficial 
layers  of  the  mucosa,  and  these  ulcers  also  may  become  continent. 

The  skin  presents  certain  complications  that  are  ahvays  secondary 
and  are  deserving  of  mention  (erysipelas,  abscess,  gangrene,  bed-sores). 

(/;)  The  Fever. — The  temjierature  at  the  onset  rises  rapidly,  and  may 
touch  lUo°  or  104°  F.  (40°  C.)  on  the  first  day,  its  range  being  high 
and  of  the  continued  type  during  the  invasion  period.  Evening  tem- 
perature of  105°  F.  (40.5°  C.)  or  higher  may  be  observed,  and  in  three 
days  (or  with  the  first  appearance  of  the  papules),  the  temperatore  remits, 
but  does  not  intermit  in  true  variola.  It  remains  at  a  low  elevation  till 
the  stage  of  suppuration  is  reached,  "when  a  fresh  rise  occurs.  This 
secondary  fever-curve  is  apt  to  show  exaggerated  points  of  elevation  and 
deep  remissions.  The  latter  are  generally  the  result  of  septic  absorp- 
tion (the  fever  of  suppuration).  Secondary  fever,  since  the  variolous 
infection  has  grown  milder  in  type,  is  often  slight  or  may  be  wanting 
(vide  supra).  This  period  lasts  from  one  to  three  or  four  days.  When 
desiccation  of  the  pustules  begins,  defervescence  also  commences,  and 
proceeds  in  a  gradual  manner  by  lysis.  There  may  be  a  post-variolous 
rise,  an<l  if  so,  its  presence  is  to  be  attributed  to  some  sequel  or  other. 

(c)  The  Circulatory  System. — The  puhe  is  soft  and  much  accelerated 
(100  to  loO)  and  of  good  volume  during  the  invasion  stage.  It  is  slower 
during  the  period  of  remission,  only  to  be  greatly  increased  in  frequency 
during  the  second  stage  of  fever.  During  the  latter  period  it  may, 
owing  to  cardiac  failure,  become  very  rapid,  and  finally  irregular  or  even 
intermittent.  Simple  endocarditis  rarely,  and  pericarditis  somewhat 
more  commonly,  occur  as  complications.  In  typical  cases  the  leukocyte 
curve  shows  two  exacerbations — one  about  the  eighth  day,  another  from 
the  twelfth  to  the  fourteenth  day. 

(d)  Respiratory  Tract. — The  laryngitis  and  pharyngitis  which  are  due 
to  the  presence  of  pocks  in  the  respiratory  mucosa  have  already  been 
mentioned.  Laryngeal  perichondritis  with  edema  of  the  glottis,  the 
latter  perhaps  being  the  result  of  a  direct  extension  of  the  pock-ulcers 
to  the  perichondrium,  may  arise ;  it  is  ominous.  Chief  among  the  grave 
secondary  complications  is  bronchopneumonia  (inhalation  pneumonia); 
and  lobar  pneumonia  also  occurs,  though  rarely.  Pleurisy  is  not  infre- 
quent, particularly  as  an  associated  condition  in  bronchopneumonia. 

(e)  The  Digestive  System. — The  variolous  efflorescence  in  the  buccal 
and  pharyngeal  mucosie  may  be  an  agency  in  predisposing  to  a  second- 
ary infiammation  in  adjacent  organs — e.  g.,  suppurative  otitis  media, 
suppurative  parotitis,  pseudo-diphtheria,  etc.  Palpation  almost  always 
shows  an  enlarged  spleen,  and  not  infrequently  an  enlarged  liver.  The 
vomiting  which  is  usual  at  the  onset  is  due  to  a  catarrhal  condition  of 
the  stomach.  Constipation  is  common,  but  diarrhea  is  also  sometimes 
met  with,  being  excited  by  a  catarrh  of  the  large  intestine,  and  is 
especially  common  in  children.  The  pocks  may  be  found  in  the  rectum 
and  they  sometimes  excite  dysenteric  symptoms. 

(/)  The  Nervous  Symptoms. — The  chief  of  these  have  been  already 
pointed  out.  Violent  delirium  (previously  alluded  to)  may  be  followed 
by  fatal  coma,  and  in  children  convulsions  may  be  seen.  Very  rarely 
paraplegia  has  been  observed  during  the  attack,  though  it  is  more  com- 


VARIOLA.  193 

mon  during  tlie  convalescence,  and  is  then  due  to  different  causes,  such 
as  peripheral  neuritis  and  disseminated  myelitis  (Westnlialj.  Multrple 
neuritis  may  he  a  se(|uel  or  tlie  pharyngeal  nerve  may  alone  be  afTected, 
Among  other  conditions  rarely  arising  during  convalescence  are  insanity, 
epilepsy,  aphasia,  and  hemiplegia. 

[g)  The  joints  may  be  swollen  and  painful  after  small-pox,  and  in 
rare  cases  periostitis  may  be  observed. 

(A)  Renal  Symptoms. — Welch  and  Schamberg  ^  made  analyses  of  the 
urine  in  128  cases  of  variola,  and  found  the  presence  of  albumin  in  05 
per  cent,  and  tube-casts  in  45  per  cent.  ;  they  believe  that  the  albuminuria 
in  most  cases  is  the  expression  of  a  structural  change  due  to  the  small- 
pox poison.  The  clinical  symptoms  of  variolous  nephritis  are  mild  as  a 
rule.     Hemorrhagic  nephritis  may  occur,  but  it  is  rare. 

{i)  The  Special  Senses. — The  pustules  may  form  upon  the  conjunctivae 
and  eyelids,  and  several  important  conditions  result  from  this  variolous 
involvement  of  the  eye — viz.,  conjunctivitis,  keratitis,  choroiditis,  and 
panophthalmitis.  Hebra  met  with  ocular  complications  in  1  per  cent,  of 
5000  cases  of  smal!-pox.      Otitis  media  has  already  been  mentioned. 

Special  Clinical  Forms. — There  are  two  unusual  types  of  variola 
that  are  important  in  being  severer  than  the  moderate  (discrete)  form. 

(a)  The  Confluent  Form. — This  is  the  result  of  an  abnormally  severe 
infection,  and  is  less  common  than  formerly.  The  vshering-in  Hywptom» 
are  very  severe,  and  the  eruption  may  appear  as  early  as,  or  even  before, 
the  third  day,  when  the  temperature  remits.  The  separate  papules  are 
vastly  more  abundant  and  close-set ;  and  after  the  stage  of  pustule  is 
reached  the  face  and  hands  present  an  uninterrupted  area  of  suppuration. 
The  deformity  of  the  countenace  is  correspondingly  pronounced.  Nat- 
urally the  local  symptoms  are  intense  and  the  fever  and  its  concomitants 
are  in  exact  proportion.  The  nervous  symptoms  often  predominate. 
Salivation  is  frequent.  The  eruption  may  also  entirely  cover  the  mucous 
surfaces.  The  lymphatics  of  the  neck  may  be  greatly  swollen — a  cir- 
cumstance that  contributes  to  the  facial  disfigurement.  The  various  com- 
plications previously  adduced  are  of  comparatively  frequent  occurrence, 
and  following  these  a  general  pyemic  process  may  develop.  When  death 
occurs  it  is  usually  preceded  by  the  typhoid  state  (typhomania,  tremors,  a 
rapid,  feeble  pulse,  dry,  brown  tongue,  and  diarrhea).  On  the  other 
hand,  if  recovery  ensues,  it  is  tardy. 

{h)  Black  Small-pox. — In  this  form  the  blood  is  much  changed,  so  that 
hemorrhages  into  the  skin,  mucous  membranes,  and  various  viscera  occur. 
It  is  important  to  distinguish  several  sub-varieties,  as  follows  :  (1)  A 
henign  form,  in  which  blood  is  infused  into  the  pustules  when  patients  are 
allowed  to  leave  their  bed  too  early  in  convalescence.  Here  the  condition 
is  due  to  the  effect  of  gravitation,  and  hence  is  confined  almost  solely  to 
the  lower  extremities.  (2)  Doubtless  the  ordinary  variolous  eruption  may 
become  slightly  hemorrhagic  without  aggravating  the  constitutional  con- 
dition. (3)  A  c?an^gro^tsAemorr^ag'^6' tendency  may  be  manifested.  During 
any  of  the  eruptive  stages — papular,  vesicular,  or  pustular— ^hemor- 
rhages may  occur  into  the  eruption,  and,  moreover,  free  bleedings  may 
take  place  from  the  various  mucous  surfaces.  The  initial  symptoms  are 
usually  intense,  the  eruption  abundant,  and  in  consequence  of  the  hemor- 
» Phila.  Med.  Jour.,  Dec,  1902. 
13 


194  INFECTIOUS  DISEASES. 

rhages  collapse  often  occurs.  The  most  serious  complications,  pneumonia, 
diphtheria,  and  nephritis  (followed  by  uremia),  are  also  apt  to  develop 
and  terminate  life.  This  and  the  subsequent  sub-variety  are  truly 
anomalous.  (4)  A  not  uncommon  form  is  met  with  in  wliich  the  acute 
hemorrhagic  diathesis  develops  during  the  period  of  invasion.  Its  onset 
is  characterized  by  the  usual  symptoms  intensified,  and  as  early  as  the 
second  day  ecchymotic  patches  appear  upon  the  skin  surface  and  grow 
rapidly  by  peripheral  extension,  the  mucous  surfaces  also  showing  more 
or  less  extensive  ecchymoses.  The  variolous  eruption  rarely  appears, 
though  occasionally  shot-like  papules  may  be  detected.  The  tempera- 
ture may  be  slightly  elevated,  but  is  rarely  high.  Death  often  occurs 
before  the  time  for  the  appearance  of  the  characteristic  eruption. 

There  are  also  varieties  of  small-pox  that  pursue  an  abnormally  mild 
course.  Of  these  (c)  varioloid  deserves  first  place.  By  this  term  is  usually 
meant  small-pox  occurring  in  individuals  who  have  been  protected  by  a 
successful  vaccination,  but  it  may  also  be  the  result  of  natural  insus- 
ceptibility. Hence  variola  and  varioloid  are  one  and  the  same  affection. 
The  initial  symptoms  of  varioloid  do  not  differ  either  in  character  or 
severity  from  those  of  true  variola,  but  the  general  course  of  the  attack 
is  peculiarly  prone  to  manifest  irregularities.  In  the  pre-eruptive  stage 
an  erythematous  rash  is  very  common,  and  its  appearance  is  regarded 
by  many  as  being  of  value  in  discriminating  varioloid  from  variola. 

When  the  regular  eruption  appears,  the  fever  falls  to  normal  and 
remains  there.  The  rash  comes  out  by  the  end  of  the  first  or  on  the 
second  day,  the  papules  being  scanty,  but  may  appear  first  upon  the 
trunk,  not  the  face.  They  are  identical  with  the  papules  of  variola,  as 
is  true  also  of  the  vesicles  ;  but  pustulation  rarely  develops,  since  reso- 
lution takes  place,  but,  as  a  rule,  before  the  latter  stage  is  reached. 

The  secondary  fever  is  either  very  slight  or  entirely  wanting.  The 
mucous  surfaces  are  affected  only  slightly.  Papules  and  vesicles  may 
be  found  in  close  proximity  ;  not  so  in  variola.  Desiccation  begins 
between  the  fifth  and  seventh  days  of  the  eruption  (the  eighth  and  tenth 
of  the  disease),  and  hence,  as  compared  with  variola,  the  course  is  cut 
short  and  serious  complications  almost  never  occur.  There  has  been 
noted  the  same  marked  tendency  to  extreme  mildness  of  phenomena 
that  characterize  variola  in  the  recent  epidemics. 

(cZ)  An  abortive  form  is  occasionally  observed.  It  is  characterized 
the  intensity  of  the  invasion  symptoms,  but  these  subside,  and  the  pati- 
ent enters  at  once  upon  a  stage  of  speedy  recovery. 

An  exceedingly  mild  type  may  arise  during  seasons  of  epidemic  preva- 
lence of  the  disease,  either  with  or  without  a  scanty  and  undeveloped 
eruption  ;  the  diagnosis  is  made  from  the  etiologic  circumstances. 

Diagnosis. — With  a  clear  history  and  the  presence  of  the  cliarac- 
teristic  features  a  positive  diagnosis  is  a  simple  problem.  But  at  any 
period  before  the  papules  are  fully  developed  it  may  l)e  confounded  with 
certain  other  acute  infections,  notably  cerebro-spinal  meningitis,  typhus 
fever,  scarlatina,  and  measles.  After  the  variolous  eruption  makes  its 
appearance  the  disease  may  be  confounded  with  impetigo  contagiosa, 
pustular  syphiloderm,  and  varicella.  Councilman^  advocates  two  meth- 
ods to  decide  the  diagnosis:  one  is  by  corneal  inoculation  on  the  rabbit, 
the  other  direct  microscopic  examination  of  the  suspected  lesion. 

^  Osier's  Modern  Medicine,  vol.  ii,  page  295. 


VARIOLA.  195 

Differential  Diagnosis. — In  typhuH  fever  the  onset  is  very  like  that  of 
small-pox.  The  former  may,  however,  be  distinguished  by  its  peculiar 
etiologic  factors,  especially  its  origin  by  importation  or  its  non-prevalence 
in  the  vicinity  ;  the  appearance  of  the  eruption,  first  upon  the  trunk 
(chest  and  abdomen)  in  the  form  of  macul3e,  and  later  becoming  pete- 
chial. Moreover,  in  typhus  the  temperature  does  not  remit  with  the 
appearance  of  the  eruption. 

From  hemorrhagic  small-pox  typhus  is  sometimes  distinguished  with 
great  difficulty.  In  the  former  death  often  occurs  before  the  eruptive 
stage  is  reached.  In  typhus  shot-like  papules  are  never  detected, 
whereas  they  are  sometimes  found  in  hemorrhagic  small-pox. 

Hemorrhagic  small-pox  may  be  simulated  by  cerebrospinal  m^eningitu. 
If  the  history  be  not  clear,  lumbar  puncture  will  settle  the  doubt. 

Scarlatina  may  early  be  distinguished  fromi  the  erythematous  (scar- 
latinous) rash  which  often  precedes  the  appearance  of  the  variolous  erup- 
tion ;  this  is,  as  a  rule,  neither  so  intense  nor  so  uniformly  distributed 
over  the  skin-surface  of  the  body  as  in  true  scarlatina.  Hemorrhagic 
scarlatina  may  readily  be  confused  with  black  small-pox. 

The  macular  stage  of  the  eruption  may  be  confounded  with  measles. 
The  absence  of  the  characteristic  prodromes  and  symptoms  of  invasion 
belonging  to  the  latter  disease,  the  redness  and  swelling  of  the  conjunc- 
tivae, the  photophobia  and  marked  coryza,  the  stubborn  cough,  and 
increased  fever  after  the  eruption  appears,  make  the  separation  easy, 
as  a  rule.  After  the  maculae  develop  into  hard,  shot-like,  conical  papules 
the  scales  are  turned  in  favor  of  variola. 

Impetigo  contagiosa  presents  no  initial  stage ;  it  begins  as  vesico- 
pustules  (not  papules)  which  appear  "  on  the  normal  skin  and  are  super- 
ficial and  enlarge  by  peripheral  extension,  often  attaining  the  size  of  a 
10-cent  piece  and  having  a  flat  appearance  "  (W.  M.  Welch).  The  pa- 
tient may  infect  new  areas  by  scratching.      Scars  do  not  result. 

Syphilis  distinguishes  itself  by  a  milder  initial  stage,  by  the  indurated 
base  of  the  pustule,  by  the  appearance  in  crops  of  the  skin-lesions,  and 
by  the  polymorphous  character  of  the  latter.  There  is  neither  umbili- 
cation  nor  characteristic  pitting  after  the  scabs  fall,  but  a  coppery  hue. 

To  differentiate  certain  mild  cases  of  discrete  small-pox  (in  the  non- 
vaccinated)  and  varioloid  from  varicella  is  difficult.  In  the  table  below, 
however,  will  be  found  contrasted  points  of  distinction : 

Variola.  Varicella. 

History. 

Absence  of  previous  attack.  Same. 

Previous  or  existing  case  in  the  vicinity.      Traceable  to  previous  or   present  case  of 

varicella. 
Not  successfully  vaccinated.  Negative. 

Occurs  at  any  age.  More  commonly  in  childhood. 

Characteristic    pre-eruptive    stage — rash      Eruption  not  preceded  by  prodromes;  de- 

on  the  third  day.  velops  more  rapidly. 

Sacral   pain,    high  fever,   and   vomiting      Quite  uncommon. 

common. 

Eruption. 

Appears  first  upon  the  forehead,  extend-      Appears  first  over  parts  covered  by  clotii- 
ing  downward.  ing.     No  regular  procession  over  the 

body. 


1 96  INFECTIO  US  DISEASES. 

Variola.  Varicella. 

Eruptio7i. 

Vesicles  uniform  in  size,  umbilicated,  and  Vary  in  size,  sharply  elevated,  i-arely  um- 

deeper  seated.  bilicated,  and  feel  soft  and  velvety. 

Eruption  contains  serum,  later  pus.  Only  soruui.  nivini;;  pearly  translucency. 

Most  abundant  oil  face  and  fingers.  Most   abundant    upon    back    and    lower 

extremities. 

Various  stages  of  eruption  observed  at  Various  stages  side  by  side. 
points  removed  from  each  otlier. 

Pin-prick  does  uot  cause  collapse  of  ves-  Does  cause  collapse,  being  unilocular, 
icles,  being  niultilocuhvr. 

Secondary  fever  usually  present.  Absent. 

Park  found  that  monkeys  are  susceptible  to  inoculation  "with  small- 
po.x  virus,  whereas  tliat  taken  from  cases  of  varicella  produced  no  result. 

Prognosis. — The  prognosis  depends  upon  (a)  the  degree  of  severity 
of  the  type,  the  severer  forms  (confluent  and  certain  of  the  hemorrhagic) 
being  grave.  The  hemorrhagic  variety,  in  which  large  ecchymoses  sud- 
denly develop,  is  almost  invariably  fatal,  and  often  before  the  cases  have 
advanced  to  the  eruptive  stage.  The  aggregate  number  of  pocks  that 
appear  and  the  gravity  of  the  infection  are,  as  a  rule,  proportionate. 

(b)  The  prognosis  is  modified  by  individual  peculiarities  (age,  intem- 
perance). Thus  it  is  more  fatal  in  the  very  young  than  in  older  subjects, 
more  fatal  in  the  intemperate  than  in  the  temperate,  and  so  on. 

(c)  Complications  increase  the  death-rate  considerably.  Of  these, 
bronchopneumonia,  lobar  pneumonia,  acute  nephritis  with  uremia, 
septico-pyemic  conditions,  pseudo-diphtheritic  angina,  and  pericarditis 
are  most  potent  for  evil.  Among  the  foremost  serious  symptoms  may 
be  mentioned  excessive  vomiting,  wild  delirium,  coma,  a  temperature 
of  106°  F.  (41.1°  C.)  or  over,  urgent  diarrhea,  and  dysentery. 

The  death-rate  has  been  computed  to  be  between  If)  and  30  per  cent., 
varying,  however,  with  each  epidemic.  Welch's  statistics  from  the 
Municipal  Hospital,  Philadelphia,  are  as  follows :  In  2831  cases  of 
variola,  54.18  per  cent.,  while  in  2169  cases  of  varioloid  only  1.29  per 
cent.  died.  During  the  recent  widespread  prevalence  of  the  disease  in 
the  United  States  the  mortality  rate  was  unprecedentedly  low.  Welch 
and  Schamberg  found  the  death-rate  in  unvaccinated  persons  49.45  per 
cent,  in  the  blacks  and  44  per  cent,  in  the  whites. 

Treatment. — The  varied  indications  in  the  treatment  of  small-pox 
will  be  considered  separately  : 

(1)  Prophylaxis. — The  rules  that  have  been  laid  down  elsewhere 
(vide  Treatment  of  Typhoid  Fever)  for  disinfection  in  infectious  diseases 
must  be  rigidly  enforced  in  this  aifection.  Quarantine  [public  and 
private)  must  be  secured  if  the  deadly  progress  of  small-pox  is  to  be 
averted.  Absolute  isolation  cannot  be  carried  out  successfully  in  private 
houses,  and  in  view  of  this  fact  special,  well-efjuipped  hospitals  should 
be  provided  for  the  reception  of  the  disease.  It  is  important  also  to  re- 
member that  persons  who  have  been  afflicted  Avith  the  disease  cannot 
with  safety  to  others  resume  their  former  places,  either  in  the  family 
or  in  society  at  large  before  they  are  completely  convalescent.  The 
best  means  of  prevention,  however,  is  vaccination  (vide  p.  200). 

(2)  General  Management. — The  room  occupied  by  the  patient  should 


VARIOLA.  197 

be  large  and  freely  ventilated  (an  essential  matter,  though  strong  drafts 
are  to  be  avoided),  and  all  carpets,  curtains,  and  articles  of  furniture 
not  absolutely  needful  should  be  removed. 

The  diet  should  receive  careful  attention,  and  should  be  varied 
according  to  the  stage  of  the  afi'cction.  During  the  initial  stage  it 
must  be  restricted  to  liquid  nourishment  (milk,  animal  broths,  etc.), 
and  in  addition  cooling  drinks,  including  ice,  lemonade,  and  other 
of  the  various  fruit-juices  (diluted).  During  the  stage  of  remission 
we  may  add  soups,  jellies,  eggs,  toast,  and  with  the  onset  of  the  stage  of 
suppuration  a  supportive  diet,  reinforced  by  the  judicious  use  of  stimu- 
lants, is  an  essential  part  of  the  treatment.  Light  forms  of  nourishment 
must  now  be  given  in  definite  quantities  and  intervals. 

(3)  The  fever  and  associated  symptoms  during  the  invasion  stage  are 
best  controlled  by  the  cold  or  gradually  cooled  baths,  which  possess  all 
the  advantages  in  this  disease  that  they  command  in  typhoid  fever.  Cold 
sponge-baths,  the  ice-cap,  or  the  cold  pack  may  be  resorted  to  if  cold 
immersion  baths  are  not  accessible  to  the  patient.  The  internal  antipy- 
retics must  be  given  with  a  sparing  hand,  if  at  all,  and  only  as  anti- 
septic agents,   on  account  of  their  depressing  effects. 

The  therapy  of  this  stage  also  embraces  the  treatment  of  certain 
symptoms.  The  vomiting  may  be  incessant  and  exhausting,  and  chipped 
ice,  champagne,  dilute  hydrocyanic  acid,  and  cocain-hydrochlorate  should 
be  tried  in  the  order  mentioned.  If  diarrhea  be  severe  it  should  be 
checked  (though  neither  wholly  nor  suddenly)  bv^  the  use  of  arsenite  of 
copper,  the  acetate  of  lead  (gr.  ij — 0.1296)  and  opium  (ext.,  gr.  | — 
0.0162),  in  combination,  or  by  bismuth  salicylate  (gr.  v — 0.324)  and 
/9-naphtol  (gr.  iij — 0.1944).  The  nervous  symptoms  are  usually  re- 
strained by  the  cold  affusions,  but  occasionally  a  wild  delirium  may 
necessitate  a  combination  of  sodium  bromid  (gr.  x-xv — 0.648-0.972) 
with  the  deodorized  tincture  of  opium  (TTlv — 0.333),  given  every  two  or 
three  hours.  Very  often  the  wise  administration  of  stimulants  removes 
all  necessity  for  the  use  of  further  means  of  overcoming  the  nervous 
symptoms.  The  catheter  must  be  used  if  retention  of  urine  should 
occur.  For  the  intense  pains  that  belong  to  this  stage  no  other  remedy 
can  be  compared  with  morphin  sulphate  (gr.  ^  to  ^ — ^0.008  to  0.016),  to 
be  administered  hypodermically,  and  repeated  if  necessary. 

(4)  As  previously  stated,  the  eruption  appears  with  the  termination 
of  the  initial  febrile  period,  and  deserves  the  closest  attention.  The 
indications  are  twofold :  (a)  to  limit  the  eruption  as  far  as  is  possible, 
and  (b)  to  modify  its  course,  so  that  extensive  suppuration  and  conse- 
quent disfigurement  may  be  prevented.  Ablutions  with  lukewarm  water, 
to  which  may  be  added  some  antiseptic  (carbolic  acid  and  glycerin,  or, 
better,  a  mercuric-chlorid  solution — 1  :  5000  or  1  :  10.000)  will  be  found 
of  great  use.  To  prevent  pitting  many  local  applications  have  been 
used.  Formerly,  a  common  mode  of  treatment  was  to  open  the  pustules 
as  early  as  possible  and  touch  them  with  silver  nitrate — either  in  the 
solid  stick  or  brushed  over  in  a  strong  aqueous  solution.  The  formula 
of  Schwimmer,  herewith  given,  gave  excellent  results  in  a  case  of  my 
own  : 


198  INFECTIOUS  DISEASES. 

^.  Plienolis,  4.0-10.0; 
01.  olivce,  40.0 ; 

Cretae  prreparat.,  60.0. 

M,  et  ft.  pastamolis. 

It  has  been  recommended  to  touch  each  pustule  with  carbolic  acid,  then 
to  apply  this  agent  in  equal  parts  with  the  oil  of  thyme  (Sansom).  It  is 
important  that  only  a  certain  proportion  of  the  pustules  be  touched  at 
once.  Welch  and  Schamberg  recommend  painting  the  surface  with  tinc- 
ture of  iodine.  The  parts  must  be  kept  aseptic,  Avhile  irritation  from 
scratching  must  be  carefully  avoided.  Moore  and  Fingen  have  recom- 
mended the  use  of  red  curtains  or  shades  to  cut  out  certain  chemical  rays. 
N.  R.  Finsen  has  advocated  the  exclusion  of  daylight,  especially  the 
chemical  rays,  by  means  of  a  red  light,  the  skin  being  rendered  very  sensi- 
tive to  light  by  the  small-pox  infection.  The  supposed  eflfect  is  to  pre- 
vent pustulation,  and  hence  the  formation  of  pitting  or  scars.  A  saturated 
solution  of  potassium  permanganate  applied  to  the  exposed  regions  has 
been  recommended  instead  of  Finsen's  red-light  treatment,  which  acts 
similarly  in  that  it  excludes  certain  chemical  rays.  But  as  the  result  of 
treatment  of  test  cases  by  Schamberg,  Eicketts,  and  Byles,  the  claims 
made  for  red  light  have  not  been  substantiated.  The  daily  use  of  scrub- 
baths,  though  severe,  appears  to  prevent  vesiculation  and  the  further 
progress  of  the  eruption,  thereby  avoiding  pitting  (S.  M.  Wilson).  For 
the  itchina:,  Welch  and  Schambero;  recommend  an  ointment  containing 
2  drams  of  sodium  bicarbonate  in  1  ounce  of  petrolatum. 

During  convalescence,  warm  baths,  with  the  free  use  of  carbolic  soap, 
are  to  be  given  at  intervals  of  two  days  until  several  baths  have  followed 
the  separation  of  the  crusts. 

(5)  The  Period  of  Remission  of  Fever. — There  are  very  rarely  any 
symptomatic  indications  apart  from  those  presented  by  the  eruption.  It 
is  of  first  importance,  however,  to  support  the  powers  of  the  system. 

(6)  The  Suppurative  Stage. — All  measures  tending  to  support  the 
strength  of  the  patient  are  needed — the  mineral  acids,  with  the  elixir  of 
calisaya,  quinin,  strychnin,  etc.  Stimulants  are  often  required,  and  it 
may  become  necessary  to  give  them  unsparingly,  the  character  of  the 
pulse  being  the  physician's  principal  guide  as  to  dosage.  Gradually 
cooled  baths  of  the  usual  duration  or  warm  baths  somewhat  more  pro- 
longed give  excellent  results.  The  ulcers  in  the  mouth  and  throat  are 
best  relieved  bv  the  use  of  a  saturated  solution  of  chlorate  of  potassium 
in  water  as  a  gargle  or  in  the  form  of  an  atomizer  spray.  Ice  allowed 
to  melt  in  the  mouth  is  valuable.  Hemorrhages  demand  ergot  subcutan- 
eously.  Internally,  the  tincture  of  the  chlorid  of  iron,  gallic  acid,  the 
mineral  acids,  or  turpentine  may  be  administered. 

The  complications  are  not  numerous,  and  are  for  the  most  part 
secondary.  By  frequently  changing  the  position  of  the  patient  when 
bronchitis  is  present,  and  by  encouraging  him  to  cough  frequently, 
as  well  as  by  the  timely  use  of  stimulants  and  the  proper  care  of  the 
mouth,  pulmonary  complications  can  often  be  obviated.  Should  lobular 
pneumonia  occur,  the  plan  of  treatment  which  is  likely  to  meet  with 
most  success  may  be  briefly  put  thus :  Free  stimulation  with  alcoholics 
and  other  cardiants,  the  assiduous  use  of  cold  sponges  or  gradually  cooled 
baths,   and   nourishing   foods.     Laryngeal    perichondritis    with    edema 


VARIOLA.  199 

of  the  glottis  may  suddenly  demand  traclieotomy.  To  avoid  the  devel- 
opment of  bed-sores  an  air-cushion  should  be  provided,  if  needful.  Care 
should  also  be  exercised  to  prevent  ocular  complications,  and  their  occur- 
rence demands  supportive  treatment.  I  have  much  confidence  in  the  use 
of  cold  compresses,  instilling  into  the  eyes  at  the  same  time  a  solution  of 
boric  acid  (gr.  x  to  xv— 0.648  to  0.972— to  f.sj— 30.0j. 

(7)  Special  Modes  of  Treatment. — These  would  be  found  to  be  numer- 
ous, were  we  to  enumerate  all  of  them,  but  only  those  based  on  the  prin- 
ciple of  antisepsis  are  vi^orthy  of  notice.  According  to  one  plan,  which 
has  many  advocates,  antiseptic  agents  are  administered  internally.  The 
remedies  that  have  been  most  frequently  employed  in  this  manner,  and 
with  perhaps  the  most  promising  results  are  the  sulphocarbolates,  salol, 
sodium  salicylate,  carbolic  acid,  creasote,  mercuric  chlorid,  and  the  sul- 
phites. R.  A.  Woodson '  adopted  as  a  plan  of  treatment  in  the  Holguin 
epidemic,  daily  scrub-baths,  1-2000  mercuric  chlorid,  and  open-air 
treatment.  Du  Castel  advises  at  the  time  of  the  eruption  injections  of 
ether  morning  and  evening ;  during  the  day  a  solution  containing  2  or 
3  grains  of  the  extract  of  opium  is  to  be  given  in  divided  doses. 

Kinyoun,  Lundmann,  and  B^cl^re  have  used  the  serum  from  vacci- 
nated subjects  (human  beings  and  the  lower  animals)  or  from  variolous 
patients  in  advanced  stages  of  the  disease  in  the  treatment  of  small-pox. 
The  cases,  however,  are  insufiBcient  to  warrant  deductions. 

Special  Methods  of  External  Medication. — Talamon  recommends  a 
mercuric-chlorid  spray  for  small-pox  vesicles  and  pustules  as  follows : 

^.  Mercuric  chlorid,  gr.  xv  (1.0) ; 

Tartaric  acid,  gr.  xv  (1-0)  ; 

Alcohol  (90  per  cent.),  fejss      (6.0) ; 

Ether  to  make  fgjss     (45.0). 

Sig.  To  be  applied  as  a  spray  three  or  four  times  daily  for  one 

minute. 

It  is  essential  to  exercise  the  precaution  to  protect  the  eyes,  which  may  be 
covered  by  layers  of  cotton  dipped  into  a  saturated  solution  of  boric  acid. 
Talamon  advises  the  commencement  of  his  method  on  the  first  day  of  the 
eruption,  the  application  to  be  preceded  with  a  vigorous  washing  of  the 
face  with  soap,  which  may  be  rinsed  ofi"  with  boric  acid  and  then  dried 
with  absorbent  cotton.  After  the  spray  has  been  used  the  face  should 
be  covered  with  a  layer  of  a  50  per  cent,  glycerolate  of  mercuric  chlorid 
in  order  to  keep  the  skin  continuously  aseptic.  After  the  fourth  day  the 
number  of  sprayings  per  diem  is  gradually  lessened,  so  that  by  the  seventh 
day  they  may  be  discontinued ;  but  the  application  of  the  glycerolate 
should  be  continued. 

Talamon  added,  in  the  confluent  and  other  grave  forms  of  the  disease, 
general  mercuric-chlorid  baths,  lasting  for  three-quarters  of  an  hour  to 
an  hour.  The  buccal  and  pharyngeal  eruption  is  to  be  treated  by  gargles 
and  lotions  of  boric  acid. 

Convalescence. — A  furfuraceous  desquamation  may  persist   for   some 
time ;  it  is  to  be  treated  by  applications  of  oils  containing  some  disinfec- 
tant.    Convalescen.ce  is  not  established  until  desquamation  ceases. 
1  Saunders'  Year-Book,  1901. 


200  INFECTIOUS  DISEASES. 

VACCINATION. 

Historic  Note. — One  of  the  first  steps  in  preventive  medicine 
■was  tlie  praetice  of  inoculation  as  a  method  of  protection  against  the  in- 
fection of  small-pox.  It  had  been  practised  in  China  and  other  Asiatic 
countries  for  centuries,  and  Lady  Montague,  the  wife  of  an  English  am- 
bassador to  Turkey,  early  in  the  eighteenth  century  introduced  it  into 
England,  after  which  time  and  until  vaccination  was  known,  it  was  very 
extensively  practised  there. 

Pus  taken  directly  from  a  small-pox  pustule  was  introduced  beneath 
the  epidermis,  and  the  person  inoculated  developed  variola,  though  in  a 
milder  form  than  when  arising  from  ordinary  infection. 

The  objections  to  this  method  were  that  it  did  not  always  produce  a 
mild  form  of  variola,  a  small  percentage  of  cases  having  a  fatal  termina- 
tion, and  that,  however  mild  the  attack,  other  unprotected  persons 
brought  in  contact  with  it  were  as  liable  to  contract  virulent  small-pox. 

In  a  paper  published  in  1798,  Edward  Jenner,  a  physician  of  Glouces- 
tershire, England,  and  a  pupil  of  John  Hunter,  first  made  known  to  the 
world  the  value  of  vaccination.  Twenty  years  previous  he  had  observed 
that  persons  employed  in  dairies,  who  were  accidentally  inoculated  with 
cow-pox  were  insusceptible  to  the  contagion  of  small-pox.  and,  after  ex- 
perimenting all  these  years,  he  became  satisfied  that  inoculation  with  the 
vaccine  lymph  was  a  preventive  against  small-pox.  After  tlie  publication 
of  his  paper  he  was  subjected  to  ridicule  and  abuse  by  the  profession, 
but  through  his  persistence  he  was  finally  allowed  to  practise  his  method 
of  vaccination  in  the  wards  of  a  hospital,  and  in  the  course  of  a  few  years 
it  became  generally  recognized  and  was  practised  in  France  and  America, 
as  well  as  in  England.  Later,  the  method  fell  into  disrepute  for  a  time, 
owing  to  the  fact  that  certain  persons  who  had  been  vaccinated  subse- 
quently contracted  the  disease,  it  not  being  known  then  that  a  revaccina- 
tion  was  necessary  from  time  to'  time.  At  present  it  is  generally  held 
that  successful  vaccination  imposes  complete  immunity  against  variola. 

Vaccinia,  or  cow-pox,  is  a  mild  eruptive  disease  that  occasionally 
occurs  among  cattle,  a  similar  disease  being  produced  in  them  by  inocu- 
lation with  the  small-po.x  virus  from  man.  It  is  communicable  by  con- 
tact only,  and  is  usually  carried  from  one  cow  to  another  by  the  hands  of 
the  milkers ;  hence  being  usually  found  on  the  udder  or  teats  of  milch 
cows.  Since  Jenner's  time  many  theories  have  been  advanced  as  to  the 
exact  nature  of  this  disease  in  cattle,  and  at  the  present  day  the  subject 
is  still  in  dispute.  It  is  now,  however,  generally  conceded  that  if  cow- 
pox  is  a  distinct  disease,  originating  only  with  the  cow,  the  eruptive  dis- 
ease produced  in  this  animal  either  by  inoculation  of  small-pox  virus  from 
man  or  of  "grease"  from  the  horse  is,  at  least  in  all  essential  respects, 
a  disease  not  to  be  distinguished  from  primary  or  idiopathic  vaccinia. 
Guarnieri  has  described  certain  parasitic  organisms,  the  Cytorectes  Guar- 
nieri,  found  in  corneal  lesions  produced  by  the  injection  of  vaccine  lymph. 
This  observation  has  been  confirmed  by  PfeifFer  and  others,  but  the 
pathogenic  nature  of  these  protozoa  has  not  been  determined. 

The  vaccine  virus  consists  either  of  the  licjuid  contained  in  the  ves- 
icle or  of  the  scab  resulting  from  the  desiccation  of  the  pustule.  The 
former  is  furnished  from  vaccine  farms,  of  which  there  are  several  in  this 


VACCINATION.  201 

country,  is  then  dried  on  ivory  points,  and,  if  kept  in  a  cool  place,  re- 
tains its  virtue  for  a  week  or  ten  days,  or,  possibly,  longer,  but  should 
be  used  as  fresh  as  possible  to  ensure  a  successful  result.  It  is  also  some- 
times preserved  in  capillary  glass  tubes,  sealed  at  both  ends,  or  between 
glasses,  and  kept  in  this  way  it  is  less  liable  to  infection  tbrough  unclean- 
liness  in  handling.     The  scab  from  the  cow  is  not  used. 

The  Site. — The  point  usually  chosen  for  vaccination  is  on  the  arm 
over  the  insertion  of  the  deltoid  muscle  ;  but  in  girls,  for  cosmetic  reasons, 
it  is  sometimes  preferred  on  the  leg,  and  the  most  common  site  is  over  tiie 
junction  of  the  two  heads  of  the  gastrocnemius  muscle. 

Technique,  in  Vaccination. — After  the  part  selected  has  been  rendered 
surgically  clean,  gently  scrape  the  skin  with  an  aseptic  lancet  or  other 
instrument  until  serum  begins  to  exude.  If  by  too  vigorous  scraping 
blood  should  be  drawn,  it  must  be  carefully  dried  with  a  piece  of  sterile 
cotton  before  the  lymph  is  applied.  Hutchins  has  recommended  a  method 
in  vaccination  of  denuding  the  surface  of  the  skin  with  a  caustic  in  place 
of  the  lancet.  A  piece  of  cotton,  as  large  as  the  spot  to  be  denuded,  is 
wet  with  liquor  potassse  and  laid  on  the  skin  for  two  or  three  minutes, 
after  which  the  spot  is  wiped  dry  and  the  softened  epidermis  rubbed 
away  with  an  ink-eraser,  a  piece  of  soft  wool,  or  preferably  a  piece  of 
sterile  gauze  cotton,  when  the  vaccine  is  applied  in  the  usual  Avay.  The 
chief  advantage  of  this  method  is  its  painlessness. 

The  charged  end  of  a  vaccine  point,  covered  with  glycerinated  virus 
and  protected  by  a  thick  covering  of  paraffin,  is  now  gently  rubbed  over 
the  abraded  spot  and  the  limb  left  exposed  to  the  air  until  the  lymph  has 
been  dried  upon  it.  It  may  then  be  protected  by  a  piece  of  gauze 
strapped  on  it.  Humanized  lymph  is  still  preferred  by  some,  and  when 
this  is  used  the  "arm-to-arm  "  vaccination  is  best.  The  lymph  is  taken 
from  characteristic  vaccine  vesicle  (from  the  fifth  to  the  seventh  day)  of 
a  healthy  child  and  applied  directly  to  the  arm  of  another.  The  virus 
may  be  dried  and  preserved  for  use  as  in  the  case  of  bovine  virus. 

The  scab  resulting  from  a  vaccine  vesicle  on  a  healthy  child  was  for- 
merly quite  generally  used,  and  it  could  be  kept  a  long  time  without 
losing  its  virtue.  It  Avas  sure  in  its  action,  and  offered  the  advantage  to 
the  physician  of  being  easily  preserved ;  but  it  was  more  liable  to  become 
infected  than  the  lymph  when  preserved  in  the  usual  Avay,  and,  since  the 
vaccine  farms  are  so  convenientl}-  located,  lymph  may  be  obtained  from 
them  at  any  time  without  delay.  The  possible  danger  of  conveying 
syphilis  or  other  constitutional  disease  from  one  person  to  another  by 
means  of  humanized  lymph  should  lead  to  its  abandonment  in  favor  of 
the  bovine  lymph.  In  recent  years,  however,  bovine  virus  has  been 
shown  to  be  occasionally  infected  with  tetanus,  and  that  implantation  of 
the  tetanus  germs  at  the  time  of  vaccination  may  occur. 

Period  of  Life  for  Vaccination. — It  is  usually  advised  to  vaccinate 
infants  within  a  few  weeks  or  months  after  birth  ;  but  unless  small-pox  is 
prevalent,  it  is  best  tc  wait  until  the  latter  part  of  the  second  or  the 
beginning  of  the  third  year,  as  the  child  has  then  passed  through  its 
teething  period  and  W'ill  be  better  able  to  resist  the  effects  (slight  though 
they  may  be)  consequent  upon  vaccination.  If  an  epidemic  be  prevailing, 
vaccination  should  be  performed  during  the  first  week  or  even  the  first 
day  after  birth  ;  and  pregnant  women  should  receive  prompt  vaccination 
at  any  period  of  gestation  if  exposed  to  small-pox. 


202  INFECTIOUS  DISEASES. 

Time  for  Revaccination. — To  ensure  the  individual  against  infection 
be  should  be  revaccinated  at  puberty  and  every  few  years  afterward,  or 
at  any  time  wlien  small-pox  is  epideniic  or  is  liable  to  become  so. 

Symptoms. — After  vaccination  no  local  or  constitutional  effects — 
except  the  slight  irritation  due  to  scarification — are  noticed  until  the 
third  day.  rarely  as  late  as  the  fifth  or  even  sixth  day,  when  a  small  red 
papule  appears.  By  the  fifth  or  sixtli  day  a  vesicle  appears.  By  the 
ninth  day  it  is  fully  developed,  and.  like  the  vesicle  of  variola,  is  filled 
■with  colorless  lymph,  is  uuibilicated,  multilocular,  and  has  a  distinctly 
infiamed  areola  of  deep  red  color,  accompanied  by  heat,  itching,  and 
tenderness.  By  the  tenth  day  this  may  extend  an  inch  or  two  from  the 
vesicle.  Quite  frequently  the  axillary  or  inguinal  glands  (depending  upon 
tlie  location  of  vaccination)  are  swollen  and  tender,  and  in  a  tubercular 
child  they  may  go  on  to  suppuration.  After  the  tenth  day  all  these 
symptoms  gradually  decline ;  tiie  pustule  dries  up,  and  then  forms  a 
brown  scab  which  is  usually  detached  in  the  third  or  fourth  week,  leaving 
a  permanent  cicatrix.     The  course  is  more  rapid  in  revaccinations. 

Complications. — Occasionally  one  or  more  additional  vesicles  are 
formed  at  a  little  distance  from  the  point  of  inoculation,  and,  rarely, 
there  is  a  general  vesicular  eruption,  due  to  absorption  of  the  lymph. 
An  erytliematous  rash  about  the  sixth  day  is  not  uncommon.  Erysip- 
elas may  occur  as  a  complication,  and,  if  it  is  prevalent  in  the  house, 
vaccination  should,  as  a  rule,  not  be  performed.  Among  other  rare  com- 
plications are  tetanus  {vide  p.  313)  and  the  hemorrhagic  diathesis. 

An  ulcer  may  form  which  may  be  weeks  in  healing.  Sexton  noted 
marked  improvement  from  the  constant  local  application  of  antistrepto- 
coccus  serum.  Eczema  and  other  skin  aifections  are  usually  aggravated 
during  the  course  of  vaccination,  and  it  is  possible  for  syphilis  to  be  in- 
oculated with  the  vaccine  virus.  Any  of  these  complications  call  for  the 
usual  treatment. 


VARICELLA. 

{Chicken-pox.) 


Definition. — An  acute,  contagious  disease,  characterized  by  a  cutane- 
ous eruption  of  papules,  passing  into  vesicles  and  pustules ;  also  by  slight 
fever  and  mild  constitutional  symptoms.  For  a  long  time  it  was  con- 
founded with  varioloid,  but  its  distinct  character  has  now  been  recognized 
for  many  years.     Complications  and  sequelae  are  infrequent. 

i^tiologfy. — The  virus  is  not  transmitted  by  the  inoculation  of  the 
vesicle  contents,  as  a  rule,  although  it  has  rarely  been  thus  communicated. 
The  specific  poison  has  not  been  satisfactorily  isolated,  but  it  is  suspected 
that  certain  protozoa  are  the  direct  cause.  Positive  proof,  however,  is 
wanting.  Varicella  may  be  transmitted  by  exposure  to  another  case  or 
possibly  through  the  medium  of  a  third  person,  the  school  and  asylum 
being  the  most  frequent  points  of  its  origin.  It  affects  children  of  all 
ages,  and  usually  one  attack  is  protective.  Doty  and  others  have  observed 
varicella  in  the  adult.    It  closely  resembles  measles  in  its  contagiousness. 


VARICELLA.  203 

Symptoms. — The  incubation  period  is  uniformly  from  fourteen  to 
sixteen  days.  If  there  be  a  prodromal  stage  of  tlie  disease,  certainly  in 
the  vast  majority  of  cases  it  cannot  be  recognized,  though  a  slight /ever 
and  general  indisposition  may  be  noticed  for  twenty -four  hours  before  the 
appearance  of  the  eruption.  In  many  cases  the  erujAion  is  the  first 
symptom.  This  occurs  in  the  form  of  small  reddish  puncta,  from  which 
rapidly  develop  rosy-colored  maculations,  and  these  become  densely  dis- 
tended, transparent,  or  slightly  yellowish  vesicles  of  the  average  size  of 
a  split  pea.  The  eruption  appears  first  upon  the  upper  part  of  the  body, 
the  chest  and  back,  neck,  scalp,  and  face  (on  the  latter  quite  sparingly), 
and  always  upon  the  hairy  scalp.  Frequently  the  vesicles  form  on  the 
mucous  surface  of  the  lips,  inside  the  cheeks,  on  the  tongue,  palate,  con- 
junctivae, and  in  the  progenital  regions  of  both  sexes.  At  times  the 
glands  of  the  throat  become  slightly  enlarged  and  painful,  the  vesicles 
are  superficial,  the  child  has  the  appearance  of  having  received  a  shower 
of  boiling  water,  and  the  firm  papule  which  precedes  the  variolous  rash 
is  altogether  wanting.  The  vesicles  are  at  first  transparent,  and  their 
contents  plainly  show  through  their  translucent  roof-wall  which  is  com- 
posed only  of  tne  stratum  corneum  of  the  epidermis.  The  contents  of 
the  vesicles  become  lactescent,  and  gradually  seropurulent.  The  areola 
is  most  distinct  when  the  vesicle  is  fully  formed  and  fades  as  the  latter 
dries.  Desiccation  begins  at  the  apex  of  the  vesicles.  Crusts  form, 
which  drop  ofi"  in  from  five  to  twenty  days,  depending  upon  the  depth  to 
which  the  skin  has  been  involved.  On  the  trunk,  as  a  rule,  no  mark  is 
left,  but  after  the  more  severe  attacks,  when  the  true  skin  has  been 
involved,  scars  remain,  and  frequently  there  is  quite  deep  pitting.  The 
marks  are  usually  on  the  face  when  the  skin  has  been  unprotected.  On 
the  hands  and  feet  the  vesicles  appear  without  having  been  preceded  by 
a  papule,  and  sometimes  there  is  no  areola,  each  vesicle  resembling  a 
drop  of  water  upon  a  healthy  skin.  Pustules  may  develop  in  conse- 
quence of  irritation  or  infection,  as  the  result  of  scratching,  or  in  feeble 
or  poorly  nourished  children,  and  in  unhealthy  children  deep  ulceration 
may  occur,  lasting  for  weeks. 

In  mild  cases  only  ten,  twenty,  or  thirty  spots  may  be  found  on  the 
body,  but  in  severe  cases  the  skin  may  be  almost  covered  in  certain 
regions.  The  eruption,  however,  is  never  confluent.  The  temperature 
is  highest  on  the  second  or  third  day,  when  the  eruption  is  appearing.  In 
mild,  uncomplicated  cases  the  thermometer  registers  101°  or  102°  F. 
(38.8°  C.)  for  two  or  three  days  at  most,  but  in  severe  cases  the  tempera- 
ture may  be  as  high  as  104°  F.  (40°  C).  This  is  usually  due  to  broken 
health  prior  to  the  acute  illness.  The  temperature  falls  gradually  as  the 
rash  fades,  and  presents  a  temperature-curve  similar  to  that  of  measles. 

There  is  usually  neither  coryza,  cough,  vomiting,  nor  diarrhea. 

Complications. — Erysipelas  occasionally  acts  as  a  serious  compli- 
cation in  delicate  children.  It  may  develop  about  the  pocks,  particularly 
when  they  are  deep  and  associated  with  some  ulceration,  and  scratching 
with  unclean  fingers  is  its  prime  causal  factor.  In  rare  cases  there  may 
be  necrotic  inflammation  about  the  site  of  the  pox  {varicella  gangrcenosa). 
Adenitis.,  mild  and  isolated,  and  suppuration  in  the  deeper  cellular  tissue 
may  occur. 

Nephritis  is  infrequent,  but  may  occur  in  carelessly  managed  cases. 
L.  Ceof^  has  collected  40  cases  of  nephritis  complicating  varicella. 
^Arch.  de  Med.  des  En/.,  Feb.,  1901. 


204  lyFECTIOUS  DISEASES. 

Varicella  is  also  quite  frequently  complicated  Avitli  other  infectious 
diseases,  and  varicella,  scarlet  fever,  and  measles  have  been  seen  curiously 
blended  in  ejiideiuic  form.  Ceof  has  reviewed  the  literature  and  found 
40  cases  of  scarlatiuiform  eruption  occurring  in  varicella.  Varicella  and 
measles,  however,  are  more  commonly  associated. 

The  diagnosis  of  varicella  offers  no  special  difficulties.  The  erup- 
tion comes  out  slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts 
may  be  seen  upon  the  skin  in  close  jtroximity.  Again,  it  should  be  noted 
that  the  umbilication  is  due  only  to  the  fact  that  the  drying  up  of  the 
vesicle  begins  at  the  center.  Varicella  is  distinguished  from  urticaria  by 
the  presence  of  fever,  and  from  eczema  pustulusunt  by  the  mild  febrile 
symptoms  of  the  latter,  the  discreteness  of  its  pustular  lesions,  the  absence 
of  itching  and  of  infiltration  of  the  skin  in  patches,  and  by  its  tendency 
to  symmetric  development. 

Variola  and  varioloid  of  infants  are  to  be  distinguishetl  from  varicella 
by  the  prodromal  symptoms,  and  by  the  greater  rise  of  temperature, 
though  the  distinction  between  mild  varioloid  and  severe  varicella  will 
always  tax  to  the  utmost  the  skill  of  the  keenest  diagnostician  [vide 
table,  p.  195).  The  sooner  it  is  understood  that  intermediate  forms  are 
likely  to  occur,  which  cannot  be  positively  assigned  to  one  or  the  other 
category,  the  better  it  will  be  for  both  the  profession  and  the  laity. 

The  prognosis  in  private  practice  is  always  favorable.  Only  in  the 
slums  or  iu  iiospital  cases  complicated  by  erysipelas,  adenitis,  gangrene, 
or  nephritis  may  grave  results  be  anticipated.  The  milder  cases  may, 
however,  leave  slight  monuments  of  their  existence  in  the  form  of  one  or 
more  depressed  cicatrices  which  may  mar  an  otherwise  beautiful  face. 

Treatment. — Isolation  should  be  enforced  in  schools  and  in  all  in- 
stitutions cDutaining  many  young  children.  In  private  houses,  unless  the 
younger  children  are  delicate,  quarantine  is  unnecessary.  The  disease 
may  be  transmitted  to  others  as  long  as  the  crusts  are  present,  and  hence 
isolation  should  be  maintained  until  they  have  fallen  off".  In  most  cases 
constitutional  symptoms  of  the  disease  are  so  mild  as  to  require  no  treat- 
ment. It  is  best  at  the  outset  to  place  the  child  in  bed  for  a  few  days, 
and  sponge  daily  with  warm  earboli/.ed  water;  the  local  itchin;^  may 
be  allayed  by  sponging  with  a  Aveak  solution  of  carbolic  acid  or  by  the 
use  of  carbolized  vaselin.  When  the  crusts  have  formed,  especially  on 
the  face,  an  ointment  of  zinc  oxid  containing  ichthyol  (2  per  cent.)  should 
be  applied,  and  care  should  be  exercised  to  keep  the  skin  clean  and  to 
prevent  scratching.  In  all  cases  the  urine  should  invariably  be  examined 
several  times  during  and  followintr  the  attack. 


SCARLET    FEVER. 

(Scarlet  Bash  ;  Scarlatina. ) 

Definition. — Scarlet  fever,  or  scarlatina,  is  a  self-limiting,  acute,  con- 
tagious disease,  characterized  by  vomiting,  fever  (more  or  less  typical), 
angina,  and  in  twelve  or  twenty-four  hours  by  a  diff'use,  punctiform,  scar- 
let eruption,  followed  by  membranous  desquamation  and,  frequently,  by 
nephritis.     It  is  a  disease  of  childhood,  but  may  occur  at  any  time  of  life. 


SCARLKT  FFA'KR.    ■  20o 

Scarlatina  is  a  widespread  disease,  though  perhaps  less  universal  than 
measles.  It  is  endemic  in  all  the  large  cities  of"  the  glohe,  and  at  inter- 
vals the  cases  multiply  into  more  or  less  extensive  epidemics.  Smaller 
towns  and  rural  districts  are  visited,  and  the  epidemics  are  usually  trace- 
able to  importation  of  scarlatinal  poison,  so  that  it  may  he  stated  that 
they  never  originate  de  novo. 

Pathology. — There  are  no  pathognomonic  changes.  When  death 
occurs  early  the  chief  lesions  are  presented  by  the  throat,  while  in  addi- 
tion engorgement  of  the  viscera  is  noted,  especially  of  the  brain.  "J'he 
exanthem  is  rarely  visible.  In  malignant  types,  however,  in  which  the 
eruption  is  not  seen  during  life,  it  makes  its  appearance  rarely  after  death, 
and  this  aids  in  establishing  the  nature  of  the  affection. 

When  death  occurs  at  an  advanced  stage  the  lesions  are  those  either 
of  nephritis  (with  dropsy),  or  of  septico-pyemia,  or  of  inflammation  of  one 
or  more  of  the  serous  surfaces  (pleurisy,  pericarditis,  endocarditis,  menin- 
gitis, etc.).  Additional  changes  in  the  various  viscera  are,  for  the  most 
part,  identical  with  those  met  with  in  other  acute  infective  diseases,  and 
hence  need  not  be  described  here.  The  blood  is  dark,  fluid,  and  coagu- 
lates feebly,  owing  to  a  decrease  in  its  fibrin  factors. 

Among  other  lesions  which  are  more  or  less  peculiar  to  the  disease  are 
(a)  The  eruption,  which  is  a  dermatitis  of  very  mild  grade.  J.  F. 
Schamberg  ^  points  out  that  the  discrete  vesicles  sometimes  seen  origin- 
ate in  the  hair-follicles  or  in  the  deeper  layers  of  the  rete,  and  contain 
a  turbid  leukocytic  fluid,  (b)  Scarlatinal  avgina^  which  in  its  mildest 
form  usually  presents  more  or  less  hyperemia  and  a  slight  swelling 
of  the  mucosa  of  the  tonsils,  soft  palate,  and  phai'ynx.  In  the  severer 
grades  the  inflammation  is  phlegmonous  (scarlatina,  anginosa),  and  some- 
times terminates  in  ulceration.  There  is  great  swelling  (especially  of  the 
tonsils),  and  the  formation  of  abscesses  is  common.  Extension  of  the 
purulent  inflammation  to  the  connective  tissue  of  the  neck  produces 
marked  induration,  and  more  or  less  extensive  abscesses  may  take  place. 
Gangrene  sometimes  supervenes,  [c)  In  certain  epidemics  a  inemhran- 
ous  exudate  accompanies  the  scarlatinal  angina.,  and  this  may  or  may 
not  be  truly  diphtheritic.  When  it  appears  early  it  is  non-diphtheritic, 
as  a  rule,  and  often  due  to  the  streptococcus ;  on  the  other  hand,  when  it 
comes  on  late  it  often  shows  the  presence  of  the  Loffler  bacillus.  Schabad 
has,  however,  shown  that  bacilli  taken  from  the  throats  of  incipient  cases 
of  scarlet  fever,  although  morphologically  characteristic,  have  little  or  no 
virulence.  There  is  also  a  malignant  form  of  membranous  scarlatinal 
angina,  occasioned  by  a  secondary  streptococcic  infection  (Hirschfeld). 
(d)  The  Nephritis. — The  renal  lesions  are  included  in  the  description  of 
"Acute  Bright's  Disease." 

Etiology. — The  bacteriology  of  the  affection  is  imperfectly  known. 
The  streptococcus  pyogenes  has  been  found  in  nearly  all  the  inflamma- 
tory complications  of  the  disease,  especially  scarlatinal  pneumonia  and 
angina,  and  some  pathologists  (Babes,  Berge,  Klein)  have  held  it  to  be 
the  cause.  Raskin  and  Mosny,  howevei",  believe  that  it  is  an  example  of 
mixed  infection,  the  streptococcus  being  merely  a  secondary  factor,  and 
Charlton  has  shown  it  to  be  the  cause  of  the  unfavorable  complications. 
1  Proc.  Phila.  Path.  Soc,  Jan.,  1901. 


206  INFECTIOUS  DISEASES. 

W.  J.  Class'  first  described  an  organism  {dijjiocoecus  scarlattnce) 
His  researches  have  been  confirmed  by  those  of  Gradwohl,-  Jaques,* 
Page,*  and  others.  The  habitat  of  the  diplococcus  is  not  known,  but  it 
has  been  found  in  the  blood,  throat,  epidermal  scales,  and  urine  of  scar- 
latinal cases.  The  size  of  the  organism  is  variable,  and  it  stains  with 
standard  -watery  dyes  easily,  uniformly,  and  regularly  (Gradwohl).  Class* 
reports  on  his  experiments  to  obtain  an  antitoxin  for  diplococcus  scarla- 
tina', in  which  he  was  successful.  SommerfiekP  has  found  the  constant 
presence  of  streptococci  in  the  tissues  and  blood.  This  may  be  the  same 
organism  as  the  Class  coccus. 

F.  A.  Mallory''  has  demonstrated  the  presence  of  protozoa  {cyclaster 
scarlatinaJis)  in  the  skin  in  early  stages  of  scarlet  fever.  They  are  best 
observed  on  the  second  day  of  the  cutaneous  rash,  and  usually  occur 
Avithin  the  epithelial  cells,  but  have  been  observed  also  in  the  lymph 
spaces  in  the  corium.  The  most  striking  form  is  a  rosette-shaped  body 
not  unlike  a  similar  appearance  seen  in  the  life  cycle  of  the  hematozoon 
of  Laveran,  and  about  one-third  larger  than  the  latter.  Yipond  claims 
to  have  found  a  bacillus  in  the  enlarged  axillary  and  inguinal  lymphatics. 

The  receptivity  for  scarlet  fever  is  not  so  great  as  in  certain  other  ex- 
anthemata {e.  g.,  measles) ;  hence  in  a  household  in  which  there  are  sev- 
eral children,  some  are  apt  to  escape  the  disease,  even  though  all  have 
been  equally  exposed.  The  virus  is  probably  contained  in  the  excretions 
from  the  throat,  nose,  or  ear,  and  in  the  epidermal  scales  thrown  off  from 
the  surface  of  the  body.     It  is  also  present  in  the  blood. 

Modes  of  Conveyance. — (a)  The  majority  of  the  cases  are  produced  by 
contagion,  and  I  have  observed  that  a  single  contact  of  a  healthy  child 
with  a  scarlet-fever  patient  suffices.  The  disease  may  also  be  transferred 
by  persons  who  have  been  in  the  sick-room,  wliile  they  themselves 
escape.  Aaser^  found,  out  of  3800  cases,  79  had  been  infected  by  dis- 
charged hospital  patients  from  one  to  five  wrecks  after  cessation  of  des- 
quamation (••return  cases  '").  The  source  of  infection  in  these  cases  is 
an  abnormal  secretion  due  to  some  local  aifection  of  throat,  nose,  or  ear 
associated  with  discharge,  {h)  It  is  also  communicated  by  fomites,  and 
the  poison  of  scarlatina  contained  in  clothing  retains  its  infective  power 
for  months.  Again,  any  objects  (furniture,  utensils,  library  books,  toys) 
which  the  patient  has  handled  may  serve  to  communicate  the  poison, 
(c)  Infected  dairies  have  been  known  to  disseminate  the  poison  and  give 
rise  to  epidemics.  ((/)  The  infection  may  also  be  air-borne,  though  not 
for  any  great  distance,  (e)  Behle  reports  an  outbreak  of  human  scar- 
latina in  swine  ;  and  kine  are  potent  to  transmit  it  to  man. 

Mode  of  Infection. — Most  probably  the  poison  is  inhaled  into  the 
throat,  where  infection  usually  occurs  :  but  it  may  gain  entrance  to  the 
body    through    the    alimentary  tract.     Infection    may    also    take  place 

'  Monthly  BuUetin  of  the  Chicago  Dept.  of  Health,  March,  1899. 

'  Philada.  Med.  Journ.,  March  24,  1900. 

^  BuUelin  N.  W.  Univ.  Medical  School,  March  31,  1900. 

*  Journ.  Boston  Med.  Sci.,  June  20,  1899. 

5  Philada.  Med.  Journ.,  .June  23,  1900. 

^  Arch,  fill-  Kind.,  Jan.,  1902. 

^  Medical  News,  Mav  14,  1904. 

^Nord.  Med.  Arch.  J190S,  Abt.  II.,  Anhang  51. 


SCARLET  FEVER.  207 

through  the  bloody  as  is  shown  by  the  fact  that  chihlrcn  have  been  horn 
in  all  stages  of  the  disease.  Artificial  inoculation  with  the  bhjod  of 
scarlatina  patients  has  resulted  in  more  or  less  typical  forms  of  the  com- 
plaint. Open  lesions  predispose,  but  whether  they  are  essential  to  in- 
fection is  not  known. 

Predisposing  Causes. — (1)  Age. — The  period  of  chief  liability  is  from 
the  second  to  the  tenth  year,  after  which  it  diminishes.  It  is  rare  under 
the  age  of  one  year,  and  especially  so  under  six  months.  (2)  Recent 
wounds — accidental  or  surgical — increase  the  susceptibility  to  the  pecu- 
liar poison.  (3)  Women  in  childbed,  for  the  same  reason  as  (2) ;  but  care 
must  be  exercised  lest  this  class  be  confounded  with  septic  affections.  (4) 
Season. — The  autumn  and  winter  months  furnish  the  most  cases.  (5) 
Seitz  believes  there  is  evidence  of  &  family  predisposition,  as  371  out  of 
800  cases  occurred  in  152  families. 

Immunity. — Single  attacks  during  the  life  of  a  person  form  a  rule  to 
which  there  are  rather  frequent  exceptions. 

Clinical  History. — The  incubation-period  is  variable,  lasting,  on  the 
average,  from  ten  to  fourteen  days  (McCollam).  It  may  rarely,  however, 
be  longer,  although  more  commonly  a  briefer  period,  three  to  eight  days. 

The  invasion  of  scarlet  fever  is  generally  quite  sudden  and,  as  a  rule, 
active.  The  child  feels  uncomfortable,  looks  stupid,  complains  of  sore 
throat  and  decided  nausea,  and  in  the  great  majority  of  the  cases  vomits. 
The  tongue  is  furred.  If  he  be  very  young,  nervous  symptoms  are 
prominent,  and  the  initial  symptom  may  be  a  convulsion.  The  pulse, 
which  is  a  strong  diagnostic  factor,  is  rapid  and  hard,  reaching  140  to 
160  at  the  very  onset.  The  temperature  rises  quickly  to  104°  or  105° 
F.  (40.5°  C),  and  remains  high. 

Eruption. — Within  the  first  twenty-four  or  thirty-six  hours  the  charac- 
teristic rash  appears,  and  is,  as  a  rule,  first  seen  on  the  neck  ;  there  is  no 
certainty  about  this,  however,  as  it  may  first  come  out  on  the  abdomen  or 
back  of  the  hands  or  on  the  thighs,  and  not  be  seen  on  any  other  part  of 
the  body.  Frequently  it  is  found  on  the  dependent  portions  of  the  trunk. 
At  first  it  is  slight,  but  perfectly  characteristic,  and  usually  takes  two 
days  to  mature.  In  mild  cases  it  disappears  within  thirty-six  to  forty- 
eight  hours,  and  at  no  time  is  more  than  a  very  fine  rash,  but  when 
typical  it  cannot  be  mistaken,  especially  if  accompanied  by  the  premoni- 
tory symptoms.  When  seen  from  a  short  distance  at  the  end  of  the  first 
twenty-four  hours  of  its  appearance  the  whole  body  (except  the  face)  is  of 
a  uniform  bright  scarlet  color.  If  we  examine  more  closely,  we  find  that 
the  eruption  consists  of  a  multitude  of  red  points  (puncta)  that  correspond 
to  the  hair-follicles.  These  points  are  surrounded  by  zones  of  erythem- 
atous redness,  which,  joining  with  one  another,  give  a  generally  difi'use 
red  appearance  to  the  whole  skin.  Frequently,  howevei',  the  rash  con- 
sists of  points  representing  the  hair-follicles  without  the  erythema,  and 
in  rough  skins  the  rash  may  be  more  punctiform — that  is,  more  strictly  a 
condition  of  "goose  skin."  Sudamina  are  quite  frequent.  Pressure  by 
the  finger  causes  a  pallor  which  at  once  disappears  when  the  finger  is 
removed.  The  patient's  lips  and  chin  are  pale  and  in  striking  contrast 
with  the  vividly  scarlet  cheeks.  In  some  cases  the  rash  is  patchy,  espe- 
cially on  the  limbs,  and  in  these  cases  it  may  suggest  measles,  the  patches 
consisting  of  clusters  of  fine  papules  or  points  with  much  surrounding 


208  ISFECTIOUS  DISEASES. 

ervtlicma,  while  normal  skin  is  present  between  the  patches.  An  intense 
continuous  linear  (.'xantheiu  in  the  skin  folds  at  the  bend  of  the  elbow 
(Pastias  sign)  is  supposed  to  be  ])roof  of  scarlet  fever.  In  severe  cases 
the  rasii  may  be  hemorrhagic  in  character,  minute  extravasations  of  blood 
taking  place  in  the  skin;  this  may  occur  even  in  mild  attacks,  and  not 
be  seen  until  after  death,  but  more  frequently  it  is  seen  in  malignant 
cases.  Purpuric  patches  are  frequently  found  after  death  when  even  in 
life  they  do  not  appear.     There  is  itching,  which  may  be  intense. 

The  rash  is  succeeded  by  a  des'fuamation  that  will  be  extensive  or 
slight  acconling  to  tiie  intensitv  of  the  fever.  In  ynild  cases  the  tonsils, 
palate,  uvula,  and  pharynx  are  deeply  congested,  and  the  mucosa  of  the 
cheeks,  palate,  and  tonsils  may  show  the  eruption.  In  severer  forms 
the  tonsils  are  red  and  inflamed,  and  covered  with  tenacious  secretions, 
while  minute  yellow  points  corresponding  to  the  tonsillar  crypts  are 
usually  prominent.  (  J'^ide  Malignant  Scarlatina.)  The  nasal  chambers 
are  swollen,  producing  a  free  discharge,  and  the  deefier  cervical  glands 
at  the  angle  of  the  jaw  are  freipiently  enlarged.  The  tongue  is  coated 
with  a  thick,  dense  white  fur  (dead  epithelium),  and  frequently  shows  a 
dry,  glazed  central  band.  In  a  few  days  the  dead  epithelium  is  cast  off, 
clearing  the  tongue,  when  we  have  a  red.  clean,  glazed  tongue  with 
greatlv  enlarged  fungiform  papillre.  giving  us  the  stratvberri/  tongue  of 
classical  history.  The  eyes  are  frequently  swollen  and  the  conjunctivae 
injected.  Sleeplcsi^ncsn  and  mild  delirhun  often  mark  a  typical  case,  sug- 
gesting a  congested  state  of  the  meninges,  but  it  is  neither  usual  fur  the 
child  to  be  violent  nor  for  the  delirium  to  continue  long. 

The  pulse  is  usually  a  strong  diagnostic  feature,  and  is  always  hard, 
quick,  and  wiry,  varying  from  14U  to  160;  its  rate  is  out  of  proportion 
to  the  temperature  and  the  general  condition  of  the  child.  Leukocytosis 
is  noted  ;  it  develops  early  and  is  most  marked  in  cases  showing  suppura- 
tive lesions.  This  leukocytosis  is  a  true  one,  i.  e.,  an  increase  absolute 
and  relative  in  the  polymorphonuclear  cells.  With  the  onset  of  defer- 
vescence there  is  a  constant  eosinophilia  (Tileston  and  Locke).  The 
temnerature  in  average  cases  reaches  104°  or  105°  F.  (40.5°  C),  and 
in  severe  forms  it  may  touch  106°  F.  (41.1°  C.).  the  nocturnal  remis- 
sions being  sliglit  and  defervescence  gradual  (ride  Fig.  17).  The  urine 
is  scanty,  thick,  and  contains  urates,  Avith  a  small  quantity  of  albumin. 

Within  one  week,  if  no  complications  have  occurred,  the  attack  will 
have  reached  its  height  and  the  .symptoms  have  begun  to  decline.  The 
rash  gradually  fades,  temperature  falls,  the  tongue  is  less  red,  the  throat 
less  inject"d,  and  the  child  seems  more  natural.  If  at  the  end  of  one 
week  the  fever  continues,  it  suggests  one  of  the  many  possible  comj)lica- 
tions,  the  most  frequent  of  which  are  a  throat  or  tonsillar  ulceration,  in- 
flammation of  the  cervical  glands,  otitis,  or  acute  nephritis  (common). 
It  must  be  well  understood  that  no  two  cases  of  scarlet  fever  are  alike. 

Clinical  Types. — Mild  Scarlet  Fever. — The  premonitory  symptoms 
are  sometimes  absent,  the  rash  being  the  only  indication  of  the  complaint. 
There  is  neither  vomiting  nor  fever  to  be  recognized,  and  no  tonsillar 
trouble  of  any  importance,  Avhile  the  rash  is  neither  uniform  nor  well 
marked.  In  these  cases  we  must  be  very  careful  not  to  confound  the 
eruption  w  ith  urticaria  or  some  of  the  many  medicinal  rashes. 

During  house  epidemics  when  several  children  are  affected  it  fre- 
quently happens    that    a    child    has    sore  throat  and    the    "  strawberry 


SCARLET  FEVER. 


209 


tongue"  without  a  development  of  tlie  nish.  This  may  also  occur  in 
adults,  and  is  the  so-called  scarlatina  nine  eruptione.  These  very  slight 
cases  of  the  fever  may  be  followed  by  the  most  severe  attack  of  nephritis. 

Here  may  be  mentioned  the  so-called  "'■fourth  disease,"  in  which  the 
symptoms  are  said  to  resemble  both  German  measles  and  mild  scarlet 
fever  and  yet  to  be  unlike  either.  It  is  to  be  recollected  that  "  the 
symptoms  may  be  caused  by  the  poisons  of  both  these  affections  acting 
simultaneously"  (Dent). 

Traumatic  scarlatina  is  that  form  in  which  infection  occurs  in  a 
wound.  The  eruption  makes  its  appearance  at  the  Avound,  and  then 
spreads  over  the  body  ;  it  is  less  severe  in  its  course  than  ordinary  scar- 
latina. 

Malignant  Scarlet  Fever. — Death  occurs  usually  by  the  end  of  the  first 
week  in  severe  cases,  Drs.  Ashby  and  Wright  reporting  a  death  within 
the  first  twenty-four  hours  (^atactic  form).  In  malignant  cases  such  as 
usually  occur  among  the  unhygienic  and  delicate,   the  tonsils   may   be 


-40" 


39' 


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Fig.  17. — Temperature-curve  of  a  case  of  scarlatina  with  favorable  course— William  C ,  aged 

seven  years. 


covered  by  a  membranous  exudate,  and  the  system  quickly  receive  an 
overwhelming  dose  of  the  poison ;  death  then  results  from  septic  causes 
{anginose  forrri).  In  cases  in  which  death  occurs  early  a  child  soon  be- 
comes cyanotic,  restless,  or  more  frequently  somnolent.  In  all  these 
cases  the  temperature  remains  high — 105°  to  106°  F.  (41.1°  C),  and 
very  frequently  107°  F.  (41.6°  C).  Diarrhea  is  frequently  a  trouble- 
some factor  in  severe  cases;    coryza  is  very  abundant;   there  is  much 


210  INFECTIOUS  DISEASES. 

glandular  swelling  and  cellulitis,  the  neck  becoming  enormouslv  enlarged 
and  hard,  the  skin  dull  and  livid  in  color ;  the  extremities  grow  cold ; 
the  heart  gradually  becomes  irregular,  losing  a  beat,  and  finally  fails. 

If  life  is  sustained  through  such  an  ordeal,  the  tonsils  slough  and 
the  lungs  may  eventually  become  the  seat  of  a  septic  pneumonia.  General 
septicemia  is  most  likely  to  occur.  In  this  condition  the  tonsils  ulcerate, 
sloughing  patches  appear  on  the  fauces,  the  glands  about  the  neck  be- 
come enlarged  and  doughy,  and  the  nasal  mucous  membrane  gives  out  a 
purulent  secretion  in  abundance.  The  temperature  may  remit,  but  con- 
tinues high ;  the  urine  is  albuminous ;  pus  wells  from  both  ears ;  and 
thus  the  child  is  gradually  consumed  and  perishes. 

A  third  variety  (honorrhagic)  shows  at  first  cutaneous  petechise 
which  grow  rapidly  into  large  ecchyraotic  patches.  Hemorrhages  also 
take  place  from  the  mucous  surfaces,  epistaxis  and  hematuria  being  very 
common.      Death,  as  a  rule,  follows  in  two  or  three  days. 

Desquamation. — By  the  end  of  the  first  week  the  rash  commences  to 
disappear,  the  skin  is  (or  soon  becomes)  mottled,  dry,  and  rough,  and 
gradually  the  scarf  skin  begins  to  separate.  This  process  usually 
begins  about  the  neck  and  trunk,  and  frequently  large  flakes  are  de- 
tached, the  Avhole  cuticle  of  the  hand  or  foot  sometimes  coming  off  in 
one  mass  like  a  glove.  The  degree  and  character  of  the  desquamation 
bear  some  relation  to  the  severity  of  the  eruption.  In  some  cases  the 
hair  and  nails  have  been  cast  off.  In  many  cases  desquamation  is  pro- 
longed to  the  eighth  week  ;  it  is  usually  longest  on  the  hands  and  feet. 

Complications. — Otitis. — The  inflammation  may  extend  from  the 
throat  along  the  Eustachian  tubes  to  the  middle  ear,  and  pus  be  formed 
in  the  tympanic  cavity,  making  its  exit  by  perforating  the  membrane. 
This  complication  may  occur  either  during  the  fever  or  at  some  time 
during  convalescence.  Suppuration  in  the  middle  ear  is  one  of  the 
common  causes  of  a  continued  high  temperature  after  the  disappear- 
ance of  the  rash.  Pain  in  the  ear  may  not  attract  our  attention  to 
this  unfortunate  complication ;  most  frequently,  however,  the  child  will 
place  its  hand  on  the  ear  and  shake  its  head,  as  if  to  get  rid  of  some 
source  of  in'itation. 

Pyemia. — Pyemia  and  abscess  of  the  lungs  may  follow,  and  throm- 
bosis of  the  lateral  sinus  may  occur.  The  tonsils  may  be  the  seat  of 
deep  ulceration,  and  the  soft  palate  may  slough  and  show  cicatrization 
of  the  soft  parts  of  the  throat  in  cases  which  may  yet  recover.  The 
cervical  glands  may  become  enlarged  and  suppurate,  either  during  the 
fever  or  while  the  child  is  convalescent.  In  debilitated  or  strumous 
children  this  complication  may  be  very  troublesome,  with  the  formation 
of  deep  ragged  ulcers,  slow  to  heal,  and  in  rare  cases  exposing  the 
larger  blood-vessels.  Broncho-  or  hhar-jmeumonia  may  occur,  and  is 
most  usual  during  the  second  week,  being  due  to  extension  downward 
of  the  lesion  from  the  throat.  Pneumonia  followed  by  empyema  may 
also  occur  during  convalescence. 

Joint-affections. — (a)  Scarlatinal  synovitis,  which  occurs  in  7  per  cent, 
of  cases,  nearly  always  appearing  from  the  fourth  to  the  tenth  day;  in 
72  per  cent,  of  cases  affecting  the  wrists  (Marsden).  Less  commonly 
the  small  joints  of  the  fingers,  the  elbows,  the  ankles,  the  knees,  and 
soles  of  the  feet  may  be  aflfected.  The  trouble  is  fugitive,  and  seldom 
returns  to  the  same  joint,  and  is  caused  by  the  scarlatinal  poison,     {h) 


SCARLET  FEVER.  211 

Septic  artltritis,  met  with  in  severe  or  fatal  cases,  is  often  associated  with 
grave  throat  symptoms.  In  these  cases  the  knees  may  be  most  severely 
affected,  remaining  swollen  for  weeks,  and  in  unusual  cases  suppuration 
may  take  place  and  be  followed  by  pyemia,  [c)  Jiheumatic  Hynovitin, 
which  usually  develops  during  convalescence.  Two  cases  have  occurred 
in  my  practice,  complicated  with  simple  acute  endocarditis.  Rarely 
tuberculous  invasion  of  the  joints  occurs  as  a  sequel.  Here  the  scar- 
latina merely  affords  a  predisposition  to  tuberculosis. 

Nephritis. — No  other  complication  of  scarlet  fever  can  equal  nephritia 
in  importance  or  interest,  this  condition  always  giving  rise  to  anxiety  in 
otherwise  mild  and  hopeful  cases.  During  the  height  of  the  fever  there 
is  commonly  a  transient  albuminuria,  and  it  is  possible  for  the  kidneys  to 
escape  without  greater  damage  than  occurs  in  other  acute  febrile  affec- 
tions. Independently  of  this  febrile  albuminuria,  there  are  two  forms 
of  nephritis  which  it  is  important  to  bear  in  mind,  though  they  have 
been  frequently  confounded : 

(a)  Septic  Nephritis. — In  severe  forms  of  scarlet  fever,  when  the 
throat  symptoms  include  sloughing  tonsils,  involvement  of  the  soft 
palate,  and  general  adenitis,  the  urine  quickly  becomes  loaded  with 
albumin,  but  shows  scarcely  any  blood  and  but  few  casts.  No  renal 
symptoms  will  be  recognized,  and  if  present  they  may  be  masked  by  the 
general  condition  of  septicemia.  There  may  be  neither  dropsy  nor  uremic 
phenomena,  but  the  patient  usually  dies  by  the  end  of  the  second  week, 
when  a  typical  pyemic  kidney  is  found  containing  minute  abscesses. 
This  condition  of  the  kidney  is  only  one  part  of  the  general  pyemia, 
and  merely  illustrates  the  fact  that  this  organ  suffers  during  the  course 
of  the  general  inflammation. 

(6)  Post-scarlatinal  Nephritis. — The  kidneys  are  undoubtedly  in- 
volved in  an  acute  sympathetic  inflammation,  and  at  the  end  of  the 
fever,  more  than  at  the  beginning,  are  engaged  in  carrying  off  waste 
products  of  the  fever  itself.  From  the  nature  of  the  disease  they  are 
in  an  irritable  condition  and  prone  to  take  on  inflammatory  changes, 
just  as  the  bronchial  tubes  and  the  lungs  are  left  in  a  very  susceptible 
condition  following  measles  and  whooping-cough.  In  this  way  the  urin- 
iferous  tubules  become  choked  up  by  the  desquamation  that  is  going  on 
inside.  The  number  of  eases  that  suffer  from  post-scarlatinal  nephritis 
varies  according  to  social  conditions,  the  nature  of  the  epidemic,  the 
season  of  the  year,  the  nature  of  the  treatment  received  during  the  dis- 
ease, and  especially  the  care  received  throughout  convalescence.  Ash  by 
and  Wright  fix  the  rate  of  those  who  suffer  at  6  per  cent,  of  hospital 
cases,  but  this  is,  undoubtedly,  too  high,  since  hospital  cases  receive 
excellent  care  during  convalescence  as  a  rule.  The  usual  time  for  this 
form  of  nephritis  to  occur  is  from  the  end  of  the  second  up  to  the  fourth 
week,  but  it  usually  begins  very  insidiously.  Traces  of  albumin  may 
be  found  for  a  few  days  before  the  blood  and  larger  quantities  of  albumin 
occur,  but  it  is  often  impossible  to  date  the  commencement  of  an  attack. 
Usually  after  the  fever  has  subsided  the  patient  for  a  few  days  feels  well, 
but  very  suddenly  grows  restless,  is  feverish  at  night,  is  thirsty,  has  a 
quick,  hard  pulse,  and  passes  a  small  quantity  of  dark-colored  urine. 
The  temperature  almost  invariably  rises  again  and  there  is  no  rela- 
tion between  the  pulse  and  the  temperature.  If  care  has  been  exer- 
cised, it  will  be  found  that  the  urine  has  been  gradually  diminishing 


212  INFECTIOUS  DISEASES. 

for  several  days,  and  a  slight  puffiness  about  the  face  frequently  an- 
nouucea  the  beginning  of  the  trouble.  Later  the  face  becomes  pale  and 
puffy,  while  there  may  be  edema  of  the  feet  and  scrotum,  and  some 
vomiting.  Under  favorable  treatment  improvement  may  take  place, 
large  quantities  of  urine  may  be  passed,  and  the  child  resume  convales- 
cence. The  nephritic  symptoms  may,  however,  deepen  until  uremia 
appears,  the  pulse  becoming  slow  and  wiry  in  character,  the  tempera- 
ture subnormal,  and  the  tongue  dry  and  brown.  Vomiting  is  now 
a  frequent  occurrence ;  diarrhea  is  not  unusual ;  nose-bleed  and  hemor- 
rhages from  the  various  mucous  surfaces,  and  muscular  twitchings 
may  be  noted,  and  most  likely  the  end  may  be  reached  in  a  general 
convulsion.  After  scarlet  fever,  kneeling  for  ten  minutes  in  the  lordotic 
position  may  produce  albuminuria.  Fatal  results,  however,  are  more  fre- 
quent from  cardiac  failure  than  from  the  uremic  convulsions.  The  con- 
stant effect  of  nephritis  is  to  raise  the  blood-tension,  followed  by  dilatation 
of  the  lieart.  Another  not  unusual  result  is  endocarditis  or  pericarditis, 
Avith  possible  embolism. 

Sudden  death  frequently  occurs  during  the  course  of  nephritis.  The 
child  may  be  doing  Avell,  possibly  sitting  up  in  bed  and  playing  Avith  its 
toys,  Avhen  an  attack  of  dyspnea  occurs;  the  face  becomes  livid,  the 
pulse  disappears,  and  death  quickly  takes  place.  Death  in  such  cases 
is  due  to  a  dilated  heart,  followed  by  edema  of  the  lungs. 

It  is  not  unusual  for  a  false  membrane  to  form  upon  the  larynx.  This 
is  not  infrequently  due  to  the  streptococcus  pyogenes,  but  the  Klebs- 
Ldffler  bacillus  is  oftener  found.  A  bacterial  examination  should  always 
be  made,  and  if  the  diphtherial  nature  of  the  infection  has  been  deter- 
mined the  serum  treatment  should  be  employed  at  once. 

Diagfnosis. — A  typical  form  of  scarlet  fever  offers  few  difficulties  in 
diagnosis.  The  period  of  incubation  is  short  in  comparison  Avith  that  of 
any  of  the  other  exanthemata,  particularly  variola,  measles,  and  varicella. 
The  vomitinsr,  associated  with  hisrh  fever,  Avould  also  exclude  the  other 
eruptive  diseases.  The  pulse  in  itself  is  strongly  diagnostic,  being  quick, 
hard,  and  wnry,  striking  the  finger  at  the  rate  of  140  to  180  per  minute. 
The  early  sore  throat  and  the  intense  hyperemia  of  the  whole  mucous 
membrane,  associated  Avith  marked  constitutional  symptoms,  make  it  easy 
to  differentiate  from  measles,  varicella,  and  variola.  Leukocytosis  occurs 
in  this  disease,  but  is  not  present  in  measles  or  varicella.  Dohle^  dis- 
covered certain  inclusion  bodies  in  the  polymorphonuclear  leukocytes 
from  scarlatinal  blood  prior  to  the  sixth  day.  This  vicAV  is  confirmed  by 
Granger  and  Pole,  but  Bongartz  and  others  state  that  it  is  not  possible 
to  consider  the  inclusion  bodies  pathognomonic  for  any  one  disease. 
The  punctate  eruption  of  scarlet  fever  is  not  found  in  any  of  the  other 
eruptive  diseases  (vide  table  on  page  219).  If  a  child  has  never  had 
scarlatina  and  the  characteristic  symptoms  are  present,  a  rapidly  growing 
culture  (taken  from  the  throat)  of  the  Class  coccus  from  such  a  case 
determines  the  presence  of  scarlet  fever,  while  its  absence  excludes  the 
disease  (Jacques). 

The  differential  diagnosis  embraces  the  discrimination  of  those  rashes 

that  foUoAV  the  use  of  certain  drugs  (quinin,  belladonna,  potassium  bro- 

mid    and    iodid,   chloral,  etc.).       The  characteristic    invasion-symptoms 

(vomiting,   angina,   etc.)  of  scarlatina  are  absent :    also  the  high  fever 

^  Centralbl.  f.  Bacteriol,  Nov.  23,  1911. 


SGAELET  FEVER.  213 

and  frequent,  hard  pulse  of  the  latter  disease.     Di-wj-ranlieH  are  seldom 
so  vivid  or  diffuse  as  the  eruption  of  scarlatina. 

Scarlatina.  Acutk  Exfoliatino  Dermatitis. 

Onset  is  sudden,  with  vomiting,  angina,  Sudden,  with  fever  only. 

fever,  and  frequent,  hard  pulse. 

Eruption  appears  first  on  neck,  face,  and  Ay)pear8  first  on  trunk. 

cheet,  soon  becoming  diffuse. 

Duration,  three  or  four  days.  Duration,  five  or  six  davs. 

Desquamation  begins  after  eruption  has  Desquamation  begins  earlier,  often  before 

faded,  often  one  week  later.  eruption   has   faded,  and   involves   the 

hair  and  nails. 

Ear  and  throat  complications  common.  Absent. 

Nephritis  is  a  common  sequel.  Not  so. 

Relapses  exceptional.  Relapses  common. 

The  prognosis  in  regular,  uncomplicated  scarl-et  fever  is  almost  always 
favorable,  and,  unless  the  treatment  is  unusually  indifferent,  the  patient 
will  recover.  Severe  types,  however,  and  especially  malignant  scarlatina 
are  very  fatal.    Complications  arise  that  will  most  seriously  endanger  life. 

The  treattnent  of  scarlet  fever  is  that  of  the  symptoms,  together 
with  an  attempt  at  arresting  the  complications. 

Prophylaxis. — The  patient  should  be  strictly  quarantined  in  an  upper 
room  for  at  least  eight  weeks  or  until  desquamation  has  been  completed. 

During  convalescence  hematinics  are  required  to  overcome  the  symp- 
tomatic anemia  and  debility.  Preisich  urges  the  importance  of  sep- 
arating the  convalescents  from  patients  in  the  first  stages,  and  of  get- 
ting the  mucosae  into  a  healthy  condition  before  the  patient  is  discharged. 
A  competent  nurse  should  be  put  in  charge,  and,  whether  a  member  of 
the  family  or  otherwise,  she  should  wear  a  washable  dress,  and  should 
not  mingle  with  the  family  except  her  clothing  be  changed  or  thoroughly 
disinfected.  The  room  is  to  be  stripped  of  all  superfluous  hangings  and 
furniture.  Inunctions  are  required  as  soon  as  desquamation  commences, 
with  a  view  to  preventing  the  diffusion  of  the  dried  epidermal  scales  ; 
and  the  best  preparation  for  this  purpose  consists  of  cosmolin,  menthol, 
and  carbolic  acid,  ten  grains  each  of  the  latter  to  one  ounce  of  cosmo- 
lin after  the  plan  of  J.  Lewis  Smith.  Carbolized  water,  1  :  40,  may  be 
used  to  sponge  the  surface  and  may  be  agreeably  followed  by  cocoa-butter. 
The  naso-pharynx  must  also  be  kept  disinfected. 

The  disinfection  of  the  physician  himself  is  important.  He  should 
generate  chlorin  gas  by  the  following  simple  method,  and  allow  it  to  per- 
meate his  clothes  thoroughly  before  going  into  other  families  :  A  dram  of 
powdered  potassium  chlorate  is  placed  in  a  saucer,  and  a  small  quantity 
of  hydrochloric  acid  added.  The  dish  is  then  placed  on  the  floor,  and 
the  physician  stands  over  the  vapor  chlorid  as  it  arises  until  it  penetrates 
all  his  clothing.  This,  with  the  free  use  of  the  whisk  and  thorough  hand- 
washing, renders  him  non-contagious  and  safe  in  entering  any  home  or 
sick-room.  The  best  method  is  to  have  in  the  patient's  house  a  linen 
duster  or  surgeon's  apron  that  has  been  dipped  in  a  bichlorid  solution 
and  allowed  to  dry.  This  is  slipped  over  the  clothing  before  entering 
the  sick-room,  and  is  removed  after  leaving. 

In  the  room,  if  the  case  be  a  severe  one  involving  the  throat,  I  keep 
the  gas  or  an  alcohol  lamp  burning  under  a  small  dish  of  water,  so  that 
steam  is  constantly  generated.      To  the  boiling  water  I  frequently  add 


214  IXFECTIOUS  DISEASES. 

carbolic  acid  or  oil  of  eucalyptus;  this  saturates  the  room  very  pleasantly, 
and  at  the  same  time  tends  to  limit  the  extent  of  the  contagion. 

General  Management. — The  siik-room  should  be  larire  and  well-ven- 
tilated, and  should  be  kept  at  a  uniform  temperature  (t)M°  to  70°  F. — 
21.1°  C).  A.  light  flannel  night-dress  should  be  worn  by  the  child,  and 
the  bed-clothinjr  should  be  liwht  as  well.  The  diet  should  consist  of 
milk,  egg-white,  and  fruit-juices,  and  after  the  temperature  has  declined 
soft  diet  may  be  allowed.  J.  McCrae  ^  insists  upon  twenty-one  days' 
milk  diet.  A  return  to  ordinary  solid  foods,  especially  proteids,  must 
be  made  gradually  during  convalescence. 

The  evidences  of  heart-enfeeblement  often  arise  and  call  for  the  judi- 
cious use  of  stimulants.  This  class  of  agents  is  remarkably  well  borne  in 
this  aifection.  To  a  child  of  four  years  I  give  one  dram  (4.0)  of  brandy  or 
whisky  every  second  hour,  and  often  increase  the  dose  as  required.  The 
preparations  of  ammonium,  particularly  the  carbonate  and  the  aromatic 
spirits,  have  also  been  warmly  recommended.  They  should  be  adminis- 
tered in  milk  as  the  vehicle  to  prevent  gastric  irritation.  Heart-failure  is 
best  treated  by  baths  at  90°  to  95°  F.  and  oxygen  inhalations  (Ausset). 

Special  Treatment. — In  the  classical  work  of  Thomas  Watson,  now 
over  fifty  years  old,  he  hints  in  his  treatment  of  scarlet  fever  "that,  if 
the  heat  on  the  surface  be  very  great  and  distressing,  he  should  not 
recommend  the  cold  affusion,  but  cold  or  tepid  sponging  would  be  very 
refreshing  and  beneficial."  This  sentiment  finds  its  eclio  in  most  works 
on  practical  medicine  at  the  present  day.  The  physician  must  quietly 
but  firmly  insist  upon  the  patient  being  sponged  three  or  four  times  daily, 
according  to  the  severity  of  the  individual  case,  using  carbolized  Avater 
(1  :  60),  mercuric  chlorid  (1  :  8000),  or  alcohol  and  water,  at  a  tempera- 
ture of  70°-100°  F.  (21.1°-37.7°  C).  Systematic  bathing  and  inunc- 
tions as  above  described  protect  the  body  from  certain  complications  and 
sequelae.  The  ice-cap  may  be  combined  with  cool  spongings.  In  ex- 
treme cases,  with  marked  nervous  symptoms  and  high  temperature,  the 
cold  pack,  Avith  cold  affusions  applied  to  the  head  and  nape  of  the  neck, 
may  be  employed,  and  a  description  of  the  method  of  giving  a  cold  pack 
may  be  found  under  the  treatment  of  Typhoid  Fever.  A  notable  reduction 
of  temperature  ma}'  be  secured  from  an  injection  of  a  pint  or  more  of  cool 
water  containing  2  to  10  grains,  according  to  the  age  of  the  patient,  of 
sulphocarbolate  of  soda  per  rectum  (de  Yoe).  To  eliminate  the  toxins, 
the  baths  should  be  aided  by  the  administration  of  large  quantities  of 
water,  and  the  bowels  should  be  kept  freely  open. 

In  regard  to  the  use  of  internal  antipyretics,  I  prefer  phenacetin  for 
older  children,  combined  with  quinin  in  capsules.  Acetanilid  is  better 
for  younger  children,  and  I  generally  give  one-third  as  many  grains  as 
there  are  years  in  the  child's  life.  When  medicine  can  be  exhibited  in  the 
form  of  capsules,  I  always  prefer  to  combine  it  with  quinin  or  strychnin 
to  overcome  the  tendency  to  depression.  Phenacetin  and  acetanilid  act 
successfully  in  controlling  the  nervous  element,  relieving  headache  and 
fever,  promoting  diaphoresis,  and  inducing  refreshing  sleep.  Acetanilid 
is  much  more  prompt  in  its  action  than  phenacetin,  but  its  effects  are  not 
so  lasting.     These  agents,  however,  are  rarely  required. 

Internal  Antiseptics. — Those  remedies  that  are  purely  antiseptic, 
administered  internally,  have  not  given  proof  of  their  utility  as  yet. 
1  Montreal  Medical  Jour.,  Sept.,  1908. 


SCARLET  FEVER.  21  5 

The  sulphocarbolates  of  zinc  and  of  sodium,  on  account  of  their  breaking 
up  in  the  system  and  liberating  carbolic  acid,  cannot  be  used  in  a  suf- 
ficiently large  dose  to  meet  with  success.  The  syrup  of  phenic  acid  is 
used  by  many  physicians.  Marraorek,  and  later  Charlton,  has  used  his 
antistreptococcic  serum  extensively,  and,  although  it  does  not  act  as  a 
specific,  it  prevents  the  serious  complications  and  invariably  renders  the 
attack  mild.  Moser  of  Vienna  has  discovered  a  new  serum  which  has 
given  good  results  in  a  series  of  400  cases. 

The  care  of  the  nose  and  throat,  and  eventually  of  the  ears  will  re- 
quire all  the  skill  of  the  medical  attendant,  and  by  commencing  early 
in  the  case  to  give  careful  and  constant  attention  to  these  parts  we  may 
prevent  much  trouble  and  danger  later  on.  The  attendant  should  use  a 
small  atomizer  filled  with  warm  water  containing  sodium  bicarbonate 
(gr.  xv-^j — 0.975-32.0).  If  decided  inflammation  should  occur,  a  solu- 
tion of  hydrogen  peroxid  and  cold  water  or  glycerin  (1  :  5)  may  be  used, 
and  then  be  followed  by  an  oily  preparation,  such  as  liquid  albolene  con- 
taining menthol  (a  5  per  cent,  solution). 

If  the  patient  cannot  tolerate  an  atomizer,  an  application  of  the  anti- 
septic oil  directly  to  the  posterior  nasal  spaces,  by  means  of  an  aluminum 
applicator,  may  be  made.  Faithful  attention  to  the  removal  and  disin- 
fection of  the  secretion  from  the  nose  and  throat  will  prevent  accumula- 
tion, and  thus  prevent  regurgitation  up  the  Eustachian  tube  with  its 
associated  ear-troubles.  In  this  way  diphtheria  can  also  be  prevented 
from  gaining  its  full  lodgement.  For  the  appropriate  treatment  of  this 
complication  the  reader  is  referred  to  the  treatment  of  Diphtheria.  It 
has  been  shown  that  the  return  cases  (after  return  from  hospital)  are 
caused  by  the  discharges  from  the  nasal  and  aural  passages.  If  pain  in 
the  ear  should  indicate  the  extension  of  the  trouble  up  the  Eustachian 
tube,  we  must  redouble  our  efforts,  even  though  the  desquamation  within 
the  tube  itself  may  be  quite  beyond  the  reach  of  our  detergent  wash. 

The  external  auditory  canal  may  become  blocked  by  desquamating 
epithelium,  and  this  must  be  removed  by  gentle  sponging.  If  the  ten- 
sion of  the  ear-drum  becomes  very  great,  it  must  be  punctured.  The 
method  of  dropping  laudanum  and  sweet  oil  in  the  ear  is  objectionable, 
as  it  serves  as  a  nidus  for  a  collection  of  dust,  dirt,  and  dead  epidermis. 

Moser's  antistreptococcic  serum  has  been  employed  with  doubtful  results, 
but  it  should  be  used  in  streptococcic  pseudomembranous  aff'ections. 

Scarlatinal  synovitis  I  have  encountered  in  but  a  small  proportion  of 
cases,  and  then  it  was  of  a  transient  character.  I  am  inclined  to  attribute 
this  fortunate  result  to  the  faithful  use  of  daily  bathing  and  inunctions, 
long  continued  and  at  least  until  after  completion  of  desquamation. 
Widowitz  recommends  the  administration  of  from  1  to  8  gr.  (0.06—0.5 
gr.)  of  hexamethylenamine  (urotropin)  to  prevent  nephritis.  Preisich 
administered  the  drug  in  600  cases,  nephritis  occurring  in  9.16  per  cent., 
as  against  13. 6  per  cent,  of  the  cases  in  which  the  remedy  was  not  used. 

The  specific  poison  of  scarlet  fever  is  peculiarly  obnoxious  to  the 
kidneys,  and  is  largely  eliminated  through  them  ;  and  upon  this  fact 
hinges  the  scientific  part  of  the  treatment  of  this  disease.  Free  bathing 
has  the  happy  efi'ect  of  vicariously  eliminating  the  poison  in  a  measure 
at  least.  In  post-scarlatinal  uremia  venesection  supplemented  by  saline 
infusion  produces  excellent  results.  (For  the  treatment  of  nephritis,  see 
Diseases  of  the  Kidneys,  p.  1025). 


216  ISFECTIOUS  DISEASES. 

"FOURTH  DISEASE." 

This  complaint  was  first  described  by  Clement  Duke^  in  1900.  The 
so-called  "  fourth  disease"  resembles  both  German  measles  and  mild 
scarlatina.  The  etiology  is  obscure.  The  incubation  period  is  from  one 
to  three  weeks,  and  the  time  of  transmissibility  ranges  from  two  to  three 
weeks.  Prodromata  are  often  absent,  though  a  slight  febrile  nu)vement 
may  precede  the  eruj^tion  by  from  six  to  twenty-four  hours. 

Cotton  states  that  catarrhal  symptoms  of  the  faucial,  oral,  or  ocular 
mucosa  may  rarely  be  present.  Usually  the  postccrvical  and  occipital 
lymph-nodes  are  palpable  early  in  the  attack.  The  eruption,  which  re- 
sembles that  of  scarlatina,  appears  first  on  the  face  or  neck  and  spreads 
downward,  quickly  covering  the  trunk  and  portions  of  the  extremities. 
Itching  is  absent,  and  the  rash  fades  rapidly  after  two  or  three  days  with- 
out stain. 

A  fine,  branny  desquamation  follows  the  disai)pearance  of  the  eruj)- 
tion.  The  pulse  is  accelerated  in  proportion  to  the  febrile  movement, 
which  is  marked,  but  lasts  only  two  or  three  days.  Complications  are 
rare,  while  sequelse  almost  never  occur. 

The  discrimination  of  Duke's  disease  from  scarlatina  is  made  with 
readiness  by  noting  the  absence  of  vomiting,  of  a  pulse-rate  out  of  pro- 
portion to  the  fever,  the  strawberry  tongue,  lamellar  desquamation,  and 
of  the  characteristic  oronasal  pallor.  In  rubella  the  rash  is  light  in 
color  and  pi-esents  patches  of  irregular  shape  (vide  p.  221).  Corlett  and 
Cole-  state  that  aberrant  forms  of  scarlatina  should  not  be  regarded  as 
distinct  affections,  and  that  the  consensus  of  opinion  does  not  substa.ntiate 
the  claim  for  a  fourth  disease. 

The  prognosis  is  favorable  and  treatment  that  of  mild  scarlatina. 


MEASLES. 


Definition. — An  acute  contagious  disease,  characterized  by  an  initial 
coryza,  general  catarrhal  symptoms,  fever  in  the  earlier  stage,  followed 
by  a  peculiar  papular  eruption  on  the  face  and  body. 

Pathology. — In  uncomplicated  measles  we  have  no  pathologic 
lesions.  The  only  post-mortem  changes  found,  as  a  rule,  are  those  of 
catarrhal  pneumonia  and  acute  nephritis.  All  the  internal  organs  are 
gorged  with  blood,  and  minute  hemorrhages  are  found  on  their  surfaces. 
The  skin  presents  the  following  histologic  lesions  :  focal  necrosis,  with  the 
formation  of  small  vesicles,  isolateil  necrotic  epithelia,  diffuse  perinuclear 
vacuolation  of  cells  of  the  epidermis  and  of  the  dermal  glandular  struc- 
tures, with  congestion,  edema,  swelling,  proliferation  of  the  endothelial 
cells,  and  a  moderate  increase  of  the  large  round-cells  (Ewing). 

Htiology. —  Measles  occurs  in  epidemics,  although  sporadic  cases  are 
common  in  the  larger  cities.  There  is  an  epidemic  prevalence  in  large 
centers  of  population  every  eighteen,  months  or  two  years,  but  the  different 
epidemics  vary  in  their  extent  and  fatality.  It  generally  happens  that 
when  once  the  disease  enters  a  home,  street,  or  small  court,  scarcely  any 
1  Lancet,  July  14,  1900.  ^  Jour.  Amer.  Med.  Assoc,  July  16,  1910. 


MEASLES.  217 

one  escapes  who  has  not  been  protected  by  a  previous  attack.  The  sus- 
ceptibility to  measles  in  children  is  very  great,  except  in  the  newborn, 
who  seldom  contract  the  disease.  Biedert  *  found  that  only  14  per  cent, 
of  unprotected  children  escaped.  In  the  Faroe  Islands,  under  similar 
conditions,  only  1  per  cent,  escaped  (Madsen,  Pannum).  There  is  the 
same  experience  in  schools  and  hospitals.  The  epidemics  occur  mostly 
in  the  fall  and  winter,  yet  the  season  has  little  influence.  The  poison  is 
conveyed  principally  by  contagion,  less  commonly  by  fomites.  It  is 
probably  most  contagious  during  the  initial  catarrhal  stage. 

Bacteriology. — Micrococci,  e.  g.,  streptococci,  are  found  in  the  secretionB 
of  the  respiratory  tract,  but  they  have  not  been  proved  to  be  specific. 
Czajkamski^  described  motile  bacilli,  2.5  to  5  micromillimeters  in  length, 
which  did  not  color  by  Gram's  method.  They  grew  on  glycerin-agar, 
bouillon,  and  blood-serum.  Schottelius^  found  the  Stapltylococcus  pyo- 
genes aureus  frequently  in  40  cases  of  measles  conjunctivitis,  v/hile  in  40 
fatal  or  very  severe  cases  he  found  the  streptococcus  in  50  per  cent,  in 
the  lungs  and  spleen.  J.  Goldberger  and  J.  F.  Anderson*  have  discov- 
ered an  infective  virus. 

Immunity. — One  attack  of  measles  almost  always  exhausts  the  soil, 
but  in  exceptional  instances  recurrent  attacks  may  occur. 

Clinical  History. — The  period  of  incubation  is  from  seven  to  four- 
teen days,  and  in  inoculated  cases  from  seven  to  ten  days. 

Catarrhal  Stage. — The  early  symptoms  are  those  of  a  cold  with  some 
fever.  The  child  has  marked  coryza,  watery  eyes,  sneezes,  and  has  a 
dry,  croupy  cough.  Frequently  the  symptoms  are  those  of  a  catarrhal 
laryngitis  and  bronchitis,  the  fauces  and  tonsils  being  hyperemic,  with 
abundant  secretion,  and  there  is  conjunctivitis.  The  patient  may  be 
acutely  ill,  the  temperature  rising  several  degrees  in  the  evening,  and 
falling  slightly  in  the  morning ;  the  fever  continues  high  until  the  rash 
is  fully  developed.  The  rash,  consisting  of  one  or  more  distinct  papules, 
may  be  seen  on  the  hard  palate  fully  twenty-four  hours  before  it  appears 
on  the  face.  A  transient  prodromal  eruption,  which  may  be  erythema- 
tous, truly  scarlatiniform  or  urticarial,  may  rarely  be  observed. 

The  eruptive  stage  is  very  characteristic,  and  usually  makes  its  appear- 
ance at  the  end  of  the  fourth  day.  The  neck,  face,  forehead,  and 
trunk  receive  the  eruption  in  the  order  of  mention.  The  whole  physi- 
ognomy of  the  child  is  so  characteristically  altered  that  a  well-marked 
case  may  be  diagnosticated  at  a  glance.  The  face  is  flushed ;  the  eyes 
are  red  and  watery ;  a  short,  dry  cough,  frequently  metallic  in  ring,  is 
present ;  and  the  nose  and  cheeks  are  covered  with  crops  of  dusky-red 
papules  surrounded  by  a  zone  of  erythema  which  sharply  contrasts  with 
the  normal  skin  between  the  patches.  The  rash  on  the  face  is  both  dis- 
crete and  confluent,  or  may  be  arranged  at  times  in  small  crescents,  and 
in  the  course  of  a  day  or  two  the  whole  trunk  is  invaded,  but  in  a 
slighter  degree.  By  the  fifth,  and  seldom  the  sixth  day,  the  eruption 
has  reached  its  height,  and  commences  to  fade,  first  on  the  face  and 
neck,  then  on  the  body  and  limbs,  followed  by  a  fine  desquamation. 
By  the  seventh  or  eighth  day  the  rash  is  nearly  gone,  leaving  a  blue, 

^  Jahrbuch  fiir  Kinderheilkunde,  vol.  xxiv.,  p.  94. 

^  Centralblatt  fiir  Baeteriologie,  vol.  xviii.,  Nos.  17  and  18. 

^  Miinchener  med.   Woch.,  March  1,  1904. 

*  Jour.  Amer.  Med.  Assoc,  Sept.  16,  1911. 


218 


INFECTIOUS  DISEASES. 


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Fig.  is.— Temperature-curve  of  a  case  of  measles. 


mottled  stain  over  the  body.  The  temperature,  which  has  reached 
103°  F.  (39.4°  C.)  or  even  i05°  F.  (50.5°  C),  falls  when  the  rash  is 
fully  established — i.  e.,  on  the  fifth  or  sixth  day — while  the  headache, 

the  severe  cough,  and  general 
features  also  subside  with  the 
fever.  If  the  temperature  con- 
tinues high  after  the  rash  is  out, 
Ave  may  look  for  some  complica- 
tion, such  as  pneumonia  or  acute 
nephritis  [vide  Fig.  18). 

An  eruption  first  described 
by  II.  Koplik  also  occurs  on  the 
buccal  and  labial  mucous  mem- 
brane ;  it  appears  "  as  long  as 
twenty-four  hours,  forty-eight 
hours,  and  even  three  to  five 
days  before  the  appearance  of 
the  skin  exanthem."  It  is 
present  before  the  signs  of  con- 
junctivitis appear,  and  when 
little  or  no  fever  is  present.  It 
was  found  in  fifty-two  consecu- 
tive patients  in  Koplik's  clinic. 
This  eruption  consists  of  small,  irregular  spots  of  a  bright  red  color,  and 
in  the  center  of  each  red  spot  is  the  interesting  sign  which  Koplik  has 
described,  a  minute,  bluish-white  speck.  To  see  the  latter  requires  a 
strong,  glaring  daylight,  and  they  must  be  looked  for  by  everting  the 
mucous  membrane  of  the  lips  and  that  of  the  cheeks.  The  spots  may 
be  few,  and  again  they  may  be  quite  numerous.  Widoweiz  ^  and  Cotter^ 
fail  to  find  the  spots  in  about  10  per  cent,  of  the  cases,  while  Lepit'  in 
an  analysis  of  327  cases,  found  them  almost  always  present.  Among 
recent  writers,  J.  L.  Hirst,  C.  C.  Ross,  and  Roily  attach  great  value  to 
Koplik's  sign  in  the  diagnosis.  By  recognizing  this  sign,  measles 
patients  may  be  early  quarantined  and  institutional  epidemics  checked. 
Complications. — In  some  epidemics  the  character  of  the  disease 
is  very  severe,  being  marked  by  high  fever  (105°  to  106°  F. — 40°  to 
41°  C),  a  dry,  brown  tongue,  delirium  and  convulsions,  and  feeble  heart- 
action,  due  to  the  intense  hyperemia  of  internal  organs — lungs,  brain, 
kidneys,  etc.     The  eruption  may  be  petechial — liemoi^rhagic  measles. 

The  main  complications  are  presented  by  the  lungs.  The  accompany- 
ing bronchitis  tends  to  extend  to  the  bronchioles,  causing  bronclio- 
pneumo7iia  ;  this  occurred  in  50  among  457  cases,  11.8  per  cent.  (Landi.s). 
The  extent  and  seriousness  of  this  complication  are  largely  dependent 
upon  the  degree  of  the  previous  debility.     Lobar  pneumonia  is  rare. 

Catarrhal  or  membranous  laryngitis  is  frequent  in  the  pre-eruptive 
stage  or  as  a  sequela.  Quite  rarely  edema  of  the  glottis  occurs.  Oph- 
thalmia may  occur  in  anemic  and  strumous  children  if  strict  eye-toilet 

»  Wiener  klin.  Woch.,  1899,  No.  37. 
2  Archive.'^  of  PedialricK,  Dec,  1900. 
»  Med.  Mod.,  1899,  No.  76;  Bev.  Mens,  des  Mai.  de  FEnf.,  July,  1900. 


MEASLES. 


219 


is  not  enforced.  Glandular  involvernent  may  take  place  in  the  cervical 
glands.  Otitis  is  frequent  during  desquamation,  suppuration  taking 
place  in  the  middle  ear  and  meningitis  is  rarely  observed.  Canorum  oris 
and  noma  pudendi  may  appear  as  complications  of  the  disease.  JJiarrhaa 
is  frequent  at  the  end  of  the  eruptive  period  and  as  ;i,  sc(juela. 

The  health  of  the  child  often  remains  impaired  for  a  long  time  after 
an  attack  of  the  measles :  it  is  at  this  period  that  whooping-cough,  diph- 
theria, nephritis,  and,  later  on,  acute  tuberculosis,  may  arise.  Tuber- 
culosis very  frequently  gains  entrance  into  the  system  from  the  existence 
of  enlarged  and  cheesy  bronchial  and  mediastinal  glands.  Biehler  found 
pyelitis  or  pyelonephritis  in  9  out  of  147  cases.  Nervous  sequelae  rarely 
occur  (hemiplegia,  paraplegia).  Certain  eruptive  diseases  are  rarely  con- 
current, as  scarlet  fever,  variola,  chicken-pox,  and  rubella.  The  cutaneous 
tuberculin  reaction  is  absent  for  about  one  week  in  measles  (von  Pirquet). 

Diagnosis. — Epidemics  may  be  characterized  by  irregular  forms  of 
the  disease,  and  the  diagnosis  of  sporadic  cases  is  often  very  difficult. 
We  cannot  recognize  it  by  its  dermal  lesions,  but  by  the  prodromal 
symptoms,  by  the  fall  of  temperature  after  the  eruption  is  well  out  (dif- 
fering here  from  scarlet  fever),  and  by  the  character  of  the  pulse,  tongue, 
and  desquamation.  Koplik's  early  sign  is  usually  present  and  is  dis- 
tinctive. For  two  or  three  days  prior  to  the  eruption  the  leukocyte  count 
is  increased  (Hecker).  During  the  latter  part  of  the  pre-eruptive  and 
early  part  of  the  eruptive  period,  a  distinct  leukopenia  occurs.  A  fever- 
ish period  of  four  days,  associated  with  catarrhal  symptoms  of  the  eyes, 
nose,  and  upper  air-passages,  a  few  papules  on  the  hard  palate,  followed 
within  twenty-four  hours  by  a  papular  efflorescence  on  the  face,  will 
differentiate  the  disease  from  variola,  varicella,  scarlet  fever.,  and  rubella. 

The  accompanying  table  from  Rotch  will  aid  the  discrimination : 


Measles. 

Vaeiola. 

Varicella. 

Scarlet 
Fever. 

Rubella.. 

Incubation    .    .    . 

10  days. 

12  days. 

17  days. 

4  days. 

21  days. 

Prodromata      .    . 

3  days. 

3  days. 

A  few  horn's. 

2  days. 

A  few  houi-s. 

Efflorescence    .    . 

Papules. 

Macules. 
Papules. 
Vesicles. 
Pustules. 

Vesicles. 

Erythema. 

Papules. 

Desquamation 

Furfuraceous. 

Large  crusts. 

Small  crusts. 

Lamellar. 

Complications  and 

Eye  and  Lung. 

Larynx. 

Kid  n  e  y, 

sequelae     .    .    . 

Lungs. 

ear,  and 
heart. 

The  mortality  differs  according  to  the  surroundings  of  the  patient. 
In  healthy  children  under  favorable  environment  the  mortality  is  prac- 
tically nil,  while  in  tuberculous  and  wasted  children  it  is  very  large,  this 
being  especially  due  to  complications  and  sequelge.  Infants  may  be 
born  with  the  rash  on  them.^  The  disease  is  quite  fatal  when  it  follows 
other  acute  infections  {e.  g.,  scarlatina). 

Treatment. — Measles  is  a  self-limited  disease,  and  we  are  unable 
to  shorten  its  duration,  nor  is  there  any  means  of  producing  immunity 
from  the  attack.  The  treatment  is  necessarily  symptomatic  ;  hence  our 
efforts  should  be  directed  toward  protecting  the  various  organs  that  are 
most  likely  to  become  involved  by  complications,  remembering  at  the  same 
*  jBem.  Med.  Chronicle,  May,  1890 ;  Brit.  Med.  Journal,  vol.  i.,  p.  612,  1890. 


220  INFECTIOUS  DISEASES. 

time  that  the  nose,  ears,  eyes,  and  throat  are  involved  during  the  fever- 
ish stage,  and  that  the  skin  is  in  a  \qv\  susceptible  condition. 

The  patient  should  be  placed  in  a  large,  dark,  -well-ventilated  room, 
with  a  uniform  temperature  between  08°  and  70°  F.  (21.1°  C).  He 
should  remain  in  bed  until  the  temperature  has  been  normal  for  one 
week,  and  until  the  efflorescence  has  nearly  faded  and  the  desquamation 
is  almost  complete.  The  diet  during  the  period  of  fever  shouhl  be  milk, 
bread,  and  light  soups.  Near  the  end  of  desfjuamation,  if  all  symptoms 
are  favorable,  a  more  generous  dietary  may  be  allowed. 

The  bronchial  cough,  which  may  be  very  troublesome  during  the 
first  few  days,  can  be  readily  relieved  by  some  simple  expectorant  and 
fever  mixture,  as — 

^.  Potassii  citrat.,  5ss(16.0); 

Succi  limonis,  5J  (32.0) ; 

Tr.  opii  camph.,  3ij  (8.0^ : 

Syr.  ipecac,  oil  (8.0) ; 

Syr.  tolu.,  q.  s.  ad  sij  (64.0).— M. 

Sig.  3SS-3J  every  two  or  three  hours,  according  to  the  age  and 
condition  of  the  patient. 

Eor  the  coryza  I  have  found  that  atomizing  the  nares  with  some  oily 
vehicle  (oleum  petrolatum  album,  etc.)  is  advantageous. 

The  skin  is  in  a  state  of  great  irritation,  and  from  the  commencement 
of  the  disease  until  the  end  of  desquamation  a  daily  warm  bath  (95°  to 
100°  F.— 35°  to  87.7°  C.)  should  be  given  the  patient,  and,  after  drying 
the  body,  cocoa-butter  thoroughly  rubbed  over  the  entire  surface.  The 
child  should  live  in  an  equable  temperature  for  at  least  three  weeks.  For 
months  he  should  be  protecteil  from  sudden  atmospheric  changes  in  order 
to  avoid  respiratory  troubles.  If  he  be  predisposed  to  tuberculosis,  cod- 
liver  oil  and  creosote  should  be  prescribed  for  a  period  of  two  months  or 
more.  Otitis  media  may  be  avoided  by  frequent  cleansing  of  the  post- 
nasal spaces  during  desquamation. 

Chatiniere  has  suggested  the  treatment  of  measles  by  red  light,  simply 
hanging  red  curtains  over  the  windows  and  other  sources  of  light,  and 
exposing  the  patient  to  these  rays. 


RUBELLA. 
[R'dtheln  ;  Rubeola  Not  ha  ;    German  Measles ;  French  Measles). 

Definition. — An  acute  contagious  disease.  It  has  no  prodromal 
stage,  and  is  characterized  by  slight  fever,  enlargement  of  the  post-cervical 
glands,  and  an  efflorescence  upon  the  skin. 

Htiology. — Rubella  was  not  distinguished  from  measles  and  scarlet 
fever  until  about  the  middle  of  the  eighteenth  century.  Since  then  con- 
siderable controversy  has  arisen  at  different  times  as  to  its  nature,  the 
theory  being  at  one  time  strongly  advanced  that  it  was  a  combination 


RUBELLA.  221 

of  these  two  diseasee,  as  many  of  the  milder  cases  have  symptoms  com- 
mon to  both.  That  there  is  a  diflferoricc,  however,  in  the  character  and 
course  of  these  diseases  has  been  proved  beyond  doubt  to  careful  ob- 
servers by  the  facts  that  rubella  occurs  independently  of  either  measles 
or  scarlet  fever ;  that  contagion  from  this  disease  produces  a  similar  dis- 
ease; that  one  attack  affords  immunity  to  subsequent  seizures  (although 
out  of  a  total  of  719  cases,  second  attacks  were  seen  in  2.5  per  cent. — To- 
beitz) ;  and  that  its  onset  and  clinical  course  are  characteristic. 

Rubella  may  occur  epidemically  or  sporadically.  Although  of  un- 
doubted microbic  origin,  the  specific  organism  has  not  been  isolated. 

In  hospitals  or  where  persons  are  crowded  and  living  under  unhy- 
gienic circumstances  the  disease  is  very  contagious.,  though  probably  less 
so  than  measles,  and  the  epidemic  will  be  quite  general ;  but  in  family 
practice  it  is  but  slightly  so,  and  the  epidemics  are  limited,  often  being 
confined  to  a  single  household  and  attacking  perhaps  but  one  or  two  of 
the  family.  As  compared  with  measles,  the  incidence  shows  a  larger 
percentage  of  adults.  As  stated  by  Edwards,  it  is  spread  by  the  cuta- 
neous exhalations,  breath,  fomites,  and  clothing,  and  is  probably  conta- 
gious from  the  period  of  incubation  until  far  into  convalescence. 

Clinical  History. — The  incubation  stage  lasts  from  ten  to  sixteen 
days,  though  this  period  may  vary  and  the  disease  appear  three  or  four 
days  after  exposure.  On  the  other  hand,  cases  have  been  reported  in 
Avhich  it  was  as  long  as  twenty-five  days.  As  a  rule,  the  period  of  incuba- 
tion is  longer  perhaps  than  in  measles.  The  stage  of  invasioyi  covers 
from  one  to  three  days. 

For  a  period  of  a  few  days  before  the  rash  appears  there  may  be 
noticed  chilliness,  pains  in  different  parts  of  the  body,  a  dull,  heavy 
feeling,  perhaps  feverishness,  sore  throat,  enlarged  tonsils,  and  a  slight 
bronchitis.  Enlargement  and  induration  of  the  postcervical  glands  is 
constant,  while  the  anterior  are  also  commonly  enlarged. 

Just  before,  or  with  the  appearance  of,  the  rash  there  is  a  rise  in 
temperature  to  99°  or  100°  F.  (37.7°  C),  or  in  severe  cases  as  high  as 
103°  F.  (39.4°  0.)  or  more.  Again,  the  invasion  symptoms  may  be 
absent  or  so  mild  as  to  escape  notice,  and  the  first  sign  of  infection  be 
the  appearance  of  a  rash  which  first  shows  itself  on  the  face  and  extends 
downward  over  the  body.  In  some  cases  the  eruption  does  not  follow 
the  regular  course,  and  is  confined  to  one  part  of  the  body,  and  cases 
have  been  reported  in  which  it  only  appeared  on  the  roof  of  the  mouth 
or  on  the  tonsils.  In  other  instances  every  part  of  the  body,  including 
the  palms  of  the  hands  and  the  soles  of  the  feet,  may  be  covered. 

The  eruption  consists  of  papules,  is  multiform,  confluent,  and  of  a 
pale  or  rosy-red  color.  The  patches  do  not  assume  any  regular  shape 
or  fox'm,  and  the  skin  between  them  may  become  hyperemic  and  cause 
itching.  The  rash  reaches  its  height  on  different  parts  of  the  body  in 
succession,  fading  in  one  pai't  while  appearing  in  another.  Its  duration 
is  from  two  to  five  days,  and  possibly  longer  in  some  cases. 

A  slight  desquamation  usually  occurs,  and  a  slight  pigmentation  of 
brownish  color  after  the  rash  fades  is  frequently  noticed,  disappearing 
after  a  few  days.  The  temperature-curve  is  variable,  but  as  a  rule  it 
remains  between  100°  F.  (37.7°  C.)  and  102°  F.  (38.8°  C)  while  the 
eruption  is  present.     As  mentioned  above,  sore  throat  is  nearly  always 


222  lyFECTIOUS  DISEASES. 

present,  with  enlarijed  tonsils,  a  dry  cough,  and  bronchitis.  The  gland- 
ular enlargement  will  also  continue  with  the  rash,  and  in  severe  cases 
the  axillary  and  in<;uinal  glands  may  become  involved.  The  pulse 
varies  with  the  temperature  and  respiration.  Vomiting  has  been 
noticed  as  occurring  during  the  eruption  in  severe  cases. 

After  a  period  varying  from  three  days  to  a  week,  with  the  disap- 
pearance of  the  rash,  convalescence  begins  and  the  child  rapidly  regains 
its  former  health,  and  the  whole  course  of  the  disease  may  be  so  mild 
that  the  patient  cannot  be  persuaded  to  remain  in  bed. 

Complications. — The  most  common  are  affections  of  the  respira- 
tory tract  (pneumonia  or  severe  bronchitis),  and  in  some  cases  we  have 
a  g astro-intestinal  catarrh  of  a  troublesome  character.  Diphtheria  or 
other  contagious  diseases  may  occur.  A  relapse  is  not  uncommon,  and 
may  be  as  severe  as  the  initial  attack. 

Diagnosis. — Rubella  may  be  distinguished  from  measles  by  its  less 
severe  onset  and  course,  by  the  absence  of  coryza,  severe  bronchitis,  high 
fever,  Koplik's  spots  and  complications,  by  the  lighter  color,  shorter  dura- 
tion, and  more  diffuse  character  of  its  rash,  and  the  irregular  shape  which 
the  patches  assume.  The  presence  or  absence  of  an  epidemic  is  an  im- 
portant factor  in  the  diagnosis,  and  in  cases  occurring  when  there  is  no 
epidemic  the  diagnosis  between  this  disease  and  measles  of  a  mild  type  is 
difficult  if  not  altogether  impossible. 

From  typical  scarlatina  the  diagnosis  offers  no  difficulty.  The  absence 
of  its  initial  vomiting,  the  straAvberry  tongue,  the  character  of  the  rash 
(which  in  scarlet  fever  is  erythematous),  and  the  shorter  duration  and 
milder  course  of  rubella,  all  render  the  diagnosis  easy. 

KuBELLA.  Erythema.  Urticaria. 

Occurs  first  on  the  face.  On  the  hands  and  feet.  In  wheals  on  arms  and  legs. 

Enlargement  of  cervical  No  enlargement.  No  enlargement. 

glands. 

At  first  no  itching.  Burning  pain.  Intense  itching. 

Contagious.  Not  contagious.  Not  contagious. 

Microbic  origin.  Reflex  origin.  Gastric  origin. 

The  prognosis  in  uncomplicated  cases  is  invariably  good  but  when 
the  surroundings  are  unhygienic,  or  in  cases  in  which  the  child  has  been 
delicate  previously,  it  is  more  serious.  Complications,  especially  pneu- 
monia or  diphtheria,  may  prove  fatal,  and  in  some  cases  the  mortality 
reported  has  been  as  high  as  9  per  cent. 

Treatment. — The  treatment  is  simple  and  principally  symptomatic. 
A  mild  cough-mixture,  such  as  is  recommended  in  measles  for  the  bron- 
chitis, nutritious  but  easily  digested  food,  and  medicine  to  regulate  the 
bowels  when  necessary,  fulfil  all  the  indications  for  internal  medication. 
As  in  measles,  cool  sponging  should  be  resorted  to  before  and  during 
the  rash  ;  and,  when  the  fever  is  high,  a  cool  tub-bath,  where  practicable, 
will  be  found  to  reduce  the  temperature,  quiet  the  patient,  and  hasten 
the  appearance  of  the  eruption.  During  convalescence,  if  the  child  does 
not  rapidly  regain  his  appetite  and  strength,  tonics,  such  as  tincture 
of  nux  vomica  and  syrup  of  hydriodic  acid,  are  indicated. 

The  complications  are  to  be  treated  as  they  arise,  but  the  sponging 
should  not  be  discontinued  until  the  temperature  becomes  normal. 


wiJoopiNC-couajf.  223 

WHOOPING-COUGH. 

( Pertussis  ;    Tussvs  Conmdsiva  ;  KeachhuslcM. ) 

Definition. — Whooping-cough  is  a  highly  contagious  disease,  char- 
acterized by  a  catarrhal  inflammation  of  the  respiratory  tract,  associated 
with  a  peculiar  spasmodic  cougli,  ending  in  a  whooping  inspiration. 

Patholog^y. — There  is  no  lesion  that  can  be  considered  characteristic 
of  whooping-cough,  and  none  around  which  all  the  symptoms  and  compli- 
cating conditions  are  grouped.  In  the  beginning  there  is  catarrh  of  the 
nasopharynx,  and  this  may  be  the  only  change  coincident  with  the 
development  of  the  characteristic  cough.  In  advancing  cases  this  naso- 
pharyngeal catarrh  becomes  generalized  by  extension  to  the  lachrymal 
ducts,  the  conjunctivae,  the  Eustachian  tube  and  the  middle  ear,  to  the 
glottis,  trachea,  large  and  small  bronchi,  and  the  air-vesicles.  The  more 
decided  pulmonary  lesions — emphysema,  pulmonary  collapse,  pulmonary 
congestion  and  edema,  and  bronchopneumonia — are  advanced  pathologic 
conditions  accompanying  the  later  stages  (W.  W.  Johnston). 

The  postmortem  table  does  not  give  as  much  information  as  to  the 
pathology  except  as  to  the  sequences  of  the  disease.  In  the  early  stages 
swelling  and  redness  of  the  respiratory  and  digestive  tracts  will  be  found, 
together  with  a  large  quantity  of  viscid  mucus. 

i^tiology. — The  disease  occurs  in  epidemics,  yet  occasionally  may 
appear  sporadically.  Pertussis  seems  to  have  a  tendency  to  occur  in 
epidemics  every  two  years,  although  in  large  cities  the  disease  is 
generally  endemic.  Pertussis  is  directly  contagious,  though  scarcely  so 
in  houses  and  school-rooms,  unless  it  be  for  those  of  a  specially  susceptible 
nature.  It  is  possible,  however,  for  the  disease  to  be  propagated  in  schools, 
though  not  to  the  same  extent  as  measles  and  scarlet  fever.  It  seems  that 
a  more  decided  and  prolonged  personal  contact  must  be  made,  as  with 
members  of  a  family,  to  ensure  transmission.  One  close  exposure  in  a 
susceptible  child  may  be  sufficient  to  ensure  an  attack.  The  germs  seem 
to  be  located  at  first  in  the  secretions  of  the  respiratory  tract,  and  are 
thus  disseminated  through  the  air,  the  disease  being  most  highly  con- 
tagious, therefore,  during  the  paroxysms  of  coughing.  Groodhart  reports 
a  case  in  which  a  third  party  conveyed  the  disease  from  one  child  to 
another,  thus  suggesting  that  the  contagion  is  ponderable. 

Predisposing  Causes. — The  influence  of  the  seasons  does  not  seem  to 
have  any  effect,  though  perhaps  fall  and  spring  are  the  more  frequent 
periods ;  the  station  in  life,  whether  hygienic  or  unhygienic,  does  not 
modify  the  disease.  Bad  ventilation,  however,  may  propagate  the  dis- 
order, and  cause  additional  cases  by  favoring  the  increase  of  germs  in  the 
immediate  surroundings.  The  previous  condition  of  health,  especially  of 
the  respiratory  mucous  membrane,  seems  to  possess  some  predisposing 
influence,  weak,  delicate  children,  with  an  irritable  digestive  tube  associ- 
ated with  a  catarrhal  state  of  the  respiratory  passages,  more  readily  con- 
tracting whooping-cough  than  those  in  robust  health. 

There  is  an  intimate  association  between  whooping-cough  and  measZesy 
epidemics  of  measles  are  often  followed  by  whooping-cough  in  the  same 
sufferers.  This  is  possibly  due  to  the  sensitive  condition  of  the  mucous 
membrane  left  by  the  measles,  which  is  so  favorable  to  the  lodgement  of  the 
germs  of  pertussis ;  and  the  association  of  the  two  diseases  must  be  more  than 


224  INFECTIOUS  DISEASES. 

accidental.   There  exists  a  certain  individual  susceptibility,  which,  however, 
is  not  universal  to  whooping-cough,  as  well  as  to  other  infectious  diseases. 

Age  exercises  some  influence  on  the  development  of  whooping-cough, 
most  cases  occurring  before  the  tenth  year;  after  this  time  the  frequency 
of  the  disease  rapidly  diminishes.  West  states  that  one-half  of  all 
cases  develop  urtder  tliree  years,  but  he  njust  have  based  his  knowledge 
upon  an  experience  in  hos])itals  and  children's  homes,  as  the  experience 
of  others  does  not  sustain  his  statement.  The  disease  occurs  in  adults 
but  rarely,  this  being  due  partly  to  the  fact  that  so  many  have  suffered 
from  it  while  young,  and  partly  to  a  lessened  susceptibility.  It  occurs 
frequently  before  the  iirst  year,  and  when  it  does  it  is  the  most  fatal  of  all 
the  diseases  of  childhood  (Goodhart). 

The  sexes  are  about  equally  divided  as  regards  susceptibility;  many 
writers,  however,  seem  to  think  that  girls  are  more  liable. 

The  highway  of  the  contagion  of  whooping-cough  into  the  system  is 
evidently  the  respiratory  tract,  though  this  fact  needs  confirmation. 
Published  cases  of  pertussis  in  the  newborn  would  even  seem  to  make  its 
transmission  possible  through  the  fetal  circulation,  yet  the  reports  are 
neither  numerous  nor  satisfactory.  One  attack  is  usually  protective  for 
the  rest  of  life,   although  exceptions  to  the  rule  may  be  found. 

Nature  and  Bacteriology. — The  true  nature  of  whooping-cough  has 
been  thoroughly  discussed,  but  is  not,  as  yet,  fully  settled.  Many 
writers  claim  it  to  be  a  simple  bronchitis  due  to  "cold,"  associated  with 
a  certain  nervous  habit  or  mimicry.  The  cough  is  started  by  the  bron- 
chial irritant  and  soon  tends  to  become  a  habit,  thus  returning  again 
and  again,  until  it  dies  out  in  the  oblivion  engendered  by  more  healthy 
and  regulated  discharges  of  nervous  energy  (Goodhart).  It  has  been 
held  that  the  disease  is  a  lesion  of  either  the  pneumogastric,  phrenic, 
sympathetic,  or  recurrent  laryngeal  nerves,  or  perhaps  even  of  the 
medulla.  If  this  ground  be  valid,  whooping-cough  is  simply  a  neurosis. 
Eustace  Smith  says  it  is  caused  by  the  pressure  of  the  enlarged  tracheal 
and  bronchial  glands  upon  the  terminal  filaments  of  the  pneumogastric 
nerve.  Whatever  the  direct  cause,  the  contagious  character  of  whooping- 
cough,  its  appearance  in  epidemics,  its  incubating  period,  and  the  possible 
immunity  from  subsequent  attacks,  seem  to  prove  beyond  argument  that 
it  should  be  classed  among  purely  infectious  diseases. 

Bacteriology. — Linnteus  (to  quote  Dr.  J.  P.  C.  Griffith,  in  the  Ameri- 
can Text-Book  of  Diseases  of  Children)  attributes  pertussis  to  the  pres- 
ence in  the  nose  of  larvae  of  insects.  The  researches  of  Afanassieff  in 
1887  have  attracted  much  attention.  This  observer  isolated  a  short 
bacillus,  which  he  named  the  bacillus  tussis  convulsiva\  and  of  which 
he  was  able  to  obtain  pure  cultures  upon  various  media.  Animals 
inoculated  upon  the  respiratory  mucous  membrane  with  these  cult- 
ures exhibited  some  of  the  symptoms  of  the  disease  and  developed 
catarrhal  conditions  of  the  respiratory  tract,  with  a  tendency  to  broncho- 
pneumonia. These  observations  have  been  confirmed  by  others,  and  a 
toxin  has  also  been  reported  as  present  in  the  urine  of  patients  suffer- 
ing from  pertussis  which  is  identical  with  that  produced  by  Afanassieff 's 
bacillus.  Kuoloff  believes  that  the  parasite  of  whooping-cough  is  a  spe- 
cific micro-organism,  a  protozoon,  and  has  found  uniformly  in  the  fresh 
sputa  of  patients  ameboid  organisms  with   spheric  spores  characterizea 


WHO  OPING -CO  UGH.  225 

by  concentric  laminations.'  Czaplcnvski  and  Jlonsol  describe  a  sliort 
bacillus  with  distinctly  staining  rounded  ends,  and  commonly  occmi-Jng 
in  pairs.  It  is  found  in  sputum,  both  free  and  in  pus-cells,  increasing 
as  the  disease  advances.  It  can  be  obtained  in  pure  culture;  and  grows 
on  any  ordinary  medium  except  potato.  It  resembles  Koplik's  bacillus. 
The  latter  is  facultative-anaerobic.  The  organism  is  not  found  in  the 
sputum  during  the  prodromal  stage.^  Arnheim  ^  found  in  fatal  cases  of 
pertussis  Czaplewski's  pole  bacteria,  which  he  was  able  to  cultivate  and 
which  were  pathogenic  to  white  mice.  Jochmann  and  Krause^  have 
recently  isolated  a  specific  microbe  and  called  it  the  baci/lus  pertussis 
eppendorfii,  but  their  claims  have  not  as  yet  received  full  confirmation. 
The  careful  investigation  of  Myer-Huni  and  of  von  Ileroif  indicate  that 
the  catarrhal  inflammation  is  especially  pronounced  on  the  posterior  wall 
of  the  larynx  in  the  interarytenoid  region,  the  so-called  "cough  region." 
Undoubtedly  we  have  in  whooping-cough  an  infectious  catarrhal  process 
which  affects  the  mucous  membrane  controlled  by  the  superior  laryngeal 
nerve.     Hence  the  value  in  many  cases  of  purely  local  treatment. 

The  nature  of  the  "whoop"  has  been  frequently  discussed  to  show 
the  nervous  origin  of  the  disease,  yet  the  infantile  larynx  is  capable  of 
responding  to  purely  neutral  stimuli  owing  to  the  flexible  nature  t)f  the 
young  cartilage.  If  we  carry  a  young,  sleeping  child  from  a  warm  room 
out  in  the  cool  air,  the  same  characteristic  whoop  may  be  produced. 

Clinical  History. — The  period  of  incubation  varies  from  four  to 
fourteen  days,  according  to  the  extent  of  catarrhal  trouble  in  the  child 
existing  at  the  time.  Goodhart  gives  several  authenticated  cases  in  which 
the  incubation  ended  on  the  eighth  day.  In  the  beginning  the  symptoms 
are  those  of  a  slight  bronchial  cough,  which  has  a  tendency  to  be  more 
pronounced  during  the  night.  After  a  few  days  the  cough  assumes  an 
influenzal  character,  and  at  the  same  time  it  gradually  grows  metallic  in 
ring  and  shows  a  laryngeal  type.  There  is  some  fever  present.  There 
is  a  pronounced  leukocytosis,  with  preponderance  of  the  lymphocytes. 
This  catarrhal  or  feverisli  stage  lasts  for  a  week  or  more,  when  it  is  followed 
by  the  paroxysmal  stage,  and  these  stages  are  divisions  of  the  symptoms 
worthy  of  recognition,  as  the  treatment  in  the  first  is  not  applicable  to 
the  second.  Many  authorities  speak  of  a  third  stage  as  one  of  decline, 
which  does  not  sharply  occur,  but  includes  the  sequence  of  the  disease. 
The  catarrhal  stage  lasts  about  one  week  or  ten  days,  during  which  the 
child  is  ill  at  ease,  is  feverish,  and  has  a  hoarse,  dry  cough.  The  symp- 
toms may  either  be  entirely  laryngeal  at  first  or  bronchial,  with  a  loss 
of  appetite  and  broken  rest  at  night.  Auscultation  at  this  time  will 
reveal  a  few  moist  or  dry  rales  in  the  larger  bronchial  tubes,  but  there 
is  very  little  secretion.  The  cough  seems  to  be  out  of  proportion  to  the 
physical  signs.  As  the  catarrhal  stage  proceeds  the  cough  commences 
to  indicate  its  character  by  becoming  more  noisy,  increasing  especially  at 
night.  The  physiognomy  of  the  child  commences  to  change,  the  face  is 
swollen,  the  eyes  suffused  and  Avatery,  the  under  lids  swollen  and  pink  in 
color.  This  is  one  of  the  most  decisive  indications  of  the  trouble,  and 
may  be  recognized  by  a  careful  observer  a  few  days  before  the  "whoop" 
begins  which  stamps  the  disease  and  ushers  in  the  second  stage.     The 

•  Medical  News,  Nov.  9,  1906.  ^  Saunders'  Year-Book  for  1899,  p.  696. 

*  Berlin,  klin.  Woch.,  Aug.  6,  1900.  *  La  Semuine  iMedicale,  Aug.  21,  1901. 

15 


226  INFECTIOUS  DISEASES. 

commencement  of  tlie  paroxysmal  stage  is  (juite  different  from  the  easy 
and  more  constant  coughing  of  the  first  stage.  If  the  child  is  in  bed, 
the  onset  of  a  paroxysm  is  usually  quite  sudden,  but  if  he  is  up  and 
playing,  there  is  a  period  of  restlessness,  a  premonition  of  the  coming 
storm  similar  to  the  aura  in  epilepsy,  and  the  child  may  even  have  time 
to  run  to  his  mother  or  nurse  before  the  paroxysm  comes  on.  Usually 
the  paroxysms  are  induced  by  a  quick  inspiration,  as  during  drinking, 
eating,  or  crying.  The  first  (expiratory)  part  is  short,  and  followed  by 
a  short  whoop;  this  is  very  quickly  followed  by  a  long  series  of  short 
expiratory  efforts  and  a  second  and  longer  whoop,  when  the  paroxysm 
may  cease.  In  some  cases  a  third  and  a  fourth  may  quickly  follow,  un- 
til the  child  is  quite  exhausted.  The  paroxysms,  whether  short  or  long, 
generally  terminate  with  vomiting  or  eructation  of  a  quantity  of  stringy 
mucus.  Food  is  ejected,  and  in  most  cases  a  little  blood  is  mixed  with 
the  vomited  mucus. 

At  this  stage  of  the  disease,  if  at  all  severe,  the  countenance  of  the 
child  is  characteristic,  and  so  much  so  that  a  mistake  is  no  longer  pos- 
sible :  the  features  are  swollen,  puffy,  and  dusky  in  color ;  the  eyes 
are  injected,  the  lids  swollen  and  pink  ;  the  skin  livid,  due  to  a  minute 
ecchytoosis  of  the  smaller  capillaries.  In  many  cases  there  will  be  ex- 
travasation of  blood  beneath  the  conjunctiva,  due  to  the  violence  of  the 
congestive  cough.  If  the  chest  be  examined  at  this  stage,  it  will  tell 
but  little,  provided  we  have  no  broncho-pneumonia,  though  a  few  moist 
rales  may  be  found  scattered  through  the  larger  tubes. 

The  spasmodic  stage  of  whooping-cough  has  no  set  duration  and 
varies  frequently  in  intensity.  In  severe  cases  it  may  consist  of  twenty 
to  forty  paroxysms  during  the  twenty-four  hours.  Some  spasmodic 
coughs  are  not  accompanied  by  a  whoop,  and  the  absence  of  this  sign 
may  be  noted  in  very  young  children,  as  well  as  in  those  that  are  very 
ill  with  broncho-pneumonia.  Some  children  vomit  after  a  coughing 
spell  without  the  whoop. 

It  is  frequently  observed  that  long  after  the  spasmodic  spell  has  come 
to  an  end  the  paroxysms  return  again  and  again,  perhaps  years  after- 
ward, with  almost  characteristic  features,  evidently  acting  under  the 
stimulus  of  some  perfectly  neutral  catarrh. 

Complications. — In  severe  cases  the  complications  maybe  numerous. 

Epistaxis  often  occurs  in  children ;  hemoptysis  when  vomiting  is  fre- 
quent ;  ulceration  of  the  frenum  lingune  in  violent  coughing  ;  convulsions 
in  vigorous  children;  and  broncho-pneumonia,  p>leurisy,  pericarditis, 
laryngitis,  and  hernia  in  severe,  prolonged  coughing.  Convulsions  and 
broncho-pneumonia  are  alarming,  and  in  young  children  a  profound 
stupor  may  replace  the  convulsions.  Eshner^  states  that  peripheral 
neuritis  is  a  rare  complication  of  this  disease.  Interlobular  emphysema 
has  resulted  from  whooping-cough  (Finch). 

Sequelae. — Acute  nep>hritis  frequently  occurs,  and  is  as  severe  as 
that  found  in  scarlet  fever.  In  a  series  of  over  200  cases  I  have  found 
the  kidneys  affected  in  20  per  cent.  Knight  found  albuminuria  in 
66  out  of  86  cases  examined.  Emaciation  is  a  very  important  se- 
quence of  pertussis.  All  the  viscera  are  liable  to  fatty  degeneration, 
and  nutritional  changes  open  the  door  to  cheesy,  glandular  altera- 
'  American  Medicine,  June  21,  1902. 


WJ-IOOPINO-COUOH.  227 

tions,  and  eventually  to  a  secondary  tuberculosis.  Atelectasis,  by 
curtailing  lung  space,  frequently  brings  about  a  general  collapse,  and 
this  condition  frequently  explains  the  flattened  chest  found  in  young 
adults.  Conversely,  emphysema  may  be  initiated  by  peitussis  early  in 
life.  Emaciation  may  also  be  due  to  mucous  disease,  a  chronic  gastro- 
intestinal catarrh  of  lonij  standing:. 

Prognosis. — Associated  with  its  complications,  pertussis  is  a  very 
fatal  disease,  especially  in  children  under  two  years  of  age.  Dolan  re- 
gards it  as  third  in  rank  among  the  fatal  diseases  of  England,  where 
the  death-rate  per  million  is  five  thousand  annually.  The  deaths  occur 
chiefly  among  children  of  the  poor  and  in  bottle-fed  infants. 

Goodhart  regards  whooping-cough  as  the  most  fatal  of  all  the  dis- 
eases in  children  under  one  year  of  age.  He  places  the  mortality  at  12 
per  cent.,  and  thinks  that  this  is  not  too  high;  his  statement,  however,  is 
hardly  warranted,  as  he  includes  the  deaths  from  the  many  sequelae  which 
we  cannot  estimate.  Ashby  and  Wright  place  the  mortality  at  7.6  per  cent. 

Differential  Diagnosis. — Young  infants  usually  do  not  "  whoop," 
but  cough  spasmodically.  Children  with  pleurisy/  or  pneumonia  do  not 
whoop,  yet  we  diagnose  whooping-cough  by  the  preceding  catarrhal 
fever.  From  influenza  in  its  early  stages  it  is  most  difficult  to  differen- 
tiate the  affection.  The  pink  under  eyelid  has  to  me  been  the  most  cer- 
tain sign.  When  the  whoop  appears  and  during  the  existence  of  an 
epidemic,  however,  the  diagnosis  may  be  rendered  certain. 

The  diagnostic  points  prior  to  the  whooping  stage,  enunciated  by 
Eustace  Smith  are  as  follows  :  "  If  a  child  be  made  to  bend  back  the 
head,  so  that  his  face  becomes  almost  horizontal,  and  the  eyes  look 
straight  upward  at  the  ceiling  above,  a  venous  hum,  varying  in  intensity 
according  to  the  size  and  position  of  the  diseased  glands,  is  heard  with 
the  stethoscope  placed  upon  the  upper  bone  of  the  sternum.  As  the 
chin  is  now  slowly  depressed  the  hum  becomes  less  loudly  audible,  and 
ceases  shortly  before  the  head  reaches  its  ordinary  position."  It  is  true 
that  we  do  not  recognize  the  hum  caused  by  the  enlarged  bronchial 
gland,  but  it  occurs  long  after  other  symptoms  are  manifest. 

I  have  for  several  years  been  able  to  place  considerable  value  on  the 
peculiar  puflfiness  of  the  mucous  membrane  of  the  eyes  and  the  swollen 
or  edematous  condition  of  the  Avhole  face  and  almost  dusky  color.  This 
condition  may  exist  for  days  before  the  catarrhal  symptoms  have  extended 
throughout  the  respiratory  mucous  membrane.  The  cough  at  this  stage 
may  not  be  at  all  suggestive,  but  purely  bronchial. 

This  symptom  of  fulness  about  the  eyes  suggests  measles,  and  must 
be  differentiated  from  it.  As  we  are  able  to  diagnosticate  measles  by  its 
appearance  first  on  the  hard  palate,  so  we  may  diagnosticate  whooping- 
cough  in  its  earliest  stage  by  the  characteristic  swollen  condition  of  the 
eyes  and  face.  The  diagnosis  may  be  confirmed  by  leukocytosis  and  the 
presence  of  a  sublingual  ulcer. 

Treatment. — The  gravity  of  pertussis  is  scarcely  appreciated  either 
by  the  general  physician  or  the  public,  and  there  is  more  criminal  neglect 
in  connection  with  whooping-cough  than  with  any  other  disease. 

Hygiene. — Throughout  the  whole  course  of  the  disease  out-door 
life,  as  far  as  possible,  should  be  encoui-aged,  and  if  convenient  a  sojourn 
at  the  sea-shore  will   shorten   the  progress  of  the  trouble  and  limit  to  a 


228  INFECTIOUS  DISEASES. 

great  extent  tlio  number  of  se([ne\x.  Only  the  severe  and  complicated 
cases  need  to  be  kept  in  bed.  It  has  been  shown  that  the  number  of  attacks 
is  directly  dependent  upon  the  amount  of  CO.^  present  in  the  atmosphere 
(Forcheiuier).  In  cities  the  sufferer  must  be  protected  against  the  dust; 
this  may  be  accomplished  by  the  ■wearing  of  a  veil  in  suitable  cases. 

Medicinal  treatment  is  exceedingly  unsatisfactory,  althouizh  the  thera- 
peutic measures  which  have  been  advocated  are  boundless.  The  remedies 
most  in  use  are  the  antispasmodics  and  the  germicides. 

Whooping-cough  has  a  striking  parallel  in  diphtheria,  in  that  it  has 
in  its  early  stages  a  strong  tendency  to  fasten  itself  upon  the  throat. 
How  long  this  period  exists  we  do  not  know  to  a  certainty  ;  yet  there  is 
undoubtedly  a  period  in  whooping-cough,  as  there  is  in  diphtheria,  long 
or  short,  in  which  the  virus — if  it  could  be  recognized — could  be  destroyed 
and  the  disease  terminated.  To  abort  cases  thus  within  two  weeks  is  not 
unusual,  and  this  explains  the  number  of  reported  cures  made  by  germici- 
dal remedies. 

I  have  notes  of  2  recent  cases  in  which  the  characteristic  whoop  com- 
menced at  once  with  the  general  catarrhal  symptoms,  and  was  cut  short 
by  a  hydrogen-peroxid  gargle.  These  2  cases  illustrate  very  clearly  the 
fact  that  the  germs  of  the  disease  will  locate  on  the  mucous  membrane 
of  the  respiratory  passages  and  bring  about  a  nerve-discharge  which  ends 
in  the  characteristic  whoop.  In  mj  treatment  of  this  disease  I  find  the 
greatest  necessity  for  recognizing  the  aff"ection  early  in  the  catarrhal 
stage.  We  must  remember  that  the  two  stages  are  not  sliarply  defined, 
and  that  either  the  one  or  the  other  may  be  lacking. 

The  drugs  I  have  found  most  efficient  in  the  catarrhal  stage  have  been 
hydrogen  peroxid  for  sterilizing  the  naso-pharynx,  and  belladonna  and 
asafetida  for  the  paroxysms. 

To  be  more  explicit,  I  will  detail  the  methods  of  procedure  in  a  fam- 
ily in  which  I  have  instituted  my  plan  of  thorough  treatment :  A  child 
of  four  years  attending  kindergarten  was  brought  to  me  with  a  suspicious 
cough.  The  history  was  given  of  an  exposure  of  over  two  weeks  prior. 
The  child  had  coughed  for  a  few  days,  more  at  night  than  in  tlie  day- 
time ;  Avas  feverish  during  the  evenings  ;  showed  slightly  swollen  eyelids, 
thus  suggesting  the  nature  of  the  impending  trouble.  I  ordered  hydro- 
gen peroxid  and  pure  glycerin  in  equal  parts,  which  were  well  diluted 
and  thoroughly  sprayed  through  the  naso-pharynx  every  four  hours. 
The  diet  was  light  and  digestible ;  out-door  life  was  encouraged,  except 
on  windy  days.  At  night  the  child  was  placed  in  a  large,  well-ventilated 
room,  and  over  its  cot  was  erected  a  mosquito  netting,  so  as  to  prevent 
any  unusual  draught — a  procedure  Avhich  I  have  found  highly  beneficial. 
When  the  cough  was  fully  established  and  was  accompanied  by  eructa- 
tions of  stringy  mucus,  I  commenced  the  exhibition  of  the  mixture  of 
asafetida  h  dram  (2.0)  every  two  hours.  The  record  of  the  paroxysmal 
stage  Avas  as  follows  :  The  first  week  averaged  six  coughing  spells  per 
day;  the  second  Aveek  averaged  ten  per  day;  the  third  week,  four  par- 
oxysms ;  and  the  fourth  and  fifth  weeks  averaged  about  tAvo  paroxysms 
during  the  tAventy-four  hours.  When  the  younger  brother,  but  eight 
weeks  old,  commenced  to  shoAv  evidences  of  the  disease,  I  first  used 
hydrogen  peroxid  as  in  the  older  brother,  and  immediately  followed  it 
with  asafetida.     The  case  ended  favorably. 


PAROTITIS.  229 

My  second  choice  is  tlie  tincture  of  belladonna,  exhibited  in  doses  of 
one  drop  for  every  year  of  the  child's  life,  the  doses  being  rapidly  in- 
creased until  toxic  effects  are  reached.  ^Flien  I  gradually  increase  tlie 
amount  as  tolerance  of  the  drug  seems  to  be  established.  In  very  young 
children  I  have  obtained  good  results  from  the  use  of  a  freshly  prepared 
belladonna  plaster  placed  between  the  scapulae,  and  the  physiologic  action 
of  the  drug  seems  thus  to  be  more  constantly  maintained.  I  have  gained 
a  decided  advantage  by  an  application  of  a  2  per  cent,  cocain  solution 
directly  to  the  naso-pharynx  in  a  few  bad  cases.  This  treatment,  liow- 
ever,  does  not  preclude  the  use  of  hydrogen  peroxid,  which  should  be 
continued  throughout  the  catarrhal  stage.  Irrigation  of  the  nostrils  thrice 
daily  with  a  1  :  40  carbolic  acid  solution  has  proved  curative  in  its  effects. 
Bradt  declares  tiiat  local  treatment  of  the  naso-pharynx  tends  to  arrest 
the  syndrome. 

Bromoform  was '  resorted  to  in  fully  20  per  cent,  of  my  cases,  and 
was  a  keen  disappointment.  The  coal-tar  products,  pushed  to  the  toxic 
limit,  modified  the  disease  but  slightly.  A  drug  that  has  almost  reached 
the  rank  of  a  specific  in  my  hands  is  the  following  :  Atropin  sulph.,  gr.  j  ; 
aqua  distil.,  5J.  Each  drop  contains  -^^  gr.  atropin  and  this  dose 
may  be  increased  drop  by  drop  until  the  full  physiologic  effect  of  the 
drug  has  been  obtained.  If  this  effect  is  maintained  with  the  onset  of 
the  paroxysmal  stage,  much  time  is  saved.  This  outline  of  the  drug- 
treatment  in  whooping-cough  has  reference  solely  to  the  catarrhal  and 
paroxysmal  stages  of  the  disease.  Kilmer  has  advocated  a  tightly 
placed  thoracic  and  abdominal  belt,  which  has  yielded  great  satisfaction. 
Goodson  commends  the  use  at  the  earliest  moment  of  the  continuous  in- 
halation of  creasote ;  he  also  advocates  clearing  the  lungs  of  bronchitis 
as  much  as  possible  before  using  any  special  internal  antispasmodic 
remedies.      Graham  advises  a  trial  of  the  vaccine  treatment. 

Oomplicatioyis  and  Sequelce. — Complications  may  be  avoided  by  main- 
taining constantly  the  alkalinity  of  the  body  fluids.  Sodium  bicarbonate 
and  the  various  alkaline  waters  are  strongly  indicated,  and  milk  should 
be  given  in  seltzer  water. 

Passalarqua^  has  employed  diphtheria  antitoxin  successfully  in  7 
cases ;  it  is  especially  indicated  when  bronchial  or  pulmonary  complica- 
tions exist.  Diet  of  the  simplest  character  and  a  uniformly  quiet  life 
must  be  maintained. 


PAROTITIS. 

{Mumps  ;  Parotiditis  ;  Epidemic  Parotitis?} 

Definition. — An  acute  contagious  disease,  characterized  by  an  in- 
flammation and  swelling  of  the  parotid  gland,  and  occasionally  by  an 
involvement  of  the  salivary  glands,  the  testicles,  and  in  the  female  the 
mammae. 

Pathology. — Opportunities  for  post-mortem  examinations  are  rare, 
leaving  in  some  doubt  the  pathologic  course  of  the  disease;  but  it 
probably  begins  as  a  catarrhal  inflammation  of  the  ducts,  involving  the 
'  Rev.  Francaise  de  Med.  et  de  Chirurg.,  1905,  No.  11. 


230  INFECTIOUS  DISEASES. 

periglandular  connective  tissue.  The  inflammation  is  seldom  severe 
enough  or  of  such  a  nature  as  to  produce  suppuration. 

Etiology. — Mumps  is  undoubtedly  a  constitutional  or  blood-disease 
■with  local  manifestations.  ''It  is  a  question."  Goodhart  says,  "with 
mumps  ^\•hother  this  disease  shall  be  placed  with  the  specific  diseases  or 
•with  those  affecting  the  parts  or  organs  with  which  the  symptoms  more 
particularly  concern  themselves." 

The  disease  is  no  doubt  of  wicrohic  origin,  but  the  specific  organism 
has  not  yet  been  isolated,  and,  while  there  has  been  some  reason  to  be- 
lieve that  it  is  a  bacillus,  this  has  not  been  proved  and  is  still  doubtful. 
It  is  highly  contagious,  and  at  times,  usually  during  the  spring  and 
autumn,  becomes  epidemic.  It  is  communicated  principally  by  the 
breath  and  crhalations,  the  greatest  source  of  contagion  being  the 
salivary  secretions.  It  may,  however,  be  carried  by  a  third  person  or 
by  fomites,  and  is  most  liable  to  be  communicated  during  the  begin- 
ning of  the  attack,  although  the  contagiousness  continues  until  after  the 
subsidence  of  the  febrile  symptoms.  It  occurs  mostly  among  cliildrot 
and  young  adults,  infants  and  old  persons  being  rarely  affected,  while 
males  are  more  liable  than  females.  One  attack  usually  gives  immwiity 
from  a  second  attack  in  the  same  gland. 

Clinical  History. — The  average  period  of  incuhatinn  is  fourteen 
days,  but  it  may  develop  as  early  as  ten  or  as  late  as  twenty  days  after 
exposure.  The  invasion  is  marked  by  languor  and  a  temperature  from 
101°  to  103°  F.  (38.3°-39.4°  C),  with  possible  headache  and  vomit- 
ing; the  patient  complains  of  pain  at  the  angle  of  the  jaw,  and  this 
is  greatly  increased  if  an  acid  (such  as  vinegar)  is  swallowed.  With 
these  symptoms  is  noticed  a  pgriforin  swelling  of  the  parotid  glands, 
the  one  on  the  left  side  usually  appearing  first,  and  the  other  one 
soon  following.  Occasionally  cases  are  seen  in  which  but  one  gland  is 
involved,  or  the  swelling  may  begin  in  both  at  the  same  time.  This 
increases  gradually  until  some  time  between  the  third  and  sixth  days, 
involving  the  other  salivary  glands  and  causing  marked  disfigurement; 
the  swelling  fills  the  depression  beneath  the  ear  and  extends  to  the 
cheek  and  neck,  the  most  prominent  part  l)eing  just  below,  and  ]n-essing 
outward,  the  lobe  of  the  ear.  The  salivary  secretions  are  generally 
much  increased,  though  there  may  be  the  opposite  condition  of  marked 
dryness  of  the  mouth.  When  the  swelling  has  reached  its  height,  pres- 
sure on  the  adjacent  tissues  causes  a  disagreeable  sensation  of  tension, 
and  chewing,  swalloAving,  and  even  speaking,  are  at  times  painful  and 
difficult.  The  skin  over  the  affected  part  may  be  of  a  pale  or  of  a  dull- 
red  color.  Rinffino-  in  the  ears  and  a  dullini2:  of  the  hearing  is  common. 
The  nervous  system  may  be  affected,  causing  headache  and  delirium,  or 
a  low  typhoid  state  may  be  present.  The  duration  is  about  one  week 
(six  to  ten  days),  after  which  time  the  swelling  subsides,  and  by  the 
tenth  or  twelfth  day  entirely  disappears. 

Diagnosis. — The  diagnosis  is  easy,  tlie  nature  and  position  of  the 
swelling  and  the  course  of  the  disease  being  characteristic,  while  the 
fact  that  the  tonsils  are  seldom  involved  prevents  a  diagnosis  of  acute 
tonsillitis. 

Occasionally,  however,  in  the  course  of  septic  infection  or  after 
operations,  or  owing  to  tlie  extension  of  inflammation  along  the  duct 


TUBERCULOSIS.  231 

from  the  mouth,  tlie  parotid  frhind  becomes  the  seat  of  an  acute  infhirn- 
mation  at  first  hardly  distinguishable  from  mumps.  The  existence  of  a 
possible  source  of  infection,  and  the  fact  that  the  gland  under  these 
circumstances  usually  undergoes  suppuration,  should  lead  to  the  recog- 
nition of  the  true  nature  of  the  case. 

Complications  and  Sequelae. — Mumps,  as  a  rule,  runs  a  mild 
course  without  any  serious  symptoms,  but  occasionally  complications 
arise.  The  most  common  of  these  are  orchitis  in  the  male,  which  may  be 
followed  by  atrophy  of  the  testicle;  and  mastitis,  ovaritis,  or  vulvo-vag- 
initis  in  the  female,  especially  after  puberty.  These  complications  appear 
after  the  subsidence  of  the  swelling  of  the  glands  of  the  neck,  only  occa- 
sionally developing  while  the  glands  are  still  affected,  though  cases  have 
been  reported  in  which  the  disease  first  manifested  itself  by  involvement  of 
the  sexual  organs.  This  complication  lengthens  the  course  of  the  attack 
and  increases  the  constitutional  symptoms,  but  the  rule  is  complete  re- 
covery. Otitis  media  sometimes  occurs,  and  a  lesion  in  the  auditory 
nerve,  with  more  or  less  deafness  (which,  unfortunately,  may  be  perma- 
nent), has  been  observed.  Meningitis,  with  active  brain-symptoms, 
facial  paralysis,  convulsions,  albuminuria,  and  arthritis,  have  all  been 
noted  in  certain  cases.  Jacob  and  others  report  cases  of  mumps  compli- 
cated with  acute  pancreatitis. 

Treatment. — The  patient  should  be  kept  in  a  well-ventilated  room 
of  even  temperature,  and  in  bed  if  the  fever  is  at  all  severe,  and  should 
be  isolated  from  those  Avho  have  not  had  the  disease.  Either  hot  or 
cold  applications  to  the  swelling  will  often  give  relief,  and  support  to 
the  swollen  gland  by  means  of  cotton  and  a  bandage  is  very  comforting. 
Saline  laxatives  may  be  given,  and  aconite  or  some  simple  fever-mixture 
at  the  beginning  of  the  attack  is  usually  indicated.  These  simple 
measures  are  all  that  are  required  in  an  ordinary  case,  while  complica- 
tions or  unusual  conditions  must  be  treated  as  they  arise. 


TUBERCULOSIS. 


Definition. — A  chronic  (less  frequently  acute)  infectious  disease, 
caused  by  the  bacillus  tuberculosis.  This  organism  produces  specific 
lesions,  taking  the  form  either  of  separate  nodular  masses  or  diffuse 
growths,  infiltrating  the  tissues,  while  aggregations  of  these  element- 
ary tubercles  give  rise  to  large  tubercular  masses.  Tubercles  undergo 
caseation  and  sclerosis,  followed  in  turn  by  ulceration  (in  consequence 
of  secondary  pyogenic  infection),  or,  more  rarely,  calcification. 

Historic  Note. — Prior  to  the  discovery,  in  the  early  part  of  the 
nineteenth  century,  by  Bayle  and  Laennec,  of  the  tuberculous  new 
growth  as  a  distinctive  body,  this  disease  had  been  studied  chiefly  from 
a  clinical  point  of  view.  At  this  early  period  the  disease  was  believed 
to  consist  chiefly  of  a  suppurative  process,  and  in  its  observation  the 
physician  was  unaided  by  auscultation.  Later,  the  tubercle  was  recog- 
nized  as   a   small   rounded   nodule   without   any   special  histologic   cha- 


232  INFECTIOUS  DISEASES. 

racteristics.  Villemin  in  18G5  performed  bis  epoch-making  experi- 
ments, and  the  tubercle  was  no  longer  distinguished  by  its  anatomic 
characters  alone.  Though  the  theory  of  the  infectious  nature  of 
tuberculosis  had  been  previously  advanced  by  Buehl  and  others,  it 
was  first  clearly  demonstrated  by  Villemin's  beautiful  inoculation- 
experiments  ujion  rabbits  and  guinea-jjigs  ^vith  particles  of  tubercular 
and  cheesy  substances,  producing  the  characteristic  lesions  of  tubercu- 
losis. It  then  remained  for  Koch  to  discover  (in  1881)  the  sj)ecific 
cause  of  the  most  important  of  all  human  ills — the  tubercle  bacillus. 
So  soon  as  the  specificity  of  the  disease  was  definitely  established  it 
became  clear  that  the  associated  inflammatory  processes,  that  were  for- 
merly believed  to  be  primary  lesions,  were  secondary. 

Geographic  Distribution. — Tuberculosis  prevails  in  almost  every 
quarter  of  the  globe,  but  is  more  prevalent  in  certain  latitudes  than  in 
others.  Thus,  in  general  terms,  it  may  be  said  to  prevail  more  exten- 
sively in  Avarm  than  in  cold  countries.  Local  conditions,  however,  exer- 
cise a  more  decisive  influence  in  engendering  predisposition  than  mere 
geographic  position.  It  is  of  quite  frequent  occurrence  in  all  densely 
populated  municipalities,  and  more  especially  in  the  overcrowded  sections 
of  the  latter;  this  fact  explains  why  the  iniiabitants  of  cities  of  the  North 
are  but  little  less  spared  than  those  of  the  cities  of  the  South.  On  the 
other  hand,  residents  of  mountainous  countries,  owing  to  the  purity  of 
the  atmosphere  and  the  elevation,  are  rarely  victims. 

General  Pathology  of  Tubercular  I/esions. — Distribution  of 
the  Lesions  in  the  Body. — Tuberculous  new  growths  elect,  most  fre- 
quently, the  lung,  and  when  the  disease  occurs  in  the  adult  this  organ 
is  almost  invariably  implicated.  Next  in  frequency  follow  the  larynx, 
intestines,  peritoneum,  urogenital  organs,  and  the  brain.  The  other 
chief  viscera  of  the  body  (spleen,  liver,  heart,  etc.,  particularly  the  lat- 
ter) are  less  commonly  the  seat  of  tuberculosis.  In  children  the  lesions 
exhibit  a  diff"erent  distribution,  the  favorite  seats  being  the  lymph-glands, 
intestines,  bones,  and  joints.  In  them  the  distribution  corresponds 
pretty  closely,  if  we  except  the  bronchial  and  mesenteric  glands,  to  that 
of  surgical  tuberculosis. 

The  Elementary  (Nodular)  Tubercle. — This  may  be  developed  in  any 
tissue  to  which  the  tubercle  bacillus  has  found  its  way,  and  the  presence 
of  the  bacillus  is  its  sole  distinguishing  feature,  since  apparently  iden- 
tical bodies  are  produced  by  other  micro-organisms — f.  ^.,  certain  of  the 
worms  (eggs  of  the  distoma),  actinomyces,  aspergillus  glaucus,  aspergil- 
lus  funigatus,  and  even  as  a  result  of  irritation  by  certain  foreign  bodies 
(podophyllum).  Various  forms  of  pseudo-tuberculosis  have  been  de- 
scribed, but  all  are  due  to  micro-organisms  that  differ  from  the  bacillus 
tuberculosis.  Mallassez  and  A^ignal  described  a  form  produced  by  a 
micrococcus  occurring  in  a  zooglea ;  this  was  confirmed  by  Nocard, 
Eberth,  and  others.  Charrin  and  Rogers  have  described  still  another 
form,  in  which  they  found  bacilli  about  1 /i  long,  actively  motile,  and 
growing  freely  upon  ordinary  media,  but  not  growing  upon  glycerin  and 
agar,  ami  not  liquefying  gelatin. 

The  various  stages  in  the  development  of  a  tubercle  are — 

(a)  Proliferation  of  the  fixed-tissue  elements  (connective  tissue,  endo- 
thelium of  the   capillaries,    etc.)   of  the  part  infected,   due  to  the  local. 


TUBERCULOSIS.  233 

specific  irritant  action  of  the  bacilli.  These  anatomic  elements  are 
transformed  into  epithelioid  and  giant  cells.  The  epithelioid  cells 
assume  various  shapes,  chiefly  rounded  and  polygonal ;  they  liave  vesic- 
ular nuclei,  and  soon  show  tubercle-bacilli  in  their  interiors.  A  certain 
proportion  of  the  epithelioid  cells,  as  the  result  of  increase  in  their  size 
and  a  repeated  division  of  their  nuclei,  or  by  union  of  contiguous  cells, 
become  giant  cells.  The  latter  occupy  the  center  of  the  tubercle,  and 
also  contain  bacilli,  the  number  of  giant  cells  and  of  the  bacilli  being 
largely  reciprocal.  Thus,  the  giant  cells  are  numerous  in  tubercular 
lymph-glands,  joints,  etc.,  in  which  the  bacilli  are  relatively  few  ;  on 
the  other  hand,  they  are  scanty  in  miliary  tubercles,  in  which  the 
bacilli  are  numerous — two  facts  supporting  the  view  that  giant  cells 
display  phagocytic  action.  Hektoen  asserts  that  the  giant  cell  is  a 
living  defensive  agent. 

[h)  About  the  site  of  infection  a  diapedesis  of  leukocytes  occurs  in 
the  nature  of  a  defensive  inflammatory  process.  At  first  the  leukocytes 
are  of  the  polynuclear  variety  and  are  quickly  destroyed ;  but  later 
mononuclear  leukocytes  (lymphocytes)  appear.  These  latter  resist  the 
action  of  the  bacilli,  and  I  think  their  true  function  is  a  phagocytic 
one.  The  various  forms  of  cells  described  are  connected  and  sur- 
rounded by  a  reticular  stroma  "formed  by  the  fibrillation  and  rarefac- 
tion of  the  connective-tissue  matrix  "  (Baumgarten). 

The  fully-developed  tubercles  are  small,  nodular  bodies  whose  diam- 
eters range  from  |-  to  2  or  3  mm.  At  first  they  are  almost  transparent, 
but  soon  lose  this  quality  in  consequence  of  the  further  changes  de- 
scribed below.  They  are  avascular  bodies,  and  invariably  undergo  de- 
generative changes  :  {a)  caseation  and  (h)  sclerosis. 

(a)  Caseation. — This  implies  "coagulation-necrosis" — a  destructive 
process  proceeding  from  the  center  toward  the  periphery  of  the  tubercle, 
and  the  result  of  the  local  action  of  the  bacilli  or  their  toxins.  The 
cells  are  thus  transformed  into  a  uniformly  yellowish-gray  structureless 
matter.  When  the  foci  are  numerous  and  closely  set,  fusion  may  occur, 
with  the  production  of  larger  or  smaller  homogeneous  masses  (cheesy 
pneumonia).  The  latter  may  soften,  resulting  in  the  formation  of 
cavities :  this  is  due,  usually,  to  secondary  pyogenic  infection,  causing 
ulceration.  Less  frequently  the  cheesy  masses  undergo  calcification  or 
become  encapsulated,  and  are  then  practically  harmless. 

(6)  Sclerosis. — Preceding  and  during  the  time  that  cell-destruction 
is  going  on  in  the  center  of  the  tubercles  the  protective  forces  of  nature 
are  asserting  themselves,  though  too  often  without  avail.  In  the  first 
place,  hyaline  transformation,  with  conversion  of  the  cellular  elements 
into  fibrous  tissue  occurs.  Frequently,  now,  the  center  of  the  tubercle 
is  caseous  and  contains  bacilli,  while  the  peripheral  parts  are  quite 
hard.  Here  the  bacilli  are  incarcerated  {latent  tuberculosis).  The 
fibroid  change  may  pervade  the  entire  tubercle.  Again,  the  fibroid  ele- 
ment in  the  tissues  immediately  surrounding  the  tubercle  may  be  greatly 
increased  and  form  new  connective  tissue,  and  this  process  be  followed 
by  secondary  contraction,  converting  the  tubercle  into  a  firm  fibrous 
nodule.  The  fibroid  change  in  its  completest  development  is  observed 
in  tuberculosis  of  serous  membranes. 

In  every  case  of  tuberculosis  there  is  a  battle  for  supremacy  between 


234  INFECTIOUS  DISEASES. 

the  destructive  forces  on  the  one  hand  and  the  resisting,  conservative 
forces  on  the  other  hand.  As  mentioned  above,  limitation  of  the  tuber- 
culous process  takes  place  by  fibrous  encapsulation.  In  the  majority 
of  instances,  however,  the  bacilli  fall  upon  a  receptive,  favorable  soil, 
when  nature's  benign  curative  means  fail  and  extension  occurs  by  the 
appearance  of  secondary  tubercles  in  adjacent  tissues.  The  dissemina- 
tion and  transportation  of  the  bacilli  are  effected  principally  through  the 
lymph-channels  and  blood-vessels,  although  to  some  extent  also  by  the 
phagocytic  leukocytes.  Again,  infection  may  occur  by  actual  contact 
of  the  affected  organ  with  neighboring  parts,  the  disease  spreading  by 
continuity.  Lastly,  lesions  may  be  propagated  by  the  movement  of 
orjrans ;  thus  localized  peritoneal  tuberculosis  mav  rarelv  become  gren- 
eralized  in  consequence  of  the  peristaltic  movements. 

Again,  fusion  of  minute  centers  of  infection  or  of  miliary  tubercles 
results  in  the  formation  of  larger  nodules  or  areas,  which  lead  by  a 
process  of  local  extension  to  diffuse  tuberculous  infiltration  (gray  infil- 
tration of  Laennec).  An  entire  lobe  may  become  similarly  involved 
(tuberculous  pneumonia^  and  ''  there  may  also  be  a  diffuse  infiltration 
and  caseation  without  any  special  foci,  a  widespread  tuberculous  pneu- 
monia induced  by  the  bacilli  "  (Osier). 

The  term  '•  gray  infiltration  "'  is  misleading,  since  the  morbid  changes 
differ  in  no  essential  manner  from  those  described  as  occurring  in  the 
miliary  or  nodular  tubercle.  Moreover,  the  latter  also  presents  a  grayish 
appearance.  The  apparent  difference  between  a  miliary  tubercle  and 
diffuse  tubercular  infiltration  lies  in  the  fact  that  the  latter  displays  a 
clearer  tendency  to  spread  b.v  direct  extension. 

Associated  Inflammatory  Processes. — The  tubercle  bacilli  excite  asso- 
ciated inflammatory  processes  in  the  organs  affected,  and  if  the  tubercu- 
lous lesions  run  a  slow  course  a  limiting  wall  of  true  fibroid  induration 
circumscribes  the  area  involved.  By  means  of  this  induration  the  nat- 
ural protective  forces,  either  temporarily  or  permanently,  check  the 
progress  of  the  local  lesions,  and  the  change  is  strictly  analogous  to  the 
sclerosis  that  takes  place  in  the  peripheral  parts  of  the  elementary 
tubercle  or  immediately  surrounding  the  latter,  as  in  tuberculosis  of 
serous  membranes.  On  the  other  hand,  when  the  tuberculous  infiltra- 
tion is  less  tardily  developed  the  collateral  reactive  inflammation  may 
show  changes  similar  to  those  of  catarrhal  or  croupous  pneumonia  (vide 
supra).  Examination  of  the  sputum,  to  determine  the  nature  of  a  mixed 
infection,  is  of  little  value,  since  the  sputum  may  show  various  organisms 
that  have  not  caused  any  real  infection,  and  that  have  entered  the  sputum 
from  the  throat  or  buccal  cavity. 

Etiology. — The  Specific  Cause  and  its  Physical  Characteristics. — In 
1881,  Koch  discovered  the  tubercle  bacillus.  Avliich  is  the  sole  cause 
of  the  disease.  The  bacillus  is  rod-shaped,  straight  or  somewhat  bent, 
and  slender,  its  length  equalling  about  one-third  or  one-half  of  the 
diameter  of  a  red  blood-corpuscle  (Fig.  19).  Its  ends  are  slightly  rounded, 
it  is  non-motile,  and  on  the  interior  of  the  Ijacilli  small  colorless  spots  can 
be  observed  on  microscopic  examination  :  these  clear  spaces  represent 
plasuiolysis.  Spores  do  not  occur,  except  in  mixed  infection  (e.  g.,  old 
cavities)  due  to  symbiotic  growth. 


TUBERCULOSIS. 


235 


When  stained  the  Ijacilli  have  a  somewhat  beaddl  appearance.  The 
tubercle  bacillus  is  one  of  tlie  lew  varieties  of  bacteria  that  I'etain  the 
aniliu  dye  after  washings  with  acids. 

Biology. — The   bacilli    can 
be    erown    on    culture-media, 


.'J  A^  ^^r. 


:■¥■  '  ;;^/'',ii^ 


IK 


M5^ 
,.%^-'''i  ^//. 


'''%" 


CP-A'V 


'^^*  ^^ 


^'^  ', 


,y- 


■'/ 


"^ 


Fig.  19.— Tubercle  bacillus   in  sputum   (Frankel  aud 
PfeittcD. 


but  not  without  difficulty,  since 
they  demand  an  even  temper- 
ature between  98°  and  100°  F. 
(37.7°  C),  or  that  of  the  hu- 
man body.  The  best  soil  is 
blood-serum  previously  coag- 
ulated by  heating  and  glycerin- 
agar.  Over  the  surface  of  the 
medium  gently  rub  tubercu- 
lous tissue,  which  is  then  al- 
lowed to  remain  on  the  surflice. 
The  growth  of  the  bacilli  re- 
quires about  two  weeks,  when 
colonies  appear  as  dry,  gray- 
ish-white or  grayish-brown, 
thin  scales  or  masses  on  the 
surface  of  the  culture-medium. 
From  such  cultures  others  may 
be  grown  on  glycerin-agar  or  on  the  potato.  The  grass  or  butter  bacillus 
has  staining  properties  much  like  those  of  the  tubercle  bacillus,  and 
since  this  organism  is  commonly  found  on  hay  and  straw  it  should 
be  carefully  excluded  in  the  study  of  milk,  butter,  etc.  Both  the  lepra 
bacillus  and  the  smes:ma  bacillus  resemble  the  tubercle  bacillus  in  their 
manner  of  taking  stains,  but  neither  organism  is  capable  of  cultivation. 

Inoculations  into  the  guinea-pig  and  other  animals  are  succeeded  in 
three  to  six  weeks  by  the  appearance  of  elementary  tubercles — first, 
.locally,  and  then  in  other  organs  of  the  body. 

Chemical  Products. — The  growth  of  the  bacilli  is  possibly  attended  by 
the  formation  of  secretory  products.  Thus  an  albuminoid  substance  has 
been  separated,  and  this  when  injected  into  the  bod}-^  of  an  animal  pro- 
duces slight  fever.  The  albuminoid  separated  from  cultures  of  tubercle 
bacilli  is  a  nuclear  proteid,  and  not  a  specific  toxin.  The  constitutional 
features  of  the  disease  may  be  ascribed,  in  part,  to  the  circulation 
of  these  poisons  in  the  blood,  but  principally  to  the  pus-producing 
organism. 

Bovine  Tuberculosis. — The  disease  is  common  among  cattle  (TO 
to  20  per  cent.),  and  Koch  first  pointed  out  certain  differences  between 
the  bovine  bacillus  and  the  bacilli  of  human  and  animal  tuberculosis. 
Smith's^  studies  show  that  the  bovine  bacillus  possesses  the  greater 
virulence.  It  is  known  that  the  human  bacillus  infects  cattle  with  diffi- 
culty, while  "  the  bovine  bacillus  infects  animals,  and  probably  also 
man,  with  great  readiness  "  (MacFarland).^  Koch.^  in  an  address  before 
the  English  Congress  on  Tuberculosis,  said  that  man  is  rarelv  infected 


^  Trans,  of  the  Assoc,  of  Amer.  Pliys.,  1896,  xi.,  p. 
^  Text-Book  Upon  the  Pathogenic  Bacteria,  p.  331. 
^  Jour.  Compar.  Path,  and  Tlierap.,  Sept.,  1901. 


1^8,  and  1898,  xiii.,  p.  417 


236  INFECTIOUS  DISEASES. 

with  bovine  tuberculosis.  At  the  seventh  International  Congress  on 
Tuberculosis  (1908),  Koch  stated  that  he  knew  of  no  authenticated 
case  of  pulmonary  tuberculosis  in  -which  bovine  bacilli  had  been  found 
repeatedly  in  the  sputum.  The  results  of  the  investigations  made  by 
the  German  Imperial  Board  of  Health  sliow  that  the  dangers  from  the 
use  of  milk  and  other  dairy  products  derived  from  cows  with  tuberculous 
udders  is  extremely  slight.^  The  British  Hoyal  Commission  found  that 
one-third  of  the  cases  of  tuberculosis  in  children  under  five  years  of 
age  were  due  to  the  bovine  bacillus,  hence  attention  must  be  paid  to  this 
factor  in  connection  with  methods  of  prophylaxis  (Woodhead).  M.  P. 
Ravenel  concludes :  (1)  That  the  tubercle  bacillus  from  bovine  sources 
has  in  culture  fairly  constant  and  persistent  characteristics  of  growth  and 
morphology,  by  which  it  may  tentatively  be  distinguished  from  that 
ordinarily  found  in  man ;  (2)  that  cultures  from  the  two  sources  differ 
markedly  in  pathogenic  poAver,  affording  further  means  of  differentiation, 
the  bovine  bacillus  being  very  much  more  active  than  the  human  for  all 
species  of  experimental  animals  tested,  with  the  possible  exception  of 
swine,  which  are  highly  susceptible  to  both  ;  (3)  the  tuberculous  mate- 
rial from  cattle  and  from  man  corresponds  closely  in  comparative  patho- 
genic power  to  pure  cultures  of  the  tubercle  bacillus  from  the  two  sources 
for  all  animals  tested ;  (4)  that  it  is  a  fair  assumption  from  the  evidence 
at  hand  and  in  the  absence  of  evidence  to  the  contrary,  that  the  bovine 
tubercle  bacillus  lias  a  high  degree  of  pathogenic  poAver  for  man  also. 

Sources  of  the  Bacilli. — The  chief  sources  are  the  sputum  of  tubercu- 
lous patients  and  the  dejecta  of  persons  with  tuberculous  enteritis  and 
infected  meats  and  milk.  The  desiccated,  germ-laden  sputum  is  wafted 
into  the  atmosphere  in  the  form  of  dust-like  particles. 

Distribution  of  the  Bacilli. — The  tubercle  bacilli  are  found  in  a  viable 
condition,  both  {(()  inside  and  (6)  outside  of  the  body. 

(a)  Inside  of  the  Body. — As  before  stated,  the  number  of  bacilli 
found  in  tuberculous  growths  varies  within  wide  extremes.  In  general 
terms,  it  may  be  said  that  the  more  rapidly  the  process  advances  the. 
greater  the  number  of  bacilli  present.  It  must  not  be  forgotten,  how- 
ever, that  the  activity  of  the  tuberculous  processes  is  intimatelv  con- 
nected with  the  degree  of  resistance  offered  bv  the  tissues.  A  clironic 
tuberculous  focus  may  establish  a  fistulous  connection  with  a  vein  or  a 
lymph-vessel,  and  thus  scatter  the  bacilli  to  the  remotest  parts  of  the 
body ;  and  in  such  instances  (as  the  direct  effect  of  the  original  number 
of  bacilli  present)  a  chronic  is  quickly  converted  into  an  acute  form  of 
tuberculosis.  Strauss  ^  demonstrated  virulent  bacilli  within  the  nasal 
cavities  of  healthy  persons  whose  positions  necessitated  their  association 
with,  and  frequent  presence  in  rooms  occupied  by,  tuberculous  patients. 

{h)  The  Bacilli  Outside  of  the  Body. — Tubercle  bacilli  can  maintain 
their  existence  almost  indefinitely  outside  the  body.  On  the  other  hand, 
they  probably  do  not  develop  or  multiply  under  the  usual  external  influ- 
ences, but  their  vitality  is  extraordinary.  Their  destruction  cannot  be 
effected  by  freezing  nor  by  desiccation,  and  they  survive  for  months  in 
water.  Their  power  to  resist  chemical  agents  (nitric  acid,  etc.)  is  also 
very  great,  but  they  may  be  destroyed  by  boiling  for  four  or  five  min- 
utes or  by  exposure  to  the  direct  solar  rays  from  four  to  eight  hours 
'  A.  AVeber  in  Ileft  10  of  Research  Work  in  Tubercvlom.  ^  Milnch.  med.  Wochen, 


TUBERCULONTS.  2'i7 

(Jousset).  In  milk  they  may  be  destroyed  by  beating  in  a  closed 
pasteurizer  for  a  period  of  twenty  minutes  at  140°  F.  (60°  C). 
Tubercle  bacilli  are  undoubtedly  present  in  all  inhabited  places,  and 
they  may  be  conveyed  for  long  distances  by  means  of  water,  food,  and 
fomites.  Willson  and  Rosenberger  have  shown  that  tlie  presence  of 
living  tubercle  bacilli  in  the  urine  and  the  feces  is  of  importance  in 
relation  to  the  infectiveness  of  sewage  and  of  drinking  water. 

The  sputum  dries  and  flies  into  the  atmosphere  in  the  form  of  dust, 
which  not  only  floats  in  this  medium,  but  also  settles  upon  articles  of 
furniture,  the  floor,  the  walls  of  living-rooms,  hospital  wards,  draperies, 
clothing,  bed-linen,  etc.  ;  and  from  these  resting-places  it  may  be  con- 
veyed back  into  the  atmosphere.  It  has  been  shown,  experimentally, 
that  the  dust  obtained  from  the  walls  or  from  the  air  of  rooms  and 
hospital  wards  occupied  by  tuberculous  patients  is  frequently,  though 
not  invariably,  infected.  It  is  the  in-door  atmosphere,  laden  with  bacilli, 
that  is  especially  liable  to  be  dangerous.  In  places  only  rarely  frequented 
by  consumptives  the  dust  is  usually  free  from  virulent  bacilli. 

Modes  of  Infection. — (1)  Inhalation  of  the  Bacilli. — Inhalation  tuber- 
culosis is,  doubtless,  less  common  than  formerly  supposed.  There  is  some 
question  as  to  the  power  of  dust  containing  tubercle  bacilli  to  infect 
persons  and  animals  when  inhaled.  It  has  been  demonstrated  conclu- 
sively that  when  such  dust-like  material  is  mixed  with  the  food,  infection 
follows.  In  view  of  this  evidence  it  is  probable  that  the  particles  of 
sputum  floating  in  the  atmosphere  are  deposited  in  the  mucosa  of  the 
nasopharyngeal  ring  and  tonsils,  gaining  the  lymphatics  through  these 
structures  and  passing  to  the  cervical  glands,  thence  to  the  apices  of  the 
lungs.  Klebs  and  Flligge  claim  that  infection  may  result  from  moist 
particles  (salivary  droplets)  thrown  ofi"  in  coughing,  and  Boston  ^  has 
demonstrated  that  in  75  per  cent,  of  consumptives,  with  cavity  forma- 
tion, a  fine  spray  containing  tubercle  bacilli  is  emitted  during  the  acts 
of  coughing,  sneezing,  laughing,  and  talking.  Ravenel  ^  has  shown 
experimentally  that  tubercle  bacilli  may  be  disseminated  by  cows  in 
coughing.  It  is  highly  probable  that  such  spray  magnifies  the  danger 
of  infection  from  tuberculous  cooks  and  bakers.  Occasionally  the  bacilli 
attack  first  the  upper  respiratory  passages  (larynx,  nose).  Usually, 
however,  primary  infection  takes  place  in  the  smaller  bronchi  in  the  api- 
cal area  or,  less  frequently,  in  a  bronchus  ;  this  is  shown  by  the  fact  that 
healed  lesions  in  persons  dying  of  other  causes  are  commonly  met  with 
in  these  situations  in  the  dead-house.  The  bronchial  glands  may  be 
found  to  present  tuberculous  lesions. 

It  has  long  been  supposed  that  tuberculosis  is  a  contagious  affection  ; 
unlike  small-pox,  scarlatina,  and  other  acute  contagious  diseases,  how- 
ever, tuberculosis  is  not  transmitted  by  a  single  contact  with  a  person  ill 
of  the  disease.  Flick  and  others  have  shown  that  persons  who  live  in 
close  proximity  to  affected  persons  frequently  fall  victims  to  the  disease 
as  the  result  of  prolonged  contact. 

Flick's  topographic  study  of  phthisis  in  the  Fifth  Ward  of  the  city  of 
Philadelphia,  extending  over  a  period  of  twenty -five  years,  shows  conclu- 
sively that  consumption  obeys  the  laws  of  infectious  and  contagious  diseases. 
His  researches  furnish  incontestable  proof  that  tuberculosis  is  limited  to 

^  Jour.  Anier.  Med.  Assoc,  Sept.  14,  1901.  ^  Jour.  Compar.  J\red..,  .Jan.,  1901. 


238  INFECTIOUS  DISEASES. 

centers,  and  eacli  case  owes  its  existence  to  previous  cases  in  the  same  house 
or  locality ;  that  a  house  which  has  had  a  case  of  consumption  Avill  probably 
have  others  within  a  few  years,  and  may  have  a  large  number  of"  cases  in 
rapid  succession;  and  that  approximate  houses  are  considerably  exposed. 

The  contagious  theory  of  tuberculosis  gains  support  from  the  fact 
that  husbands  have  been  fre(iuently  observed  to  contract  the  disease 
from  their  wives,  and  the  latter,  since  they  are  more  constantly  con- 
fined in  the  house,  to  become  infected  yet  more  frequently  from  the 
former.  Weber  has  observed  the  case  of  a  tuberculous  husband  who 
lost  four  wives  in  succession,  another  who  lost  three,  and  four  others 
who  lost  two  each.  In  like  manner,  the  statistical  studies  of  Cornet, 
Niven,  Baer,  and  others  show  that  the  disease  spreads  through  factories, 
prisons,  cloisters,  and  even  among  the  physicians,  nurses,  and  attend- 
ants in  hospitals  for  the  reception  of  tuberculous  patients,  producing  a 
mortality-rate  from  this  disease  ranging  from  45  to  75  per  cent.  Sev- 
enty-three per  cent,  of  nurses  up  to  the  age  of  fifty  die  of  tuberculosis 
(Whittaker).  Those  who  are  engaged  in  making  the  beds,  dusting  and 
sweeping  the  rooms  of  patients  are  most  exposed ;  and,  on  the  other 
hand,  better  hygienic  living  among  these  classes  of  individuals,  and  im- 
proved hygienic  arrangements  in  prisons,  institutions,  and  hospitals,  have 
been  found  to  reduce  the  death-rate  decidedly.  This  result  is  to  be 
accounted  for  as  follows :  (a)  There  is  thus  established  a  greater  tissue- 
resistance  to  the  bacillus  tuberculosis  on  the  part  of  the  persons  exposed  ; 
and  {I))  the  germs  are  thus  more  widely  disseminated.  Obviously,  then, 
in  institutions  in  which  the  proper  sanitary  precautions  are  used  there 
mav  be  few  if  any  instances ;  and  from  the  records  of  the  latter,  facts 
opposed  to  the  contagious  theory  of  the  disease  can  readily  be  furnished. 

(2)  Infection  by  Swallowing. — ((/)  That  the  milk  of  tuberculous  ani- 
mals contains  the  bacillus,  and  that  the  use  of  contaminated  milk  may 
infect  the  human  subject,  are  well-established  facts.'  Gerlach  and  Klebs 
long  since  observed  the  occurrence  of  the  disease  in  animals  fed  with  milk 
from  cows  affected  with  the  so-called  "pearl  disease."  It  is  not  even 
necessary  that  the  animal  infected  should  have  tuberculous  mammitis 
(Ernst),  though  some  are  of  contrary  opinion  (Flick,  Sidney  Martin, 
and  others).  The  exact  frequency  of  this  mode  of  infection  is  not 
known.  Infected  animals,  especially  cows  and  pigs,  that  suckle  their 
young  very  frequently  transmit  the  disease  to  the  latter,  the  infection 
usually  resulting  in  intestinal  and  mesenteric  tuberculosis.  The  bacillus 
is,  in  this  instance,  swallowed  and  finds  lodgment  in  the  'primce  vice. 
Bang  has  even  shown  that  butter  made  from  the  milk  of  tuberculous 
cows  may  be  infectious  {vide  also  Bovine  Tuberculosis,  p.  235).  Human 
tuberculosis  is  entirely  analogous,  and  hence  the  tuberculous  mother  is 
likely  to  transmit  the  disease  to  her  suckling  offspring.  This  explains, 
adequately,  why  abdominal  tuberculosis  is  frequent  in  children. 

(i)  The  meat  of  a  tuhercuhns  animal  {e.  g.,  cow,  pig,  or  fowl)  may 
rarely  be  infectious,  but  the  bulk  of  experimental  evidence  would  seem 
to  show  that,  unless  the  parts  consumed  are  the  seat  of  tuberculous  de- 
posit, infection  does  not  follow.     D.  H.  Bergey,^  holds  that  the  lower 

'  See  the  elaborate  statistical  studies  of  Dr.  George  Cornet:  "Die  Tuberkulose  in  den 
Strafanstalten,"  Zeii.ochrift  fur  Hyqiene,  Bd.  x,  1891. 
*  Saundei-s'  Yeai-Book  for  1899. 


TUBERCULOSIS.  239 

mortality  from  this  disease  shown  by  tlie  Jewish  race  is  ascribable  to  their 
careful  meat  inspection.  Again,  the  possibility  of  contnmination  during 
the  course  of  preparation  for  the  market,  and  during  transportation,  must 
be  recollected.  The  experiments  of  Aufrecht,  Chauveau,  Klebs,  Parrot, 
Trappeiner,  and  others  show  that  tuberculosis  may  be  commiinicated  by 
incorporating  with  the  food  the  expectoration  from  tuberculous  patients. 
The  introduction  into  the  stomachs  of  cattle  and  goats  of  a  single  quan- 
tity of  virulent  bacilli  is  followed  regularly  in  from  thirty  to  forty-five 
days  by  the  development  of  tubercles  at  the  tops  of  the  lungs  (Calmette 
and  Gu^rin  ^). 

(3)  Infection  by  Inoculation. — Tuberculosis  may  be  transferred  by 
direct  inoculation,  as  shown  originally  by  Yillemin's  beautiful  experi- 
ments upon  the  eyes  of  guinea-pigs.  Infection  may  take  place,  though 
this  is  rare,  through  slight  cutaneous  lesions  (cuts,  fissures,  excoriations), 
as  the  result  of  accidental  inoculation  of  tuberculous  matter.  In  this 
manner  there  is  produced  a  local  tuberculosis  of  the  skin,  as  a  rule. 
Rarely,  the  contagion  is  conveyed  by  the  lymphatics  to  the  glands  in  the 
vicinity.  Persons  who  follow  certain  occupations  are  more  or  less  liable 
to  this  mode  of  infection — e.  g.,  butchers,  handlers  of  hides,  dissectors 
of  dead  bodies,  and,  rarely,  surgeons.  Rare  instances  occur  in  divers 
ways  (the  bite  of  a  consumptive,  a  cut  from  a  broken  spit-glass,  or  even 
from  his  pocket-knife,  as  I  have  seen  in  one  instance). 

The  handkerchiefs,  body-  and  bed-linen  of  the  patient  may  infect 
by  inoculation  those  who  handle  or  wash  them  frequently,  if  they  chance 
to  have  a  fissure  or  excoriation  upon  the  hand.  No  doubt  lupus  also 
arises  in  the  same  way.  Czerny  has  reported  2  cases  of  infection  by 
transplantation  of  skin;  Ceilings  and  Murray,  3  cases  by  tattooing  (?). 
The  contact  of  the  lips  of  tuberculous  operators  with  surgical  wounds 
(as  in  sucking  the  latter)  may  transmit  tuberculosis,  as  in  the  perform- 
ance of  the  rite  of  circumcision.  Ravenel  ^  reports  3  cases  of  accidental 
inoculation  of  the  skin  in  man  with  the  bovine  tubercle  bacillus. 

(4)  Direct  Hereditary  Transmission. — In  exceptional  cases  the  bacillus 
is  found  in  the  fetus  in  utero.  In  such  instances  the  disease  may 
remain  latent,  to  break  forth  during  childhood  or  later  in  life ;  and 
though  the  fetus  itself  may  display  no  evidence  of  tuberculosis,  the 
fetal  viscera  may  yet  be  infective  to  guinea-pigs  (Birch-Hirschfeld). 
Lehmann '  has  reported  an  undoubted  instance  of  intra-uterine  infec- 
tion. The  tuberculous  mother  died  of  tuberculous  meningitis  three 
days  after  the  birth  of  her  child,  and  the  child  lived  twenty-four  hours. 
In  its  spleen,  lungs,  and  liver  were  found  nodules  resembling  tubercles 
and  containing  tubercle  bacilli  in  large  numbers.  Galtier  has  inocu- 
lated a  pregnant  animal  with  the  disease,  and  found  that  the  ofisprino^ 
was,  in  consequence,  tuberculous  at  birth.  The  views  of  Baumgarten 
upon  this  question  should  be  accorded  careful  consideration.  This 
author  believes  that  the  contagion  may  be  transmitted  and  become 
pathogenic  at  a  variable  period  after  birth — first,  because  the  affection 
is  very  frequent  in  young  children,  even  during  the  first  months  or 
weeks  of  life ;  and,  secondly,  because  certain  structures,  not  apt  to  be 

1  Ann.  de  I'lnst.  Pasteur,  1905,  vol.  xix. ;  1906,  vol.  xx.,  609. 
'  Proc.  Philada.  Path.  Soc,  October,  1900. 
3  Berlin  klin.  WocL,  July  9,  1895. 


240  INFIX'TTOrS  DISEASES. 

accidentally  infected,  are  commonly  the  seat  of  tuberculous  lesions  in 
children — the  bones  and  joints.  After  birth  the  bacillus  may  at  any 
time  either  lose  its  vitality  or  take  on  a  luxuriant  growth.  It  is  not 
known,  however,  in  what  percentage  of  these  cases  the  lungs,  intestines, 
peritoneum,  and  lymph-glands  are  free  from  tuberculous  lesions.  Kiiss 
disputes  the  theory  of  the  latency  of  the  tubercle  bacilli,  and  contends 
that  latent  foci  do  not  exist  before  the  age  of  three  months ;  that  they 
are  rare  before  the  first  year,  Avhen  they  mature  progressively. 

Two  facts  deserve  to  ne  here  emphasized :  First,  that  a  child  born  of 
tuberculous  parents  is  more  receptive  than  one  born  of  healthy  stock  ; 
and  second,  that  it  is  more  liable  to  accidental  infection. 

The  instances  of  direct  transmission  that  have  been  traced  occurred 
through  tiibercufpus  mothers.  The  observations  of  Csokor  ^  upon  heredi- 
tary tuberculosis  in  cattle  also  corroborate  this  dictum.  Friedman,^  on 
the  other  hand,  has  practically  demonstrated  the  possibility  of  transmis- 
sion of  tubercle  bacilli  through  the  semen.  Yignal^  has  shown  experi- 
mentally that  invasion  by  heredity  is  very  rare. 

(5)  Dock  ami  Chadbourne  state  that  mixed  modes  of  infection  occur. 

(6)  Baldwin  invites  forcible  attention  to  the  danger  of  infection  from 
the  unclean  hands  of  tuberculous  patients. 

Predisposing  Causes. — (1)  Race  and  Nationality. — The  effect  of  nation- 
ality upon  the  receptivity  to  tuberculosis  can  be  studied  advantageously 
in  America  on  account  of  the  cosmopolitan  character  of  the  popula- 
tion. The  tuberculous  tendency  on  the  part  of  Indians  of  this  conti- 
nent, even  in  the  most  favorable  climates,  is  universally  acknowledged,  and 
the  fact  that  the  negro  I'ace  is  highly  receptive  to  tuberculosis  is  also 
well  known.  Osier*  gives  the  following  corroborative  statistics:  "Of 
the  427  cases  of  pulmonary  tuberculosis  at  the  Johns  Hopkins  Hos- 
pital for  the  two  years  ending  June  1,  1891,  there  were  41  cases  in  the 
colored — i.  e.  about  1  :  10.  The  ratio  of  colored  to  Avhite  of  all  patients 
in  the  wards  has  been  1  :  7."  It  is  more  than  twice  as  common  in  the 
African  as  in  the  white,  and  still  more  prevalent  Avith  the  Indian  (AV. 
L.  Hodman).  At  present  the  number  of  tuberculous  Indians  is  120,  24 
per  1000  population.  Sears'"^  found  that  in  200  cases  of  tuberculosis 
nearly  50  per  cent,  belonged  to  the  first  and  second  generations  of  Irish 
immigrants. 

(2)  Hereditary  Predisposition. — The  percentage  of  cases  in  which 
heredity  can  be  traced  has  been  variously  estimated  at  from  10  to  40. 
As  before  intimated  {vide  Direct  Hereditary  Transmission),  a  child 
reared  by  tuberculous  parents  runs  great  danger  of  being  infected  acci- 
dentally ;  and  again,  a  person  living  in  an  infected  house  (with  or  with- 
out the  presence  of  a  tuberculous  patient)  is  very  liable  to  become 
infected,  whether  his  antecedents  give  a  tuberculous  history  or  not. 
It  follows  that  a  correct  estimate  of  the  number  of  cases  of  phthisis  in 
which  hereditary  influence  plays  an  etiologic  part  cannot  be  obtained. 
Too  much  importance  has  heretofore  been  attached  to  the  influence  of 

'  Deutsche  mediziitdl  Zeilnng,  Berlin,  Jan.  29,  1892. 

'  DeulHch.  mefl.   [Voch.,  Feb.  128.  1901. 

'  La  Semaine  medicate,  Paris,  Aug.  1,  1892. 

*  Tert-Book  of  Medicine,  p.  204. 

^  Boston  Medical  and  Surgical  Journal,  April  4,  1895. 


TIWJ'JRCULOSIS.  241 

inherited  constitutional  peculiarities  to  the  exclusion  of  other  potent 
fiictors,  especially  an  infective  environment.  Moreover,  a  similar 
degree  of  predisposition  may  be  accpiired  as  the  result  of  certain 
debilitating  influences  (childbirth,  defective  food-supply,  close  living-  or 
working-rooms).  An  inherited  tendency  to  tuberculosis  is  more  unfail- 
ingly transmitted  through  the  mother  than  the  father.  Multiple  appear- 
ance is  commoner  in  families  with  tuberculous  parents  (Dock  and  Chad- 
bourne).  Children  begotten  of  parents  who  are  drunkards,  or  who  suffer 
from  certain  chronic  incurable  diseases  (syphilis,  cancer,  etc.)  at  the 
time  of  the  birth  of  their  children,  are  liable  to  inherit  a  condition  of 
the  system  that  greatly  increases  morbidity,  unless  the  tendency  is  over- 
come by  a  proper  environment,  together  with  systematic  physical  train- 
ing during  the  first  years  of  life.  Moreover,  persons  who  have  the  so- 
called  tiiberculous  diathesis  are  frequent  sufferers  from  catarrhal  affec- 
tions, especially  of  the  respiratory  organs.  The  latter  condition  forms 
a  marked  predisposing  factor  ;  yet,  on  the  other  hand,  tuberculosis  is 
met  with  in  persons  of  robust  figure. 

The  older  authors  of  medical  text-books  describe  two  types  of  con- 
formation— the  tuberculous  and  the  scrofulous.  The  latter  has  a  heavy 
figure,  thick  lips  and  hands,  large,  thick  bones,  and  an  opaque  skin ;  the 
former,  a  light  figure,  bright  eyes,  thin  skin,  oval  face,  and  long,  thin 
bones.  The  phthisical  type  of  the  chest  will  be  referred  to  in  connec- 
tion with  the  physical  signs  of  pulmonary  tuberculosis.  Here  emphasis 
should  be  given  to  Cohnheim's  view,  which  is  for  the  greater  part  cor- 
rect, to  the  effect  "  that  the  so-called  phthisical  habit  is  not  an  indication 
of  a  tendency  to,  but  actually  of  the  existence  of,  tuberculosis."  Whilst 
the  recognition  of  a  pre-tubercular  condition  has  its  practical  bearing, 
it  must  be  recollected  also  that  the  term  implies  merely  a  "  delicacy  of 
constitution,  incomplete  growth,  and  imperfect  development  "  (Fagge). 

(3)  Previous  Infectious  Diseases. — That  there  is  no  tendency  to  the  tran- 
sition of  other  diseases  into  tuberculosis,  as  was  formerly  supposed, 
cannot  now  be  questioned  in  view  of  the  undoubted  specific  nature  of 
the  latter  disease.  Tuberculosis  is,  however,  embraced  among  the  sequels 
of  many  acute  infectious  and  chronic  diseases — influenza,  measles, 
pneumonia,  whooping-cough,  typhoid  fever,  cirrhosis  of  the  lungs,  and 
diabetes  mellitus  (the  latter  disease  involving  a  predisposition  to  the 
former) — for  the  reason  that  they  render  the  tissue-soil,  especially  that 
of  the  respiratory  tract,  more  favorable  to  tubercular  infection.  Dock 
and  Chadbourne  have  analyzed  100  cases  of  adult  tuberculosis  (bacillary 
phthisis) ;  it  developed  rapidly  after  influenza  in  16,  and  followed  pneu- 
monia in  9.  It  seems  proper  to  mention  here  the  fact  that  certain  other 
diseases  are  thought  by  most  writers  to  display  an  antagonistic  effect 
(chronic  valvular  disease,  pulmonary  emphysema,  etc.). 

(4)  Age. — This  affects  predisposition  decidedly,  though  tuberculosis 
may  occur  at  any  or  all  times  of  life.  Certain  forms  of  tuberculosis  are 
especially  frequent  in  young  children  (meningeal,  mesenteric,  and  lym- 
phatic). Pulmonary  tuberculosis  is  most  common  between  twenty  and 
thirty.  It  is  more  rare  during  early  childhood  and  in  the  aged,  and  the 
cases  that  occur  in  young  children  are  likely  to  be  rapid  in  their  progress. 
Tuberculosis  in  adults  usually  develops  in  an  organism  already  infected. 

(5)  Sex. — Predisposition  has  but  slight  relation  to  sex.     Females  are, 

16 


242  JNFECTTOUS  DISEASES. 

however,  somewhat  more  liable  than  males,  and  pregnancy  in  particular 
is  a  disposing  factor.  Again,  when  tuberculous  females  become  preg- 
nant the  progress  of  the  aft'ection  is  accelerated,  and  even  more  so  by 
the  period  of  lactation.  Regarding  tuberculosis  as  being  pre-eminently 
a  house-disease,  females  are  more  exposed  to  contagion  than  males, 
because  they  are  more  closely  confined  in-doors. 

((i)  Climate  and  Soil. — Humidity  of  the  soil  and«abundant  atmospheric 
moisture  increase  the  prevalence  of  tuberculosis.  It  is  especially  com- 
mon in  regions  in  which  sadden  variations  of  temperature,  or  protracted 
cold  with  dampness,  prevail.  This  increase  is  most  probably  associated 
with  a  heightened  vulnerability,  due  to  an  increased  tendency  to  ca- 
tarrhal affections  of  all  kinds  (Osier).  It  has  been  .shown  that  proper 
drainage  of  marshv  districts  has  diminished,  to  some  extent,  the  fre- 
quency  of  this  disease  (Buchanan),  and,  on  the  other  hand,  mountainous 
districts  are  often  remarkable  for  freedom  from  the  disease. 

Local  Causes. — (1)  Occupation. — Persons  whose  employment  exposes 
them  to  different  forms  of  irritating  inhalations  are  particularly  liable. 
In  such,  however,  there  is  usually  first  developed  a  fibroid  induration 
(I'ide  Pneumonokoniosis),  and  the  latter  in  turn  is  followed  by  pulmonary 
tuberculosis.  The  continual  inhalation  of  an  atmosphere  laden  with 
noxious  particles,  such  as  is  met  with  in  ill-ventilated  ami  overcrowded 
working  or  living  apartments,  renders  the  tissues  more  vulnerable. 

(2)  Bronchial  Catarrh. — An  acute  catarrh  of  the  small  bronchi  pre- 
pares the  soil  for  tuberculous  infection.  Frequently,  however,  this  is 
the  first  step  in  tuberculosis,  since  the  latter  disease  almost  invariably 
begins  as  a  local  catarrhal  process,  involving  the  smaller  apical  bronchi. 
Here  may  be  pointed  out  that  gastro-intestinal  catarrh  (of  protracted 
duration — H.  M.  King)  increases  the  receptivity  for  tuberculosis. 

(3)  Tubercular  Pneumonia. — In  like  manner,  pulmonary  tuberculosis 
may  follow  an  unresolved  pneumonia,  but  such  cases  are,  as  a  rule, 
instances  of  tuberculous  pneumonia  primarily. 

(4)  Hemoptysis. — According  to  some  authors,  hemoptysis  is  potent  in 
producing  pulmonary  tuberculosis.  It  is,  however,  certain  that  in  most 
instances  in  which  it  appears  to  precede  phthisis,  and  to  exert  a  causative 
influence,  it  is  in  reality  a  symptom  of  existing  tuberculosis. 

(5)  Pleurisy  may  be,  though  rarely,  the  starting-point  of  phthisis. 
Its  predisposing  effect  may  be  attributable  to  compression  of  the  lung, 
thus  interfering  with  the  respiratory  excursions,  or  to  the  bronchitis 
which  is  frequently  associated.  Pleurisy  sometimes  initiates  fibroid  in- 
duration, which  may  then  terminate  in  a  tuberculous  affection ;  but  the 
fact  is  to  be  emphasized  that  a  very  large  proportion  of  the  cases  of 
apparently  primary  pleurisy  are  tuberculous  in  nature. 

(6)  Intrathoracic  Tumor. — Tuberculosis  is  often  associated  with  intra- 
thoracic tumors,  and  especially  with  aneurysm.  Fehde^  has  reported 
3  interesting  cases  of  the  kind. 

(7)  Congenital  or  acquired  contraction  of  the  orifice  of  the  pulmonary 
artery  predisposes  markedly  to  tuberculosis.  The  lungs  are  often  found 
to  be  undersized  and  ill-nourished  from  birth. 

(8)  Trauma. — Injuries  to  the  chest-wall,  with  or  without  laceration 
of  the  lung,  are  frequently  followed  by  pulmonary  tuberculosis.  The 
explanation  of  this  association   is  to  be  found  in  the  fact  that  trauma 

* "  Lungentuberculose  mit  Brusthohlengeschwulste,"  Inaug.  Diss.,  Leipzig,  1894. 


TUBERCULOSIS  OF  THE  LYMPH-GLANDS.  243 

increases  largely  the  susceptibility  of  the  parts  injured  by  diminishing 
phagocytic  activity — the  natural  power  of  resistance.  It  is  a  familiar 
observation  in  surgical  practice  that  after  injuries  to,  or  operations  on, 
joints,  tuberculosis,  often  acute,  frequently  ensues — in  about  8  per  cent. 
of  the  cases. 

Tuberculosis  op  the  Lymph-glands. 

{Scrofula.) 

Scrofula  implies  tuberculous  infection,  and  scrofulous  material  inocu- 
lated upon  susceptible  lower  animals,  especially  guinea-pigs  and  rabbits, 
invariably  causes  tuberculosis.  The  virus  is,  however,  less  virulent  than 
that  derived  from  other  sources,  and  this  explains  the  slow  progress  and 
often  latent  character  of  tuberculosis  of  the  glandular  system.  A  major 
predisposing  factor  is  age,  this  form  of  tuberculosis  preponderating  in 
children.  Hecker,  from  an  examination  of  the  records  of  the  Munich 
Pathological  Institute,  found  that  in  147  cases  of  tuberculosis  among 
children  the  lymphatics  were  affected  in  92  per  cent.;  and  in  young 
adults  tuberculous  adenitis  is  not  uncommon.  It  is  rarely  met  with  also 
during  and  after  the  middle  period  of  life.  The  lesions  generally  remain 
limited  to  the  glands  first  infected — i.  e.,  the  cervical,  mesenteric,  etc.,  as 
the  case  may  be — and  this  for  the  I'eason  that  the  natural  powers  of  re- 
sistance in  the  tissues  are  often  able  to  oppose  the  march  of  the  destructive 
forces.  Another  predisposing  condition  is  an  acute  or  chronic  catarrh  of 
the  mucous  membranes. 

The  cases  are  all  divisible  into  two  groups :  (1)  Local  tuberculous 
adenitis,  and  (2)  general  tuberculous  adenitis. 

(1)  Local  Tuberculous  Adenitis. — (a)  Cervical. — This  is  the  most  fre- 
quent form,  and  is  especially  common  among  children. 

Etiology. — Of  2035  persons  examined  by  Valland,  enlarged  cervical 
glands  were  found  between  the  ages  of  seven  and  nine  in  96  per  cent. ; 
between  ten  and  twelve  in  96.1  per  cent.  ;  between  thirteen  and  fifteen 
in  84  per  cent.  ;  between  sixteen  and  eighteen  in  69.7  per  cent. :  and 
between  nineteen  and  twenty-four  in  68.3  per  cent.  Tubercle  bacilli 
were  found  in  the  cervical  lymph-glands  in  about  68  per  cent,  of  adults. 
Negroes  are  found  to  be  more  prone  to  the  affection  than  whites. 

Mode  of  Infection. — I  have  stated  before  that  tubercle  bacilli  are 
sometimes  found  on  the  nasal  mucous  membrane  of  healthy  persons. 
The  presence  of  an  acute  or  chronic  catarrh  of  the  nasopharynx  may 
now  lower  the  resistance  of  the  tissue-cells,  so  that  the  bacilli  may  gain 
access  to  the  lymph-current,  and  through  the  latter  to  the  neighboring 
glands,  setting  up  tubercular  adenitis.  The  cervical  lymph-glands,  how- 
ever, do  not  furnish  a  highly  favorable  soil  for  the  growth  and  develop- 
ment of  the  bacilli,  and  hence  the  tendency  toward  latency. 

The  to7isils,  owing  to  their  free  communication  with  the  atmosphere, 
in  which  there  is  a  wide  diffusion  of  tubercle  bacilli,  may  be  primarily 
infected.  Friedman  suggests  that  primary  tuberculosis  of  the  tonsils  is 
usually  set  up  by  infection  through  the  food.  But  here  also,  as  in  the 
case  of  other  glandular  structures,  there  is  a  tendency  for  the  affection  to 
become  encapsulated,  for  the  reason  that  the  tissue-soil  after  a  prolonged 
contest  generally  gains  the  ascendency  over  the  invading  bacilli.  The 
latter  may,  however,  under  certain  favorable  conditions,  break  down  the 


244  lyFECTIOUS  DISEASES. 

barriers  opposed  by  nature  and  eftect  a  lodgement  in  the  cervical  glands, 
or  even  become  widely  diffused  through  the  economy.  Thus  Kinckniann 
in  64  autopsies  found  2.")  cases  of  tuberculosis,  in  12  of  which  the  tonsils 
■were  affected. 

A  third  mode  of  infection  of  the  cervical  lymph-glands  is  through 
the  medium  of  slight  injuries  and  abrasions  of  the  skin  or  certain  forms 
of  skin-eruptions  (eczema,  etc.).  These  serve  as  doors  of  entrance  for 
the  bacilli,  which  find  their  way  into  the  neighboring  lymph-glands 
through  the  lymph-channels.  Compared  with  infection  from  within, 
this  mode  is  most  probably  much  less  frequent. 

Si/mptofiis. — The  main  feature  is  a  visible  enlargement  of  the  af- 
fected cervical  glands,  chiefly  the  submaxillary.  At  first  the  glands 
are  too  small  to  be  even  palpated  ;  later,  they  can  be  felt  as  small,  firm 
tumors  underneath  the  skin.  By  and  by  they  appear  as  visible  protuber- 
ances, ranging  in  size  from  that  of  an  English  walnut  to  that  of  a  hen's 
egg  or  even  larger.  The  skin  over  the  enlarged  gland  is  freely  movable, 
as  a  rule ;  less  frequently  it  becomes  adherent — an  indication  of  suppu- 
ration. When  an  abscess  forms  and  is  allowed  to  open  spontaneously, 
there  remains  a  chronic  discharging  sinus.  Suppuration  is  attended 
with  fever,  anemia,  and  emaciation.  In  well-marked  cases  the  separate 
tumors  coalesce,  forming  large  and  irregular  masses.  The  affection  is 
usually  bilateral,  though  almost  invariably  it  is  more  marked  on  one 
side  than  on  the  other. 

Not  infrequently,  in  addition  to  the  enlargement  of  the  submaxillary, 
post-cervical,  and  supraclavicular  glands,  there  is  also  involvement  of 
the  axillary,  as  was  the  case  in  a  fatal  instance  in  my  own  practice. 
The  patient  was  a  male  child,  eight  years  of  age,  who  developed  pul- 
monary tuberculosis.  It  may  reasonably  be  assumed  that  the  bronchial 
glands  also  become  implicated,  and  may  excite  lung  tuberculosis. 

The  diagnosis  is  based  upon  the  history  and  the  associated  evidences 
(keratitis,  conjunctivitis,  eczema  of  the  face,  nasopharyngeal  or  bronchial 
catarrh),  coupled  with  the  glandular  enlargement.  Bacilli  have  occa- 
sionally been  found  in  the  purulent  discharge  from  abscesses.  Otis 
applies  the  tuberculin-test,  and  obtains  positive  reactions  in  62  to  69  per 
cent.      The  Yon  Pirquet  cutaneous  reaction  may  be  also  employed. 

The  course  of  this  affection  is  exceedingly  slow,  often  extending 
over  a  number  of  years.  Many  cases,  however,  recover  after  timely 
surgical  intervention.  On  the  other  hand,  neglected  cases  are  a  menace 
to  the  life  of  a  patient,  since  they  may  be  followed  by  diffusion  of  the 
bacilli,  with  the  development  of  a  fatal  form  of  disease. 

{J})  Bronchial. — Tuberculosis  of  the  bronchial  glands  may  be  primary, 
or  secondary  to  infection  of  the  lungs,  and  it  is  commonly  preceded  by  or 
associated  with  bronchial  catarrh,  which  is  its  chief  predisposing  cause. 
The  primary  form  is  met  with  frequently  in  young  children,  the  medias- 
tinal lymph-glands  being  affected  uniformly  in  127  cases  at  the  New 
York  Foundling  Hospital  (Northrup). 

The  bronchial  and  tracheal  glands  are  the  receptacles  for  all  foreign 
substances,  including  the  tubercle  bacilli  that  are  not  dealt  with  by  the 
broncho-pulmonary  phagocytes.  After  infection  with  tubercle  bacilli 
the  lymph-glands  become  swollen,  tumefied,  and  are  the  seat  of  caseous 
*:hange ;  later  they  may  undergo  calcification  or  proceed  to  abscess-for- 


TUBERCULOSIS  OF  THE  LYMPH-GLANDS.  245 

mation.  The  latter  may  rupture  either  into  the  lungs,  into  the  trachea 
or  the  bronchi,  or  into  a  pulmonary  blood-vessel. 

Symptoms. — If  a  fistulous  communication  be  established  with  the  air- 
passages,  cough  and  expectoration  of  purulent  material,  blood,  and 
caseous  matter  containing  bacilli  will  be  noted. 

Secondary  infection  of  the  lung  may  occur  in  this  manner.  When 
rupture  takes  place  into  a  vessel  systemic  infection  promptly  follows. 
Tubercular  adenitis  involving  mediastinal  lymph-glands  may  also  lead 
to  infection  of  the  pericardium  and  then  proceed  to  tuberculous  peri- 
carditis. 

(c)  Mesenteric  (Tabes  Mesentericd). — This  may  be  primary  or  sec- 
ondary, the  latter  being  common  as  a  secondary  infection  to  intestinal 
tuberculosis. 

The  former  is  rare,  however,  and  the  intestinal  catarrh  with  which 
it  is  associated  is  doubtless  tuberculous  in  the  vast  majority  of  cases. 
The  mode  of  infection  has  already  been  pointed  out.  The  lesions  pre- 
sented are  similar  to  those  met  with  in  tuberculous  bronchial  glands. 

The  symptoms  are  not  always  distinctive,  and  may  be  entirely  nega- 
tive during  the  life  of  the  patient ;  hence  the  condition  is  often  incident- 
ally discovered  during  the  post-mortem  examination.  The  local  symp- 
toms when  marked  are  due  in  the  main  to  an  associated  peritonitis.  The 
abdomen  is  painful  and  more  or  less  swollen.  Peritoneal  effusion  is 
present,  and  sometimes  sufficient  in  amount  to  be  detected  by  the  cus- 
tomary physical  signs.  Large  and  small  nodules  may  sometimes  be  felt. 
Diarrhea  is  a  marked  and  an  obstinate  feature  and  is  usually  due  to  tuber- 
culous intestinal  ulcers.  Fever  of  an  intermittent  type  is  almost  constantly 
present,  causing  emaciation,  and  the  objective  changes  (pallor  of  skin, 
mucous  membranes)  due  to  anemia  become  pronounced.  This  form  of 
tuberculosis  may  persist  as  a  local  condition,  but  there  is  danger  of 
extension  to  other  organs  (pleura,  lungs).  On  the  other  hand,  in  the 
adult  pulmonary  tuberculosis  may  be  followed  by  involvement  of  the 
mesenteric  glands  without  involvement  of  the  intestines,  and  in  such  in- 
stances there  occurs  an  extension  by  contiguity  along  the  course  of  the 
lymphatics  that  pass  through  the  diaphragm,  and  finally,  in  adults,  pri- 
mary tuberculous  new  growths  may  be  met  with  in  the  mesenteric  glands. 

Diagnosis. — A  probable  diagnosis  can  usually  be  made  if  carefiil  at- 
tention be  paid  conjointly  to  the  symptoms,  physical  signs,  and  course 
of  the  aflFection.  The  detection  in  a  child  of  a  tumor  which  may  be 
moderately  hard,  doughy,  or  even  fluctuating  will  aid  materially  in  the 
diagnosis,  and  will  also  afford  evidence  of  tuberculous  disease  in  other 
organs.     The  Von  Pirquet  cutaneous  reaction  will  be  found  present. 

(2)  General  Tuberculous  Adenitis. — This  term  implies  tuberculous  dis- 
ease of  the  lymph-glands  throughout  the  body,  with  little  if  any  involve- 
ment of  other  organs  ;  it  is  a  rare  condition.  The  affection  may  begin 
as  a  local  tuberculous  lymphadenitis,  nearly  all  the  rest  of  the  glands  of 
the  body  becoming  secondarily  implicated.  The  primary  seat  of  the 
trouble  is  perhaps  most  frequently  the  cervical  lymph-glands,  though  in 
one  instance  observed  by  myself  the  mesenteric  glands  first  became 
affected,  the  case  terminating  in  pleuro-pulmonary  tuberculosis. 

Symptoms  and  Diagnosis. — There  is  protracted  fever,  the  temper- 
ature being  of  the  remittent  or  intermittent  type.      Wasting  and  debility 


246  INFECTIOUS  DISEASES. 

are  progressive  until  the  patient  presents  a  decidedly  puny  aspect, 
while  the  lymph-glands  tliat  are  accessible  to  inspection  and  palpa- 
tion are  more  or  less  enlarged  and  manifest  a  marked  tendency  to  sup- 
puration. The  affection  is  usually  chronic,  though  very  exception- 
ally it  may  exhibit  an  acute  course.  One  of  the  chief  dangers  over- 
hanging the  sufferer  in  this  affection  is  that,  owing  to  liberation  of  the 
bacilli,  the  meninges  or  the  lungs  may  become  tuberculous ;  these  cases 
may  also  eventuate  in  death  from  asthenia.  Cases  in  which  the  glands 
are  but  little  enlarged,  while  the  general  features  are  marked,  are 
puzzling.  On  the  otlier  hand,  when  the  superficial  lyiuph-glands  are 
greatly  enlarged,  the  affection  may  bear  a  striking  resemblance  to  Hodg- 
kins  disease.  Indeed,  certain  recent  writers  hold  that  generalized  tu- 
berculous adenitis  and  pseudo-leukemia  are  etiologically  identical  [vide 
Hodgkin's  Disease,  p.  483). 

Acute  Tuberculosis. 

This  form  of  tuberculosis  is  characterized  anatomically  by  the  rapid 
development  of  miliary  tubercles  in  many  and  widely-separated  parts  of 
the  body.  In  some  instances  the  ncAv  growths  are  pretty  evenly  distrib- 
uted through  all  the  organs  of  the  body,  manifesting  the  clinical  symp- 
toms of  an  aciite  general  infection.  In  other  instances  there  is  a  tend- 
ency to  centralization  of  tuberculous  growths,  as,  for  example,  in  the 
lungs  (pulmonary  variety)  or  in  the  meninges  of  the  brain  and  spinal 
cord  (meningeal  variety). 

Pathology. — The  fact  is  to  be  emphasized  that  somewhere  in  the 
body  there  is  an  old  tuberculous  focus.  Apart  from  this  primary  lesion, 
the  anatomic  changes  consist  in  the  Avidely  disseminated  miliary  tuber- 
cles. Their  most  frequent  seats  are  the  lungs,  liver,  and  spleen ;  less 
commonly,  the  marrow^  of  the  bones,  the  heart,  the  choroid,  and  the 
meninges.  In  s6me  of  the  organs,  particularly  the  meninges,  lungs, 
etc.,  the  tubercles  may  be  readily  perceived  by  the  naked  eye,  while  in 
others  they  frequently  cannot  be  detected  without  the  aid  of  the  micro- 
scope. It  must  not  be  forgotten  that  in  some  of  the  more  protracted 
cases  the  nodular  tubercles  may  grow  into  foci  of  considerable  size, 
ranging  from  that  of  a  lentil  to  that  of  a  pea. 

Ktiology. — This  has  been,  in  the  main,  given  in  connection  with  the 
general  etiology  of  tuberculosis  {vide  supra),  though  a  few  special  points 
remain  to  be  adduced.  The  acute  forms  of  tuberculosis  are  decidedly 
more  frequent  during  infancy  and  childhood  than  during  adult  life,  and 
with  few  exceptions  the  cases  are  secondary  to  a  local  tuberculous  focus 
in  one  or  more  lymph-glands  (tracheal,  bronchial,  mesenteric)  or  in  the 
lungs.  More  rarely  a  pre-existing  tuberculous  focus  in  the  kidneys,  the 
bones,  or  the  skin  may  give  rise  to  the  affection,  as  may  the  occurrence 
of  certain  other  acute  infectious  diseases  (such  as  measles,  whooping- 
cough,  and  influenza)  in  children,  and  typhoid  fever  and  lobar  pneumonia 
(especially  with  delayed  resolution)  in  adults. 

Modes  of  Infection. — Most  frequently  there  is  established  a  fistulous 
connection  between  the  local  tuberculous  focus  and  a  vein,  especially  the 
pulmonary  vein.  Under  these  circumstances  there  may  be  large  num- 
bers of  bacilli  discharged  into  the  blood-stream  ;  but  oftener  only  small 


ACUTE  TUBERCULOSIS.  247 

numbers  of  bacilli  enter  and  subsequently  multiply,  inducing  general 
infection  (Ribbert  and  Wild').  A  second  mode  of  infc^ction,  though 
decidedly  more  rare  than  tlie  above,  is  the  rupture  of  a  tuberculous 
focus  into  the  thoracic  duct,  in  which  case  the  tuberculous  material 
passes  almost  directly  into  the  subclavian  vein. 

Clinical  History. — That  miliary  tubercles  may  exist  in  many 
organs  of  the  body  (liver,  heart,  etc.)  without  giving  rise  to  symptoms  is 
a  noteworthy  fact.  Cohnheim  and  Manz  have  discovered  miliary  tuber- 
culosis of  the  choroid  with  the  aid  of  the  ophthalmoscope  alone. 

The  following  forms  of  the  disease  may  be  distinguished  : 

General  Miliary  Tuberculosis. 

(a)  TYPHOID    FORM. 

The  symptoms  are  those  of  a  general  infection  of  the  body,  there 
being  in  most  cases  a  period  of  incuhation,  during  which  the  patient 
complains  of  malaise,  headache,  chilliness,  feverishness,  and  increasing 
debility.  Rarely,  the  onset  is  comparatively  sudden.  The  reaction  of 
the  nervous  system  against  the  poison,  which  is  now  scattered  to  all 
parts  of  the  body,  is  shown  by  such  symptoms  as  the  fever,  which  rapidly 
increases,  a  rapid,  feeble  pulse,  and  mental  dulness  or  delirium.  The 
tongue  becomes  dry,  and  sometimes  also  brown.  The  res2nrations  are 
accelerated,  and  there  is  more  or  less  cyanosis,  with  which  symptom  is 
associated  a  peculiar  and  characteristic  pallor  of  countenance.  Coinci- 
dently  with  the  febrile  exacerbations  the  cheeks  wear  a  circumscribed 
blush.  Among  the  rarer  early  symptoms  is  epistaxis.  The  patient  soon 
becomes  either  profoundly  prostrated  or  anxious  :  if,  as  sometimes  happens, 
the  course  is  protracted,  weakness,  anemia,  and  especially  emaciation 
are  well  marked  and  assume  diagnostic  importance.  These  cases  some- 
times pass  into  the  pulmonary  or  the  meningeal  form,  the  patients  often 
succumbing  speedily  to  such  localized  developments. 

Fever. — The  temperature  usually  pursues  a  high  range,  although 
there  are  a  few  cases  in  which  the  entire  course  is  afebrile.  Again,  it 
occurs  not  infrequently  that  the  temperature  is  normal  or  nearly  so  for 
a  short  period.  The  usual  temperature-curve  ranges  at  first  between 
102°  and  104°  F.  (38.8°-40°  C),  and  then  continues  to  rise,  with  the 
development  of  the  serious  general  condition  in  a  way  exactly  similar 
to  that  observed  in  typhoid  fever.  In  many  instances  the  fever  is 
irregularly  remitting,  at  least  at  intervals,  if  not  so  constantly.  Thus, 
periods  of  irregular  fever  may  alternate  with  others  of  continued,  and 
later  deeply  remittent  or  distinctly  intermittent,  fever. 

Nervous  Symptoms. — In  most  cases  the  nervous  symptoms  are  not 
prominent.  In  a  smaller  number  headache,  vertigo,  delirium,  and  often 
stupor,  become  marked  at  an  early  stage  and  may  persist.  They  are  due 
to  the  general  infection. 

Circulatory  System. — The  pulse  is  small,  and  its  rate  is  out  of  pro- 
portion to  the  fever,  varying  from  100  to  140  or  higher.  It  may  be- 
come irregular,  particularly  if  the  meninges  be  involved. 

Respiratory  System. — The  breath  is  somewhat  hurried  and  labored : 
there  is  a  cough,  but  it  is  not  annoying  as  a  rule;  and  there  is  a  slight 
expectoration,  which  is  not  characteristic.     If  there  be  present  simul- 
1  Deutsche  medicinische  Wochensehrift,  Dec.  30,  1897. 


248  INFECTIOUS  DISEASES. 

taiieouslv  in  the  lungs  an  old  tubevoulous  focus,  the  expectoration  may 
)»e  more  profuse  and  typical.  The  bacilli  are  also  absent  from  the  sputum 
unless  an  old  tuberculous  lesion  exists  in  the  lungs.  J.  A'^ogl  states  that 
individual  tubercles  can  be  demonstrated  on  the  .r-ray  plate. 

The  physical  signs  are  those  of  a  diffuse  bronchitis,  though  signs  of 
consolidation'  or  pleurisy  may  develop  late  in  the  course  of  the  affection. 
Such  signs,  however,  may  be  evidences  of  an  old  tuberculous  affection. 

Digestive  System. — As  before  noted,  there  are  anorexia  and  a  dry 
tongue  (s^^mptoms  due  to  the  systemic  infection),  while  vomiting  may 
occur  at  the  outset,  and  excessive  thirst  is  common.  The  spleen  usually 
becomes  enlarged,  though  only  to  a  slight  extent,  as  a  rule. 

Ocular  Symptoms. — The  important  symptom  presented  by  the  eye  is 
the  presence  of  choroid  tubercles.  Their  demoijstration  is  only  possible 
with  the  skilled  o])lith:ilniologist.  Their  absence,  however,  does  not 
militate  against  the  diagnosis  of  this  disease.  Tileston  has  described  an 
eruption,  in  cases  occurring  among  children,  Avhich  consists  of  scattered, 
discrete  j)apules  about  the  size  of  a  pinhead,  and  on  these  are  tiny  vesi- 
cles Avith  cloudy  contents  or  minute  pustules,  followed  by  drying,  with 
slight  incrustation. 

Diagnosis. — In  the  following  table  I  have  endeavored  to  contrast 
points  of  dissimilarity  between  this  disease  and  typhoid  fever : 

Acute  General  Miliary  Tuberculosis.  Typhoid  Fever. 

Family  history  of  tuberculosis,  or  pres-  Coexistent  with  an  epidemic  or  following 

ence  of  an  old  focus.  previous  cases  of  typhoid. 

Evolution  of  the  disease  not  characteris-  Evolution  of  the  disease  is  character- 
tic,  istic. 

Epistaxis  rare.  Epistaxis  a  common  early  symptom. 

Fever-curve  of  decidedly  irregular  type.  Temperature-curve     of     the     continued 

^type-         .      .      ,      . 

Pulse  rapid,  out  of  proportion  to  fever.  Pulse  often  dicrotic  ;  slow  in  proportion 

to  fever. 
Respirations  rapid  and  labored.  Respiration  moderately  increased. 

Face  dusky,  with  peculiar  pallor.  No  duskiness  of  face. 

Abdominal  symptoms  are  not  suggestive.       Abdominal    symptoms  (stools,   enlarged 

spleen,  tympanites,  etc.)  suggestive. 
No  characteristic  eruption.  The  eruption    (appearing    in  successive 

crops)  is  distinctive. 
Von  Piiquet  reaction  usually  positive.  Widal  reaction  present. 

Knee-jerk  may  be  absent.  Knee-jerk  never  wanting. 

Choroid  tubercles  may  be  detected.  Choroid  tubercles  absent. 

Tubercle  bacilli  rarely  demonstrable  in  Cultures  from  venous  blood  show  typhoid- 
the  blood.  bacilli.     They  may  also  be  found  in  the 

stools  and  urine. 
Hemorrhage  from  bowels  exceptional.  Hemorrhage  from  the  bowels  common. 

Perforative  peritonitis  absent.^  Perforative  peritonitis  often  present. 

The  tuberculin  test  may  prove  an  aid  to  diagnosis  in  cases  pursuing 
an  apyrexial  course. 

(b)  PULMONARY    FORM. 

Though  all  gradations  between  the  typhoid  and  the  pulmonary  types 

occur,  the  latter  should  be  recognized  and  briefly  described.     It  may 

develop   suddenly,  the   ushering-in   symptom  being  sometimes  a  chilly 

though  more  frequently  there  is  a  premonitory  period,  during  which 

^  See  also  Differential  Diagnosis  of  Typhoid  Fever. 


ACUTE  TUBERCULOSIS.  249 

the  general  health  fails  materially.  Some  acute  illness,  as  measles  or 
whooping-cough,  in  which  there  has  been  marked  catarrhal  bronchitis, 
often  constitutes  the  point  of  departure  for  this  variety. 

The  respirator^/  symptoms  are  early  prominent,  and  later  preponder- 
ate in  the  clinical  picture.  From  the  start  there  is  dyspnea,  and  this 
gradually  increases  until  the  respirations  become  rapid  (40  to  60  per 
minute).  When  dyspnea  becomes  pronounced,  the  face  presents  a  char- 
acteristic cyanotic  pallor.  The  cough  at  first  is  moderately  severe,  but 
it  soon  becomes  troublesome,  being  frequent  and  attended  with  a  slight 
expectoration,  which,  however,  is  non-characteristic. 

The  physical  signs  are  those  of  broncho-pneumonia,  and  the  latter 
may  or  may  not  be  preceded  by  the  signs  of  generalized  bronchitis. 
With  the  onset  of  consolidation  there  appear  spots  that  yield  either 
dulness  or  a  tympanitic  resonance  on  percussion,  and  broncho-vesicular 
breathing  with  numerous  subcrepitant  rales  on  auscultation. 

The  general  symptoms  are  marked  from  the  beginning.  The  fever 
is  high— from  103°  to  105°  F.  (39.4°-40.5°  C.)  or  often  higher.  The 
pulse  ranges  from  100  to  140,  is  small,  feeble,  and  sometimes  irregular, 
and  it  may  be  more  rapid  still  during  the  advanced  stage  of  the  affec- 
tion (see  Fig.  20).      Cerebral  symptoms  rarely  appear. 

The  course,  as  a  rule,  is  more  prolonged  than  that  of  general  miliary 
tuberculosis,  except  in  children,  in  whom  it  often  runs  an  exceedingly 
acute  course.  As  the  end  approaches  the  signs  of  suflFocation  are  gradu- 
ally intensified,  and  finally  lead  to  a  fatal  termination. 

Dia^^OSis. — The  diagnosis  is  difficult ;  but  a  family  history  of 
tuberculosis,  a  knowledge  of  the  pre-existence  of  a  tuberculous  focus  or 
of  an  antecedent  predisposing  afiection,  will  aid  in  its  recognition. 
Tubercle  bacilli  are  perhaps  not  demonstrable  in  the  sputum  unless  an 
old  tuberculous  lesion  is  present.  In  doubtful  cases,  however,  an 
attempt  should  be  made  to  detect  the  bacilli  in  the  blood.  Occasionally 
either  tuberculous  meningitis  or  peritonitis  supervenes,  and  aids  in 
removing  the  doubt,  and  in  a  small  percentage  of  the  cases  choroid 
tubercles  are  detectable.  These  points,  together  with  the  more  marked 
general  symptoms,  will  usually  enable  the  clinician  to  distinguish  this 
variety  of  tuberculosis  from  non-tuherculous  broncho-pneumonia. 

(c)  CEREBRAL    OR    MENINGEAL    FORM    (TUBERCULOUS    MENINGITIS). 

This  variety  is  of  quite  frequent  occurrence,  appearing  in  not  less 
than  50  per  cent,  of  the  cases  of  miliary  tuberculosis.  When  it  devel- 
ops, the  symptoms  referable  to  other  organs  than  the  meninges  are  in 
abeyance.  With  reference  to  the  etiology,  the  fact  needs  to  be  empha- 
sized that  most  cases  occur  between  the  ages  of  two  and  seven  years ;  it 
may,  however,  be  met  with  at  any  time  of  life.  The  affection  frequently 
has  its  origin  in  tuberculous  bronchial  glands  (Jacobi),  and  the  history 
of  a  fall  is  common.  A  few  cases  have  been  found  to  be  associated 
with  erythema  nodosum.  Exceptionally,  the  meninges  are  primarily 
involved. 

Pathologfy. — The  chief  site  of  the  tubercles  in  children  is  the  pia 
mater  at  the  base  of  the  cerebrum  (basilar  meningitis),  while  in  adults 
the  pia  at  the  vertex  is  more  apt  to  be  involved.     The  membrane  sur- 


ACUTE  TUBERCULOSIS.  251 

rounding  the  tubercles  may  not  be  inflamed,  there  being  a  simple  tu- 
berculous deposit.  On  the  other  hand,  more  or  less  inflammation,  with 
sero-fibrinous  or  fibrino-purulent  exudation,  is  generally  present  in  the 
region  of  the  base.  This  exudate  is  usually  abundant  in  the  Sylvian 
fissures,  and  may  find  its  way  to  the  external  surface  of"  the  hemispheres. 
It  is  gray  in  color,  transparent,  and  gelatinous,  and  contains  in  its 
meshes  the  tubercles,  which  appear  as  grayish-white  bodies,  and  which, 
in  cases  of  equal  severity,  may  be  either  numerous  or  scanty.  They 
may  be  scarcely  visible  to  the  naked  eye,  but  may  vary  from  the  size  of 
a  pinhead  to  that  of  a  French  pea.  The  branches  of  the  Sylvian 
artery  may  be  implicated,  either  owing  to  the  direct  pressure  of  the 
exudate  or  to  the  obliterating  arteritis  produced  by  a  tuberculous  infil- 
tration. The  pia  looks  like  wet  blotting-paper  over  the  quadrangle  at 
the  base  (Gray).  Elsewhere  it  is  thickened  and  opaque,  though  easily 
detachable.  Osier  says :  "  The  arteries  of  the  interior  and  posterior 
perforated  spaces  should  be  carefully  withdrawn  and  searched,  as  upon 
them  nodular  tubercles  may  be  found  when  not  present  elsewhere.  In 
doubtful  cases  the  middle  cerebral  arteries  should  be  very  carefully  re- 
moved, spread  on  a  glass  plate  with  a  black  background,  and  examined 
with  a  low  objective.  The  tubercles  are  then  seen  as  nodular  enlarge- 
ments on  the  smaller  arteries."  Involvement  of  the  chief  vessels  that 
nourish  the  walls  of  the  ventricles  and  the  ependyma,  and  stretch  from 
the  vermis  cerebelli  forward  over  the  quadrigemina,  explains  the  con- 
stant presence  of  a  turbid  fluid  in  the  ventricles,  with  softening  of  their 
walls.  As  the  result  of  undue  intraventricular  pressure  the  cerebral 
convolutions  become  more  or  less  flattened,  with  elfacement  of  the  sulci. 
The  cortex,  to  a  variable  depth,  is  generally  the  seat  of  red  softening, 
and  more  rarely  of  white  softening  alone.  The  tuberculous  infiltration 
involves  the  cranial  nerves. 

Histology. — The  tubercles  grow  in  the  perivascular  sheaths,  which 
are  often  distended  with  lymphoid  and  epithelioid  cells,  and  there  is 
observed  not  infrequently  a  thrombosis  of  the  arteries  and  of  the 
venules  of  the  pia,  obliterating  their  lumen.  The  pia  mater  is  gradu- 
ally thickened  through  cellular  infiltration,  and  in  a  small  proportion  of 
the  cases  the  spinal  meninges  are  similarly  involved,  chiefly  in  the  cer- 
vical portion  of  the  cord. 

Symptoms. — There  is  z>  prodromal  period  which  lasts  one  or  more 
weeks,  during  which  the  patient  (usually  a  child)  is  pale,  peevish,  has 
headache  and  photophobia,  and  grinds  its  teeth  during  sleep  ;  the  tongue 
is  coated,  appetite  impaired,  and  there  may  be  occasional  vomiting, 
either  propulsive  or  regurgitative.  Constipation  is  present  and  may  be 
marked.  Among  rare  premonitory  symptoms  are  slight  hyperesthesia 
of  the  abdomen  and  a  diminished  urinary  secretion.  A  tendency  to 
emaciation  is  quite  constant.  These  prodromal  symptoms  present  varia- 
tions as  to  their  number  and  combinations  in  difi"erent  cases.  In  few 
instances  only  is  the  onset  acute.  The  symptoms  usually  indicate  basic 
meningitis,  and  at  first  there  is  associated  considerable  mental  excite- 
ment; later  there  are  pressure-symptoms  (caused  by  the  exudate),  with 
total  loss  of  the  mental  faculties. 

(1)  Stage  of  Cerebral  Excitement. — The  invasion  is  generally  gradual, 
or  even  quite  insidious,  its  most  characteristic  phenomena  being  severe 


252  INFECTIOUS  DISEASES. 

vomiting,  marked  headache,  and  chills  foUoived  by  fever.  Certain  other 
symptoms  now  arrest  the  attention,  such  as  extreme  irritability,  scream- 
ing, and  great  obstinacy,  and  occasionally  drowsiness  appears  early.  When 
the  onset  is  sudden  the  disease  may  be  disclosed  by  convulsions,  paral- 
ysis, wild  delirium,  or  coma.  The  established  disease  exhibits  certain 
distinctive  features.  The  pain  is  often  most  excruciating,  causing  the 
child  to  utter  short  penetrating  screams  (hydrocephalic  cry),  and  in  rare 
instances  the  sharp  cries  may  be  continuous  and  lead  to  physical  exhaus- 
tion. The  headache  is  increased  by  light,  noise,  or  movement.  Vertigo 
is  common  ;  the  pupils  are  contracted  at  this  period ;  the  face  pales  and 
then  flushes :  the  pupils  alternately  dilate  and  expand ;  and  the  expres- 
sion is  sometimes  sad,  though  more  often  stupid.  Generally  hyperes- 
thesia or  dysesthesia  may  appear,  and  there  may  be  a  slight  mind-wan- 
dering at  night,  though  active  delirium  is  rare.  Tdches  cerehrales  may 
be  obtained,  but  are  not  characteristic.  The  patient  is  intolerant  of 
every  form  of  disturbance.  All  the  symptoms  of  the  prodromal  stage 
are  now  aggravated ;  slight  muscular  twitchings  and  sleep-starts  occur ; 
the  vomiting  is  apparently  causeless,  and  may  be  frequently  repeated ; 
and  constipation  persists. 

Fever  is  present,  but  is  of  slow  development,  and  rarely  rises  higher 
than  102°  or  103°  F.  (39.4°  C.)  in  the  evening.  The  shin  is  dry  and 
harsh.  The  pulse  is  slow  or  moderately  accelerated,  but  soon  quickens 
to  120  or  even  130,  and  later  it  may  be  irregular.  At  times  the  pupils 
are  unequally  contracted,  and  ptosis  is  usually  an  early  sign. 

(2)  Second  or  Transitional  Stage, — The  symptoms  of  cerebral  irrita- 
tion now  abate,  the  patient  becoming  more  quiet,  while  mental  dulness 
often  supervenes.  The  vomiting  and  headache  gradually  subside,  and 
the  child  rarely  cries  out.  The  abdomen  is  now  distinctly  scaphoid 
and  the  head  occasionally  retracted.  Constipation  is  obstinate.  The 
evidences  of  localized  organic  foci,  such  as  slight  twitchings  of  the 
muscles  of  the  face,  followed  by  strabismus,  ptosis,  or  paralyses  of  the 
face  or  limbs,  may  appear.  Generalized  convulsions  may  occur,  and 
muscular  tremors  and  athetoid  movements  may  appear.  Both  pupils 
(or  one  only)  may  be  dilated  as  intracranial  pressure  develops ;  patchy 
flushing  of  the  face  is  common.  The  respiration  is  now  irregular  and 
sighing. 

(3)  The  Stage  of  Paralysis. — On  account  of  the  exudation  the  mental 
faculties  are  abolished,  so  that  the  patient  is  comatose,  though  convul- 
sions or  localized  spasms  of  the  muscles  in  different  parts  of  the  body 
(neck,  back,  limbs,  etc.)  may  be  observed.  Optic  neuritis  develops, 
■while  the  paralysis  of  the  ocular  muscles  above  noted  deepens.  The 
pupils  are  dilated,  the  eyes  are  partly  closed,  and  the  eyeballs  at  inter- 
vals slowly  and  alternately  move  in  a  lateral  direction.  Hemiplegia 
sometimes  develops,  and  more  rarely  monoplegia,  affecting  the  face  or 
one  of  the  extremities.  There  may  be  paralysis  of  the  third  nerve,  with 
involvement  of  the  face,  hypoglossal  nerve,  and  limbs  on  the  opposite 
side  (a  combination  of  symptoms  first  observed  by  Weber),  consequent 
upon  a  lesion  localized  in  the  internal  inferior  portion  of  the  crus. 
Monoplegia  of  the  right  side  of  the  face  has  been  observed  in  a  few 
instances,  associated  with  aphasia.  Exceptionally  aphasia  and  brachial 
monoplegia  have  been  combined.     The  temperature  in  the  early  part  of 


AGVTK   TUBERCULOSIS.  25,3 

this  stage  usually  rises  to  103°  F.  (39.4°  C.)  or  hifflier,  but  later  it  may 
drop  to  a  subnormal  level,  and  in  rare  instances  as  low  as  94°  F,  (34.4° 
C).  Immediately  preceding  the  fatal  termination  the  temperature  may 
rise  to  106°  or  107°  F.  (41.6°  C),  the  pulse  becoming  frequent,  small, 
and  irregular.     Anesthesia  comes  on  with  general  muscular  relaxation. 

Occasionally  a  typhoid  state  (great  prostration,  dry  tongue,  diarrhea, 
etc.)  may  develop,  and  Cheyne-Stokes  respiration  is  almost  invariably 
present,  preceding  the  fatal  event.     Leukocytosis  has  been  observed. 

Ophthalmoscopic  Examination. — The  ophthalmoscopic  appearances 
are — hyperemia  of  the  disk,  later  the  changes  belonging  to  neuritis 
(swelling  and  striation)  appear,  and  choroidal  tubercles  may  be  detected. 

Diagnosis. — This  is  based  :  (1)  On  the  reaction  to  tuberculin  ;  (2) 
Examination  of  eyes,  which  present  the  characteristic  appearance  of  the 
choroid  coat  (Jacobi).  Macewen  first  pointed  out  that  if  the  patient  is 
caused  to  assume  the  upright  position  with  the  head  inclined  to  one  side, 
percussion  over  the  pterion  gives  a  tympanitic  note  which  is  indicative 
of  internal  hydrocephalus.  Koplik  found  this  sign  present  in  34  of  52 
cases.  Post-hasic  meyiingitis  gives  the  same  symptoms,  and  lumbar 
puncture  is  the  only  means  of  diagnosis.  In  tubercular  meningitis  the 
diplococcus  intracellularis  is  not  found.  Syphilitic  meningitis  and  men- 
ingitis due  to  trauma  may  bear  a  close  resemblance  to  the  tubercular 
form,  but  the  history  should  prevent  confusion. 

Clinical  Types. — (a)  Mild  Type. — The  marked  or  alarming  symp- 
toms (tetanic  rigidity  of  the  muscles,  convulsions,  and  paralysis)  develop 
at  a  late  period.  In  this  class  should  be  placed  those  cases  in  which  the 
meningitis  is  but  feebly  indicated — e.  g.  when  it  is  but  a  small  factor  in 
the  condition  of  acute  general  tuberculosis. 

{h)  Malignant  or  Rapid  Form. — This  type  is  comparatively  rare,  oc- 
curring most  frequently  in  adult  life,  while  the  lesions  have  their  seat 
almost  exclusively  upon  the  convexity.  The  onset  is  marked  by  the 
most  frightful  tetanic  convulsions,  which  precipitate  a  fatal  termination 
in  a  couple  of  days. 

(e)  Chronic  Type. — Cases  pursuing  a  chronic  course  are  rarely  en- 
countered, and  the  symptoms  usually  point  to  localized  cerebral  lesions 
(Jacksonian  epilepsy,  etc.). 

Prognosis. — The  disease  lasts  from  two  to  four  or  five  weeks, 
though  chronic  cases  may  continue  for  several  months.  When  the  con- 
vexity is  implicated,  however,  the  duration  is  only  one  or  two  weeks. 
It  should  be  emphasized  that  frequently  in  the  course  of  well-marked 
cases  a  decided  remission  in  the  leading  symptoms  occurs,  so  that  con- 
valescence is  suggested ;  but  this  is  deceptive,  and  is  almost  invariably 
followed  by  a  renewal  of  the  unfavorable  features  of  the  aifection.  A 
few  cases  only  are  recorded  in  medical  literature  as  ending  in  recovery. 

Freyhan  has  reported  a  case  with  recovery  in  which  the  diagnosis 
was  proved  by  puncture  of  the  spinal  canal  and  the  withdrawal  of  fluid, 
in  the  sediments  of  which  tubercle  bacilli  were  found.  A.  Jacobi  has 
met  with  2  cases  that  terminated  favorably,  and  Leube  has  also  reported 
a  case  in  which  the  symptoms  were  characteristic,  and  at  the  autopsy, 
some  years  later,  old  tuberculous  lesions  were  found  in  the  meninges. 
It  is  to  be  recollected,  however,  that  the  course  of  tuberculous  menin- 
gitis is  probably  uninfluenced  by  human  agency. 


254  INFECTIOUS  DISEASES. 


Acute  Pneumonic  Phthisis. 

{Acute  Phthisis  ;  Florid  Phthisis  :   Galloping  Consumption.) 

This  may  be  primary  or  secondary,  the  latter  form  being  consequent 
either  upon  a  localized  tuberculous  area  in  the  lung,  tuberculous  pleurisy 
(acute  or  chronic),  tuberculous  peritonitis,  or  tuberculous  disease  of  some 
other  organ.  Acute  phthisis  may  occur  at  any  age.  though  it  is  rela- 
tively more  frequent  in  childhood  and  early  adult  life,  but  whether 
primary  or  secondary,   the  infection  of  the  lungs  is  rapid. 

Pathology. — Two  forms  may  be  recognized :  (1)  This  reveals  the 
appearances  of  an  acute  lobar  'pneumonia,  one  lobe  only  being  impli- 
cated, as  a  rule,  though  sometimes  the  whole  lung  is  involved.  The 
process  leads  to  a  destruction  of  lung-tissue,  so  that  a  section  may  show 
the  existence  of  cavities.  The  latter  are  usually  small,  while  surround- 
ing them  may  be  seen  tubercles  in  hepatized  tissue,  and  here  and  there 
caseous  masses  of  a  yellowish-white  color  may  be  visible.  These  often 
indicate  old  or  pre-existing  foci.  It  is  sometimes  exceedingly  difficult 
to  distinguish  a  tuberculous  croupous  pneumonia  from  the  ordinary  form, 
and  the  most  careful  inspection  may  fail  to  reveal  the  presence  of  ele- 
mentary tubercles  in  the  acutely  consolidated  tissue.  In  cases  in  which 
this  disease  is  suspected,  however,  the  opposite  lung,  the  bronchial  glands, 
the  peritoneum,  and  other  organs  should  be  carefully  examined. 

The  lesions  presented  by  cases  that  have  run  a  long  course  are 
somewhat  characteristic,  though  not  always  the  same.  If  the  case  has 
had  a  duration  of  two  or  more  weeks,  apical  softening  with  more  or  less 
extensive  cavity  formation  often  occurs.  Less  frecjuently,  a  lobe  or  an 
entire  lung  is  found  to  be  consolidnted  throughout,  "and  converted  into 
a  dry,  yellowish-white,  cheesy  substance,  in  which  condition  it  may  remain 
till  the  end." 

(2)  Presenting  the  Appearances  of  Broncho-pneumonia. — This  vari- 
ety is  more  common  than  the  previous,  especially  in  children.  The 
evidences  of  bronchitis  aifecting  the  finer  tubes,  together  with  con- 
solidation of  the  lobules  to  which  the  tubes  lead,  are  striking.  As  in 
ordinary  broncho-pneumonia,  so  here,  the  solidified  areas  appear  as 
grayish-red  masses  in  the  early  stage,  while  later  they  are  of  an  opaque- 
white.  The  products  that  fill  the  air-cells  may  caseate  and  break 
down,  with  the  formation  of  irregular  cavities  that  vary  in  size.  When 
large  areas  are  involved  they  are  the  result  of  the  fusion  of  contiguous 
smaller  areas  of  hepatized  tissue.  The  trouble  often  begins  in  the 
upper  lobes  and  spreads  downward,  though  not  infrequently  the  lower 
lobes  are  most  extensively  involved. 

In  not  a  few  cases  the  masses  are  small,  multiple,  and  widely  dissem- 
inated throughout  the  lungs,  and  miliary  tubercles  in  the  lungs  or 
pleurge  are  associated  with  the  broncho-pneumonic  lesions  before  de- 
scribed. In  nearly  all  cases  signs  of  pleurisy  may  be  noted,  as  is 
shown  by  pleural  adhesions  or  by  deposits  of  lymph  on  the  pleura. 
The  bronchial  glands  are  also  usually  infected,  and,  particularly  in  chil- 
dren, are  the  seat  of  tuberculous  processes. 

Baumler  has  called  attention  to  a  type  of  tuberculous  inhalation 
pneumonia  consequent  upon  hemoptysis,  the  blood  and  contents  of  the 


ACUTE  PNEUMONIC  PHTJJISLS.  255 

cavities  being  drawn  into  tlie  finer  tubes  in  respirntion.  This  form  of 
broncho-pneumonic  phthisis  sometimes  follows  pulmonary  tuberculosis 
in  the  early,  though  more  often  in  its  late,  stage.  On  microscopic  ex- 
amination tubercle  bacilli  are  found,  though  rarely  in  abundance,  in  the 
infiltrated  masses  and  in  the  walls  of  the  cavities. 

Clinical  History. — (1)  Acute  Cases. — Preceding  the  attack,  the 
patient  may  have  "  taken  cold  "  or  have  been  in  a  run-down  state  ;  more 
often,  however,  he  has  been  apparently  healthy.  The  onset  is  sudden, 
marked  by  a  rig  or  ^  pain  in  tlie  side  ^  fever  ^  couyk,  aiid  systemic  prostra- 
tion, and  there  may  be  bronchial  hemorrhage  which  may  last  one  or 
more  days.  The  total  amount  of  blood  expectorated  may  be  consider- 
able. In  the  majority  of  cases  the  expectoration  is  mucoid  at  first, 
and  then  becomes  rusty-colored,  often  containing  tubercle  bacilli, 
though  at  first  they  may  be  absent  and,  indeed,  not  appear  until  late  in 
the  disease.  Dyspnea  appears  early,  and  may  soon  become  extreme, 
and  the  fever  quickly  rises  to  104°  F.  (40°  C.)  or  over.  It  may  be  of 
the  continued  type,  or  it  may  early  assume  the  remittent  or  hectic  type, 
and  with  the  latter  forms  of  fever,  which  usually  begin  about  the  end 
of  the  first  week,  are  associated  night-sweats  and  rapid  emaciation.  The 
prostration  of  the  vital  powers  is  now  extreme.  The  expectoration  is 
more  abundant,  muco-purulent,  and  often  greenish-yellow  in  color. 

In  the  course  of  one  or  two  days  after  the  onset  we  obtain  physical 
signs.  Usually,  as  before  stated,  there  are  present  the  anatomic  appear- 
ances of  acute  lobar  pneumonia — viz.,  the  complete  consolidation  of  one 
or  more  lobes,  which  is  usually  followed  by  signs  of  softening,  provided 
the  patient  survives  the  first  week  or  ten  days.  The  physical  signs 
during  the  stage  of  consolidation  are  precisely  the  same  as  in  lobar  pneu- 
monia. The  signs  of  softening  and  of  cavity  will  be  given  in  detail 
below  {vide  Chronic  Phthisis). 

The  course  is  usually  rapid,  occupying  from  two  to  six  weeks  on  the 
average,  though  rarely  cases  that  reach  the  stage  of  cavity-formation 
are  protracted  to  three  or  even  four  months.  Considering  the  brevity 
of  the  attacks,  the  extreme  degree  of  emaciation  (shown  especially  by 
the  hollow  cheeks  and  temples,  pinched  nose,  and  thin  hands)  is  truly 
remarkable.  The  patient  usually  maintains  a  hopeful  state  of  mind, 
notwithstanding  the  rapid  downward  course  of  the  affection,  and  it  may 
be  admitted  that  recovery  is  possible.  The  parts  involved  are  in  such 
cases  destroyed  and  replaced  by  fibrous  tissue,  and  it  should  be  remem- 
bered that  the  apex  is  oftenest  involved.  It  may  happen  that  consolida- 
tion only  is  present  in  the  second  lobe  affected,  while  in  the  upper  lobe 
one  or  more  cavities  have  already  been  developed.  The  pleural  crepi- 
tating friction  is  often  audible  before  consolidation  is  complete. 

Diagnosis. — The  onset,  symptoms,  and  course  during  the  first  week 
may  be  those  of  ordinary  lobar  pneumonia,  but  in  some  cases  certain 
symptoms  may  arise  which  will  excite  suspicion  of  their  tuberculous 
character  in  the  early  stage.  Thus,  hemoptysis  rarely  occurs  in  a 
pneumococcus  infection,  and  the  appearance  of  the  patient,  as  well  as  his 
previous  and  family  history,  may  also  be  of  a  confirmatory  character. 
The  points  of  discrimination  have  been  fully  set  forth  in  the  section  on 
Lobar  Pneumonia  (pp.  123,  124). 

(2)  Subacute  Cases  (rarely  acute). — The  onset  is  less  sudden  than  in 


256  INFECTIOUS  DISEASES. 

the  former  type,  while  the  patient's  antecedent  condition  may  either  be 
good  or  below  the  standard.  At  the  beginning  he  has  repeated  chills, 
though  hemoptysis  may  be  the  first  symptom  which  indicates  a  pre-ex- 
isting tuberculous  focus.  The  fever  rises  high,  and  is  apt  to  be  irregu- 
lar from  the  start ;  the  pulse  and  respirations  are  rapid,  and  there  is 
a  muco-purulent  expectoration  which  may  either  be  profuse  or  scanty. 
Occasionally  it  is  fetid,  and  the  sputa  may  early  contain  elastic  fibers 
and  tubercle  bacilli,  though  more  often  these  are  noted  after  the  affec- 
tion has  become  fully  established.  During  the  progress  of  the  case, 
also,  hemoptysis  may  arise.  Later,  drenching  yright- sweats  increase  the 
exhaustion  and  emaciation,  which  speedily  reach  an  extreme  degree, 
and  soon  or  late  a  typhoid  condition  of  the  system   is  developed. 

The  physical  signs  are,  at  first,  those  of  general  bronchitis,  with  or 
without  indications  of  pleurisy.  Later,  small  areas  of  consolidation, 
which  often  increase  in  size,  are  indicated  by  impaired  percussion  reso- 
nance or  dulness  and  by  broncho-vesicular  (rarely  tubular)  breathing, 
with  subcrepitant  rales.  These  signs  may  be  unilateral,  though  more 
often  they  occur  bilaterally.  In  many  cases  softening  with  cavity-for- 
mation ensues,  with  the  usual  physical  signs  of  this  condition. 

Course  and  Duration. — For  some  time  the  patient  may  remain  out 
of  bed,  although  in  most  instances  the  disease  constantly  progresses. 
Less  frequently  there  are  exacerbating  periods  and  remissions.  Rarely 
these  cases  recover  Avith  a  loss  of  more  or  less  lung-tissue.  Again,  the 
condition  may  pass  into  chronic  phthisis.  It  is  important  to  recollect 
that  the  local  lesions  may  become  extensive,  as  the  result  of  fusion  of 
small  consolidated  masses,  until  an  entire  lobe  is  involved,  and  when  this 
occurs  the  symptoms  and  course  simulate  those  of  the  acute  type.  The 
duration  ranges  from  two  to  eight  weeks  or  more. 

Diagnosis.  — This  variety  is  frequently  confounded  with  non-tubercu- 
lous broncho-pneumonia,  and  the  chief  distinctions  will  be  mentioned 
in  connection  with  the  latter  disease.  Bronchiectasis  may  be  accom- 
panied by  emaciation,  fetid  expectoration,  night-sweats,  and  the  signs 
of  cavity,  and  this  disease  has  been  mistaken  for  acute  phthisis.  Im- 
portant in  the  recognition  of  the  latter,  however,  are  marked  fever  and 
emaciation.  MToreover,  the  physical  signs  are  more  frequently  referable 
to  the  apices,  and  the  disease  is  more  steadily  progressive,  running  a 
shorter  course  than  bronchiectasis.    The  sputum  contains  tubercle  l)acilli. 

Acute  Broncho-pneuinonic  Phthisis  in  Children. — The  belief  that  the 
form  of  broncho-pneumonia  that  so  frequently  follows  certain  infec- 
tious diseases  (measles,  whooping-cough,  etc.)  is  in  the  majority  of 
instances  tuberculous  has  been  steadily  gaining.  Osier  recognizes  three 
groups  of  cases:  (a)  Those  in  which  the  child  suddenly  becomes  ill 
while  teething  or  during  convalescence  from  fever,  Avith  high  tempera- 
ture, severe  cough,  and  the  signs  of  consolidation  of  one  or  both  apices. 
Death  may  occur  within  a  few  days.  To  the  naked  eye  the  lesions  do 
not  appear  to  be  tuberculous,  {b)  In  this  group  the  children  show  the 
ordinary  symptoms  of  broncho-pneumonia,  and  the  cases  are  more  pro- 
tracted, death  occurring  about  the  sixth  week,  (c)  The  child  feels  ill 
during  convalescence  from  an  infectious  disease,  fever,  cough,  and  dys- 
pnea being  present.  The  intensity  of  the  symptoms  abates  within  a  fort- 
night, and  the  physical  examination  shpws  the  presence  of  diffuse  bron- 


CHRONIC  TUBERCULOSIS.  251 

chitis  with  scattered    minute    areas    of  consolidation.      Many   of   these 
cases  develop  into  chronic  phthisis. 

Chronic  Tuberculosis. 

{Chronic  Pulmonary  Tuberculosis;   Chronic  Ulcerative  Phthisis) 

This  form  is  much  more  common  than  the  acute,  the  term  embracing 
sub-varieties  to  -which  attention  will  be  incidentally  directed.  Its  most 
typical  clinical  form  follows  a  mixed  infection  as  a  result  of  a  septic  ele- 
ment superadded  at  some  time  to  the  primary  tuberculous  infection. 

The  Causal  Factors  have  been  detailed  under  General  Etiology. 

Pathology. — The  pathologic  characters  of  tuberculosis  in  general 
have  been  already  presented,  but  it  will  be  necessary  to  describe  briefly 
the  special  anatomic  conditions  met  with  in  chronic  ulcerative  phthisis. 

The  post-mortem  appearances  of  the  lungs  in  chronic  pulmonary 
tuberculosis  are  remarkable  for  their  great  diversity,  not  only  in  the 
extent  of  tissue  involved,  but  also  as  to  the  character  of  the  morbid 
processes.  Often  the  associnted  lesions  form  no  unimportant  part  of 
the  picture.  In  nearly  all  fatal  cases  the  most  advanced  and  extensive 
lesions  are  found  near  the  apex,  and,  as  a  rule,  the  entire  upper  lobe  of 
one  of  the  lungs  is  implicated.  In  addition,  it  is  observed  that  the 
destructive  process  has  extended  to  the  lower  lobe  of  the  same  side,  and 
later  to  the  apex  of  the  opposite  lung.  Though  both  lungs  are  affected 
in  fatal  cases,  they  represent  different  stages  of  the  disease.  The  case  is 
very  different  in  an  old  and  cured  tuberculosis  of  the  lungs,  such  as  is 
frequently  met  with  in  persons  who  have  died  of  some  other  affection. 
Here  the  lesions  may  occupy  but  a  small  part  of  one  lung,  and  usually 
near  the  summit. 

Kingston  Fowler  has  investigated  the  question  of  the  points  of  elec- 
tion and  paths  of  distribution  of  the  lesions  in  chronic  phthisis,  and 
has  found  that  the  primary  lesion  is  not,  as  a  rule,  at  the  summit  of  the 
upper  lobe,  but  that  it  occurs  from  1  to  1|  inches  (3.79  cm.)  below 
this  point  and  near  the  postero-external  borders.  Favored  by  normal 
respiration,  the  lesions  advance  downward,  so  that  on  physical  examina- 
tion the  first  evidences  of  disease  are  to  be  found  posteriorly  over  the 
lower  part  of  the  supraspinous  fossa,  while  anteriorly  the  early  signs 
are  met  with  immediately  below  the  middle  of  the  clavicle,  extending 
along  a  line  running  about  1-|-  inches  (3.79  cm.)  from  the  inner  end  of 
the  second  and  third  interspaces.  The  starting-point,  though  less  fre- 
quently, may  also  be  indicated  by  physical  signs  in  the  first  and  second 
interspaces  below  the  outer  third  of  the  clavicle,  with  subsequent  down- 
ward extension. 

From  personal  observation  of  the  post-mortem  lesions  of  this  disease, 
and  from  my  studies  at  the  bedside,  I  feel  convinced  that  the  initial 
lesion  is  frequently  located  anteriorly  and  near  the  apex,  corresponding 
on  the  chest-walls  to  the  clavicle  and  the  supraclavicular  spaces.  This 
site  has  seemed  to  me  to  obtain  more  often  on  the  right  side  than  on  the 
left.  Kingsley  has  shown  that  when  the  lower  lobe  becomes  involved 
the  consolidation  begins  about  1-^  inches  (3.79  cm.)  below  its  apex  pos- 
teriorly, and  corresponding  externally  to  a  spot  opposite  the  fifth  dorsal 
spine.     From  this  point  it  spreads  downward  and  laterally  in  a  line  fol- 

17- 


258  INFECTIOUS  DISEASES. 

lowing  the  border  of  the  scapula  "  when  the  hand  is  placed  on  the  oppO' 
site  scapula  and  the  elbow  rests  above  the  level  of  the  shoulder,"  The 
middle  lobe  on  the  right  side  is  usually  invaded  by  direct  extension  froju 
the  upper.  The  seat  of  primary  infiltration  may  even  be  the  lower  lobe, 
but  this  is  rare.  Cole '  has  found  lesions  at  the  root  to  precede  paren- 
chymal changes. 

The  relative  frequency  of  involvement  of  the  two  sides  varies  accord- 
ing to  different  authorities.  A  careful  analysis  of  my  records  and  those 
of  other  observers  show  that  out  of  a  total  of  1286  cases  726  occurred  on 
the  left  side  and  510  on  the  right. 

In  all  cases  the  primary  lesions  are  due  to  tuberculous  infiltration, 
which  at  first  is  confined  to  certain  lobules,  though  it  may  later  involve 
extensive  areas  of  lung-tissue  {tuberculous  broncho-pneumonia.)  In 
most  instances  the  starting-point  of  the  morbid  changes  is  in  the  smaller 
bronchi  and  also,  according  to  Payne,  the  inside  of  the  alveoli.  Soon 
the  bronchioles  and  the  corresponding  air-cells  become  blocked  with  in- 
flammatory products.  These  areas  then  undergo  caseation  and  present 
the  usual  opaque,  grayish-yellow  appearance,  a  cross-section  of  these 
yellow  nodules  showing  the  central  bronchus  usually  plugged  Avith  exu- 
date and  surrounded  by  caseous  matter.  Softening  and  sometimes 
complete  liquefaction,  with  expectoration  or  absorption  of  the  altered 
morbid  products,  may  take  place,  and  this  disintegration  is  associated 
with  ulceration  in  the  wall  of  the  bronchus,  consequent  upon  secondary 
pyogenic  infection,  and  a  resulting  formation  of  small  cavities.  Ulcers 
may  form  in  the  bronchioles  before  necrotic  processes  supervene,  and 
they  are  generally  shallow,  with  sharply-defined  edges.  Recovery  may 
ensue  as  the  result  of  calcification  with  encapsulation  of  the  cheesy 
masses,  or  the  affected  area  may  undergo  fibroid  transformation — a  con- 
servative process  and  one  that  may  lead  to  actual  cure.  It  often  happens, 
however,  that  old  and  apparently  healed  tuberculous  lesions  undergo 
ulceration,  when  the  calcareous  masses  (pulmonary  calculi)  may  be  dis- 
lodged and  expectorated,  and  the  more  rapidly  the  caseous  masses  are 
formed  the  more  liable  are  they  to  softening.  Surrounding  the  healed 
areas  the  tissue  may  be  the  seat  of  atelectasis,  though  more  often  of 
emphysema.  Destruction  of  lung-tissue  also  results  from  interstitial 
inflammation  with  the  formation  of  new  connective  tissue,  the  latter  in 
turn  compressing  and  finally  obliterating  the  alveoli. 

Cavities  ( Vomicce). — These  result  chiefly  from  progressive  necrosis 
and  ulceration.  They  are  formed  mostly  by  dilatation  of  the  bronchi, 
whose  walls  are  tuberculous  and  suppurating.  But  they  may  also  arise 
independently  of  the  bronchi.  Cavities  vary  largely  in  number,  size, 
and  form.  They  are  often  multiple,  though  usually  not  far  removed 
from  one  another,  and  unite  as  they  increase  in  size.  In  this  way  large 
cavities,  with  irregular  walls,  involving  the  whole  of  one  lobe  and  even 
an  entire  lung  (except  the  extreme  anterior  margin),  may  be  formed,  and 
small  pockets  connecting  with  the  bronchus  may  thus  originate. 

Vomicse  may  be  classified  as  (1)  progressive  and  (2)  non-progressive. 

(1)  The  progressive  are  divisible  into  (a)  New  cavities  and  {b)  Old 
cavities. 

(a)  New  cavities  have  soft,  necrotic,  friable  Avails  so  long  as  the  de- 

^  Amer.  Jour.  Med.  Sciences,  July,  1910. 


CHRONIC  TUBERCULOSIS.  251i 

structive  processes  are  rapidly  progressing,  and  the  same  state  of  things 
prevails  in  the  cavities  of  acute  phthisis.  Thoy  may  develop  near  a 
healed  focus  or  near  old  cavities  with  limiting  walls,  and  when  situated 
near  the  periphery  of  the  lung  they  may  rupture  into  the  pleura,  caus- 
ing pneumothorax. 

(6)  Old  cavities,  as  a  rule,  have  sharply-defined  walls  that  vary 
considerably  in  thickness.  At  first  they  consist  of  a  fibro-vascular 
zone,  which  has  an  inner  suppurating  surface ;  subsequently  the  lining 
of  this  zone  is  converted  into  an  exfoliating  membrane.  The  contents 
of  vomicae  are  muco-purulent  or  purulent,  and  often  consist  of  a  shreddy 
and  sometimes  a  bloody  fluid.  Rarely  they  are  gangrenous.  Cavities 
also  contain  tubercle  bacilli  and  other  micro-organisms.  Percy  Kidd 
has  studied  the  question  of  the  relation  of  tubercle  bacilli  to  tuberculous 
pulmonary  lesions,  and  states  that  they  are  invariably  present  in  newly- 
developed  tubercles  and  fresh  cavities,  but  frequently  absent  in  old 
nodules.  Trabeculae  composed  of  blood-vessels  and  remnants  of  pul- 
monary tissue  often  traverse  the  cavities.  In  old  cavities  excavation 
may  be  complete,  not  a  vestige  of  normal  or  diseased  tissue  remaining 
in  them,  though  the  blood-vessels,  many  of  which  are  beaded  by  small 
aneurysmal  dilatations  along  their  course,  are  the  last  to  disappear. 
Their  removal  is  eifected  by  an  obliterating  inflammation.  Rupture  of 
these  miliary  aneurysms  or  the  erosion  of  a  large  vessel  gives  rise  to 
copious  hemoptysis.  Cavities  having  dense  walls  may  also  increase  in 
size  by  encroaching  upon  the  surrounding  tissue,  huge  cavities  often 
having  thin,  tense  Avails.  But,  wherever  situated,  they  usually  begin 
toward  the  summit  of  the  upper  lobe.  Another  common  seat  is  the  mid- 
dorsal  region. 

(2)  Non-progressive  Cavities. — Quiescent  cavities  are  usually  small, 
though  variable  in  size,  according  to  the  stage  at  which  the  process  of 
contraction  is  arrested.  Medium-sized  and  large  vomicae  do  not  be- 
come totally  occluded.  They  may  be  multiple,  though  more  often  per- 
haps single,  and  associated  with  them  may  be  observed  dense,  fibrous 
nodules  representing  healed  foci.  Their  interior  may  be  lined  with  a 
smooth,  cuticular  structure  resembling  mucous  membrane. 

Interstitial  Pneumonia. — In  the  course  of  chronic  phthisis  interstitial 
inflammation  of  two  sorts  will  most  probably  arise :  (a)  A  consolidation 
excited  by  the  tubercle  bacilli  themselves,  and  hence  manifesting  a  de- 
structive tendency;  (h)  A  slowly-developed  interstitial  pneumonia  which 
aims  at  arresting  the  progress  of  the  afi'ection.  It  develops  in  close 
proximity  to  caseous  masses  and  around  cavities.  The  new  connective 
tissue  thus  formed  in  obedience  to  the  well-known  pathologic  iaw^  tends 
to  contract  secondarily,  and  thus  vomicae  are  often  partly,  though  sel- 
dom entirely,  obliterated.  The  shrinking  of  the  connective  tissue  may 
also  result  in  compression,  and  finally  in  the  destruction  of  pulmonary 
tissue,  just  as  in  a  tuberculous  inflammation.  The  process  in  this  in- 
stance, however,  is  on  the  whole  conservative  and  reparative. 

Disseminated  Tuberculosis. — Miliary  Tubercles. — This  form  has  for 
its  chief  characteristic  miliary  tubercles,  which  are  scattered  not  only 
about  the  tuberculous  area,  but  also  throughout  the  rest  of  the  lung, 
and  usually  in  the  lower  lobe.  Most  of  the  tubercles  undergo  fibroid 
or  fibro-caseous  change.      These  minute,  hard  gray  or  grayish-yellow 


260  INFECTIOUS  DISEASES. 

nodules  vary  in  size  from  a  niustard-seod  to  that  of  a  pea,  and  hing- 
tissue  that  is  more  or  less  studded  with  chronic  miliary  tubercles  is  apt 
to  look  pale,  while  the  surrounding  air-cells  are  emphysematous.  The 
condition  may  lead  to  pneumonia,  and  the  whole  aspect  then  becomes 
altered.  Here,  as  before  described,  fusion  of  miliary  tubercles  results 
in  larger  masses  which  become  caseous,  and  hence  the  method  of  cavity- 
formation  is  identical  with  that  observed  in  tuberculous  broncho-pneu- 
monia. In  the  disseminated  form  tubercles  may  also  be  found  in  many 
other  organs  than  those  indicated  (pleura,  trachea,  larynx,  bronchial  and 
other  lymphatic  glands,  peritoneum,  spleen,  kidneys,  liver,  brain,  mu- 
cosa, testes,  etc.). 

Lesions  of  the  Pleura. — This  membrane  is  hyperemic  and  coated  with 
fibrinous  exudation  coextensively  with  the  affection  of  the  parts  in 
chronic  ulcerative  phthisis.  The  pleural  membranes  are  only  more  or 
less  thickened  by  organized  adhesions,  but  in  the  latter  and  also  in  the 
pleura  tubercles  or  cheesy  masses  may  be  found.  Simple  and  other 
forms  of  pleurisy  are  met — sero-fibrinous,  purulent,  and  hemorrhagic. 

Lesions  of  the  Bronchial  Glands, — At  first  these  are  enlarged  and 
edematous,  containing  tubercles,  and  later  they  present  foci  which  often 
undergo  purulent  disintegration  and  sometimes  calcification.  Other 
lymphatic  glands  than  these  may  be  aft'ected  (mesenteric,  etc.). 

Lesions  of  the  Larynx. — The  larynx  is  frequently  the  seat  of  tuber- 
culous infiltration  and  ulceration,  particularly  in  certain  parts,  such  as 
the  vocal  cords,  posterior  wall,  and  ary-epiglottidean  folds. 

Lesions  of  the  Heart. — Tuberculous  endocarditis  is  present  in  about 
5  per  cent,  of  the  cases,  and  congenital  stenosis  of  the  pulmonary  ori- 
fice is  noted  in  not  a  few  instances  (Chevers).  The  right  heart  is  often 
hypertrophied  or  dilated. 

Other  organs  may  present  lesions  in  chronic  phthisis,  and  these  will 
be  spoken  of  in  connection  with  the  clinical  history. 

Tuberculosis  of  the  intestinal  canal  is  a  common  though  late  lesion. 

Amyloid  degeneration  of  certain  organs  is  a  not  unusual  secondary 
event,  especially  of  the  kidneys,  liver,  spleen,  and  intestinal  mucosa. 
Enlargement  of  the  liver  due  to  fatty  infiltration  is  sometimes  noted. 

Clinical  History. — The  modes  of  invasion  are  quite  diverse,  but 
with  few  exceptions  the  onset  is  either  (1)  gradual  or  (2)  abru])t,  and,  as 
a  rule,  the  health  has  been  previously  undermined  for  a  longer  or  shorter 
period. 

(1)  Gradual  Onset. — (a)  The  disease  often  originates  in  a  manner 
similar  to  ordinary  bronchitis,  and  the  symptoms  of  pleurisy  are  some- 
times associated.  Tuberculous  bronchial  affections  often  follow  certain 
acute  infectious  diseases — influenza,  typhoid,  measles,  wliooping-cough — 
and  in  this  form  are  rarely  curable.  The  physical  signs  may  be  nega- 
tive for  some  time,  and  then  appear  in  the  apex  region,  and  the  nif)st 
characteristic  grouping  of  physical  signs  during  the  incipient  stage 
may  be  thus  summarized:  "Lagging"  or  defective  expansion,  as  noted 
on  inspection  and  palpation,  a  localized  increase  in  the  tactile  fremitus, 
slightly  impaired  percussion-resonance,  enfeeblement  of  the  normal 
vesicular  murmur,  with  (at  a  later  period)  prolongation  and  sharpen- 
ing of  the  expiration.  The  fact  tiiat  the  lesions  are  commonly  detect- 
able in  the  suprascapular  fossa  must  be  remembered.  At  this  period 
obvious  constitutional  disturbances  are  jjresent  (debility,  fever). 


GHRONKJ  TUBI'JRCULOSIS.  201 

(b)  Onset  with  Pleuriay. — Tliis  may  be  sudden,  as  in  an  Mcute  pleu- 
risy with  effusion,  but  often  the  latter  condition  develops  insidiously. 
Of  90  cases  of  pleurisy  with  effusion,  one-third  terniinated  in  chronic 
phthisis  (Bowditch).  It  nuiy  begin  as  a  dry  j)lenrisy  at  tlie  apex,  either 
antei-iorly  or  posteriorly,  or  the  evidence  of  pleurisy  may  be  associated 
with  the  more  common  bronchitic  onset. 

(c)  With  G  astro -intestinal  Symptoms. — There  is  impaired  digestion, 
and  soon  the  patient  becomes  anemic,  loses  flesh,  and  is  debilitated. 
Later,  the  first  indications  of  pulmonary  tuberculosis  develop  in  the 
lungs.  Close  scrutiny  of  the  data  entering  into  the  early  history  of  cases 
of  pulmonary  tuberculosis  usually  reveals  some  perversion  of  the  general 
health  before  distinctive  pulmonary  phenomena  arise. 

{d)   With  indefinite  peritoneal  symptoms,  lasting  for  months  or  years. 

(e)  With  Laryngeal  Symptoms. — This  is  a  rare  form.  It  begins  with 
hoarseness,  more  or  less  aphonia,  and  considerable  cough  ;  there  is  also 
a  slight  mucopurulent  expectoration.  Laryngoscopic  examinations  m_ay 
detect  tuberculosis  of  the  organ,  and  tubercle  bacilli  may  be  found  in 
the  sputum  before  involvement  of  the  lungs  is  discoverable. 

(2)  Cases  with  Abrupt  Onset. — («)  The  most  important  group  under 
this  category  is  heralded  by  the  symptoms  and  signs  of  pneumonia,  more 
commonly  of  the  lobular  variety.  As  compared  with  lobar  pneumonias, 
these  present  peculiar  features :  the  fever  is  irregular,  the  expectoration 
is  more  abundant,  is  blood-stained,  and  contains  bacilli.  The  signs  are 
usually  located  in  the  apical  region.  Resolution  may  occur,  but  recovery 
is  not  complete,  and  the  condition  may  pass  into  chronic  phthisis. 

(6)  Onset  ivitli  Fever. — Chills  and  fever  generally  arise  in  the  ad- 
vanced stage  of  pulmonary  tuberculosis,  but  these  symptoms  may  also 
initiate  the  attack.  There  is  no  mistake  in  diagnosis  more  commonly 
made  in  malarial  regions  than  to  ascribe  such  cases  to  paludism. 

{c)  With  Hemoptysis. — This  symptom  may  invite  attention  to  lung 
trouble.  Miiller  states  that  hemoptysis  was  an  early  symptom  in  170 
of  the  875  patients  at  the  Davos  German  Sanatorium,  and  was  twice  as 
frequent  in  the  male  as  in  the  female.  The  amount  of  blood  lost  is  either 
considerable  or  repeated  slight  hemorrhages  occur.  In  a  great  proportion 
of  cases  the  clinical  picture  of  incipient  pulmonary  tuberculosis  is  revealed, 
pursuing  its  accustomed  course  immediately  after  the  occurrence  of  the 
hemorrhage.  The  physical  signs  may  be  latent  for  a  time,  and.  while 
they  are  usually  located  in  the  subapical  area,  they  may  assume 
the  guise  of  a  pleurisy  in  the  infrascapular  region.  A  slight  tuber- 
culous lesion  is  present  in  these  cases  preceding  the  occurrence  of  the 
hemorrhage. 

The  symptoms  are  (1)  local  and  (2)  general 

(1)  Local. — (a)  Pain. — This  is  absent  in  many  cases  of  chronic 
phthisis  and  in  others  it  may  be  moderately  severe.  It  is  seated  usually 
at  the  base,  laterally  or  anteriorly,  and  not  rarely  there  is  pain  of  a 
lancinating  character  in  the  interscapular  region  in  the  early  stages  of 
the  affection.  This  symptom  is  of  diagnostic  worth  only  after  other  forms 
of  pain  (rheumatic,  neuralgic)  have  been  excluded.  The  most  common 
cause  of  pain  is  pleuritis,  with  or  without  pleuritic  adhesions :  it  is 
increased  on  deep  breathing  and  coughing.  Intercostal  neuralgia  and 
pleurodynic    stitches  may  also   develop   soon   or  late.      Tenderness    on 


262  INFECTIOUS  DISEASES. 

pressure  "with  the  right  forefinger  (algeoscopy),  which  causes  the 
patient  to  exchiim  or  make  a  grimace,  or  merely  a  contraction  in 
adjoining  muscles,  was  present  in  77.0  per  cent,  of  200  cases  studied 
by  Francke,  while  only  one-third  of  these  patients  complained  of 
spontaneous  pain. 

{h)  The  Cough. — This  may  be  looked  upon  as  an  essential  feature, 
though  in  a  few  instances  it  may  be  slight  or  even  wanting  throughout. 
Its  severity  bears  no  constant  relation  to  the  extent  of  the  pulmonary 
lesions,  but  rather  to  the  degree  of  sensitiveness  of  the  patient.  It  is 
dry  and  hacking  at  the  beginning,  and,  if  the  larynx  be  involved, 
the  cough  is  marked  and  of  a  hoarse  quality.  It  is  most  pro-  . 
nounced  at  certain  periods  of  the  day — viz.,  on  lying  down  at  night 
and  on  awakening  from  sleep.  Paroxysms  may  occur  after  meals  and 
induce  vomiting.  The  cough  is  at  times  distressing  and  debilitating  in 
its  effects. 

(c)  Expectoration. — At  the  beginning  the  sputum  is  scanty  and  mu- 
coid, rarely  hemorrhagic,  or  it  may  be  merely  streaked  with  blood ; 
later  it  may  become  muco-purulent,  and  the  appearance  of  small  gray 
or  grayish-yellow  flocculi  first  suggests  the  nature  of  the  affection.  With 
the  onset  of  the  stage  of  cavity -formation  the  sputum  becomes  more  abun- 
dant and  more  distinctly  purulent,  and,  after  the  formation  of  cavities  of 
any  size,  airless,  opaque,  and  nummular  (coin-shaped)  masses  are  expec- 
torated. The  latter  are  greenish-gray  or  greenish-yellow  in  color,  and 
sink  rapidly  when  discharged  into  water.  They  are  often  mingled  with 
more  or  less  bronchial  secretion,  and  are  sometimes  observed  in  pure 
bronchitis.  They  may  even  be  absent,  and  the  expectoration  be  merely 
purulent.  The  opening  of  a  fresh  cavity  may  be  followed  by  very  free 
expectoration.  The  sputum  is  sometimes  fetid,  and  exceptionally  it  is 
horribly  offensive,  varying  greatly  in  amount  in  different  cases  and  at 
different  stages  of  the  disease.  In  certain  cases  it  is  absent  throughout 
the  greater  portion  of  their  course,  and  is  especially  apt  to  be  slight  in 
children  and  old  people.  In  such  instances  it  may  be  impossible  to 
collect  sufficient  sputum  to  examine  for  bacilli. 

Microscopic  examination  discovers  alveolar  epithelium  (particularly 
in  the  earlier  stages),  pus-cells,  blood,  fat-globules,  elastic  fibers,  and 
tuhercle  bacilli.,  the  detection  of  the  latter  being  the  most  important 
factor  in  the  diagnosis.  It  may  be  safely  stated  that  the  finding  of 
bacilli  in  the  sputum  is  prima  facie  evidence  of  chronic  phthisis  ;  on  the 
other  hand,  however,  their  absence  in  the  early  stage  does  not  exclude 
the  disease.  It  is  often  needful  to  make  repeated  and  delicate  examina- 
tions of  the  sputa.  It  is  also  of  the  utmost  importance  to  select  for  ex- 
amination the  small  grayish  masses  that  are  usually  to  be  found,  since 
they  early  contain  the  bacilli.  In  tuberculosis  in  the  aged  tubercle 
bacilli  are  not  always  detectable  in  the  sputum. 

Method  of  Examining  the  Sputum. — "  A  small  amount  of  the  purulent 
portion  of  the  sputum  is  spread  in  a  thin  and  uniform  layer  on  a  per- 
fectly clear  cover-glass  by  means  of  forceps,  needles,  or  the  Ohse,  which 
must  previously  be  held  a  moment  in  the  flame  of  a  Bunsen  burner  or  a 
spirit  lamp,  or  by  pressing  a  small  amount  of  sputum  between  two  cover- 
glasses,  then  sliding  them  apart.  It  is  then  dried  in  the  air,  or  more 
quickly  by  holding  the  cover-glass  with  forceps  some  distance  above  the 


CHRONIC  TUBERCULOSIS.  263 

flame  of  a  burner  or  lamp.  Finally,  it  is  to  be  passed  three  or  four  times 
through  the  flame,  and  so  'fixed'"  (Musser).  Brown  and  Smith'  rec- 
ommend antiformin  for  the  cultivation  of  tubercle  bacilli  directly  from, 
and  also  to  digest,  the  sputum. 

The  preparation  may  be  stained  with  carbol  fuchsin  (basic  fuchsin  1, 
alcohol  10,  5  per  cent,  solution  of  carbolic  acid  90),  either  by  dropping 
a  few  drops  of  the  stain  on  the  smeared  side  of  the  cover-glass  and 
holding  it  above  the  flame  until  it  steams,  or  by  floating  its  face  down- 
ward upon  a  watch-crystal  containing  the  solution.  It  must  then  be 
decolorized  either  with  a  30  per  cent,  solution  of  nitric  acid,  allowing 
it  to  remain  until  the  red  color  has  entirely  disappeared  (about  fifteen 
seconds),  and  then  washing  and  counter-staining  with  methylene-blue, 
or  with  Gabbett's  solution  (methylene-blue  2  gm.,  sulphuric  acid  25 
c.cm.,  water  75  c.cm.),  in  which  it  must  remain  until  the  red  color  has 
been  replaced  by  a  faint  blue  (thirty  seconds  or  more).  Instead  of  car- 
bol-fuchsin,  anilin  gentian  violet  may  be  employed  (add  a  saturated 
alcoholic  solution  of  gentian  violet  to  a  filtered  saturated  solution  of 
anilin  until  a  metallic  luster  appears  on  the  surface).  The  specimen 
may  lie  either  several  hours  in  a  cold  solution  or  a  few  minutes  in  one 
that  is  steaming.  Decolorize  with  the  nitric-acid  solution  {^  per  cent.), 
and  counterstain  with  rubin  or  a  saturated  aqueous  solution  of  Bismarck 
brown.  It  is  often  much  simpler  to  smear  the  sputum  directly  upon 
the  slide,  and  then  examine,  when  stained,  without  the  intervention  of  a 
cover-glass.     A  much  larger  amount  of  sputum  can  thus  be  prepared. 


Fig.  21.— Elastic  fibers  (after  Strumpell). 

In  the  microscopic  examination  use  a  -j^j-inch  (2.11  mm.)  oil-immersion 
lens  and  Abb^  condenser.  If  carbol-fuchsin  has  been  used  in  staining  for 
the  bacilli,  and  methylene-blue  as  a  contrast,  the  former  will  be  found  as 
red  rods  in  a  blue  field  (background),  while  if  gentian-violet  has  been  used, 
the  tubercle  bacilli  appear  as  dark  violet  rods,  with  all  other  bodies 
brown,  if  Bismarck  brown  is  used  for  the  contrast  stain.  There  may 
be  visible  in  the  field  a  few  bacilli  only,  particularly  during  the  early 
part  of  the  case.  In  the  stage  of  cavity  their  number  is  usually  in- 
creased, and  sometimes  they  are  quite  numerous. 

The  demonstration  of  elastic  fibers  is  also  an  important  aid  to  diag- 
nosis. Fenwick's  method  is  the  following  :  Boil  the  sputum  with  an 
equal  quantity  of  a  solution  of  caustic  soda  (gr.  xv— 5j — 0.972—32.0)  : 
pour  the  product  into  a  conical  glass  and  fill  with  cold  Avater.  The  sedi- 
ment is  subsequently  examined  with  care  for  elastic  fibers. 

The  form  and  appearance  of  the  elastic  threads  diff'er  according  to 
*  Jour,  Med.  Research,  Boston,  1910,  xxii.,  517. 


264  INFECTIOUS  DISEASES. 

their  special  source.  If  they  come  from  the  alveoli,  there  is  an  inter- 
lacing of  tlie  fibers  ^Yhich  may  preserve  the  globular  contour  of  the  air- 
cells.  If  they  come  from  the  blood-vessels,  they  are  single  and  elon- 
gated, or  two  or  three  of  the  fibers  may  be  arranged  side  by  side.  Elastic 
tissue  derived  from  the  bronchi  has  a  similar  appearance. 

The  presence  of  elastic  fibers  furnishes  incontestible  proof  that  destruc- 
tion of  lung-tissue  lias  taken  place.  To  show  that  this  loss  of  structure, 
however,  is  due  to  tuberculosis,  we  must  exclude  abscess  (rare)  and  gan- 
grene of  the  lungs — diseases  in  which  it  also  occurs. 

id)  Hemoptysis. — This  symptom  of  phthisis  will  be  spoken  of  under 
Diseases  of  the  Lungs,  but  its  importance  as  a  diagnostic  feature  of  this 
disease  makes  special  reference  to  it  here  absolutely  necessary.  It  is 
present  in  the  majority  of  cases.  Gabrilowisch  ^  found  tiiat  of  380 
patients  213,  or  5t!  per  cent  ,  had  hemoptysis.  The  sputum  may  be 
merely  blood-stained,  or  the  hemorrhage  may  be  excessive  and  j)rove 
rapily  fatal,  though  hemoptysis  is  rarely  the  direct  cause  of  death  in 
tuberculosis.  Slight  hemorrhages  are  usually  produced  by  mere  hyper- 
emia, and  are  most  apt  to  occur  during  the  early  stages ;  while  severe 
bleedings  are  produced  by  the  erosion  of  a  blood-vessel  or  rupture  of  a 
small  aneurysm,  and  are  most  prone  to  occur  during  the  stage  of  cavity. 
In  certain  cases  hemoptysis  is  frequent. 

A  third  or  capillary  form  of  hemorrhage  may  occur  in  phthisis 
with  cavity-formation,  and  in  this  variety,  which  is  of  a  rather  frequent 
occurrence,  the  purulent  sputum  is  uniformly  stained  with  blood.  It 
may  also  be  nummular,  but  presents  a  reddish-brown  or  chocolate  color. 
The  exciting  cause  is  seldom  obvious,  though  in  not  a  few  instances  ag- 
gravation of  the  cough,  and  in  others  great  mental  excitement,  would 
appear  to  excite  bleedings.  Slight  hemorrhages  often,  and  severe  ones 
rarely,  afford  more  or  less  relief  to  the  pulmonary  condition.  On  the 
other  hand,  severe  bleedings  usually  exert  an  unfavorable  influence, 
being  followed  by  debility  and  anemia.  Moreover,  in  numerous  cases 
hemoptysis  is  followed  by  a  more  rapid  extension  of  the  local  lesions, 
with  corresponding  aggravation  of  the  local  and  general  manifestations. 
The  fact  remains,  however,  that  the  effect  of  severe  hemoptysis  upon 
the  progress  of  chronic  phthisis  is  by  no  means  always  untoward.  In  a 
case  of  my  own  there  occurred  periodically  copious  spontaneous  bleed- 
ings (in  spring  and  fall)  for  three  years,  which  were  as  regularly  fol- 
lowed by  marked  improvement  for  a  period  of  three  or  four  months. 
The  physical  signs  of  phthisis  then  developed.  In  a  large  number  of 
cases  of  pulmonary  tubei'culosis  the  transition  from  warm  to  cold  or 
cold  to  warm  seasons  corresponds  with  increased  cough,  hence  with  in- 
creased pressure  in  the  pulmonary  circulation ;  and  so  bleeding  is  also 
favored,  particularly  in  those  having  a  hemorrhagic  tendency. 

{e)  Dysijnea  is  present,  but  is  not  a  marked  feature,  as  a  rule,  despite 
advanced  pulmonary  lesions.  Perhaps  the  chief  reasons  for  a  lessened 
demand  for  oxygen  on  the  part  of  the  system  are — first,  the  slow  and 
gradual  manner  in  wliich  the  lesions  develop  ;  and  second,  the  pro- 
nounced bodily  wasting.  The  respirations,  however,  are  moderately 
increased  in  rate,  averaging  from  20  to  30  per  minute,  and  this  compen- 
sates admirably  for  the  diminished  breathing-space.  The  dyspnea  may 
'  Berliner  kllnische  Woehenschrift,  Jan.  2,  1899. 


CIIJiONIC  TUBEUCULOSIS.  265 

be  greatly  intensified,  however,  as  the  result  of  intercurrent  pneumonia, 
pleurisy,  active  exertion,  or  great  mental  excitement,  and  toward  the 
close  of  fatal  cases   the  most  intense  dyspnea  mny  be  manif(;sted. 

Physical  Signs  in  the  Stage  of  Consolidation. — InHpection  gives  most 
important  results.  The  paralytic  or  phthisical  thorax  is  generally  pre- 
sented to  view.  It  is  flat,  particularly  the  upper  half;  the  intercostal 
spaces  are  wide;  the  ribs  slope  at  a  sharp  angle  from  the  sternum,  mak- 
ing the  epigastric  angle  acute  and  producing  elongation  of  the  chest. 
The  same  sharp  inclination  downward  from  the  vertebral  column  is 
observed  laterally  and  posteriorly.  The  angle  of  Louis  is  prominent, 
and  the  depressions  (supra-  and  infraclavicular,  intercostal)  are  deep- 
ened, the  costal  cartilages  being  often  prominent  and  the  sternum,  par- 
ticularly in  the  lower  part,  sometimes  much  depressed  or  even  concave 
(funnel-breast).  The  scapulae  stand  out  prominently  and  may  be  dis- 
tinctly winged.  A  second  type  of  paralytic  thorax  is  narrow  and  long. 
Pulmonary  tuberculosis  may,  however,  arise  in  chests  of  apparently 
normal  build.  The  paralytic  thorax  is  often  a  resultant  of  developed 
phthisis.  In  subjects  of  obesity  the  phthisical  thorax  may  be  concealed. 
The  deformity  due  to  occupation,  as  leaning  over  a  desk,  may  ape  the 
paralytic  chest,  and,  finally,  it  may  be  the  result  of  extreme  emaciation. 
With  the  development  of  phthisis  the  depressions  of  the  side  affected  are 
relatively  deeper,  while  the  clavicle  often  stands  out  prominently. 

Defective  expansion  is  ohserved  early,  and  usually  at  the  apex  of  the 
side  first  affected  ;  subsequently  this  may  be  more  general,  and  finally 
bilateral.  To  note  the  motions  of  respiration  with  precision  the  exam- 
iner should  occupy  a  position  exactly  in  front  of  the  median  line  of  the 
patient's  body.  The  difference  in  the  movement  of  the  two  sides  often 
becomes  more  apparent  on  deep  respiration  than  on  quiet  breathing,  and 
while  at  rest  the  respirations  are  almost  normal,  but  exertion  decidedly 
increases  their  frequency. 

Palpation. — Testing  the  expansion  by  palpation  gives  better  relative 
results  than  does  inspection.  To  determine  the  comparative  movements 
of  the  apices  the  extended  hands  should  be  so  placed  (by  allowing  them 
to  diverge  below)  that  the  tips  of  the  fingers  touch  the  lower  border  of 
the  clavicle,  and  then  the  patient  should  be  asked  to  breathe  deeply, 
though  slowdy.  The  expansion  in  the  supraclavicular  spaces  is  tested 
by  standing  behind  the  patient  and  using  the  tips  of  the  fingers,  or  by 
allowing  the  two  first  fingers  of  each  hand  to  pass  parallel  with  the 
clavicles.  In  this  way  "  lagging  "  over  the  apex  will  be  the  first  symp- 
tom recognized,  and  may  for  some  time  be  the  onh^  one.  Palpation  of 
the  vagus  nerve  on  the  affected  side  elicits  pain  (Mays). 

Ta.ctile  fremitus  is  early  increased  with  oncoming  consolidation, 
though  it  is  normally  more  marked  at  the  right  than  at  the  left  apex. 
If  there  be  thickening  of  the  pleura,  however,  it  is  diminished,  and  if 
there  be  pleural  effusion  it  may  be  absent. 

Mensuration. — The  difference  between  the  measurement  of  the  chest 
in  inspiration  and  expiration  in  any  person  of  average  health  should  be 
not  less  than  three  inches,  and  a  difference  below  two  and  a  half  inches 
points  strongly  to  tuberculosis.  The  data  thus  gained  are  more  impor- 
tant than  the  shape  of  the  thorax. 

Percussion. — Resonance   is   deadened    more    and    more    as    consoli- 


266  ISFECTIOUS  DISEASES. 

dation  progresses.  If  the  consolidated  areas  are  minute,  however,  the 
percussion-note  may  be  unchanged,  and  as  the  air-cells  surrounding  the 
latter  are  often  emphysematous  and  relaxed,  it  may  be  somewhat  tym- 
panitic. The  tympanitic  sound  and  deadness  may  be  intermingled, 
giving  rise  to  the  so-called  tympanitic  deadened  sound.  Slight  dulness 
is,  as  a  rule,  noted  hrst  below  the  clavicle,  though  in  not  a  few  cases  it  is 
first  detected  above  the  clavicle.  Impaired  resonance,  however,  may  be 
detected,  first,  in  the  su]iraspinous  fossa,  and  less  frequently  in  the  inter- 
scapular space  if  the  subject  is  not  too  stout,  though  slight  dulness  in  the 
absence  of  other  signs  has  little  diagnostic  value.  The  corresponding  regions 
of  the  two  sides  must  be  compared  during  a  held  inspiration  and  also  dur- 
ing a  held  expiration.  The  degree  of  dulness  can  sometimes  be  better  esti- 
mated by  comparing  the  apical  note  with  that  obtained  lower  down  on  the 
same  side,  allowing  for  the  normal  topographic  differences  of  intensity. 
The  latter  method  is  especially  applicable  to  cases  in  which  both  apices 
are  involved.  Light  and  single  percussion  blows  must  be  used.  As  the 
lung-tissue  becomes  airless  throughout  an  area  of  considerable  size  the 
note  is  deadened,  until  dulness  is  heard ;  finally,  with  extensive  consoli- 
dation, the  note  may  be  wooden  and  the  feeling  of  resistance  increased. 

Auscultation. — The  vesicular  breathing  may  be  sharpened,  owing  to 
narrowing  of  the  smaller  bronchi,  but  more  often  perhaps  it  is  dimin- 
ished by  the  swelling  and  secretion.  The  corresponding  regions  on  the 
two  sides  must  be  compared — first  during  quiet,  and  then  deep  breath- 
ing— and  it  should  be  remembered  that  prolonged  expiration  is  an  early 
and  important  diagnostic  sign,  at  first  being  somewhat  sharpened,  and 
later  distinctly  bronchial.  Tuberculous  bronchitis  may  cause  interrupted 
or  jerking  inspiration  at  the  apex  w^ith  or  without  crepitant  rales.  If 
heard  elsewhere,  it  has  small  value.  With  lobular  consolidation  at  dif- 
ferent points  in  the  region  aff'ected,  the  conditions  favor  the  transmission 
of  the  bronchial  sounds,  but  these  are  toned  down  by  the  remaining 
intact  air-cells;  hence  there  is  "  transition  "  or  bronchovesicular  breath- 
ing. With  complete  consolidation  pure  bronchial  breathing  is  audible, 
and  with  the  latter  two  forms  of  breathing  crepitant  or  subcrepitant  rt,les 
are  heard.  A  clicking  rale,  although  not  common,  is  an  almost  conclu- 
sive indication  when  observed.  Sometimes  the  first  rales  which  accom- 
pany expiration  have  a  low  whistling  sound ;  with  liquefaction  they 
become  more  moist,  are  louder  (somewhat  ringing),  and  often  bubbling, 
and  may  be  heard  on  inspiration  and  expiration.  If  scanty,  they  may 
be  audible  on  inspiration  only  ;  they  are  increased  by  coughing.  If  the 
moist  crepitant  and  subcrepitant  r^les,  often  due  to  concurrent  bronchitis, 
be  very  numerous,  the  breath-sounds  will  be  obscured,  but  after  free 
expectoration  their  quality  becomes  appreciable. 

Pleuritic  friction-sounds  maybe  heard,  due  to  accompanying  pleuritis 
sicca,  and  these  may  be  audible  before  the  bronchial  rales  reveal  the 
disease.  Friction-sounds  and  rales  often  occur  together.  Pleuroperi- 
cardial friction  is  present  when  the  "lappet"  of  lung  over  the  heart  is 
aff'ected,  while  clicking  rSles,  occasioned  by  the  heart's  systole,  are  audible 
when  the  same  area  is  pneumonic.  The  vocal  resonance  increases  with  the 
progress  of  the  consolidation,  and  when  the  latter  is  complete,  h'oncho- 
phony  (rarely  pectoriloquy)  is  present.  In  the  subclavian  arteries  a 
systolic  murmur  is  not  uncommonly  heard,  the  latter  being  supposed  to 
be  due  to  pressure  exerted  by  the  thickened  pleura  upon  these  vessels. 


CHRONIC  TUBERCULOSIS.  267 

Physical  Signs  of  Cavity. —  Inspection  shows  a  more  marked  retraction 
and  a  more  decided  lack  of  local  motion  than  duririf^  the  previouH  stage. 
The  degree  of  shrinking  is  proportional  with  the  extent  of  fibrous-tissue 
formation. 

Palpation  corroborates  inspection  as  to  lack  of  motion,  and  gives 
increased  tactile  fremitus  if  the  cavity  connects  with  an  open  bronchus 
and  if  it  contains  but  little  secretion.  Excessive  secretion  interferes 
with  conduction  of  sound. 

Percussion. — Resonance  is  generally  more  or  less  impaired  in  con- 
sequence of  the  consolidation  of  the  surrounding  lung-tissue.  The 
note  may  be  somewhat  tympanitic,  but  varies  with  the  position  of  the 
cavities,  the  amount  of  fluid  secretion  contained  by  them,  the  condition 
of  their  walls,  and  the  vibratory  capacity  both  of  the  latter  and  of  the 
individual  thorax.  Cavities  of  the  size  of  a  walnut  situated  in  the 
apices  usually  give  a  distinctly  tympanitic  note,  while  cavities  of  the 
same  dimensions,  or  even  larger,  in  the  lower  portion  of  the  lung  do 
not.  The  metallic  tone  is  especially  noticeable  over  large  cavities  with 
smooth  walls.  The  tympanitic  sound  may  be  deadened  by  closure  of 
the  connecting  bronchus  and  by  temporary  filling  of  the  cavities  with 
secretion,  and,  again,  if  they  are  surrounded  by  thickened  lung-tissue 
or  by  a  large  thickened  pleura,  there  may  be  impaired  resonance  or 
absolute  dulness  even.  Certain  special  conditio7is  change  the  tympan- 
itic sound  over  a  cavity.  Thus  the  note  will  be  louder  and  exalted  in 
pitch  when  the  mouth  is  opened  wide,  and  lowered  when  the  mouth  is 
closed  (Wintrich's  sign),  there  being  dulness  when  the  mouth  is  closed 
and  tympanitic  resonance  when  the  mouth  is  open.  If  the  cavity  com- 
municates freely  with  the  bronchus,  a  tympanitic  note  may  change  in 
pitch  with  change  in  posture  (Gerhardt's  change  of  sound).  If  the 
patient  changes  from  the  dorsal  to  the  upright  position,  resonance  may 
give  way  to  more  or  less  flatness  over  the  lower  portion  of  the  cavity, 
since  the  fluid  contents  of  the  latter  are  thus  brought  into  contact  with 
the  chest-wall ;  this,  although  an  almost  certain  sign  of  a  cavity  when 
present,  is  exceedingly  rare.  The  so-called  cracked-pot  sound  is  often 
elicited  over  large  parietal  cavities  with  thin  walls ;  but,  since  it  also 
occurs  in  many  other  pathologic  conditions,  its  diagnostic  significance  is 
subordinate.  There  may  even  be  normal  resonance  if  the  cavity  is 
covered  by  a  layer  of  unaffected  air-cells  of  considerable  thickness. 

Auscultation  over  small  vomicae  with  lax  walls  reveals  cavernous 
(low-pitched)  breathing,  while  over  large  cavities  with  tense  walls  (if 
parietal  and  communicating  with  a  tracheo- bronchial  column  of  air)  it 
gives  amphoric  (higher-pitched)  respiration.  Moist  rales  (bubbling  and 
gurgling,  according  to  the  consistency  of  the  secretion)  may  be  pres- 
ent, and  these  correspond  in  the  main  to  the  amphoric  breathing,  hence 
being  heard  most  frequently  over  large,  smooth-walled  and  periph- 
erally-located cavities.  The  gurgling  and  slushing  sounds  caused  by 
the  air  bubbling  through  the  secretion  in  a  cavity  are  always  intensified 
by  coughing. 

The  sounds  of  falling  drops  (metallic  tinkling)  may  be  heard  over 
large  vomicae  with  tense,  smooth  Avails  containing  thin  secretion.  Pec- 
toriloquy and  amjyhoric  ivhispers  are  the  vocal  sounds  heard  over  huge 
cavities.     Whispering  pectoriloquy  was  present  in  55  out  of  58  cases  at 


268 


INFECTIOUS  DISEASES. 


the  Pbipps  Institute,  but  other  p:ith()h>gic  conditions  may  cause  this  sign, 
'^ notably  consolidation  about  a  bronchus'"  (Landi^). 


Fig.  22.-1.  bmaU  cavity  near  periphery,  with  thick  relaxed  walls,  containing  secretion  and 
communu-ating  with  a  bronchus  (vide  subjoined  table).  2.  Large  parietal  cavity,  with  thin,  tense, 
smooth  walls,  communicating  with  a  bronchus  (vide  table). 


Physical  Signs. 

{a)  Percussion-deadness  on  a  strong  blow, 
mere  impairment  of  resonance  on 
a  light  blow  -,  Wintrich's  inter- 
rupted change  of  sound,  detectable 
only  when  patient  is  upright. 

(6)  On  auscultation  low-pitched  cavern- 
ous (hollow)  breathing ;  gurgling 
r§,le-. 

(c-)  Pectoriloquy  indistinct,  owing  to 
small  size  of  cavity  and  the  con- 
tained fluid. 


Physical  Signs. 

(o)  Amphoric  percussion-resonance, 
cracked-pot  sound,  and  Wintrich's 
change  of  sound. 


(6)  On  auscultation,  high-pitched 
phoric  (musical)  respiration 
metallic  rPiles. 

(c)  Amphoric   (musical)    voice   and 
phoric  whisper. 


am- 
and 


General  Symptoms. — (a)  Fever. — Whilst  the  disease  is  progressing  fever 
is  a  constant,  significant,  and,  it  may  be,  the  earliest,  symptom.  If  a 
two-hourly  record  be  kept  for  a  few  days,  from  time  to  time  an  accurate 
conception  of  the  course  and  type  of  the  fever  can  be  formed.  In  the 
first  and  middle  stages  the  highest  temperature  occurs  about  4  or  5  P.  M., 
the  lowest  about  4  or  5  a.m.  The  fever  may  be  continuous,  remitting, 
or  intermitting,  and  in  a  general  way  these  types,  in  the  order  named, 
correspond  to  the  stages  of  tuberculization,  softening,  and  cavity -forma- 
tion. Modified  types,  due  to  the  fact  that  the  lesions  may  simulta- 
neously represent  different  stages,  are  also  observed.  Apyre.xial  periods 
are  met  with  in  the  early  as  well  as  the  late  stages  of  chronic  phthisis, 
and  indicate  cessation  of  the  processes  of  tuberculization  and  caseation. 

A  continued  fever  is  most  apt  to  1)0  met  with  during  the  initial  period, 
the  evening  temperature  sometimes  registering  but  a  degree  higher  than 
the  morning.  A  similar  curve  may  be  presented  at  any  later  time  if 
acute  pneumonia  supervene,  though  it  is  to  be  recollected  that  the  remis- 
sions in  such  cases  are  usually  greater  than  in  primary  lobar  pneumonia. 

A  remittent  fever  is  more  common  than  the  preceding  type.  It  may 
be  present  from  the  start,  but  is  oftener  seen  in  the  middle  and  less  fre- 
quently in  the  advanced  stages.     It  points  to  softening  (see  Fig.  23). 


CHRONIC  TUBERCULOSIS. 


269 


An  intermittent  fever  is   also  frequent,  and   is   invariably  associated 
with  cavity  formation.      The  temperature  may  be  intermittent  from  the 


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Fig.  23.— Temperature-chart  of  a  case  of  phthisis.    Quiescent  cavity  in  right  apex,  and  com- 
mencing excavation  in  left  apex.    Robert  G ,  aged  21  years ;  dyer. 

start,  suggesting  malaria  to  the  unguarded ;  but  it  is  due  to  sepsis,  the 
temperature    rising    during    the   day,  beginning    usually  shortly  before 


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Fio.  24. — Temperature-chart  of  a  case  of  phthisis.    Cavity  in  left  apex,  giving  cracked-pot  sound, 
Wintrich's  sign,  etc.    George  C ,  aged  22  years  ;  glass-worker. 

noon,  and  reaching;  its  maximum  at  from  5  to  8  P.  M.   It  now  falls  slowly 
until  about  4  or  5  a.  m.,  and  then  rapidly  reaches  the  minimum — a  sub- 


270  INFECTIOUS  DISEASES. 

normal  point — usually  at  from  6  to  10  A.  M.  For  a  considerable  portion 
of  every  twenty-four  hours  the  temperature  may  be  below  the  normal 
(see  Fig.  24),  sometimes  dropping  as  low  as  *d5°  F.  (35°  C). 

(h)  Night-sweats  occur  in  a  large  majority  of  cases.  They  may 
appear  during  any  part  of  the  course  of  phthisis,  though  most  apt  to 
occur  and  be  most  marked  during  the  process  of  cavity-formation  ;  they 
show  themselves  in  the  early  morning  hours  simultaneously  with  the  rapid 
decline  in  the  temperature,  and  may  appear  during  sleep  at  any  period 
of  the  day.  They  may  be  light  and  limited  to  the  neck  and  upper  por- 
tion of  the  thorax  ;  on  the  other  hand,  they  are  often  excessive,  saturat- 
ing the  bed-clothes  and  inducing  great  exhaustion.  The  drenching  sweats 
are  dependent  partly  upon  the  fever  and  partly  upon  the  existing  weak- 
ness, though  slight  exertion  may  also  engender  free  perspiration. 

(e)  Emaciation  occupies  a  prominent  place  in  the  symptomatology,  the 
muscular  and  fatty  tissues  being  involved  to  an  equal  degree  (Striimpell); 
the  extremities  and  soft  parts  of  the  thorax  are  most  affected.  An  ex- 
alted grade  of  emaciation,  however,  may  be  a  precursory  state.  In  nearly 
all  cases  an  extreme  degree  of  emaciation  is  reached  before  the  end.  The 
causes  of  emaciation  are  chiefly  the  persistent  fever,  the  loss  of  appetite, 
and  the  feeble  digestive  and  assimilative  powers.  It  is  an  almost  invari- 
able rule  that  during  the  afebrile  periods,  associated  as  they  are  with 
improved  appetite  and  digestion,  the  patient  gains  in  flesh  and  strength. 
Unilateral  atrophy  of  the  muscles  of  the  chest  may  be  observed. 

((/)  The  pulse  is  increased  in  frequency,  is  of  good  volume  and  regular 
in  rhythm,  though  of  low  tension  (soft).  When  suppurative  fever  sets  in 
it  becomes  frecjuent  and  compressible,  and  the  capillary  pulse  is  often 
observed ;  rarely  venous  pulsation  is  seen  in  the  hands. 

(c)  Anemia  is  one  of  the  symptoms  evidencing  impaired  nutrition. 
It  is  often  associated  with  an  afternoon  rise  of  temperature,  impaired 
digestion,  and  loss  of  flesh  and  strength  (chloro-anemia).  The  objective 
changes  pointing  to  anemia  are  pronounced  (pallor  of  visible  mucous 
membranes,  and  skin).  The  Mood  presents  nothing  characteristic.  In 
the  early  stage  it  may  be  chlorotic  in  type,  the  hemoglobin  being  decidedly 
deficient;  but  when  there  are  cavity  formation  and  hectic  fever,  consider- 
able leukocytosis,  as  many  as  50,000  leukocytes  per  cubic  millimeter, 
may  be  observed.  The  differential  count  shows  a  great  excess  of  the 
polymorphonuclear  cells.  Early  lymphocytosis,  however,  may  be  of  con- 
siderable diagnostic  value.  The  condition  is  due  to  secondary  infection 
by  the  pus-forming  organisms.  Absence  of  eosinopliile  cells  would  appear 
to  be  an  unfavorable  prognostic  sign,  while  an  increase  indicates  a  tend- 
ency to  arrest  the  progress  of  the  disease  (Swan).  Tubercle  bacilli  can- 
not, as  a  rule,  be  found  in  the  circulating  blood  (Ravenal  and  Smitli). 
On  the  other  hand,  Kurashige  found  them  in  every  one  of  155  tubercu- 
lous patients  in  various  stages. 

General  dehilif;/  is  complained  of  in  all  cases,  and  is  progressive. 

Symptoms  and  Complications  Presented  by  Other  Organs. — [a]  The  Heart. 
— With  retraction  of  the  upper  lobe  of  the  left  lung  the  area  of  the  heart's 
impulse  is  obviously  increased,  particularly  upward,  so  that  pulsation 
may  be  visible  in  the  fourth,  third,  and  even  second  interspaces,  near  the 
sternum,  while  the  normal  apex-beat  may  be  wanting.  The  physical 
signs  noted  may  be  rarely  those  of  displacement  of  the  heart  to  the 
right,  while  the  necropsy  may  show  the  heart  to  be  in  its  normal  posi- 


CHRONIC  TUBERCULOSIS.  271 

tion.  Functional  murmurs  })otli  at  the  apex  and  at  the  pulmonary  orifices 
are  often  audible.  In  about  7  per  cent,  of"  tiie  cases  with  murmurs,  mitral 
regurgitation,  dependent  on  weakness  of  tlie  heart  muscles,  was  diagnos- 
ticated/ Disease  of  the  tricuspid  segments  is  not  infrequent  in  phthisis, 
and  pulmonary  stenosis  predisposes  tf)  the  latter  disease.  Conversely,  there 
is  perfect  agreement  among  writers  that  left-sided  valvular  heart  disease  has 
a  retarding  influence  upon  the  progress  of  chronic  phthisis.  In  cases  in 
which  the  valve  lesions  and  the  compensatory  hypertrophy  are  propor- 
tional, a  prognosis  for  an  unusual  length  of  days  can  be  ventured,  but 
"when  this  harmonious  balance  is  disturbed  an  early  fatal  termination 
may  be  expected,  principally  from  the  cardiac  complaints."^  In  com- 
bined cases  dyspnea  is  more  pronounced  and  hemoptysis  a  more  common 
initial  symptom  than  in  non-cardiac  forms. 

{h)  Gastro-intestinal  Tract. — The  tongue  may  be  furred ;  more  often 
it  and  the  mouth  and  throat  are  red,  showing  increased  irritability.  The 
pharynx  may  be  the  seat  of  tuberculous  lesions,  which  may  interfere 
with  deglutition.  Aphthous  ulcers  and  thrush  may  also  arise.  The  ap- 
petite is  impaired  or  lost ;  thirst  is  annoying  and  the  symptoms  of  chronic 
gastritis  often  obtain.  A  catarrhal  ulceration  and  dilatation  may  be  asso- 
ciated conditions.  Vomiting  may  be  troublesome  during  the  later  stages. 
A  study  of  the  gastric  secretion  gives  variable  results,  there  being  an  early 
hyperacidity,  while  later  the  secretion  is  subacid.  Croner  found  normal 
motility  present  in  the  early  stages.  The  causes  of  gastric  symptoms  are 
not  clear.  The  mucosa  is  the  seat  of  venous  engorgement,  and  thus  occa- 
sions the  catarrhal  changes  that  are  present  in  many  instances.  Anatomic 
changes  may  be  absent. 

The  intestinal  symptoms  are  important.  During  the  early  stage  con- 
stipation is  a  frequent  condition.  Diarrhea  is  prone  to  appear  at  an  ad- 
vanced period,  and  may  pursue  an  intermittent  course.  Occasionally  it 
alternates  with  periods  of  "hectic  fever,"  and  late  in  the  affection  a 
watery  discharge  may  develop  {colliquative  diarrhea).  The  intestinal 
lesions  are  of  three  sorts :  (a)  catarrhal,  (b)  ulcerative,  and  (c)  amyloid. 
These  often  arise  in  the  order  enumerated,  but  may  be  combined  in  vari- 
ous ways.  Hemorrhoids  and  anal  fistulse  are  among  the  complications, 
(c)  Genito-urinary  Organs. — There  is  frequently  an  albuminuria  that 
may  either  be  febrile  or  due  to  chronic  nephritis  {productive  and  non- 
produGtive).  Chroyiic  nephritis  is  usually  a  late  development;  it  gives 
rise  to  albuminuria,  tube-casts  in  the  urine,  and  dropsy.  The  total  nitro- 
gen excretion  is  lower  than  the  normal.  Amyloid  changes  may  set  in 
toward  the  close  with  their  characteristic  symptoms.  Tuberculous  25?/e?i7/.s 
and  cystitis,  with  the  appearance  of  pus  and  blood  in  the  urine,  may  de- 
velop. Hematuria  may  also  result  from  temporary  congestion.  The  testes 
should  be  routinely  inspected  (Osier). 

{d)  Cutaneous  System. — Cyanosis  occurs,  but,  being  of  a  moderate 
degree,  it  is  often  veiled  by  a  decided  pallor.  The  cheeks  often  wear  a 
"■hectic  flush,"  and  the  skin,  late  in  the  affection,  is  apt  to  be  dry,  harsh, 
and  scaly.  Among  the  cutaneous  appearances  are  pigmentary  stains 
over  the  chest  (chloasmata  phthisicora)  and  brown  stains  (pityriasis  ver- 
sicolor).    Rarely,  simple  purpura  and  purpura  hemorrhagica  develop  as 

^  "A  Study  of  Murmui-s  in  Pulmonary  Tuberculosis,"  American  Journal  of  the  Medical 
Sciencen,  June,  1910,  by  C.  M.  Montgomery. 

^Anier.  Jour.  Med.  Sci.,  Jan.,  1902,  by  the  writer. 


272  INFECTIOUS  Dlii EASES. 

late  complications.  Tlie  /uiir  over  the  chest  often  hecomes  gray  ;  that  of 
the  head  and  beard,  long  and  harsh.  The  Jiii<./t'r-ends  are  often  bulbous 
(clubbed),  with  incurved  nails,  though  this  is  not  peculiar  to  chronic 
phthisis,  and  cracking  of  the  tinger-nails  is  also  often  observed. 

(f)  Nervous  System. — The  mental  attitude  is  characteristically  hopeful 
and  buoyant,  even  in  the  advanced  stages.  Hence  the  patients  are  read- 
ily encouraged  by  the  unscrupulous  to  believe  that  their  condition  is  im- 
proving: they  may  be  in  an  utterly  helpless  state,  and  yet  confidently 
e.xpect  to  recover.  The  cerebral  tfi/inptonts  are  rarely  marked,  and  the 
mind,  as  a  rule,  is  exceptionally  clear.  Tuberculous  meningitis  and  me- 
ningo-encephalitis  may  develop  near  the  close.  Focal  lesions,  due  to  the 
presence  of  tubercles,  may  produce  forms  of  paralysis  (aphasia,  hemi- 
plegia) according  to  their  location.  Rarely  peripheral  neuritis  (usually 
an  extensor  paralysis  of  the  leg)  and  insanity  are  observed.  There  may 
be  early  unilateral  dilatation  of  the  pupil,  due  to  enlargement  of  the 
bronchial  lympli-nodes  on  the  corresponding  side. 

(/)  Chest-muscles  and  Mammary  G-lands. — The  former  are  abnormally 
irritable,  and  sometimes  even  painful  on  percussion,  and  the  mammary 
gland  is  in  rare  instances  hypertrophied,  m;iles  suftering  most ;  but,  as 
pointed  out  by  Allot,  the  affection  is  a  chronic  non-tuberculous  mammitis. 

Diagnosis. — The  early  recognition  of  chronic  pulmonary  tuberculo- 
sis often  tests  severely  the  diagnostic  acumen  of  the  physician.  The 
general  and  local  symptoms,  including  the  physical  signs,  may  afford 
merely  a  strong  suspicion  of  the  existence  of  phthisis,  and  in  such  in- 
stances repeated  examinations  of  the  sputum  for  the  bacilli  are  impera- 
tive, and  only  when  they  are  found  is  the  diagnosis  set  at  rest.  Repeated 
staining  of  the  sputum  may  be  necessary  for  the  detection  of  tubercle 
bacilli.  It  is  also  desirable  to  determine  whether  they  are  constantly 
present  by  re-examinations  at  intervals.  There  are  cases  in  which  the 
physical  signs  are  obvious,  yet  the  bacilli  are  either  not  detectable  or  only 
so  after  several  examinations.  An  absence  of  the  bacilli,  however,  does 
not  justify  a  denial  of  the  existence  of  pjithisis.  and  is  of  little  negative 
value.  Philip  and  Porter  conclude  that  tubercle  bacilli  are  almost  con- 
stantly present  in  the  stools,  whether  the  patient  be  expectorating  bacilli 
or  not.  The  symptoms  of  greatest  diagnostic  value  are  cough,  expecto- 
ration, fever,  progressive  emaciation,  and  the  constant  presence  of  certain 
physical  signs  in  the  subapical  region  on  one  side  (flattening  of  the  chest, 
defective  expansion,  slight  deadening  of  the  percussion-note,  enfeeble- 
ment  of  the  vesicular  murnmr,  prolonged  expiration,  with  or  without  ad- 
ventitious sounds).  Skiagrajihs  that  show  the  presence  of  tuberculous 
deposits  and  pleuritic  exudates  may,  at  times,  give  the  earliest  positive 
information  in  regard  to  these  conditions.^  Again,  more  reliable  knowl- 
edge can  be  gained  in  the  initial  stage,  if  the  lesions  be  deep  seated,  by 
the  fluoroscope  tliau  by  practising  the  physical  signs.  Thus  enlarged 
bronchial  glands  and  peribronchial  iniiltration  are  detectable. 

The  tiibercuUn-te-st  is  Avarmly  commended  by  Ti-udeau,  Otis,  Klebs, 
and  others.  It  is  ftiirly  accurate,  and  out  of  a  total  of  1470  injections 
in  dubious  cases,  71.9  per  cent,  reacted  positively.^     Its  use  should  be 

I  For  illustrative  cases  see  "  Diagnosis  and  Treatment  of  Prehacillary  Stage  of  PuL 
raonarv  Tuberculosis,"  The  Journal  of  the  Amer.  Med.  ^s.sor.,  .Jan.  12,  1901,  by  the  writer. 

^  "The  Value  of  the  Tuberculin-test  in  the  Diagnosis  of  Pulmonary  Tuberculosis," 
by  tlie  writer,  New  York  Medical  Journal,  June  23,  1900. 


CimONIO  TUBERCULOSIS.  273 

limited  to  patients  who  have  symptoms  and  signs  of  this  disease,  since 
latent  tuberculosis  gives  the  reaction,  after  other  methods  of  diagnosis 
have  failed  us,  and  medium-sized  initial  doses  are  to  be  employed.  A 
positive  reaction  demands  an  elevation  of  temperature  to  101°  F.,  and 
this  rise  usually  occurs  within  twenty-four  hours,  but  it  may  be  delayed 
until  thirty-six  or  even  forty-eight  hours.  The  possibility  of  reaction 
occurring  in  cases  of  syphilis,  leprosy,  chlorosis,  hysteria,  actinomycosis, 
and  other  affections  will  not  lead  to  error  if  it  is  noted  that  such  reac- 
tions are  less  intense.  Calmette's  ophthalmic  reaction,  which  consists  in 
dropping  1  to  2  mimims  of  a  0.5  to  1  per  cent,  solution  of  tuber- 
culin into  the  eye,  produces  hyperemia  of  the  conjunctiva  (at  times 
actual  conjunctivitis)  in  from  three  or  four  to  twenty -four  hours  without 
constitutional  disturbance.  The  symptoms  subside  in  from  twenty-four 
to  forty-eight  hours.  Von  Pirquet  applies  the  tuberculin  with  gentle 
friction  to  the  slightly  abraded  skin.  If  the  patient  be  tuberculous,  a 
reaction  occurs  in  from  6  to  48  hours ;  this  is  especially  valuable  in  the 
diagnosis  of  tuberculosis  among  children.  In  adults,  however,  other  signs 
of  tuberculosis  must  be  present  to  render  it  of  any  diagnostic  worth.  The 
opsonin  test  is  useful  in  the  diagnosis  of  early  tuberculosis,  the  index  to 
the  tubercle  bacillus  being  very  low  or  very  high,  the  former  suggesting 
predisposition,  the  latter  shoAving  infection  against  which  the  resisting 
powers  are  raised  in  defense  (J.  C.  DaCosta).  Airlong  and  Courmont  ^ 
describe  a  method  of  serum  diagnosis,  but  from  the  reported  trials  of 
other  observers  its  results  are  too  irregular  to  be  of  value.  A  slight  rise 
of  the  evening  temperature  (99.6°  F. — 37.5°  C.  or  over)  is,  if  associated 
with  any  disturbance  of  health,  an  almost  infallible  diagnostic  symptom. 
In  the  more  advanced  stages  of  phthisis  the  diagnosis  is  rarely  difficult. 

In  the  very  early  stage  the  local  condition  may  be  obscured  by  the 
symptoms  of  impaired  digestion,  loss  of  flesh  and  strength,  fever,  and 
pronounced  anemia  (chloro-anemia,  vide  p.  270 ;   also  Modes  of  Onset). 

Differential  Diagnosis. — Bronchial  catarrh  is  with  great  difficulty  dis- 
criminated from  beginning  phthisis.  If  the  temperature  is  elevated 
from  2  to  5  P.  M.,  and  not  at  all  or  only  slightly  above  the  normal  night 
temperature  in  the  evening,  the  probabilities  are  greatly  in  favor  of 
tuberculosis  (Barlow).  In  bronchial  catarrh  there  is  no  dulness,  and 
moist  rales,  that  vary  in  intensity  from  one  day  to  another,  are  heard 
equally  on  both  sides.  From  time  to  time  rales  may  also  be  heard  at 
the  bases  in  bronchitis.  In  phthisis  one  apex  is  more  involved  than  the 
other,  the  moist  sounds  not  being  heard  equally  low,  and  after  repeated 
coughs  with  subsequent  deep  inspiration  the  rales  are  more  apt  to  remain 
than  in  ordinary  bronchitis.  In  phthisis,  also,  there  is  a  gradual  loss 
of  flesh  and  strengh,  and  repeated  microscopic  examination  of  the 
sputum  will  demonstrate  the  presence  of  the  bacillus.  A  negative  re- 
action, obtained  repeatedly,  from  the  Falk  and  Tedesko  test,^  is  evidence 
that  the  disease  process  is  limited  to  the  bronchi,  while  a  positive  reaction 
indicates  pulmonary  involvement  (tuberculosis).  According  to  Armstrong 
and  Groodman^,  however,  this  test  is  unreliable.  If  hemoptysis  be  the 
first  symptom  observed,  then  all  other  causes  for  the  spitting  of  blood 

^Deutsche  med.  Woch.,  Nov.  29,  1900. 

2  Wiener  Minische  Woch.,  Vienna,  July  8,  1909. 

^Jour.  Amer.  Med.  Assoc,  ]May  27,  1911,  p.  1553. 

18 


274  lyFECTIOUS  DISEASES. 

should  be  patiently  excluded,  unless  the  associated  evidences  of  com- 
mencing phthisis  are  conclusive.  Phthisis  in  the  stage  of  cavity  may  be 
confounded  with  bronrJuecfasis  (vidf  Diseases  of  the  Lungs). 

Pseudo-tuberculosis.— By  this  term  is  meant  a  distinct  form  of 
pulmonary  infection  caused  by  the  strcptothrix  Eppingeri  or  a  closely 
related  species,  and  clinically  resembling  pulmonary  tuberculosis.  Warthin 
and  Olney  ^  report  5  cases,  and  point  out  that  the  frequency  of  occurrence, 
tlie  symptomatology,  and  the  thera])cutics  of  this  form  of  streptothricosis 
remain  to  be  worked  out.  The  clinical  picture  presented  is  that  of 
tuberculosis  or  bronchopneumonia.  The  diagnosis,  however,  demands 
isolation  of  an  acid-resisting  streptothrix.  The  tubercle  bacillus  is 
absent,  but  streptococci  and  staphylococci  are  found  in  association,  and 
some  of  the  cases  may  be  of  primary  streptococcus  infection. 

Fibroid  Phthisis. 

Definition. — Fibroid  phthisis  implies  induration  followed  by  con- 
traction of  the  affected  lung-tissue,  due  to  an  increase  in  the  connective- 
tissue  elements.  There  are  cases  in  which  it  cannot  be  distinguished 
pathologically  from  chronic  pulmonary  phthisis,  but  they  differ  clmically. 
The  majority  of  instances  are  primarily  tuberculous,  though  manifesting 
a  strong  tendency  to  the  formation  of  fibrous  tissue — a  conservative 
process ;  in  other  instances  the  fibroid  change  may  be  primary,  followed 
by  tuberculous  infection  (vide  Pneumonokoniosis).  The  usual  form  arises 
variously  as  a  sequel  of  other  morbid  processes,  such  as — 

(1)  Pneumonias,  lobar  (rarely)  and  catarrhal  (commonly). 

(2)  Pulmonary  lesions — tubei'cle  in  the  stage  of  consolidation  or  cavity. 

(3)  Chronic  tuberculous  pleurisy. 

(4)  Bronchial  catarrh  from  inhalation  of  irritants  (steel-,  coal-,  or 
mineral-dust). 

Pathologfy. — The  process  in  the  beginning  is  very  often  localized  in 
one  apex,  and  less  frequently  in  the  middle  portion  of  the  lung  or  in  the 
bases.  It  may  remain  circumscribed,  but  more  often  it  extends  down- 
ward, and  gradually  invades  the  entire  lung.  It  is  unilateral.  Second- 
ary to  the  induration  and  contraction  there  is  dilatation  of  the  bronchi. 

The  lung-tissue  is  hard  and  dense,  the  alveoli  being  obliterated.  It 
resists  cutting  and  creaks,  and  the  section  presents  a  smooth,  dry,  gray, 
often  marbled  aspect,  though  the  fibrous  tissue  may  undergo  caseation. 

The  pleura  is  thickened,  as  a  rule,  often  to  a  marked  degree,  and  its 
layers  are  adherent ;  the  unaffected  portions  of  the  lungs  frequently  be- 
come emphysematous.      The  right  ventricle  is,  as  a  rule,  hypertrophied. 

Symptoms. — These  may  be  briefly  stated,  since  they  do  not  differ 
from  those  of  cirrhosis  of  the  lung  (vide  Diseases  of  the  Lungs).  The 
onset  is  insidious  :  a  persistent  cough,  occurring  in  severe  paroxysms  in 
the  mornings,  and  a,  purule7it  expectoration  are  for  long  the  leading  fea- 
tures. If  bronchiectasis  is  present,  the  sputum  may  be  fetid.  Dyspnea 
is  marked,  particularly  on  exertion.  Fever  is  slight  or  absent,  hence 
emaciation  progresses  slowly  or  may  even  be  absent.  The  physical  signs 
are  identical  with  those  of  fibroid  induration  of  the  lung  {vide  infra). 

The  course  of  this  disease  is  long,  ranging  from  ten  to  twenty  or  even 
thirty  years,  and  both  lungs  may  become  involved.     Again,  as  in  chronic 

1  "  Pulmonary  Streptothricosis,"  Amer.  Jour.  Med.  Sci.,  vol.  cxxviii.,  No.  4,  pp.  637-649. 


FIBROTI)  PHTHISIS.  275 

pulmonary  tuberculosis,  prolonged  suppuration  may  lead  to  amyloid 
changes  in  the  liver,  spleen,  kidneys,  and  intestines.  JJrojjHy^  (hie  to 
secondary  dilatation  of  the  right  ventricle,  often  closes  the  scene. 

Differential  Diagnosis. — Chronic  bronchitis  may  be  mistaken  for  fibroid 
phthisis.  In  the  latter  disease,  however,  there  are  unilateral  retraction 
and  the  signs  of  consolidation  or  of  an  apical  cavity,  and  the  sputum-test 
may  settle  the  doubt. 

Complications  of  Pulmonary  Tuberculosis. — Lobar  jmeurno- 
nia,  and  less  commonly  lobular  pneumonia^  may  develop  and  cause  a  fatal  ter- 
mination. In  a  study  of  100  cases  H.  M.  King  found  the  principal  compli- 
cations of  a  non-tuberculous  character  were  lobar  pneumonia  and  nephritis. 

Erysipelas  may  arise  in  the  course  of  chronic  pulmonary  tuberculosis, 
though  the  proportion  of  cases  is  not  formidable.  Out  of  1165  cases  of 
erysipelas,  15  coexisted  with  pulmonary  phthisis.^  Some  contend  that  its 
occurrence  in  this  disease  may  be  beneficial,  but  my  own  observations 
show  that  the  gravity  of  both  conditions  is  increased. 

Typhoid  fever  may  rarely  be  met  with  in  sufterers  from  chronic 
phthisis.  Out  of  a  totality  of  249  autopsies  in  cases  of  typhoid  fever, 
only  19  (7.6  per  cent.)  showed  the  presence  of  tuberculous  lesions.^  This 
contradicts  the  opinion  that  typhoid  fever  predisposes  to  tuberculosis. 

Chronic  nephritis  and  pulmonary  tuberculosis  are  often  found  in  the 
same  subject,  and  with  these  arterio-sclerosis  is  quite  commonly  combined. 
Intercurrent  acute  hemorrhagic  nephritis  may  develop. 

Chronic  endocarditis,  particularly  of  the  tricuspid  segments,  may  also 
occur  iu  phthisis,  and  from  time  to  time  cases  of  valvular  heart-disease 
are  reported,  in  which  it  is  evident  that  passive  congestion  must  have  ex- 
isted for  some  time  before  the  tuberculous  condition  developed.  The  old 
doctrine  of  the  mutual  antagonism  between  disease  of  the  left  heart  and 
pulmonary  tuberculosis  finds  support  from  these  cases,  as  in  a  large  pro- 
portion a  tendency  to  encapsulation  of  the  tuberculous  lesions  exists. 

Course  and  Duration. — Both  as  to  course  and  duration  this  dis- 
ease exhibits  unusual  variations.  If  not  promptly  treated  during  the 
incipient  stage  it  frequently  progresses  with  more  or  less  rapidity  toward 
the  grave.  It  is  common,  however,  to  observe  periods  during  which  the 
disease  is  arrested  or  improved.  Generally,  the  improvement,  though 
followed  by  an  exacerbation,  endures  for  a  long  time,  and  permanent 
cures,  even  in  the  advanced  stage,  are  by  no  means  rare.  The  duration 
of  pulmonary  tuberculosis  varies  exceedingly,  though  from  the  collective 
investigations  of  different  authors  and  from  all  the  statistics  available  I 
find  the  average  duration  to  be  about  three  years.  The  late  Austin  Flint 
long  ago  directed  attention  to  the  innate  tendency  of  a  considerable  per- 
centage of  the  cases  to  spontaneous  recovery — a  fact  that  simply  indicates 
a  victory  for  nature's  silent  defensive  processes  in  the  struggle  for  su- 
premacy. 

In  fatal  cases  death  is  by  (a)  gradual  asthenia  (most  frequently),  with 
retention  of  consciousness  until  the  end  approaches. 

(h)  Complicating  conditions  (bronchitis ;  pneumonia ;  pleurisy  ;  pneu- 
mothorax ;  amyloid  degeneration  of  the  intestines,  liver,  spleen,  kidney ; 
Bright's  disease ;  diabetes,  etc.). 

^  "  Points  in  the  Etiology  and  Clinical  History  of  Erysipelas,"  Journal  of  the  Americaj) 
Medical  Association,  July  2,  1893. 

*  Amer.  Jour,  of  the  Med.  Sci.,  May,  1904,  by  the  writer. 


276  INFECTIOUS  DISEASES. 

{e)  Tuberculosis  of  other  organs,  particularly  the  meninges,  intestines, 
and  genito-uriuary  tract. 

(d)  Hemorrhaye,  due  commonly  to  rupture  of  an  aneurysm  in  the  lung- 
cavity  ;  less  frequently  to  erosion  of  a  large  vessel.  Fatal  hemorrhage 
may,  when  the  vomica  is  of  large  size,  occur  without  hemoptysis,  as  in  a 
case  of  Roland  G.  Curtin's  at  the  Philadelphia  Hospital. 

{e)  Syncope. — Though  of  comparatively  rare  occurrence,  there  are  a 
number  of  events  that  may  lead  to  sudden,  fatal  syncope — e.  g.  hemor- 
rhagic embolism  or  thrombosis  of  the  pulmonary  artery,  pneumothorax, 
thoracentesis  for  pleural  effusion,  walking  about  in  a  moribund  state,  etc. 

(/)  Asphyxia  often  closes  the  scene  in  acute  pneumonic  phthisis,  and 
rarely  in  chronic  phthisis  complicated  with  pneumo-thorax,  or  with  a 
large  undiscovered  or  neglected  empyema,  or  with  sero-fibrinous  pleurisy. 

Tuberculosis  of  the  Alimentary  Tract. 

(1)  Lips. — Whilst  tuberculosis  of  the  lip  is  quite  rare,  the  possibility 
of  its  occurrence  must  not  be  forgotten.  It  assumes  the  form  of  a  small 
ulcer,  and  the  diagnosis  is  made  by  an  examination  of  the  labial  mucus. 
It  is  usually  associated  with  laryngeal  or  pulmonary  tuberculosis.  In 
diagiwstieating  the  condition,  chancre  and  epithelioma  must  be  excluded, 
the  former  by  the  history,  and  the  latter  chiefly  by  a  microscopic  ex- 
amination for  tubercle  bacilli. 

(2)  Tongue,  Palate,  and  Tonsil. — The  work  of  Orth,  Hanan,  Schlen- 
ker,  Kruckman,  and  others  has  shown  that  the  tonsils,  owing  to  their 
frequent  inflammation,  serve  as  the  door  of  entrance  of  the  tubercle 
bacilli.  The  fact  that  tuberculosis  of  the  tonsils  has  repeatedly  been 
found,  and  when  other  lesions  of  the  disease  were  absent,  points  to  the 
not  infrequent  occurrence  of  primary  tuberculosis  in  this  site.  The 
infiltrated  areas  often  present  small  grayish  spots,  but  the  appear- 
ance of  the  ulcers  is  not  characteristic,  frequently  bearing  a  strong 
resemblance  to  epithelioma  and  to  the  syphilitic  ulcer.  The  diagnosis 
demands  either  inoculative  experiments  or  a  microscopic  examination  of 
the  oral  mucus,  the  latter  bemg  oft  repeated  if  necessary.  E.  D.  Smith 
records  5  rare  cases  of  tuberculous  ulceration  of  the  soft  palate. 

(3)  Pharynx  and  Esophagus. — Both  miliary  tubercles  and  ulcerative 
lesions  may  rarely  arise  on  the  posterior  wall  of  the  pharynx  by  direct 
extension  from  laryngo-pulmonary  tuberculosis  or  as  the  result  of  second- 
ary inoculation.  The  chief  symptoms  occasioned  are  the  excessive  secre- 
tion of  pharyngeal  mucus  and  muco-pus,  and  painful  deglutition.  Tuber- 
culosis of  the  esophagus  is  extremely  rare. 

(4)  The  Stomach. — Tuberculous  lesions  of  the  stomach  are  of  excep- 
tional occurrence.  Marked  gastric  symptoms,  however,  are  common,  and 
they  may  be  due  to  involvement  of  the  larynx.  I  have  been  able  to 
find  reports  of  4  cases  of  tuberculous  gastric  ulcer  in  addition  to  the  12 
collected  by  Marfan.^  The  ulcers  may  be  single  (as  in  Musser's  case) 
or  multiple  (as  in  Osier's  case).  The  symptoms  are  not  characteristic, 
but  hematemesis  occurring  in  patients  suffering  from  tuberculosis  of  other 
organs  should  excite  a  strong  suspicion  of  the  existence  of  ulcer.  Pain 
coming  on  soon  after  meal-time  is  more  marked  in  tuberculous  ulcer  than 

»  Paris  Thesis,  1887. 


TUBERCULOSIS  OF  THE  ALIMENTARY  TRACT.  211 

in  ordinary  gastric  lesions.  Perforation  may  take  place.  Four  cases 
are  recorded  in  which  the  pylorus  was  found  encircled  with  a  flat,  gran- 
ular ulceration,  operated  on  under  the  diagnosis  of  carcinoma  (Alexan- 
der^). The  process  was  isolated  and  tiie  symptoms  all  pointed  to  pyloric 
cancer. 

(5)  Intestines. — The  lesions  may  be  (a)  primary  or  [h)  secondary. 

(a)  Primary  tubercle  of  the  intestines  is  chiefly  met  with  in  children, 
for  the  reason  that  they  are  more  likely  to  swallow  the  tubercle  bacilli  with 
their  food,  and  especially  in  milk.  The  intestinal  route  of  infection  is, 
according  to  my  own  observation,  more  common  in  adults  also  than  is 
supposed.  Many  cases  during  life  present  the  features  of  both  intesti- 
nal and  peritoneal  tuberculosis,  and  it  is  often  impossible  to  determine 
which  of  these  was  the  primary  condition ;  and  the  same  difficulty 
arises  when  the  cases  come  to  autopsy.  I  have  never  seen  an  instance 
(post-mortem)  of  intestinal  tuberculosis  in  which  the  peritoneum  and 
mesenteric  glands  were  not  involved  to  an  equal  degree. 

(h)  The  secondary  variety  occurs  in  more  than  one-half  of  the  cases 
of  pulmonary  tuberculosis,  the  chief  seats  of  the  lesions  being  the  lower 
part  of  the  ileum,  the  cecum,  and  the  upper  part  of  the  colon.  The  rectum 
is  also  the  seat  of  secondary  tuberculosis  in  a  small  proportion  of  the  cases 
of  chronic  phthisis   and  it  may  be  rarely  a  primary  seat  of  the  aff'ection. 

The  morbid  process  begins  in  the  solitary  glands  in  Peyer's  patches, 
where  at  first  grayish,  firm  tubercles  grow  and  form  little  prominences. 
These  caseate,  becoming  yellow  in  appearance,  and  then  soften  and  disin- 
tegrate, producing  ulcers.  Osier  thus  describes  the  characteristics  of  the 
tuberculous  ulcer:  "(a)  It  is  irregular,  rarely  ovoid  or  in  the  long  axis, 
more  frequently  girdling  the  bowel ;  (5)  the  edges  and  base  are  infil- 
trated, often  caseous ;  (f)  the  submucosa  and  muscularis  are  usually  in- 
volved ;  and  {d)  on  the  serosa  may  be  seen  colonies  of  young  tubercles 
or  a  well-marked  tuberculous  lymphangitis."  In  ^Macule  cases  the  sur- 
face-lesions show  little  tendency  to  repair  (Senn). 

In  chronic  cases  attempts  at  healing  are  the  rule  ;  and  the  cicatrices 
are  extensive  and  often  pigmented,  and  as  they  undergo  contraction  may 
produce  incomplete  or  even  complete  stricture  of  the  bowel.  At  a  point 
corresponding  to  the  seat  of  the  ulcers  local  peritonitis  invariably  develops. 
The  serosa  is  thickened  and  adherent,  and  the  ulcer  may  penetrate  through 
this  coat  without  causing  perforative  peritonitis,  Avhile  rarely  a  fistulous 
connection  is  established  between  the  diff"erent  parts  of  the  intestine. 

Symptoms. — In  children  the  symptoms  are  those  of  a  protracted 
catarrh  of  the  intestines,  or  they  may  be  absent.  Among  prominent 
features  are  diarrhea,  colicky  pains,  and  the  presence  in  the  stools  of 
pus,  blood,  and  particles  of  mucus  resembling  sago-grains.  In  many 
cases  there  is  constipation,  which  may  be  due  either  to  peritonitis 
or  cicatricial  stenosis.  The  general  symptoms  are  irregular  fever, 
wasting,  and  a  lack  of  development ;  they  are  especially  valuable  for 
diagnosis. 

In  adults  intestinal    tuberculosis   generally  gives   rise  to   srmptoms 
similar  to  the  above,  and  when  they  arise  in  the  course  of  pulmonary 
phthisis  they  are  highly  significant.      If  diarrhea  be  present,  it  stub- 
bornly resists  treatment,  and  it  must  not  be  forgotten  that  it  may  also 
^  Deutsches  Archivf.  Minische  Med.,  Berlin,  Ixxxvi.,  Nos.  1-3,  1906. 


278  IliFECTIOUS  DISEASES. 

be  due  either  to, catarrhal  colitis  or  to  amyloid  cliange,  both  of  which 
processes  may  be  associated  with  chronic  phthisis.  Constipation  is 
common  and  often  marked,  and  local  tenderness  and  colicky  pains  are 
complained  of  frequently.  The  pulmonary  signs,  however,  may  be  in 
abeyance. 

If  the  abdominal  and  oreneral  symptoms  are  such  as  to  excite  suspicion 
of  this  disease,  then  a  rigid  physical  examination  of  the  lungs  should  be 
made.  The  chief  seat  of  the  lesions  mav  be  for  a  long  time  in  the  cecum, 
or  in  the  appendix,  when  the  symptoms — both  local  and  general — will  be 
those  of  appendicitis. 

The  diagnosis  of  primary  intestinal  tuberculosis  is  beset  with  special 
difficulties.  Sawyer  ^  has  in  special  instances  demonstrated  the  presence 
of  clusters  of  tubercle  bacilli  in  the  rectal  mucus,  and  in  this  way  the 
recognition  of  intestinal  tuberculosis  at  an  early  date,  or  before  diarrhea 
sets  in,  is  rendered  possible.  The  mucus  is  obtained  after  placing  the 
patient  in  a  position  as  if  to  examine  for  piles,  and  directing  him  to  bear 
down  as  though  at  stool,  by  gently  removing  a  small  quantity  from  the 
everted  membrane  with  a  sterile  loop.  It  is  then  spread  upon  a  clean 
cover -glass  and  treated  exactly  as  sputum  in  the  ordinary  examination. 
The  same  method  is  applicable  to  cases  of  secondary  intestinal  tuberculo- 
sis, but  here  the  history  and  associated  tuberculous  lesions  usually  serve 
to  remove  all  doubt. 

Tuberculosis  of  the  Serous  Membranes. 

General  tuberculosis  of  the  serous  membranes  secondary  to  pulmonary 
and  intestinal  tuberculosis  is  of  common  occurrence,  and  that  a  primary 
form  of  tuberculosis  of  the  serous  membranes  also  occurs  is  undoubted. 
Unfortunately,  accurate  means  of  discriminating  the  secondary  from  the 
primary  form  are  wanting,  since  often  in  the  secondary  variety  the  primary 
lesions  in  other  organs  are  insignificant. 

The  anatomic  alterations  resemble  those  of  ordinary  inflammation 
of  these  structures,  plus  the  presence  of  nodular  tubercles.  The  latter 
may  be  observed,  as  a  rule,  only  over  small,  scattered,  circumscribed 
areas,  though  not  infrequently  they  are  both  numerous  and  diff"use  (gen- 
eral miliary  deposit).  The  effusion  is  in  most  instances  sero-fibrinous, 
though  sometimes  it  becomes  purulent,  and  not  uncommonly  it  is  hemor- 
rhagic. Most  instances  of  so-called  hemorrhagic  pleurisy  are  due  to 
pleural  tuberculosis. 

Clinically,  cases  are  divisible  into  (1)  acute  serous  membranous  tuber- 
culosis and  (2)  the  chronic  form.  The  acute  form  results  from  inocula- 
tion of  the  peritoneum  or  pleura,  induced  by  limited  foci  in  the  bronchial, 
tracheal,  or  mediastinal  lymph-glands,  or  in  the  Fallopian  tubes  in  women. 
The  chronic  type  is  apt  to  result  from  a  direct  extension  of  a  tuberculous 
process  from  some  organ  adjacent  to  the  pleura  or  peritoneum,  though  it 
may  attack  the  serous  membranes  primarily.  Belonging  to  this  class  of 
diseases  are  two  groups  of  cases :  those  attended  by  sero-fibrinous  or 
sero-purulent  effusion  and  the  presence  of  caseous  masses,  and  those  in 
which   there   is  a  tuberculous  deposit  with  increased  density  and  great 

1  Medical  Nevjs,  May  23,  1896. 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES.  279 

thickening  of  the  pleural  layers,  and  slight  exudation.    The  pericardium 
may  be  similarly  involved. 

(a)  Tuberculous  meningitis  has  been  described  fully  in  the  present 
section  [vide  Miliiiry  Tuberculosis). 

[b)  Tuberculous  Pleuritis. — This  subject  will  be  referred  to  in  the 
section  on  Diseases  of  the  Pleura.  Its  import,  however,  is  such  that 
brief  special  consideration  is  demanded,  and  from  a  clinical  view-point 
the  cases  may  be  grouped  under  two  heads — namely,  acute  and  chronic 
tuberculous  pleurisy. 

The  acute  form  often  has  a  sudden  onset,  the  initial  symptoms  being  a 
rigor  or  repeated  fits  of  chilliness,  a  stitch-like  pain  in  the  side  affected, 
shallow,  catching  breathing,  a  cough,  and  fever.  The  ushering-in  symp- 
toms sometimes  suggest  lobar  pneumonia,  and  a  fatal  termination  is  not 
uncommon,  though  apparent  recovery  or  a  transition  into  chronic  tuber- 
culous pleuritis  also  occurs. 

Chronic  tubercular  pleurisy  is  vastly  more  common  than  the  acute 
form,  and  it  is  sometimes  primary,  though  more  often  secondary  to  pul- 
monary tuberculosis.  In  all  cases  of  the  latter  disease  in  which  the  per- 
iphery of  the  lung  becomes  involved  the  visceral  layer  of  the  pleura  is 
invaded.  This  leads  to  plastic  pleurisy  with  adhesion,  and  the  membranes 
contain  disseminated  tubercles,  or  to  sero-fibrinous  tuberculous  pleurisy. 
As  above  stated,  the  effusion  may  be  hemorrhagic  and  may  also  become 
purulent.  When  the  tuberculous  pulmonary  focus  perforates  the  pleural 
sac,  pyopneumothorax  is  produced.  In  tuberculous  pleurisy,  as  opposed 
to  simple  pleurisy,  there  is  usually  an  absence  of  leukocytosis. 

Symptoms. — The  onset  is  very  insidious  and  often  unnoticed.  There 
may  be  few  symptoms,  and  yet  a  physical  examination  reveal  a  large 
sero-fibrinous  exudate.  The  cough  and  other  symptoms  are  frequently 
due  to  a  coexisting  tuberculosis  of  the  lungs,  and  the  presence  of  sub- 
crepitant  and  dry  rales  is  strongly  confirmatory  of  tuberculous  pleurisy. 
By  and  by  the  evidences  of  pulmonary  tuberculosis  are  of  diagnostic 
importance,  or  the  supervention  of  acute  general  miliary  tuberculosis 
makes  clear  the  nature  of  the  case.  The  subacute  variety  with  effusion 
may  terminate,  after  absorption  of  the  exudate,  in  chronic  adhesive 
pleurisy  with  great  thickening  of  the  membrane.  The  latter  may  also 
originate  as  a  primary  proliferative  process. 

(c)   TUBERCULOSIS    OF    THE    PERICARDIUM. 

The  morbid  lesions  are  analogous  to  those  of  tuberculosis  of  the  pleura. 
The  effusion  may  be  enormous  on  the  one  hand  or  insignificant  on  the 
other,  and  it  is  often  hemorrhagic,  while  in  the  chronic  form  there  is 
marked  thickening  of  the  membrane  with  the  deposit  of  tubercles  and 
cheesy  masses.  The  affection  is  less  common  than  tuberculosis  of  the 
pleura,  yet  not  so  rare  as  was  formerly  supposed,  and  occurs  in  the  acute 
and  chronic  forms. 

Acute  tuberculous  pericarditis  is  rarely  a  primary  affection,  and.  as  a 
rule,  originates  secondarily  to  pulmonary,  pleural,  or  glandular  tubercu- 
losis. It  is  especially  prone  to  arise  in  tuberculosis  of  the  bronchial  and 
mediastinal  lymph-glands,  and,  as  the  latter  condition  is  frequent  in 
young  children,  so  tuberculosis  of  the  pericardium  is  relatively  frequent 
at  this   period,  though  it  may  occur   at  any  time  of  life.      Pericardial 


280  INFECTIOUS  DISEASES. 

tuberculosis  also  results  from  direct  extension  from  a  contiguous  focus. 
The  symptoms  -will  be  detailed  in  the  discussion  of  Pericarditis.  In  the 
diagnosis  of  the  affection  the  history  and  any  associated  tuberculous  pro- 
cesses detectable  must  be  taken  into  account,  and  a  point  of  some  diag- 
nostic value  rests  in  the  fact  that  tuberculous  pericarditis  does  not  show 
the  usual  inflammatory  leukocytosis. 

Chronic  Tuberculous  Pericarditis. — This  may  be  a  part  of  the  general 
tuberculosis  of  the  serous  membranes,  or  it  may  follow  an  infection  of 
the  bronchial  and  mediastinal  glands  (most  frequently),  lungs,  pleura,  or 
peritoneum.  Cases  of  primary  origin  also  occur,  but  they  are  exceed- 
ingly rare,  the  neighboring  lymph-glands  being  genex'ally  involved.  This 
form  is  also  dependent  upon  direct  extension  from  the  spine  and  sternum. 

From  personal  observation  I  am  convinced  that  the  cases  naturally 
fall  under  two  heads,  when  considered  clinically  :  those  without  effusion, 
in  which  the  pericardium  is  adherent ;  and  those  with  more  or  less 
effusion.  The  former  are  the  more  frequent,  though  often  entirely  latent, 
the  adherent  pericardium  leading  to  hypertrophy  of  the  heart,  followed 
sooner  or  later  by  dilatation.  The  signs  are  therefore  those  of  adherent 
pericardium,  with  the  occasional  difference  that  the  dulness  may  extend 
higher  up  over  the  sternum,  in  consequence  of  the  presence  of  firm, 
cheesy  masses  at  the  base  of  the  heart  and  also  encircling  the  aorta.  The 
smaller  group  of  cases  (in  which  the  effusion  is  present)  resembles  dilata- 
tion of  the  heart  in  its  clinical  manifestations.  I  recall  one  instance  of 
this  sort  that  occurred  in  a  male  aged  about  sixty  years  at  the  Episco- 
pal Hospital,  the  autopsy  revealing  extensive  pulmonary  tuberculosis  and 
chronic  tuberculous  pericarditis,  with  the  presence  of  eight  ounces  of 
hemorrhagic  effusion. 

(d)    TUBERCULOSIS    OF    THE    PERITONEUM, 

This  is  dependent  upon  infection  by  means  of  the  bacilli  circulating 
with  the  blood,  or  upon  extension  of  tuberculous  inflammation  or  ulcera- 
tion from  adjacent  organs.  In  11  per  cent,  of  3405  autopsy  records  Cum- 
mins '  found  there  was  peritoneal  involvement.  Mention  has  already  been 
made  of  the  fact  that  the  intestines  are  often  invaded  by  tuberculosis, 
and  that  the  serosa  is  quickly  involved  in  such  instances.  The  condition 
may  rarely  be  primary.  This  involvement  may  remain  circumscribed 
and  undergo  spontaneous  cure  if  the  intestinal  lesion  cicatrizes,  as  post- 
mortem findings  frequently  indicate,  but  in  extensive  peritoneal  involve- 
ment spontaneous  resolution  is  out  of  the  question.  These  cases  may  be 
subdivided  into  acute  and  chronic.  The  ver^  acute  cases  are  those  form- 
ing a  part  of  acute  general  miliary  tuberculosi-s,  or  due  to  perforation 
into  the  peritoneal  sac  from  adjacent  organs,  and  Adlebert's  classifica- 
tion is  as  follows :  («)  The  ascitic  form,  (6)  the  ulcerous  form,  and  (c)  the 
fibroid  form.  Though  these  groups  do  not  present  sharp  clinical  distinc- 
tions, the  courses  they  run  vary  considerably,  as  do  the  results  of  treat- 
ment. In  the  asritic  form  the  exudate  is  purulent  or  sero-purulent,  and 
is  often  encapsulated.  In  the  ulcerous  the  tuberculous  new-formations, 
which  may  be  quite  large,  undergo  caseation  and  ulceration,  the  latter 
process  being  progressive,  so  that  it  may  perforate  the  walls  of  the  intes- 
tines. This  and  the  ascitic  variety  may  be  combined. 
1  University  Med.  BuUelin,  December,  1905. 


I 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES.  281 

In  the  third  or  fibroid  form  the  peritoneal  surfaces  are  adherent. 
There  is  little  exudation  ;  the  tubercles  may  be  numerous  and  difi'use, 
or  found  only  in  scattered  localized  areas.  The  lesions  may  represent 
the  concluding  stage  of  acute  or  subacute  tuberculous  peritonitis. 

!^tiology. — Most  cases  are  produced  by  extension  of  tuberculous 
inflammation  from  adjacent  organs,  and  of  107  cases  analyzed  by  Phillips 
the  lungs  were  involved  in  99,  the  pleura  also  in  60,  and  the  bowel  in 
80.  Children  are  frequent  victims  to  intestinal  tuberculosis,  and  the 
bacilli  often  reach  the  peritoneum  through  the  intestines,  as  they  are  also 
apt  to  do  in  adults  suffering  from  chronic  phthisis.  Extension  from  the 
pleura  to  the  peritoneum  is  frequent  (pleuroperitoneal),  but  from  tlie 
pericardium  is  rare.  In  females  the  starting-point  is  often  the  Fallopian 
tubes  (Mayo,  Murphy),  and  in  either  sex  it  may  be  the  appendix. 

Predisposing  Factors. — Age. — During  the  period  from  fifteen  to  forty 
years  the  incidence  is  most  frequent,  although  it  is  not  uncommon  in  chil- 
dren under  ten  years,  nor  between  the  fortieth  and  fiftieth  years  of  life. 
Subsequently,  it  rapidly  decreases  in  frequency.  I  agree  with  Osier  in 
stating  that  in  America  negroes  are  more  prone  than  whites. 

Sex  has  a  tolerably  potent  disposing  influence.  Abdominal  surgeons 
have  taught  us  that  the  disease  occurs  more  frequently  in  females  than 
males,  owing  to  the  fact  that  the  Fallopian  tubes  are  a  favorite  seat  for 
primary  tuberculous  infection.  The  ratio  based  upon  sex  is  as  8  to  2  in 
favor  of  females. 

Symptoms. — Some  cases  develop  abruptly  with  severe  symptoms,  as 
fever,  marked  constitutional  disturbance,  rapid  small  pulse,  abdominal 
pain,  vomiting,  and  sometimes  diarrhea.  The  temperature  may  be  quite 
high  (103°  to  104°  F.— 40°  C),  or  it  may  be  only  slightly  elevated  even 
in  the  worst  cases.  There  follow  quickly  such  symptoms  as  anemia, 
marked  emaciation,  and  a  pronounced  typhoid  co7idition.  The  signs  of 
peritoneal  effusion  (rarely  large)  are  soon  in  evidence,  and  are  attended 
sometimes  by  a  suppurative  type  of  temperature,  sweats,  etc.,  indicating 
the  presence  of  pus  in  the  peritoneal  sac.  A  few  cases  are  unattended 
by  effusion,  and  here  nodular  masses  are  palpable,  while  on  auscultation 
friction-sounds  may  be  audible  in  the  umbilical  region.  Tympanites,  due 
to  intestinal  paresis,  is  common  in  cases  having  an  jicute  onset. 

The  acute  stage  may  be  absent,  the  affection  then  being  marked  by 
slight  local  and  general  symptoms  (low  fever,  anemia,  slight  belly-pains, 
and  a  sense  of  distention).  The  skin  is  sometimes  pigmented,  and  usu- 
ally in  patches.  There  are  not  a  few  instances  in  which  the  aff"ection  is 
latent,  and  in  one  case  of  this  sort  with  ill-defined  general  symptoms  pig- 
mentation of  the  skin  first  directed  my  attention  to  the  peritoneum. 

The  physical  signs  of  moderate  ascites  frequently,  and  those  of  en- 
larged mesenteric  glands  sometimes,  are  present.  These  conditions  are 
often  combined  in  children,  constituting  the  so-called  tabes  mesenterica. 
I  cannot  conceive  of  the  occurrence  of  this  association  of  symptoms  with- 
out simultaneous  involvement  of  the  peritoneum,  and  doubtless  co-involve- 
ment of  the  latter  membrane  and  intestines  usually  occurs.  Hamman 
emphasizes  the  great  frequency  with  which  more  than  one  serous 
membrane  is  affected  (multiple  serosites).  The  tuberculous  new 
growth  in  the  peritoneum  may  also  form  a  distinct  tumor  not  unlike 
that   produced    by   glandular    enlargement,   while   the    intestinal    coils 


282  INFECTIOUS  DISEASES. 

with  their  now  thickened  walls  are  sometimes  knotted  together  so  firmly 
as  to  simulate  a  dense  new  growth.  The  exudation  may  be  loculated 
owing  to  adhesions  between  peritoneal  layers  of  the  intestinal  coils,  etc., 
producing  a  localized  tumor  varying  in  size  and  position.  Such  saccu- 
lated exudations  most  frequently  occupy  the  pelvic  or  umbilical  regions, 
though  they  may  also  be  found  elsewhere  in  the  abdomen.  They  may  be 
multiple,  and  are  not  infrequently  too  small  to  be  recognized  by  the 
physical  signs,  being  often  discovered  during  laparotomy.  On  the  other 
hand,  they  may  occupy  a  large  portion  of  the  abdomen.  An  omental 
tumor  of  characteristic  elongated  form  (produced  by  a  shrinking  and 
curling  up  of  this  membrane)  is  demonstrable,  its  long  axis  generally 
taking  a  transverse  direction  just  above  the  umbilicus.  Gardiner  has 
observed  this  tumor  to  disappear  by  spontaneous  resolution  in  children. 

The  dry,  fibrous  variety,  which  is  not  infrequent,  is  often  latent,  and 
the  condition  may  be  general  or  localized.  It  is  decidedly  more  frequent 
in  adults  than  in  children.  The  syyyiptoms  are  far  from  characteristic. 
Among  local  features  are  pains,  abdominal  distention  (giving  rise  to  a 
tympanitic  note  on  percussion),  tenderness  on  pressure,  and  sometimes 
a  tumor-ridge  extending  across  the  upper  abdominal  region.  Among  gen- 
eral symptoms  are  usually  anemia  and  emaciation,  with  or  without  fever. 
Indeed,  the  temperature  may  be  subnormal,  and  these  cases  may  show 
a  tendency  to  spontaneous  recovery. 

Diagnosis. — Unless  tuberculosis  of  other  organs  can  be  demon- 
strated the  diagnosis  is  often  impossible.  This  is  particularly  true  in 
cases  in  which  there  is  no  abdominal  pain,  which  is  the  most  important 
local  symptom,  nor  tenderness.  Fever  and  the  presence  of  a  tumor, 
especially  if  the  latter  be  elongated  and  lies  transversely  in  the  umbili- 
cal region,  are  important  aids  ;  but  if  tuberculosis  of  the  lungs,  pleura, 
pericardium,  appendix,  and  the  tubes,  in  women,  can  be  excluded,  the 
rectal  mucus  and  the  urine  should  be  examined  for  tubercle  bacilli. 
From  the  acute  form,  several  aflfections  must  be  discriminated : 

(a)  Internal  Hernia. — This  comes  on  suddenly ;  the  pain  is  strictly 
localized  and  paroxysmal ;  stercoraceous  vomiting  appears  in  a  few  hours; 
the  constipation  is  absolute,  and  tympanites  is  marked,  but  ascites  is 
absent. 

(6)  Similar  symptoms  belong  to  volvulus  and  to  the  quick  incarcera- 
tion of  loops  of  intestine  under  bands  of  adhesions;  on  comparison  they 
will  be  seen  to  differ  from  those  of  acute  tuberculous  peritonitis. 

(c)  Enteritis  is  discriminated /rom  acute  tuberculous  perito7iitis  by  the 
presence  of  copious  mucous  discharges,  and  by  the  absence  of  associated 
tuberculous  lesions,  peritoneal  exudate,  tumors,  and  the  phenomena  of  the 
typhoid  state. 

Chronic  tuberculous  peritonitis  often  closely  simulates  cancerous  perito- 
nitis, owing  to  the  fact  that  the  elongated  omental  tumor  may  be  met  with 
in  both,  associated  with  effusion,  abdominal  pain,  and  slight  fever.  In 
carcinoma,  however,  there  is  an  absence  of  the  tuberculous  history  and 
lesions,  and  the  presence,  sometimes,  of  a  gradually  increasing  tumor  of 
primary  growth,  the  slowly  oncoming  intestinal  obstruction  from  pres- 
sure, and  the  cancerous  cachexia.  Moreover,  tuberculous  peritonitis 
occurs  more  commonly  in  younger  subjects,  and  is  more  apt  to  be  inter- 
rupted by  periods  of  improvement,  followed  in  turn  by  rather  alarming 
symptoms.     The  tuberculin  test  is  to  be  used  in  dubious  cases. 


TUBERCULOSIS  OF  THE   OENITO-URINARY  SYSTEM.  283 

Locular  exudations  must  be  distinguished  from  ovarian  tAimorn,  and 
here  the  history,  together  with  tuberculous  lesions  elsewhere  in  the  body, 
the  occurrence  of  febrile  attacks,  and  intestinal  disturbance  with  pain, 
are  of  great  diagnostic  significance.  Such  cases  should  be  examined  by  a 
gynecologist,  since,  however  expert  the  examiner,  when  the  saccular  exu- 
dations are  located  in  the  pelvic  region  ar  exploratory  laparotomy  must 
often  decide  the  nature  of  the  condition.  Finally,  it  must  not  be  forgot- 
ten that  the  vast  majority  of  cases  of  chronic  peritonitis  are  tuberculous. 

Tuberculosis  op  the  Liver. 

The  liver  was  formerly  overlooked  in  many  instances  of  tuberculosis, 
because  the  lesions,  particularly  in  acute  tuberculosis,  are  often  micro- 
scopic. In  the  chronic  disseminated  variety,  however,  grosser  changes 
are  observed,  the  organ  being  slightly  enlarged,  pale,  and  fatty,  and  pre- 
senting an  irregular  surface  like  that  of  an  orange.  On  section,  the  par- 
enchyma cuts  with  great  resistance,  being  very  dense  (tuberculous  cir- 
rhosis). Minute  gray  and  larger  yellow  masses  are  seen,  especially  just 
under  the  capsule,  and  small  cavities,  the  result  of  a  breaking  down  of 
the  cheesy  masses  and  containing  pus  and  bile,  are  also  observed.  These 
changes  are  most  pronounced  about  the  bile-ducts. 

Etiology. — The  liver  is  implicated  in  all  instances  of  acute  miliary 
tuberculosis.  It  is  also  involved  secondarily  in  chronic  tuberculosis  of 
the  lungs,  pleura,  peritoneum,  spleen,  lymphatics,  etc. 

Symptoms. — This  is  a  common  condition,  the  organ  being  appreci- 
ably enlarged  and  its  surface  presenting  irregular,  palpable  prominences. 
The  clinical  features  of  perihepatitis  and  peritonitis  are  often  found  in 
combination.     Ascites  may  be  present,  but  is  rare. 

Here  may  be  mentioned  that  occasionally  the  spleen  seems  to  be  the 
primary  focus  of  tuberculosis. 

Tuberculosis  of  the  Genito-urinary  System. 

(1)  Tuberculosis  of  the  Kidneys. — This  may  be  primary  or  secondary, 
the  secondary  form  being  the  more  common,  and  it  may  be  either  unilat- 
eral or  bilateral. 

Pathology. — The  process  begins  in  the  calices  and  apices  of  the  pyr- 
amids (papillae),  thence  proceeding  to  the  pelvis  of  the  kidney,  so  that 
early  the  condition  may  be  pyonephrosis.  The  morbid  changes  then  ex- 
tend to  the  ureters,  and  sometimes  to  the  bladder  and  prostate,  and  in- 
stances are  even  met  with  in  which  the  process  seems  to  have  crept  from 
below  upward,  starting  from  the  bladder  or  prostate.  The  tubercles  pass 
through  the  usual  stages  of  caseation,  necrosis,  and  suppuration,  and  de- 
struction of  the  renal  tissue  to  a  greater  or  lesser  degree  occurs,  with  the 
formation  of  cysts  containing  cheesy  material  in  which  lime-salts  may  be 
deposited.  When  the  process  invades  the  kidneys  through  the  blood,  it 
may  be  limited  largely  to  the  cortical  layer  and  give  rise  to  nodular 
tuberculosis  with  caseous  masses,  yet  with  little  loss  of  renal  substance. 
H.  A.  Kelly  ^  believes  that  the  infection  of  the  kidney  is  almost  always 
hematogenous.  While  it  is  difficult  to  judge  of  the  relative  ages  of  the 
lesions  in  different  organs,   I   cannot   escape   the  conviction  that  in  a 

^  British  Medical  Journal,  June  17,  1905,  p.  1319. 


284  INFECTIOUS  DISEASES. 

sumll  group  of  cases  renal  tuberculosis  is  an  ascendmg  process  and  fol- 
lows ureterocystic  tuberculosis.  Although  both  kidneys  are  finally 
involved  in  most  instances,  for  a  considerable  period  the  disease  is  uni- 
latei'al.  Hall^  and  Motz  found  one  kidney  alone  aflected  in  89  out  of 
132  cases.  In  acute  miliary  tuberculosis,  both  kidneys  show  disseminated 
tubercles.      Caseation  and  necrosis,  however,  seldom  occur. 

Etiology. — Of  disposing  factors  age  and  sex  deserve  especial  mention, 
most  cases  occurring  during  middle  life,  though  they  are  by  no  means  rare 
both  at  an  earlier  and  a  later  period.  The  disease  is  more  frequent  in 
males  than  females. 

The  bacilli  reach  the  kidneys  with  the  blood-stream,  producing  pri- 
mary renal  tuberculosis  (hemogenic  infection),  through  the  lymphatics 
(lymphogenic  infection)  and  direct  extension  from  adjacent  structures. 

Symptoms. — In  many  cases  there  are  either  no  renal  symptoms  or 
none  until  a  late  stage  is  reached,  but  the  symptoms  of  pyelitis  are  usu- 
ally present.  Pyuria  may  be  the  only  symptom  for  a  long  time,  and  this 
symptom,  according  to  certain  authorities,  points  directly  to  cystitis. 
When  the  latter  condition  is  present,  however,  the  micturition  becomes 
frequent  and  there  is  vesical  tenesmus.  Pain  in  the  side  chiefly  affected 
is  complained  of,  and  is  sometimes  not  unlike  renal  colic  ;  hematuria  is 
not  rare,  and  it  may  be  the  initial  symptom.  Braasch  found  hematuria 
in  60  per  cent,  of  203  cases,  and  bladder  irritability  in  86  per  cent.  Cys- 
toscopic  examination  may  show  the  blood  to  be  of  renal  origin  (Tuflfier). 
It  is  useful  also  in  showing  the  state  of  the  bladder-mucosa.  The  dem- 
onstration of  tubercle  bacilli  in  the  urine,  especially  if  arranged  in 
S-shaped  groups,  is  diagnostic  (Frisch).  When  the  bacilli  cannot  be 
found,  inoculation-experiments  upon  guinea-pigs  and  rabbits  furnish  an 
accurate  criterion,  though  it  must  not  be  forgotten  that  tubercle  bacilli 
may  find  their  way  into  the  urine  from  more  distant  tuberculous  foci. 
Catheterization  of  the  ureters  may  determine  which  kidney  is  involved. 
Tubercle  bacilli  are  not  found  in  the  urine  in  the  miliary  form.  Polyuria 
is  sometimes  present,  as  well  as  alhuminuria  ;  the  urine  may  also  show 
tube-casts  (rarely)  and  pus-cells.  Macroscopic  cheesy  masses  are  occa- 
sionally found.  Roentgenographs  after  injections  of  20  c.c.  of  a  10  per 
cent,  solution  of  collargol  are  of  much  diagnostic  value. 

The  general  features  are  often  marked,   but  not  until  the  affection' 
becomes  advanced,   chills,  fever  of  a  suppurative  type,  emaciation,  and 
increasing    debility   being    the    principal    symptoms.     A    good    general 
appearance   often  accompanies  an   extensive   lesion.     Associated   tuber- 
culous lesions,  especially  of  the  lungs,  are  constantly  observed. 

Physical  Signs. — Inspection  may  show  a  tumor-like  prominence  on 
the  side  chiefly  affected,  though  rarely  of  large  size.  Renal  tumor  was 
palpable  in  but  20  per  cent,  of  Braasch's  cases  (vide  supra).  Paljiation 
often  detects  tenderness,  and  the  outline  of  the  organ  may  be  defined  by 
careful  firm  pressure  with  the  finger-tips. 

Diagnosis. — It  is  difficult  to  discriminate  calculous  pyelitis.  In  the 
latter,  however,  the  pain  is  severer,  the  tumor-mass  larger,  and  the  hemor- 
rhage more  frequent  than  in  tuberculous  nephritis.  The  discovery  of 
tubercle  bacilli  or  the  demonstration  of  tuberculosis  of  the  lungs  or 
other  organs  would  remove  all  doubt.  The  tuberculin  test  may  be  used. 
Chevassre  ^  recommends  the  antigen  reaction  of  Debr6  and  Paraf. 
1  P/-e.s.se  Medicate,  February  28,  1912,  xvii.,  173. 


TUBERCULOSIS  OF  THE  FEMALE  OENITAL   ORGANS.        285 

(2)  Tuberculosis  of  the  Ureter  and  Bladder. — 'I'his  is  almost  always 
secondary  to  tuberculous  disease  of  the  pelvis  of  the  kidney  above,  or  of 
the  deep  urethra,  testes,  or  prostate  below.  When  primary,  as  rarely 
happens,  the  process  extends  from  ureters  to  bladder.  The  HymptoniH 
are  those  of  chronic  cystitis,  and  in  all  cases  in  which  no  other  cause  for 
the  latter  can  be  found  the  primary  tuberculous  lesion  must  be  sought 
for  and  the  urine  carefully  examined  for  bacilli.  The  smegma  bacillus, 
sometimes  prestjnt  in  normal  urine,  can  be  distinguished  by  decolorizing 
with  absolute  alcohol,  which  will  take  place  in  about  two  minutes,  while 
with  the  tubercle  bacillus  a  very  much  longer  time  is  required.  Others 
say  this  is  not  sufficient,  and  that  only  their  methods  of  culture-growth 
or  inoculation  will  distinguish  them.  A  catheter  specimen  should  be 
obtained  if  possible  (Ogden).  With  the  development  of  ulcerative 
lesions  hemorrhage  is  apt  to  arise. 

(3)  Tuberculosis  of  tlie  Vesiculse  Seminales,  Prostate,  and  Testes. — The 
prostate  gland  and  testes  are  frequently  invaded  in  genito-urinary  tuber- 
culosis, and  the  vesiculse  seminales  somewhat  less  frequently.  The  mor- 
bid process  leads  to  the  formation  of  cheesy  nodules,  which  may,  though 
comparatively  rarely,  disintegrate,  causing  excavations  or  perforation. 
Rarely,  the  tubercle  does  not  pass  through  the  stage  of  caseation,  but 
merely  shows  the  presence  of  numerous  embryonic  cells. 

Etiology. — The  condition  is  usually  secondary,  but  the  existence  of 
primary  tuberculosis  in  these  organs  cannot  be  denied.  Testicular  tuber- 
culosis may  begin  at  any  period  of  life,  and  is  of  rather  frequent  occur- 
rence in  infants.  When  it  occurs  in  the  latter,  it  is  part  of  a  more  gen- 
eral tuberculous  infection,  and  is  in  many  instances  undoubtedly  congen- 
ital.    In  some  cases  it  may  be  a  late  hereditary  affection. 

Symptoms. — In  the  testicle,  tuberculosis,  as  a  rule,  induces  a  pain- 
less, protracted  orchitis,  though  when  cavernous  lesions  occur  the  symp- 
toms are  more  acute.  In  prostatic  tuberculosis  the  bladder  is  highly 
irritable,  there  is  great  distress  felt  in  the  thigh  and  groin,  and  micturi- 
tion is  very  painful.  Catheterization,  particularly  if  the  urethra  (as  is 
very  rarely  the  case)  is  the  seat  of  tuberculous  ulceration,  causes  most 
excruciating  suffering,  and  there  may  be  signs  of  stricture.  Rectal 
palpation  detects  in  the  prostate  firm  nodules  varying  in  size  from  a  pea 
to  a  bean,  together  with  enlargement  of  the  organ. 

Diagnosis. — The  diagnosis  of  tuberculosis  of  the  prostate  is  easily 
made  from  the  vesical  symptoms,  the  presence  of  tuberculosis  in  other 
organs,  the  result  of  rectal  examination,  and  the  detection  of  bacilli  in 
the  urine.  Syphilitic  involvement  of  the  testicle  is  sometimes  excluded 
with  difficulty ;  in  the  latter  disease,  however,  the  surface  of  the  swollen 
organ  presents  greater  irregularities,  and  is  even  less  painful  than  in  tu- 
berculosis. The  absence  of  the  history  of  syphilitic  infection  and  the 
presence  of  tuberculosis  in  other  organs,  particularly  in  the  uro-genital 
system,  are  valuable  points  in  the  discrimination. 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and 

Uterus. 

Tuberculosis  of  the  tubes  in  women  is  a  not  infrequent  condition,  and 
may  be  primary. 

Btiolpgy  and  Pathology. — The  tubes,  as  a  result  of  infiltration, 


286  INFECTIOUS  DISEASES. 

are  thick,  hanl,  and  bound  down  by  false  membrane.  Their  ends  are 
generally  closed,  but  the  intervening  portion  is  dilated,  and  contains 
mucus,  pus,  and  cheesy  material.  A  catarrhal  salpingitis  is  generally  in 
association.  Uterine  Tubirculos/s  is  rare,  and  its  origin  is  usually  attrib- 
utable to  similar  involvement  of  the  tubes. 

The  disease  is  most  common  during  the  period  of  greatest  sexual 
activity,  but  young  children  may  suffer  {inde  literature  of  Hennig),  and 
in  them  the  ovaries  and  uterus  may  be  implicated  without  participa- 
tion of  the  tubes,  as  in  cases  reported  by  Gusserow.  At  any  period  of 
life  the  lesions  may  be  microscopic  ;  they  usually,  however,  excite  marked 
local  peritonitis,  -which  may  become  gen3ral,  with  the  development  of 
ascites.     The  process  may  extend  to  the  vagina. 

Diagnosis. — The  age,  family  history,  and  signs  of  the  tuberculous 
diathesis  must  be  noted.  The  disease  does  not  distinguish  itself  from 
other  tubal  tumors  by  anything  characteristic  on  bimanual  palpation. 
Cases  occur  with  ascites  and  also  without,  and  m  the  latter  variety  plaque- 
like thickening  of  the  subperitoneal  tissue  is  an  aid  to  diagnosis.  The 
uterine  secretions  should  be  examined  for  bacilli  in  all  obscure  cases. 
Ashton  advises  an  exploratory  incision  or  puncture  and  examination  of 
the  contents  of  the  peritoneum  or  tubes  for  bacilli. 

Tuberculosis  of  the  Mammary  Glands. 

This  is  rare  ;  the  affected  glands  present  fistulas  and  ulcers,  with  indu- 
ration of  the  organ  and  retraction  of  the  nipple.  Warden  ^  reports  the 
finding  of  58  authentic  cases  in  the  literature.  Nearly  90  per  cent,  of  the 
patients  were  females,  and  most  cases  developed  in  the  third  decennium. 
The  si/mptoms  are  sharp  and  lancinating  pains  radiating  to  the  arm,  and 
tumor,  the  latter  consisting  of  one  or  more  nodules.  Pyogenic  secondary 
infection,  leading  to  obstinate  fistulae,  is  common.  The  axillary  glands 
are  often  enlarged.  A  positive  diagnosis  rests  crucially  upon  the  finding 
of  the  bacilli  in  the  pathologic  secretions. 

Tuberculosis  of  the  Brain. 

Pathology. — Tuberculosis  of  the  brain  occurs  in  two  forms,  one  of 
which,  acute  tubercular  meningitis,  has  been  previously  described,  while 
the  other  is  a  chronic  tuberculous  infection,  usually  localized,  of  the 
meninges  and  cortex,  and  causing  meningo-encephalitis.  Very  rarely 
the  membranes  remain  intact.  The  so-called  solitary  tubercle  is  an 
irregularly  round  mass,  varying  in  size  from  a  small  pea  to  an  apple  or 
even  larger.  It  is  generally  single,  though  sometimes  there  are  two,  and 
rarely  even  three,  nodules.  The  tubercle  may  be  imbedded  in,  and  be 
contiguous  with,  the  brain-substance,  or  may  be  separated  from  the  latter 
by  cysts.  The  peripheral  zone  is  formed  largely  of  connective  tissue,  is 
lighter  in  color  (often  translucent),  and  may  contain  miliary  tubercles, 
while  the  central  portion,  which  is  cheesy  as  a  rule,  may  liquefy  and  thus 
form  a  small  cavity  containing  a  purulent-looking  material.  They  are 
seen  with  greatest  frequency  in  the  inferior  portions  of  the  brain. 

The  new  growths  may  compress  the  longitudinal  sinus,  inducing  throm- 
bosis; they  may  interfere  markedly  with  the  circulation,  causing  cerebral 

1  Medical  Record,  October  1,  1898. 


TUIiKIlCULOSIS   OF  TIll<:  IIKAIIT.  287 

softening;  and,  finally,  they  may  excite  acute  tuberculous  meningitis. 
Tuberculosis  of  other  organs  is  usually  found  as  an  associated  condition. 
histiology. — The  disease  occurs  with  especial  frequency  in  young 
subjects,  and,  according  to  the  statistics  of  Pribram,  in  about  three- 
fourths  of  the  cases  before  the  fifteenth  year,  ^fhe  symptom-picture  is 
identical  with  that  of  brain-tumor  {({.  v.). 

Tuberculosis  of  the  Spinal  Cord. 

The  lesions  are  those  of  solitary  tubercle  of  the  brain.  It  is  an  ex- 
tremely rare  condition,  and  almost  invariably  secondary.  (For  symptoms, 
vide  Spinal  Tumor  and  Meningitis.) 

Tuberculosis  of  the  Heart. 

(a)  The  Myocardium. — Tuberculous  myocarditis,  though  compara- 
tively rare,  is  more  common  than  has  been  supposed.  It  may  be  pri- 
mary, although  practically  always  secondary  to  a  focus  in  some  other 
tissue,  and  transmission  to  the  heart  generally  occurs  by  way  of  the 
lymphatic  system.  Infection  through  the  agency  of  the  pericardium  is 
also  common,  and  rarely  it  may  be  by  the  blood.  Three  pathologic  varie- 
ties (here  mentioned  in  the  order  of  relative  frequency)  are  recognized : 
{a)  Large  tubercles ;  [b)  Miliary  variety  ;  and  (c)  Diffuse  form,  or  tuber- 
cular infiltration.  Generally  speaking,  the  smaller  nodules  are  found 
usually  in  the  ventricles,  and  the  larger  masses  in  the  auricles,  chiefly  the 
right.  In  miliary  tuberculosis  scattered  gray  granulations  or  semitrans- 
parent  areas  are  formed.  The  literature  furnishes  a  total  of  72  cases, 
nearly  one-half  of  which  have  occurred  in  persons  under  fifteen  years 
of  age,  and  is  quite  rare  after  the  forty-fifth  year.  The  diagnosis  is 
exceedingly  difficult,  and  rarely  possible.  In  addition  to  the  sus- 
picious features,  such  as  syncopal  attacks  of  short  duration  or  sudden 
collapse,  with  comparative  well-being  in  the  intervals,  that  may  be 
present,  the  existence  of  generalized  tuberculosis  and  pericardial  tuber- 
culosis, one  or  both,  are  essential  to  a  diagnosis.  Death  may  occur 
suddenly.^ 

{h)  The  Endocardium. — True  tuberculous  endocarditis  is  a  rare  con- 
dition. It  is  most  apt  to  occur  in  acute  miliary  tuberculosis.  The  endo- 
cardium is  to  an  unusual  degree  resistant  to  the  tubercle  bacillus.  In 
tubercular  invasion  of  the  mediastinal  glands  the  endocardium  may 
become  involved  by  extension  of  the  morbid  process.  Infection  of  the 
endocardium  also  takes  place  through  the  blood  supply  to  the  heart 
structure.  Vegetations  occur  on  the  valves,  and  in  cases  in  which  the 
lesions  are  of  the  ulcerative  variety  secondary  pyogenic  infection  prob- 
ably exists.  Clinically,  the  cases  of  tuberculous  endocarditis  are 
extremely  diflScult  of  recognition.  The  history  of  the  case,  however, 
may  be  of  diagnostic  significance.  "  If  it  can  be  shown  that  the  cardiac 
aff"ection  developed  subsequent  to  undoubted  pulmonary  tuberculosis,  and 
if  rheumatic  and  other  forms  of  infectious  endocarditis  can  be  eliminated, 
and  especially  if  there  have  been  neither  previous  arteriosclerosis  nor 
fibroid  degeneration  of  the  viscera,  then  a  reasonably  certain  diagnosis 
of  tuberculous  endocarditis,  given  the  usual  signs  and  symptoms,  can  be 

1  "Tuberculous  Myocarditis,"  Journal  of  the  American  Medical  Association,  Nov.  1, 1902, 
by  the  writer. 


288  INFECTIOUS  DISEASES. 

made.'"i  Of  1232  cases  studied  by  N.  G.  Seymour,  62,  or  5  per  cent., 
were  complicated  by  cardiac  disease,  of  Avbich  25  "were  cases  of  mitral 
incompetency. 

Tuberculosis  of  the  Arteries  and  Veins. 

This  may  arise  from  extension  of  an  adjacent  tuberculous  process  into 
the  vessel,  as  in  chronic  phthisis.  It  causes  infiltration  of  the  arterial 
■wall,  resulting  in  thrombosis,  or  the  vascular  tubercles  may  caseate  and 
soften,  thus  leading  to  hemorrhage.  In  tuberculous  meningitis  tlie  arte- 
rial lesions  are  conspicuous.  The  perforation  of  a  vein  by  an  old  focus 
is  followed  by  a  distribution  to  all  parts  of  the  body  of  numerous  bacilli 
and  the  production  of  acute  miliary  tuberculosis.  Infection  of  the  arte- 
ries may  also  occur  through  the  blood.  Of  1778  cases  of  pulmonary 
tuberculosis,  thrombosis  occurred  19  times,  most  commonly  in  the  veins 
of  the  lower  extremities  (H.  Ruhl  and  Hierokles). 

General  Prognosis. — The  prognosis  is  best  reached  as  in  other 
infectious  diseases — namely,  by  taking  into  account  [a)  the  severity  of 
the  type  of  the  disease  ;  {h)  the  presence  or  absence  of  frequently  associ- 
ated diseases  or  complications ;  and  (c)  the  numerous  circumstances  con- 
nected with  individual  patients. 

(a)  The  Severity  of  the  Disease. — Though  there  are  no  accurate  cri- 
teria, we  may  judge  of  the  severity  of  the  disease  by  its  progress,  by  the 
result  of  proper  treatment,  and  from  certain  symptoms.  If  the  fever  be 
high,  the  prostration  marked,  and  the  local  lesions  rapidly  advancing,  we 
may  safely  infer  that  the  disease  is  of  aggravated  type.  With  these  cer- 
tain other  considerations  are  closely  connected — the  stage  of  the  affection 
and  the  extent  of  the  local  lesions.  Thus  at  an  early  stage  the  prognosis 
is  more  hopeful  than  at  a  late  period,  and,  similarly,  when  the  lesions  are 
strictly  localized  at  one  apex  it  is  more  hopeful  than  when  they  have 
reached  the  stage  of  extensive  cavity-formation  or  are  bilateral.  As 
already  stated,  a  certain  proportion  of  the  cases  manifest  an  inherent 
tendency  to  spontaneous  arrest  or  even  cure,  and  this  may  occur  even 
after  the  stage  of  excavation  has  supervened.  Notwithstanding  this 
truth,  however,  it  is  well  to  make  in  all  undoubted  instances  of  the  dis- 
ease a  guarded  prognosis.  A  common  error  is  the  mistaking  of  a  tem- 
porary for  a  permanent  arrest  of  the  tuberculous  process,  and  in  the  nat- 
ural history  of  the  aifection  the  fact  was  emphasized  that  its  course  was 
interrupted  by  periods  of  comparative  comfort  and  noticeable  improve- 
ment, followed  by  sharp  exacerbations. 

(6)  Associated  Diseases  and  Complications. — These  unfavorably  modify 
the  prognosis — marked  toxic  symptoms  {e.  g.,  rapid  pulse,  high  tempera- 
ture, rapid  emaciation),  chronic  nephritis,  gastric  complications,  intestinal 
and  laryngeal  involvement.  Some  of  the  accidents  of  the  disease  may 
precipitate  a  fatal  result  {vide  Modes  of  Death).  The  appearance  of 
intercurrent  acute  pneumonia  is  indicative  of  danger.  The  detection  of 
secondary  infective  agents  in  the  sputum  renders  the  outlook  worse. 
Other  complications  have  been  detailed  in  the  Clinical  History. 

(c)  Circumstances  Connected  with  Individual  Patients. — (1)  A  feeble, 
delicate  constitution,  either  acquired  or  inherent  (tuberculous  diathesis), 
increases  the  morbidity  of  tuberculosis. 

(2)  When  the  fever  subsides  and  the  patient  gains  flesh  and  strength, 

^American  Journnl  of  Medical  Sciences,  January,  1902,  by  the  writer. 


TIIKA  TMKNT  OF   TUBKR(JUJJ)S1S. 


289 


the  outlook  at  once  brightens.  Maintenance  of  the  weif^ht  curve  while 
the  patient  is  in  his- usual  environment  is  a  favorable  indication.  Kon/el- 
mann  has  observed  a  number  of  instances  in  which  a  tuberculous  process 
of  the  lungs  healed  under  the  influence  of  a  pleural  efiusion,  the  theory 
being  that  the  affected  lung  is  given  rest.  The  temperature  and  local 
symptoms  often  promptly  subside.  A  high  polymorphonuclear  percent- 
age gives  a  bad  prognosis,  while  an  increasing  lymphocyte  percentage 
denotes  favorable  progress.  The  course  of  the  disease  is  unfavorable  in 
cases  showing  tubercle  bacilli  in  the  blood  (Hilgermann  and  Lessen). 

(3)  Hygienic  Surroundings. — When  the  hygienic  regimen  under 
which  the  patient  lives  is  the  best,  the  prospect  is  more  hopeful  than 
when  it  is  faulty.  A  proper  diet  aids  favorable  progress,  while  a  defec- 
tive one  often  turns  the  scales  against  recovery.  Equally  influential  for 
good  is  a  pure  atmosphere,  while,  ^er  contra,  a  vitiated  one  is  injurious. 

(4)  Age. — In  young  subjects  from  five  to  fifteen  years  of  age  tuber- 
culosis often  pursues  an  acute  course  and  the  mortality-rate  is  exceed- 
ingly high.  Chronic  tuberculosis  may,  however,  form  a  sequel,  and 
under  appropriate  surroundings  may  lead  to  recovery.  In  chronic  phthisis 
"the  younger  the  patient  the  shorter  the  duration."  I  have  observed  that 
patients  who  give  a  history  of  pleurisy  early  in  life  do  not  bear  chronic 
phthisis  well.     Naegeli  ^  found,  as  the  result  of  500  autopsies  at  Munich, 


Fig.  25.— Pasteboard  spit-cup  for  receiving  infectious  sputum.    WJien  used  tlie  pasteboard  can  be 
removed  from  the  steel  frame  and  burned, 

that  in  persons  over  thirty  years  of  age  every  one  had  been  more  or  less 
successfully  attacked  by  the  bacillus  tuberculosis ;  bu*^  from  the  fact  that 
most  deaths  had  occurred  in  subjects  under  thirty,  he  concludes  that  the 
adult  body  is,  as  a  rule,  w^ell  able  to  resist  the  attack.  '•  The  absence  of 
a  tuberculous  family  history  has  but  slight,  if  any,  favorable  significance" 
(Bonney).  During  old  age  pulmonary  tuberculosis  is  usually  more  or  less 
latent,  and,  owning  to  coexistent  emphysema  and  chronic  bronchitis,  pur- 
sues a  slow  course.^ 

(5)  The  gravity  of  tuberculosis  may  be  determined  with  some  degree 
of  accuracy  by  the  use  of  creasote  in  gradually  ascending  doses.  Hence 
this  agent  has  a  prognostic  value. 

(6)  Romer  and  Joseph  ^  claim  to  have  demonstrated  beyond  question 
that  one  infection  with  the  tubercle  bacillus  confers  a  certain  protection 
against  subsequent  infection. 

Treatment  of  Tuberculosis. 

Prophylaxis. — (1)  This  embraces  thorough  and  prompt  disinfection 
of  the  sputum  as  the  best  preventive  element.  To  this  end  the  patient 
must  be  taught  to  expectorate  at  all  times  into  a  spittoon  or  spit-cup  which 

^Hyg.  RimchcK  2,  1901. 

-  A  physician  should  not  neglect  to  examine  the  sputum  in  suspicious  cases  for  bacilK. 

3  Beitrdge  zur  Klinik  der  Tuberkulose,  AVui'zburg,  xvii.,  Xo.  3,  p.  2S1. 

19 


290  INFECTIOUS  DISEASES. 

contains  a  proper  disinfectant  solution,  and  when  tlie  break ing-doAvn  stage 
has  arrived  ])ortable  flasks  {e.  g.  DettAviler's)  containing  an  antiseptic  so- 
lution must  be  -worn  by  the  patient,  even  -while  out  of  doors.  Stokes  and 
Schmitz  advise  a  combination  of  alkaline  solution  of  sodium  hypochlorite 
(antiformin)  and  phenol.  Afterward  the  sputum  is  to  be  destroyed  by 
boiling  or  burning  and  the  spit-cup  sterilized.  The  sweat  of  tuberculous 
patients  should  be  removed  at  intervals,  and  the  surface  of  the  body 
bathed  with  appropriate  antiseptics. 

(2)  Isolation. — After  the  stage  of  softening  is  reached  the  patient 
should  invariably  occupy  a  separate  apartment,  since,  despite  great  care, 
the  room  and  bed  occupied  by  the  consumptive  become  in  time  a  source 
of  infection.  Hence,  unwashable  hangings  and  upholstered  furniture, 
as  well  as  other  objects  that  facilitate  the  harboring  of  the  bacilli,  should 
be  removed  from  the  sick-room.  The  floor  of  the  apartment  should 
not  be  carpeted,  but  may  in  part  be  covered  with  rugs  that  can  be  fre- 
quently taken  up  and  shaken  in  the  open  air.  For  like  reasons,  special 
hospitals  and  sanatoria  for  the  treatment  of  the  tuberculous  poor  are  a 
necessity.  Flligge's  important  researches  {vide  supra)  shoAv  that  phthis- 
ical patients  should  wear  a  mask  day  and  night,  that  should  be  removed 
only  for  eating  and  to  expectorate.  Tuberculous  patients  in  the  infec- 
tious stage  of  the  disease  should  be  retired  from  occupations  in  which 
they  may  infect  others  (Flick).  Kissing  by  the  patient  must  be  pro- 
hibited and  all  things  used  or  worn  by  him  should  be  kept  apart  from 
those  used  by  the  family  or  his  friends.  The  prevention  of  auto-infection, 
which  often  results  from  the  swallowing  of  sputum,  is  most  important. 

(3)  Compulsory  registration  of  tuberculous  (pulmonary)  patients  is 
desirable.  This  insures  thorough  disinfection  by  health  officers  of 
houses  in  which  deaths  from  phthisis  have  occurred,  and  serves  to  cut 
off  many  of  the  varied  channels  of  transmission  of  the  tubercle  bacillus, 
provided  that  the  measures  applied  be  not  rigorous. 

(4)  Government  Inspection  of  Dairies  and  Slaughter-houses. — This  is 
the  serious  business  of  the  State,  and,  since  infection  through  food,  espe- 
cially milk,  is  quite  common  in  infants,  skilled  veterinary  inspection  of 
dairies  is  of  prime  importance.  Of  the  greatest  benefit  would  be  the 
killing  of  all  tuberculous  cattle,  and  of  less  though  decided  efficacy  the 
confiscation  at  the  abattoirs  of  all  carcasses  that  present  marked  lesions. 

(5)  The  popularizing  of  information  relating  to  the  dangers  of,  and 
the  means  of  stamping  out,  this  great  scourge.  This  may  be  in  part 
accomplished  by  mural  placards,  stating  simple,  plain  facts  about  the  way 
in  which  the  disease  is  spreading.  Armaingaud  suggests  the  placing  in 
the  homes  of  the  people  printed  matter  in  a  form  suitable  for  preservation. 

(6)  The  Removal  of  Knovm  Predisposition  to  the  Disease. — The  tuber- 
culous diathesis,  whether  inherited  or  acquired,  must  be  overcome,  if  at 
all,  by  vigorous  measures  or  by  better  hygienic  living.  In  attempting  to 
remove  the  phthisical  tendency  the  physician  must  place  chief  reliance 
upon  the  most  favorable  environment  attainable.  The  value  of  a  change 
of  residence — from  the  city  to  the  countr\\  the  seaside,  or  the  mountains, 
in  selected  cases — cannot  be  overestimated.  It  often  renders  predisposed 
persons  immune.  For  some,  and  particularly  young  subjects,  an  equable 
climate  (Southern  California  or  Florida),  that  Avill  enable  them  to  live 
an  out-door  life  is  to  be  preferred.  Attention  to  the  food  must  not  be 
forgotten.     Milk  and  raw  eggs  are  excellent  and  should  be  used  freely. 


TREATMENT  OF  TUBERCULOSIS.  '^01 

Daily  sponging  of  the  neck  and  thorax  with  oohl  water  is  hcncficial,  and 
appropriate  liglit  gymnastics  should  be  instituted  if  the  subject  be  ohl 
enough.  In-door  occupations  are  to  ]/e  forbi(hlen,  and  tlie  ventilation  of 
living-  and  bed-rooms  must  be  looked  after  carefully. 

Tuberculosis  is  apt  to  develop  especially  in  children  while  convalescing 
from  acute  fevers,  and  hence  during  this  period  the  child  should  be 
strengthened  by  vigorous  feeding,  pure  air,  and  tonics.  In  children 
predisposition  often  results  from  obstructions  in  the  nose  and  from 
persistently  enlarged  tonsils ;  and  they  should  be  promptly  removed. 
All  local  foci  of  tuberculosis  in  children — glandular,  osseous,  and  artic- 
ular— must  be  attacked  surgically. 

Treatment  of  the  Disease. — The  treatment  of  tuberculosis,  re- 
garded as  a  parasitic  disease,  presents  two  leading  indications.  One  has 
reference  to  the  destruction  of  the  specific  cause,  the  tubercle  bacilli,  by 
the  use  of  antiseptic  inhalations  or  of  some  parasiticide  taken  internally. 
Of  the  numerous  substances  used  by  inhalation,  few  have  given  satisfac- 
tory results,  this  being  largely  due  to  our  inability  to  convey  them  to  the 
smaller  bronchi  in  a  sufficient  degree  of  concentration.  They  are  best 
adapted  to,  and  most  efficacious  in,  cases  in  which  the  larynx  is  involved. 

The  inhalation  of  antiseptic  substances  may  be  accomplished  in  various 
ways — by  inhaling  vapors,  by  the  use  of  the  steam  atomizer,  or  by  some 
form  of  "  respiration-inhaler."  I  have  long  employed  the  Robinson  in- 
haler, the  sponge  of  which  is  moistened  with  a  few  drops  of  a  mixture 
made  of  equal  parts  of  creosote,  chloroform,  and  alcohol,  the  patient  wear- 
ing the  inhaler  when  not  eating  or  sleeping.  Unfortunately,  most  patients 
object  to  the  constant  use  of  this  instrument.  When  hemoptysis  is  pres- 
ent, turpentine  may  be  added  to  the  above  mixture.  The  chief  among 
other  antiseptics  thus  employed  are  carbolic  acid,  terebene,  terpin  hydrate, 
thymol,  formalin,  and  oil  of  peppermint. 

The  most  common,  because  least  objectionable,  mode  of  introducing 
this  class  of  substances  is  by  internal  administration.  According  to  the 
results  reported  from  all  quarters  of  the  world,  creasote  thus  employed 
alone  enjoys  the  confidence  of  the  profession  ;  and  in  common  with  nu- 
merous other  observers  I  have  found  its  continued  use  to  be  followed  by 
lessened  cough  and  expectoration,  lessened  fever,  and  by  a  lessening  or 
cessation  of  the  night-sweats,  with  a  gain  of  strength  and  weight  as  the 
natural  consequence.  It  must  be  borne  in  mind  that  the  dose  is  to  be 
gradually  increased  to  the  point  of  gastric  tolerance,  which  in  my  experi- 
ence rarely  exceeds  15  to  20  drops  (0.999)  three  times  a  day. 

Following,  in  the  main,  the  practice  of  Trudeau,  who  has  used  this 
drug  quite  as  extensively  as  any  other  American  physician,  after  reach- 
ing the  point  of  tolerance  I  gradually  reduce  the  dose  to  and  maintain  it 
at  5  or  6  drops  (0.333),  three  times  daily.  Among  the  best  vehicles  are 
hot  milk,  hot  water,  and  diluted  alcohol.  Recently  I  have  ordered  it  in 
capsules,  which  the  patient  himself  fills  at  the  time  of  using,  and  have 
found  it  a  popular  and  ready  mode  of  administration.  When  creasote  is 
not  well  borne  by  the  stomach  and  its  inhalation  is  seriously  objected  to 
by  the  patient,  it  may  be  given  by  enema,  the  dose  being  20  to  30  drops 
(1.332),  in  peptonized  milk  or  mixed  with  a  little  egg-white.  It  has  also 
been  employed  hypodermically  in  a  10  per  cent,  solution  in  oil  of  sweet 
almonds,  the  dose  of  which  is  1  dram  to  11  drams  (4.0-6.0).  Lastly,  it 
has  in  rare  instances  been  employed  by  inunction. 


292  INFECTIOUS  DISEASES. 

Guaiacol.  particularly  in  the  form  of  the  carbonate,  has  of  late  been 
(juite  extensively  employed  in  place  of  creasote,  of  which  it  is  the  chief 
active  principle.  It  may  be  administered  in  pill  or  capsule,  the  dose 
being  slightly  less  than  that  of  creasote.  It  is  well  tolerated  by  the 
stomach,  and  is  broken  up  in  and  absorbed  from  the  intestinal  canal. 

Among  other  remedies  prescribed  for  their  supposed  parasiticidal 
effect  are  arsenic  and  mercuric  chlorid,  but  they  are  clearly  inferior  to 
creasote. 

I  am  of  the  opinion  that  all  antiseptics  used  internally  in  this  disease 
have  for  their  chief  influence  a  modification  of  the  soil-conditions  on 
which  the  growth  and  multiplication  of  the  bacilli  depend.  They  are, 
in  truth,  of  great  value  in  fulfilling  the  second  leading  indication  of 
treatment,  which  is  to  overcome  the  bodily  receptivity  for  the  specific 
bacillus,  or  to  aid  the  natural  defensive  processes  in  limiting  the  destruc- 
tive work  of  the  latter.  All  forms  of  tuberculosis,  however,  may  heal 
spontaneously  in  any  stage,  especially  the  local  varieties  so  common  in 
children,  affecting  the  lymph-glands,  joints,  and  bones. 

Old  pleuritic  lesions,  a  large  proportion  of  which  are  tuberculous  in 
nature,  are  constantly  met  with  at  autopsies  in  persons  dying  suddenly 
of  other  diseases.  Spontaneous  recovery  is  seen  oftenest  in  cases  that 
have  not  progressed  to  the  stage  of  cavity  formation.  Indeed,  in  the 
instances  in  which  vomicae  of  considerable  size  have  formed,  cicati'iza- 
tion  or  complete  cure  is  out  of  the  question,  though  they  may  become 
encapsulated  (quiescent).  The  percentage  of  cases  in  which  encapsulated 
and  obsolete  lesions  have  been  observed  at  the  postmortem  table  in  per- 
sons dying  of  all  causes  difters  widely  with  the  statistics  of  different 
observers.  If  we  consider  the  cases  that  are  latent  from  an  early  period 
in  life,  together  with  those  of  all  ages  after  childhood,  it  is  doubtless  true 
that  in  more  than  50  per  cent,  of  the  human  family  the  bacilli  effect  a 
lodgment.  Since  about  14  per  cent,  of  the  deaths  from  all  causes  can 
be  ascribed  to  tuberculosis,  there  must  be  manifested  a  strong  tendency 
to  limitation  and  healing. 

In  removing  the  diathesis  medicines  are  unquestionably  of  less  value 
than  the  hygienic  treatment,  the  latter  in  the  widest  sense  of  the  term 
aiming  to  reinforce  Nature's  efforts  at  spontaneous  recovery,  and  embrac- 
ing four  main  elements  :  (1)  Climate ;  (2)  Feeding ;  (3)  Special  Eeme- 
dies  ;  (4)  Treatment  of  Leading  Symptoms. 

(1)  Climate. — The  all-powerful  influence  of  environment  has  already 
been  pointed  out.  Experience  and  observation  have  shown  that  certain 
climates,  selected  with  particular  reference  not  only  to  the  stage  of  the 
affection,  but  more  particularly  to  the  individual,  are  useful  modifying 
influences  of  the  tissue-soil.  In  any  case  of  tuberculosis  that  climate  is 
most  suitable  in  which  the  patient  "  feels  well,  eats  well,  sleeps  well,  and 
gains  flesh  and  strength  "  (Delafield).  Until  the  patient  finds  such  a 
climate,  or  if  he  finds  no  single  climate  to  produce  these  results,  he  should 
travel  from  place  to  place,  unless  special  contraindications  (excessive  de- 
bility, etc.)  exist.  If  active  tuberculosis  has  existed,  the  stay  in  a 
suitable  climate  should  not  be  less  than  two  full  years. 

The  climatic  requisites  for  a  consumptive  are  (a)  purity  of  air,  (b) 
equability,  and  {c)  abundant  sunshine.  Less  beneficial,  though  impor- 
tant, are  [d)  dryness  and  (t;)  altitude. 

(a)  Purity  of  Air. — This  requirement  is  of  paramount  importance, 


TREATMENT  OF  TUBERCULOSIS.  203 

and  thus  is  expl;i,ined  the  fact  that  mountain  air  and  that  of  the  virgin 
forest  are  so  helpful  in  phthisis.  Forests,  and  particularly  pine-groves, 
favor  atmospheric  purification,  since  they  generate  ozone,  which  oxidizes 
the  impurities  contained  in  the  air. 

(b)  i^quability  has  I'eference  to  the  absence  of  rapid  variations  of  tem- 
perature. On  the  whole,  a  relatively  low  is  better  than  a  high  tempera- 
ture, the  former  being  stimulating,  and  the  latter  sedative,  in  effect.  It 
should  be  pointed  out  that  forests  also  greatly  favor  the  quality  of  equa- 
bility,^ both  as  to  temperature  and  relative  humidity.  They  tend  to 
maintain  an  almost  unvarying  degree  of  moisture  in  their  vicinity,  thus 
minimizing  the  diurnal  variations  of  temperature — a  point  that  is  of  far 
greater  importance  than  the  question  of  seasonal  variations.  Forests 
intercept  and  temper  the  bleak  Avinds  of  winter,  while  by  their  shade  and 
leaf-surfaces  they  afford  a  cooler  temperature  in  summer. 

{c)  Abundance  of  sunshine  is  demanded  by  the  consumptive.  The 
advantages  of  sunshine  are  obvious  frorn  the  observations  made  by  Munn  ^ 
in  the  year  1892,  when  in  Denver  there  was  sunshine  in  62  per  cent,  of 
the  possible  hours  during  which  it  could  occur.  A  dry  atmosphere  has 
advantages,  but  that  dryness  is  not  an  essential  element  is  shown  by  the 
fact  that  patients  often  do  well  at  places  having  comparatively  high  rela- 
tive humidity,  such  as  Florida,  Southern  Georgia,  Southern  California, 
and  the  resorts  on  the  south  coast  of  England.  The  rarefied  atmosphere 
of  high  altitudes,  on  account  of  its  stimulating  effect  upon  the  respiratory 
function,  aids  in  producing  good  results,  but  the  pulmonary  changes  in- 
duced (enlargement  of  the  air-cells,  with  augmentation  of  the  size  of  the 
chest)  make  it  necessary  for  patients  to  remain  for  the  rest  of  their  lives. 
That  it  is  not  an  essential  factor  is  shown  by  the  excellent  results  obtained 
in  the  ofttimes  purer  atmospheres  at  lower  levels.  Cases  in  which  hem- 
optysis is  severe  and  of  frequent  occurrence,  those  complicated  with  weak 
hearts,  and  neurasthenic  subjects  should  not  be  sent  to  the  high  altitudes. 

The  essential  climatic  factors  mentioned  are  found  in  certain  American 
and  European  resorts.  Of  the  former,  the  Adirondack  region,  Colorado, 
Arizona,  and  New  Mexico  are  especially  to  be  mentioned,  combining  as 
they  do  in  winter  a  uniform  cold,  much  sunshine,  and  purity  of  atmo- 
sphere. A  camp-  or  tent-life  in  the  open  air  is  strongly  advocated.  Ac- 
cording to  my  own  experience,  the  Adirondacks  meet  the  indications  best 
in  early  cases  or  in  patients  who  have  strength  enough  to  lead  an  outdoor 
life,  and  in  whom  the  breaking-down  stage  is  not  too  far  advanced. 
Some  cases,  in  the  early  stage,  also  do  well  at  Thomasville,  Ga.,  South- 
ern California,  and  at  Lakewood,  New  Jersey.  Some  of  these  resorts 
possess  the  added  advantage  of  affording  an  opportunity  of  gaining  a  liveli- 
hood. Among  foreign  resorts,  Davos  possesses  about  the  same  advan- 
tages as  may  be  met  in  Colorado,  New  Mexico,  and  the  Adirondacks, 
while  the  resorts  in  Southern  Italy  and  France  are  comparable  to  South- 
ern California,  Southern  Georgia,  Florida,  and  the  Bermudas  in  this 
hemisphere.  Good  culinary  and  home  comforts  are  considerations  of  no 
less  importance  than  the  climate. 

Briefly,  the  atmosphere  of  forest  resorts  possesses  certain  unmistakable 
advantages  for  this  group  of  sufferers.  Hence  they  should  be  sent  into 
the  neighborhood  of  the  nearest  forest  in  mild  latitude  (if  they  cannot 
enjoy  the  advantages  of  more  remote  resorts),  where   reasonably  good 

^  Houserflants  as  Sanitary  Agents  ;  Sanitary  Influence  of  Forest  Growth,  p.  31 2,  by  the 
writer.  ^  Medical  News,  Aug.  18,  1894. 


294  INFECTIOUS  DISEASES. 

food  and  other  comforts  of  life  are  obtainable.  The  superior  value  of 
the  highly  ozonized  and  torebiuthinized  atmosphere  of  the  pine-groves  in 
largngeal  tuberculosis  cannot  be  too  strongly  emphasized. 

Sanatoriiua  Treatment. — While  it  is  essential  to  send  patients  to 
suitable  resorts,  the  most  satisfactory  results  are  obtained  from  the  com- 
bined climatic  and  sanatorium  treatment.  Sanatoria  are  warmly  advo- 
cated by  Trudeau,  Knopf  liowditch,  and  others.  Of  237  early  cases, 
treated  in  the  Sharon  Sanatorium,  81  per  cent,  were  known  to  be  alive 
and  in  excellent  health  for  at  least  one  year  after  leaving  the  institution.^ 
They  should  take  the  form  of  cottages  and  pavilions.  The  principal  ad- 
vantages oifered  are  due  to  a  rigid  system  of  hygiene  under  the  close 
supervision  of  competent  medical  officers.  There  xwe  four  groups  of  cases 
among  the  middle  and  lower  classes  that  recjuire  institutional  treatment: 

Group  I. — The  numerous  cases  that  have  progressed  to  an  advanced 
and  practically  hopeless  stage  and  the  acute  forms.  These  require  every 
comfort  and  kind  care,  such  as  can  be  furnished  by  special  Jiospitah  for 
consumption  in  a  healthful  urban  locality. 

Grouj)  II. — Incipient  cases  among  the  pauper  element.  For  these, 
sanatoria  located  close  to  large  municipalities,  though  with  special  refer- 
ence to  such  factors  as  purity  of  atmosphere  and  protection  from  chilly 
blasts,  by  natural  elevations  or  the  woodland,  should  be  provided. 

Group  III. — Phthisis  pulmonalis  among  the  middle  and  working  class, 
or  persons  having  small  means.  The  members  of  this  group  will  find 
themselves  compelled  to  depend  principally  upon  private  philanthrop\% 
and  probably  to  some  extent  also  upon  semi-State  institutions ;  they 
need  sanatorium  treatment  in  the  best  climates,  and  there  is  no  valid 
reason  Avhy  the  combined  sanatorium  and  climatic  treatment  should  not  be 
attempted,  since  such  an  undertaking  could  be  made  almost  self-sustaining.' 

Group  lY. — "  A  settlement  for  patients  with  arrested  consumption 
where  they  can  be  employed  on  work  adapted  to  their  strength" 
(PowelP). 

Among  home  sanatoria  are  the  Adirondack  Cottage  Sanatorium,  the 
Sharon  Sanitarium,  near  Boston,  the  Loomis  Sanatarium,  at  Liberty, 
N.  Y.,  the  Winyah  Sanitarium,  at  Asheville,  N.  C,  the  White  Haven 
Sanitarium  and  Mont  Alto  in  Pennsylvania.  Foreign  sanatoria  are  to  be 
found  at  Falkenstein,  near  Frankfort-on-the-Main,  Goerbersdorf,  and 
llohenhonnef.  Solaria,  in  connection  with  city  hospitals  for  advanced 
cases,  would,  I  am  certain,  yield  gratifying  results.  Home  sanatoria  can 
be  readily  improvised  by  stocking  living  apartments  Avith  growing  plants. 
The  beneficial  influences  arising  from  the  presence  of  the  latter  are 
ascribable  to  two  functions — the  generation  of  ozone  and  transpiration.* 
Tuberculosis  dispensaries  and  classes  ai'e  highly  recommended  in  the 
treatment  of  tuberculosis  among  the  poor  and  persons  having  small  means. 
The  class  method  is  useful  as  an  object  lesson  to  teach  the  essentials  in 
the  home  that  ai'e  taught  to  the  individual  in  a  sanatorium  (Wood). 

Open-air  Treatmevt  at  Home. — This  method  is  now  widely  practised. 
It  is  of  inestimable  value  to  patients  who  must  perforce  be  treated  at 
home.     They  are  kept  constantly  in  the  open  air,  and  for  the  most  part 

1  V.  Y.  Bowditch  and  W.  A.  Griffin,  Jour.  Amer.  Med.  J.ssoc,  Dec.  24,  1912,  2132. 
2"  Sanntoria  and  Special  Hosjiitals  for  the  Poor  Consumptive  and  Persons  Avitli  Slight 
Means,"  by  tlie  writer. 

^Lancet,  Jan.  6,  1906.  ^  Ibid,  by  the  writer,  p.  168. 


TREATMENT  OF  TUJJERC'ULOS/S.  295 

at  rest.  At  night  tlie  bed-room  windows  should  be  open,  even  in  severe 
weather.  Indeed,  sleeping  in  the  open  air  on  a  veranda,  poreh,  or  the 
roof,  is  to  be  advised  and  encouraged,  and  ingenious  contrivances  have 
been  invented  whereby  the  patient  can  occupy  a  bed  out-of-doors  at  all 
seasons  of  the  year.  With  warm  clothing,  abundance  of  good  food, 
especially  raw  eggs  and  milk,  and  a  careful  regimen,  surprising  results 
are  obtained  even  in  large  cities.  In  my  opinion,  however,  most  tuber- 
culous patients,  at  all  events,  require  the  rigorous  discipline  of  a  sanato- 
rium for  a  variable  period  of  time  so  that  they  may  acquire  proper  habits 
of  living.  Such  a  sanatorium  for  the  reception  of  indigent  patients  should 
be  situated  in  their  home  climate.  The  experiment  has  already  been  made 
in  Chicago  and  other  cities  with  complete  success.  When  the  tempera- 
ture is  above  100°  F.  (38.7°  C.)  the  patient  should  be  kept  at  rest. 
Flick,  Minor,  and  Coleman  are  of  the  opinion  that  tuberculosis  patients 
can  be  successfully  treated  in  their  homes  and  other  places  than  sanatoria. 

(2)  Feeding. — The  diet  should  be  both  nutritious  and  generous.  Too 
close  attention  cannot  be  bestowed  upon  the  feeding.  Above  all,  when 
the  remedies  prescribed  (cod-liver  oil,  creasote)  embarrass  in  the  slightest 
degree  the  function  of  the  stomach  they  must  be  stopped. 

Such  albuminous  articles  as  milk,  eggs,  flesh,  fish,  and  fowl,  together 
•with  an  abundance  of  fats,  should  be  taken.  The  hydrocarbons  are 
urgently  needed,  but  they  must  be  taken  with  care  lest  they  derange  the 
digestive  function.  Over-alimentation  with  raw  eggs  and  milk  is  strongly 
advised.  The  eggs  are  to  be  slightly  beaten  and  stirred  into  the  milk 
and  the  quantity  is  to  be  increased  until  from  eight  to  twelve  eggs  and 
as  many  glasses  of  milk  are  taken  daily.  One-half  of  this  amount  may 
be  used  during  the  morning  hours  and  the  other  half  during  the  evening 
hours.  At  mid-day  a  generous  meal  composed  of  easily  digestible  solids 
is  allowed.  In  advanced  cases  it  is  often  needful  to  resort  to  a  rigid  sys- 
tem of  feeding,  giving  a  small  quantity  of  food,  such  as  milk,  meat-juice, 
egg-white,  and  the  like,  at  brief  intervals.  The  French  method  of  forced 
feeding  deserves  a  trial  if  there  be  absolute  loathing  for  food.  It  consists 
of  first  washing  out  the  stomach  with  cold  water,  and  then  introducing  the 
following  mixture  thrice  daily :  1  liter  of  milk,  an  egg,  and  100  grams 
of  very  finely  powdered  meat.  As  a  rule  the  patient  cannot  be  induced 
to  swallow  this,  and  it  then  must  be  poured  through  a  stomach-tube.  In 
a  minority  of  the  cases  the  appetite  is  ordinarily  keen,  often  as  a  result 
of  change  of  air,  and  these  usually  pursue  a  favorable  course.  The  fol- 
lowing combinations  will  be  found  useful  in  assisting  the  appetite: 

]^.   Sodii  bicarb.,  3jss  (6.0); 

Tr.  nucis  vomicae,  f^ijss  (10.0); 

Glycerini,  f^j       (3.75); 

Inf.  cascarillge,  q.  s.  ad  f§iv    (120.0). 

Sig.  3ij  (8.0)  t.  i.  d.,  in  water,  fifteen  minutes  before  meal-time. 

Other  simple  bitters  and  mineral  acids  may  be  tried,  and  there  are 
some  cases  in  which  the  judicious  use  of  stimulants,  particularly  wines 
and  malt  liquors,  aids  the  appetite  and  digestion  matei'ially.  The  chief 
indications  for  the  exhibition  of  alcohol  are  loss  of  appetite,  feeble  di- 
gestion, and  weak,  rapid  action  of  the  heart.  Brandy  or  whisky  in  the 
form  of  milk-punch  may  be  given  freely  in  the  advanced  stage.      Strych- 


296  INFECTIOUS  DISEASES. 

nin  is  a  valuable  remedy  in  the  later  stages.  Lavage  has  helped  some 
of  my  cases  immensely.  Lastly,  an  orderly  method  and  sound  judgment 
must  be  bronghr  to  bear  in  arranging  the  diet  and  drink. 

(o)  Special  Remedies. — The  treatment  of  tuberculosis  by  mercury  has 
been  \videly  adopted.  Wright '  recommends  the  succinimidum,  and  the 
details  follow:  "  One  injection  of  hydrargyrum  succinimidum,  grain  -l,  is 
given  every  other  day  until  30  injections  have  been  given.  Then  injec- 
tions are  discontinued  and  potassium  iodid.  grain  iij  to  x,  is  given  "well 
diluted  Avith  water  one-half  hour  after  meals  for  two  weeks.  Then  potas- 
sium iodid  is  discontinued  and  no  medicine  is  given  for  one  week. 
Injections  are  then  resumed  as  follows  :  One  injection  every  other  dav 
until  30  injections  have  been  given,  on  alternating  injection  days  giving 
hydrargyrum  succinimidum,  grain  i  and  -^^,  respectively.  After  the 
thirtieth  injection  the  same  course  of  potassium  iodid  is  given  as  followed 
the  first  series  of  injections  :  then  a  week  free  from  medication.  The 
injections  are  then  resumed  again,  the  succinimide.  grain  jL^  being  given 
every  other  day  until  30  injections  have  been  given.  By  the  end  of  this 
third  series  experience  will  direct  any  necessary  further  treatment." 

Cod-liver  oil  is  another  special  remedy  of  great  value.  It  may  rarely 
cause  further  impairment  of  the  appetite  and  digestion,  or  set  up  intes- 
tinal disturbances,  when  its  effects  are  harmful.  The  commencing  dose 
should  be  small  (oj — 4.0,  once  or  twice  daily,  to  be  increased  after  a  time 
to  oij — S-'-^  two  or  three  times  daily).  It  should  be  taken  about  meal- 
time. AVhen  the  oil  is  not  well  borne,  it  may  be  given  in  combination  with 
an  alkali  (lime,  soda).  As  a  substitute  for  cod-liver  oil,  cream,  preferably 
Devonshire,  may  be  tried  (sij  to  5ss — 8.0  to  16.0,  three  times  daily). 

The  hypopliosphites  are  especially  serviceable  in  a  certain  proportion 
of  the  cases.      The  dose  is  oj  to  ij  (4.0-8.0)  thrice  daily,  after  food. 

Arsenic  is  warmly  advocated  for  its  general  influence  in  this  disease. 
The  dose  should  be  small,  so  that  it  may  be  given  for  a  long  time  without 
interruption.  As  sodium  cacodylate,  its  use  has  increased  of  late.  Jacobi 
speaks  highly  of  digitalis  in  tuberculosis  in  children. 

Iodoform-  or  europlien-inundions  are  warmly  commended  by  Flick, 
who  asserts  his  belief  that  incipient  cases  almost  always  can  be  cured  in 
this  Avay,  and  that  advanced  cases  can  be  improved.  Crofton  advises  the 
use  of  iodoform  intravenously  (gr.  \  to  j — 0.0162  to  0.0648,  dissolved  in 
ether  with  a  little  liquid  paraffin  added)  two  to  five  times  a  week. 

Serum-therapy. — The  definition  of  this  term  embraces  also  the  em- 
ployment of  toxins  and  modified  toxins  produced  in  various  media  for  the 
establishment  of  artificial  immunity.  Kochs  tuberculin.  Rosenbach's 
tuberculin,  and  Paquin's  antitubercle-serum  have  been  highly  recom- 
mended as  remedies  in  tuberculosis  by  certain  clinicians.  Dr.  Trudeau 
prefers  antitoxic  immunity,  and  considers  tuberculin  habituation  its  es- 
sential feature  and  the  best  guide  to  dose ;  this  requires  long-continued 
and  almost  iiuporceptible  progression  in  dosage  until  a  maximum  is 
reached  without  causing  general  or  local  reactions.  A.  E.  Wright  rec- 
ommends Kochs  tuberculin,  claiming  that  in  patients  so  treated  the  for- 
mation of  opsonins  is  stimulated,  as  shown  by  a  remarkable  increase  in 
the  phagocytic  index.  Penrose^  first  obtains  a  good  tolerance  dosage  of 
tuberculin,  then  administers  a  course  of  succinimid  of  mercury,  and  later 
alternates  the  tw^o  remedies  with  a  view  to  using  larger  doses  of  tuberculin 

1  Jour.  Am^r.  Med.  Assoc,  Nov.  28,  1908.         "^ New  York  Med.  Jour.,  June  11,  1910. 


TREATMENT  OF  TUBERCULOSIS.  297 

without  risk.  Vaccines  made  from  associated  organisms  isolated  from  the 
sputum  are  of  marked  vahie  in  the  treatment  of  tuhei-culosis,'  Escoyer 
chiims  53.8  per  cent,  of  radical  cures  from  the  use  of  Cu^'uillere's  serum. 

Brauer,  Wellman,^  and  others  recommend  artificial  ];)ncumothorax  in 
the  treatment  of  selected  cases  of  pulmonary  tuberculosis.  A  limited  in- 
volvement of  one  apex  may  present  an  indication  for  either  surgery,  or 
the  injection  of  nitrogen  into  the  pleural  cavity  which  may  be  the  more 
effective  (Mumford).  Bayle  claims  to  have  cured  75  per  cent,  of  172 
patients  with  spleen  organotherapy. 

Tlie  advent  of  an  acute  diseaae  may  arrest  and  cure  a  tuberculous 
process.  Thus,  the  symptoms  and  signs  of  advanced  tuberculosis  have 
disappeared  after  an  attack  of  virulent  small~pox  and  acute  rheumatism 
(Harris  and  Beales).  Hysteria  also  exercises  an  ameliorating  effect  upon 
pulmonary  tuberculosis,  according  to  the  observations  of  Gibotteau,^  who 
advises  against  treatment  of  the  former  disease  in  tuberculous  persons. 

Treatment  of  the  Acute  Forms. — The  treatment  of  acute  tuberculosis 
is  an  expectant  one.  The  special  measures  recommended  above  should 
be  tried,  but  are  rarely  effective,  and  a  change  of  climate  is  inadvisable. 
Supportive  measures,  such  as  stimulants  and  nutritious  aliment,  are  re- 
quired. The  medicinal  treatment  must  be  adapted  to  the  acute  febrile 
condition,  but  all  depressants  are  to  be  avoided.  Special  symptoms  may 
be  relieved  in  accordance  with  general  principles. 

In  renal  tuberculosis,  recent  experience  confirms  anew  the  importance 
of  prompt  nephrectomy.  When  this  is  impossible,  for  any  reason,  coui'ses 
of  mineral  waters  may  prove  useful.  Castaigne  reports  5  cases  in  which 
he  used  tuberculin  or  Spengler's  immunizing  bodies,  or  both,  with  ulti- 
mate success.  Barney  recommends  epididymectomy  in  cases  of  tuber- 
cular epididymitis.  In  tuberculous  peritonitis,  Hoffmann  reports  good 
results  from  opening  the  peritoneal  cavity,  evacuating  the  fluid,  if  present, 
and  painting  the  peritoneal  surfaces  of  the  gut  and  abdominal  wall  with 
10  per  cent,  tincture  of  iodine.  In  tuberculous  adenitis,  the  Rcintgen 
rays  should  be  employed  early. 

(4)  Treatment  of  Leading  Symptoms. — {a)  Cough. — This  is  often  quite 
annoying.  The  special  cause  or  causes  of  the  coughing  should  be  deter- 
mined before  any  attempt  is  made  to  treat  it.  When  attributable  to 
catarrhal  irritation  of  the  upper  air-passages,  it  is  best  treated  by  topical 
applications.  The  following  substances  may  be  inhaled  :  compound 
tincture  of  benzoin,  combined  with  paregoric  or  carbolic  acid ;  formalin  ; 
creasote,  alcohol,  and  chloroform  in  equal  parts.  For  local  applications 
by  means  of  the  spray  sedatives  and  narcotics  should  be  preferred,  and  a 
solution  of  cocain  is  sometimes  most  efiicient.  The  cause  may  be  found 
in  pleurisy  or  pleuritic  adhesions,  and  for  this  condition  counter-irritants, 
as  iodin,  sinapisms,  etc.,  may  be  used.  Pleuritic  coughs  often  demand 
codein  or  even  morphin  in  moderate-sized  doses.  The  cough  is  in  most 
instances  occasioned  by  the  tuberculous  bronchitis,  and  to  a  lesser  ex- 
tent by  the  vomicae.  Cough-mixtures  as  usually  formulated  are  apt  to 
disorder  the  digestive  function,  and  in  so  far  as  they  have  this  effect 
they  are  positively  harmful.  Syrups  should  be  omitted  from  their  com- 
position. Creasote  by  inhalation  is  the  remedy  par  excellence  for  tuber- 
culous   bronchitis,    combined   with    spirits    of   chloroform    and    alcohol. 

iSee  also  Neio  York  Med.  Jour.,  Nov.  11,  1911,  hv  G-.  Sanders. 
^Beitrdge  zur  Klinik  der  Taberkulose,  Wiirzburg,  Dec.  10,  1910,  p.  2100. 
3  The  Practitioner,  October,  1894. 


298  INFECTIOUS  DISEASES. 

When  expectoration  is  copious,  preparations  of  terebene,  terpin  hydrate, 
and  tar  may  be  resorted  to ;  and  Avheu  the  cough  becomes  distressinji,  I 
employ  codein  (gr.  |-^ — 0.008  to  0.016,  every  three  or  four  hours)  in 
the  form  of  a  granule.  In  the  later  stages  morphin  is  alloAvable,  since 
it  is  at  this  time  that  constant  coughing  or  severe  paroxyms  of  cough, 
if  not  restrained  lead  to  utter  exhaustion.  Heroin,  in  doses  of  gr.  -^  to  -^\ 
(0.01-0. 005),  three  or  four  times  a  day.  acts  beneficially  in  allaying  the 
cough  th»t  accompanies  phthisis.  Stimulant  expectorants  may  be 
needful,  and  ammonium  carbonate  in  the  infusion  of  wild-cherry  bark  is 
perhaps  most  efficacious  :  a  few  drops  of  the  deodoi'ized  tincture  of  opium 
or  spirits  of  chloroform  may  be  added. 

{b)  Fever. — Creasote  has  found  a  new  field  of  usefulness  in  the  treat- 
ment of  the  fever  of  tuberculosis.  In  my  experience  at  all  events, 
the  cases  in  which  it  has  been  used,  as  above  indicated,  have  shown  a 
greatly  diminished  febrile  movement.  Cold  or  tepid  spongings  of  the 
body  at  intervals  of  one,  two,  or  three  hours,  according  to  the  intensity 
of  the  fever,  should  be  tried.  Internal  antipyretics  are  rarely  advisable, 
since  during  the  period  of  high  temperature  the  cardiac  action  is  much 
enfeebled ;  but  if  urgently  called  for,  the  following  may  be  employed : 
acetanilid  (dose  gr.  ij— iij — 0.129—0.194).  phenacetin  (gr.  iij-v — 0.194- 
0.324).  These  are  to  be  administered  about  two  hours  before  the  com- 
mencement of  the  daily  rise  in  temperature,  and  repeated  every  three  or 
four  hours  if  necessary.  Other  antipyretics  worthy  of  trial  are  the  min- 
eral acids  and  zinc  oxid,  but  not  quinin,  which  has  utterly  failed  in  my 
hands.  Keeping  the  patient  at  complete  rest  wlien  there  is  fever  is  of 
the  utmost  importance,  though  he  should  be  wheeled  into  the  fresh  air  for 
as  long  a  time  as  possible  during  the  day. 

(e)  The  Niglit-siveats. — Among  remedies  that  control  the  sweats  most 
successfully  may  be  mentioned — atropin  (gr.  xi'^^eV — 0.0005-0.001)  ; 
zinc  oxid  (gr.  ij— v — 0.129—324);  sulphuric  or  gallic  acid;  muscarin 
(TTLiij-vj — 0.399  of  a  1  per  cent,  solution) ;  agaricin  (gr.  -i— 1 — 0.008- 
0.016).  Sponging  with  equal  parts  of  alcohol  and  tincture  of  bella- 
donna is  very  effective,  but  my  own  best  results  have  been  derived 
from  the  use  of  atropin  (gr.  y^o~9V — 0.0005-0.0007)  in  combination 
with  agaricin  (gr,  -1 — 0.008). 

{d)  Secondary  Anemia. — Bullock  and  Peters  recommend  subcutaneous 
injections  of  citrate  of  iron  (0.05  gm.  injected  daily).  Barlow  and  Cun- 
ningham advise  the  subcutaneous  or  intramuscular  injection  of  arsenic  or 
iron,  or  of  the  two  in  organic  combination. 

{e)  Dysphagia  may  be  a  troublesome  symptom,  especially  from  in- 
volvement of  the  larynx,  and  it  is  best  met  by  local  applications  of  a 
solution  of  cocain  in  glycerin  and  water  (gr.  x  to  5J-0.648  to  32.0), 
thrice  daily  before  meals.  In  advanced  cases  I  have  resorted  to  hypo- 
dermic injections  of  morphin  (gr.  -| — 0.008)  before  meal-time. 

(/)  Gastric  Disturbance. — In  nearly  all  cases  of  phthisis  dyspeptic 
symptoms  come  on  sooner  or  later,  and  for  this  gastric  disorder  nothing 
is  so  important  as  a  proper  regulation  of  the  diet.  Perhaps  the  medical 
treatment  of  the  stomach  symptoms  has  been  dealt  with  at  sufficient 
length,  save  that  of  vomiting,  Avhich  may  come  on  after  meals  and  con- 
stitute a  distressing  concomitant.  Those  remedies  giving  the  best  results 
may  be  adduced  as  follows:  cerium  oxalate  (gr.  v— viij — 0.324-0.518),  in 
capsules  before  meals  ;  calomel  and  soda  in  fractional  doses  ;  hydrocyanic 


LKI'ROSY.  299 

acid  (TTLij-iij — 0.133-0.190)  ;  uiid  chipped  ice  with  hriindy  sprinkled 
over  it,  taken  at  short  intcrviils,  but  es{)ecial]y  sliortly  before  rneal-lirne. 
i^g)  Diarrhea. — The  most  important  factor  in  the  treatrwent  of  this 
symptom  is  a  properly  restricted  dietary.  Alum  whey,  mutton  and 
chicken  essence  are  of  service,  but  curds  of  milk,  beef-tea,  and  solids 
are  not  suitable.  Of  the  numerous  medical  measures  that  have  been 
employed,  the  most  useful  are  bismuth  subgallate,  lead  acetate,  opium, 
thymol,  salol,  benzo-naphthol,  and  naphthalin.  To  these  may  be  added 
the  following  acid  diarrhea-mixture,  each  dose  containing — 

3^.  Acid,  acetici  dil.  X^x         (0.666); 

Morphinse  acetat.,    '  gr.  |-       (0.008) ; 

Plumbiacetat.,  gr- j-ij  (0.0648-0.1296). 

Complications    when    they    arise    must    be   dealt  with  according  to 
accepted  therapeutic  principles. 


LEPROSY. 

{Lepra). 


Definition. — A  chronic,  contagious  disease,  caused  by  the  bacillus 
leprse.  It  is  distinguished  by  constitutional  depression  and,  pathologi- 
cally, by  tuberculous  masses  in  the  muco-cutaneous  surfaces,  and  by 
changes  in  the  nerves. 

Historic  Note. — In  1889,  Morrow  stated  that  in  India  alone 
there  were  certainly  not  less  than  150,000  lepers,  while  at  present  it  is 
estimated  that  there  are  over  250,000.  Its  geographic  distribution 
probably  covers  more  than  one-third  of  the  entire  surface  of  the  globe. 
It  is  common  in  Africa,  Brazil,  in  the  East,  and  in  Norway.  In  the 
Sandwich  Islands  the  disease  is  of  comparatively  recent  origin,  and 
yet  of  great  and  increasing  prevalence,  a  leper  settlement  having 
been  established  consisting  of  more  than  11,000  cases.  Leprosy  is  not 
unknown  in  America,  and  in  Mexico  it  has  existed  ever  since  the  time 
of  Cortes  (Morrow).  Blanc  states  that  there  are  75  to  100  lepers  in 
Louisiana  alone.  It  was  introduced  into  California  and  Oregon  by  the 
Chinese,  and  into  Illinois,  Iowa,  Wisconsin,  and  Minnesota  by  Scandi- 
navian immigrants.  It  has  been  imported  from  the  Sandwich  Islands 
to  Salt  Lake  City,  and  from  Normandy  to  Tracadie  on  the  Gulf  of  the 
St.  Lawrence,  where  the  "  disease  is  limited  to  two  or  three  counties 
which  are  settled  by  French  Canadians"  (Osier).  Sporadic  cases  have 
been  met  with  in  most  American  cities.  The  Commission  on  Leprosy 
reported  in  1902  the  records  of  278  cases,  of  which  145  were  native  born 
Americans.     The  disease  appears  to  be  lessening  in  the  United  States. 

Pathology. — The  bacilli  grow  and  develop  in  clusters  in  the  tuber- 
culous nodules  in  the  skin  and  in  the  anesthetic  and  pigmented  areas, 
residing  within  the  epithelioid  cells  and  leukocytes.  'Ihese  so-called 
lepra-cells  are  probably  derived  from  the  lymphatic  vessels  or  capillaries, 
having  been  transformed  by  the  bacilli.  Surrounding  the  granulomatous 
masses  is  a  layer  of  connective  tissue.  The  bacilli  are  aho  found  in  the 
lymphatic  glands,  the  spleen,  and  liver,  but  rarely  in  the  blood.  The 
nodular  tumors  form  projections  from  the  skin-surface,  and,  being  poorly 
supplied  with  blood-vessels,  they  soon  undergo  caseation  and  absorption 


300  INFECTIOUS  DISEASES. 

or  are  obliterated  by  dense  connective  tissue  (fades  leontina).  The  pus- 
organisms  generally  exercise  an  influence  in  causing  suppuration  with 
ulceration,  which  may  manifest  a  marked  destructive  tendency.  Similar 
changes  occur  in  the  internal  organs  or  in  the  mucous  membranes. 

Nerve-Jesiong  are  induced  by  the  presence  of  the  bacilli  within  and 
around  the  nerves.  Here  they  set  up  an  irritation  with  hyperesthesia 
(neuritis),  leading  to  atrophy,  with  marked  degenerative  changes. 

Ktiology. — Bacteriology. — In  1880  Hansen  discovered  the  bacillus 
leproe,  since  proved  to  be  the  special  agent  of  the  disease.  It  strongly 
resembles  the  tubercle  bacillus,  but  differential  stains  have  been  suggested 
by  Unna  and  others.  Bordoni-Uffredozzi  was  able  to  cultivate  a  bacillus 
which  difi'ered  from  the  lepra  bacillus  in  its  morphology,  although  staining 
in  a  similar  manner.  His  results  have  been  confirmed  by  Czaplewski. 
Inoculation  experiments  on  animals  have  not  as  yet  succeeded. 

Predisposing  Causes. — Everyone  is  susceptible  to  leprosy.  E.  B. 
Goodhue,  however,  claims  that  a  natural  immunity  exists.  The  disease 
is  most  frequent  between  the  twentieth  and  fortieth  years,  and  is  rare  in 
childhood.  Sex  and  latitude  have  little  if  any  influence.  Hereditary 
transmission  probably  influences  about  one-fortieth  of  the  instances 
(Zambaco).  Heredity  is  denied  by  both  Hansen  and  Raminez.  As 
pointed  out  by  Bidenkap,  leprosy  is  often  rare  in  large  cities,  even 
though  prevalent  in  the  surrounding  rural  districts. 

Modes  of  Infection. — The  disease  is  transmitted  by  contact ;  but 
Widal  and  others,  Avho  have  studied  the  disease  as  it  exists  in  the 
Hawaiian  Islands,  think  that  leprosy  is  contagious  only  by  inoculation. 
Long's  experiments  point  to  transmission  by  means  of  the  bed-bug. 
Morrow's  view,  that,  like  syphilis,  leprosy  is  generally  transferred  by 
sexual  intercourse,  receives  support.  Hansen  holds  that  the  infection 
atrium  is  unknown;  he  thinks  it  probable,  however,  that  the  mouth  and 
nasal  cavities  are  the  avenues  of  entrance.  Sticker  also  regards  the 
nasal  mucous  membrane  as  the  primary  focus,  and  finds  in  it  constant 
lesions.  The  bacillus  has  been  found  in  the  floors  and  w^alls  of  houses 
in  leper  colonies,  and  also  from  the  urine  and  even  the  milk  of  patients. 

Clinical  History. — Two  forms  are  recognized,  the  tubercular  and 
the  coiest/ietie,  but  neither  of  these  runs  its  entire  course  without  develop- 
ing into  a  third  or  mixed  form. 

The  incubation  is  usually  long  (three  to  five  years — Hansen).  It  may 
rarely  be  shorter  or  much  longer.  Vague  prodromes  are  present  for 
years  (drowsiness,  chilliness,  recurring  attacks  of  fever,  debility). 

(1)  Tubercular  Form. — In  the  first  stage  there  is  a  patchy,  cutaneous 
erythema  with  a  slight  hyperesthetic  elevation  of  the  affected  areas  (mac- 
ular leprosy).  These  are  oftenest  seen  on  the  face,  the  extensor  surfaces 
•  of  the  arms  and  knees.  They  may  vanish  and  leave  the  skin  pigmented 
and  anesthetic,  and  later  the  pigment  may  disappear,  while  white  spots 
of  corresponding  size  remain  (lepra  alba). 

When  the  disease  progresses  less  favorably  tuberculous  nodules  (dusky 
red  or  almost  brown  in  color)  develop  in  addition  to  anesthesia.  The 
small  ones  soon  disappear,  while  the  large  ones  are  either  absorbed  or 
break  down  and  ulcerate — changes  which,  as  they  advance  together  with 
the  slow  healing  process,  produce  marked  deformities.  The  skin  is 
greatly  thickened  and  presents  a  scaly  surface,  and  there  is  loss  of  sub- 
stance  in   certain    parts,    while    others    are    enormously    enlarged  (eye- 


LEPROSY.  301 

brows,  nostrils,  lips,  etc.).  Airiong  the  many  syrnptonis  pointing  to  in- 
volvement of  tlie  mucous  membrane  :ire  ozena,  hoarseness  or  even 
aphonia,  and  the  signs  of  inhalation-pneumonia.  Blindness  often  ensues 
as  the  result  of  extension  of  the  process.  To  ulcers  extending  deeply 
into  the  mucosa  of  the  pharynx  and  larynx,  death  may  often  be  ascribed. 

(2)  Anesthetic  Form. — In  this  variety  the  local  symptoms  point  usu- 
ally to  implication  of  the  nerves.  At  the  onset  there  are  jjain  and  patchy 
hyperesthesia.,  while  minute  bullae,  due  to  trophic  changes,  put  in  an  ap- 
pearance on  the  arms  and  legs.  The  muscles  supplied  by  the  branches 
of  the  affected  nerve-trunk  waste,  and  the  superficial  nerves  feel  thick- 
ened and  nodular.  Bright-red  patches  of  vaso-motor  congestion  appear 
and  soon  become  anesthetic,  while  the  maculae  disappear.  Anesthesia 
may  proceed  without  the  latter  eruption.  Dry,  yellowish-white,  scaly 
patches  upon  the  trunk  and  extremities  are  also  visible.  Early  their 
centers  alone  are  anesthetic,  but  subsequently  the  loss  of  sensation 
spreads  even  to  healthy  portions  of  the  skin. 

Trophic  alterations  reach  an  extreme  degree.  Bullae  appear,  and, 
bursting,  leave  perforating  or  destructive  ulcers,  usually  upon  the  extremi- 
ties. As  the  result  of  absorption,  wasting,  and  necrosis  great  deformi- 
ties are  produced.  The  hands  often  take  on  a  claw-like  form,  and  the 
fingers  and  toes  may  disappear  (lepra  mutilans). 

Diagnosis. — The  early  diagnosis  rests  upon  the  presence  of  patchy 
erythema  with  hyperesthesia,  followed  by  the  development  of  anesthesia, 
with  a  disappearance  of  the  muscular  eruption.  Nodular  neuritis  is 
pathognomonic  of  anesthetic  leprosy.  Scrapings  of  the  skin  lesions 
frequently  show  the  specific  bacilli.  In  the  advanced  stages  of  either 
form  confusion  could  scarcely  arise.  The  nodular  form  of  tubercular 
syphilis  is  distinguished  by  the  distribution  of  the  lesions,  the  history, 
the  frequent  sensory  nerve-lesions,  and  by  incising  the  tubercle  and  com- 
pressing serum  from  it — when  lepra  bacilli  are  found  in  the  exudate — 
bacilli  may  be  found  in  the  nasal  secretion.  Zambaco  and  others  have 
claimed  that  syringomyelia  and  Morvans  disease  are  in  most  cases  but 
forms  of  leprosy ;  but  this  has  been  disputed  by  Hoffman,  Schlesinger, 
and  Sahli.  Syringomyelia  depends  on  lesions  of  the  central  nervous 
system,  while  leprosy  has  its  nervous  lesions  in  the  peripheral  nerves. 
The  first  symptoms  in  syringomyelia  are  localized  usually  in  the  upper 
extremities,  while  in  leprosy  they  are  generalized.  In  leprosy  the  tactile 
sense  is  usually  lost,  in  syringomyelia  usually  not  lost.  Shoemaker  and 
Boston  ^  report  an  advanced  case  where  lepra  bacilli  were  found  in  the 
blood,  and  collected  reports  of  20  similar  cases  from  the  literature. 

Prognosis. — Leprosy  runs  a  very  chronic  course,  lasting  sometimes 
two,  three,  or  more  decades.  The  prognosis  as  to  the  final  issue  is  hope- 
less, but  the  patient  may  live  in  comparative  comfort  for  many  years 
before  the  ravages  of  the  disease  cause  great  mutilation. 

Treattnent. — Certain  diseases  are  supposed  to  exercise  a  retarding 
effect  on  leprosy  (erysipelas,  pneumonia,  variola,  phthisis).  Antagonistic 
inoculation,  however,  as  practised  by  Beaven  Rake  and  others,  has  been 
practically  negative  in  its  effects ;  and  the  same  is  true  of  the  treatment 
by  Koch's  tuberculin.  The  disease  has  thus  far  resisted  all  methods  of 
treatment.    Matthews^  treated  7  cases  representing  both  kinds  of  leprosy 

1  Proceedings  of  the  Philadelphia  County  2[edical  Societi/,  Jan.,  1903. 
^  "  Treatment  of  Leprosy  with  x-rays  and  High  Frequencv,"  Indian  3fedical  Gazette, 
Aug.,  1908. 


302  INFECTIOUS  DISEASES. 

with  .r-ravs  and  high  frequency,  and  concludes  that  it  is  the  only  method 
Avhich  has  produced  any  real  effect  on  the  progress  of  the  disease.  In- 
ternaUy,  chaulmoogra  oil  has  been  employed  with  excellent  results,  the 
dose  being  from  1  to  2  drams  (4.0-8.0).  It  is  sometimes  administered  in 
pearls  (each  containing  tUiij  to  v— 0.199-0.333),  in  ascending  doses,  until 
the  limit  of  tolerance  is  reached.  Surgical  interference  may  become 
necessary,  Manson  advises  free  excision  if  only  one  tubercle,  and  no 
signs  of  a  general  invasion,  be  present.  Segregation  of  lepers  has  been 
instituted  in  certain  localities  with  encouraging  results.  Calmette's  anti- 
venomous  serum,  while  not  a  true  antidote,  may  produce  a  marked  tem- 
porary improvement  or  even  cure  in  uncomplicated  cases.  The  Nastin 
treatment  (dose  1  c.c.  by  injection)  has  given  variable  results.  Rost 
advises  Aveekly  injections  of  vaccine. 


GLANDERS. 

[Farcy.) 

Definition. — An  infection  of  equine  origin,  caused  by  the  bacillus 
mallei.     Two  forms  are  recognized — true  glanders  andfa7'ef/. 

Pathologfy. — The  characteristic  lesions  are  new  growths  (granu- 
lomata,  according  to  Virchow),  which  are  usually  nodular  in  character, 
though  they  may  be  diffuse.  These  masses  soften  and  form  ulcers  when 
they  occur  on  the  nasal  mucosa,  and  abscesses  when  they  are  situated 
subcutaneously.  Microscopically,  the  nodular  tumors  are  composed  of 
cells — lymphoid  and  epithelioid — together  with  the  specific  bacillus. 

etiology. — The  morbid  changes  above  described  are  caused  by  a 
specific  organism,  the  bacillus  mallei,  Avhich  resembles  closely  the  tuber- 
cle bacillus,  though  it  is  a  little  thicker  as  well  as  shorter.  It  is  non- 
motile.  It  can  be  readily  grown,  and  as  readily  inoculated  into  horses, 
in  which  it  produces  the  disease  with  every  characteristic  symptom. 
Perhaps  the  simplest  method  of  staining  the  bacillus  mallei  "is  to  treat 
a  cover-glass  preparation  with  warm  carbol-fuchsin  (preceded  by  acetic 
acid),  and  then  wash  it  off  with  a  2  per  cent,  solution  of  nitric  acid." 

Modes  of  Infection. — The  virus  is,  as  a  rule,  transferred  directly  from 
the  infected  animal  to  man,  hence  the  disease  occurs  almost  invariably 
among  males  and  persons  who  come  in  contact  with  horses  (hostlers, 
coachmen,  soldiers,  veterinarians,  and  farmers).  Transmission  from  man 
to  man  has  been  observed,  but  rarely.  The  medium  of  conveyance  is 
either  the  pus  or  the  nasal  secretions,  which  may  drop  or  be  blown  from 
the  animal's  nostrils  upon  a  wound  in  the  skin  or  mucous  membranes, 
however  slight,  and  be  absorbed. 

Immunity. — The  disease  is  rare  in  man  because  of  natural  immunity. 
Singer  has  produced  artificial  immunity  by  intravenous  injections  of 
sterilized  cultures  of  the  glanders  bacillus. 

Clinical  History. — The  duration  of  the  incubation-period  is  from 
three  to  five  days,  and  rarely  longer.  Both  glanders  and  farcy  may  be 
acute  or  chronic  in  their  course. 

(1)  Acute  Glanders. — At  first  the  signs  of  inflammation  develop  at  the 
point  of  infection,  lymphangitis  and  swelling  of  the  adjacent  lymphatic 
glands  being  associated.  Fever  and  other  evidences  of  general  disturb- 
ance soon  appear,  and  at  the  end  of  two  or  more  days  the  nasal  mucosa 


OLANDEJIH.  303 

becomes  implicated,  ulcers  forming,  from  which  a  fetid  muco-pnrulent 
(sometimes  blood-streaked)  discharge  takes  place.  NoHP-lleed  is  com- 
mon. Later  an  eruption  comes  out  on  the  face,  the  trunk,  and  the  ex- 
tremities, particularly  about  the  joints.  It  is  papular,  quickly  becoming 
pustular,  and  the  pustules  may  dry  up  while  fresh  papules  are  develop- 
ing— a  characteristic  feature.  The  /ace,  particularly  the  nose,  now 
swells,  and  a  bluish-brown  tumor  covered  with  vesicles  appears.  Impli- 
cation of  adjacent  mucous  membranes — conjunctivae,  pharynx,  mouth, 
etc. — is  usual,  and  less  frequently  the  bronchial  and  gastro-intestinal 
mucous  membranes  are  involved.  The  ulcerative  processes  may  extend 
to  the  bones,  setting  up  necrosis.  True  arthritis  occurs  in  10  per  cent,  of 
the  cases  (H.  Morel).     Broncho-pneumonia  is  a  common  complication. 

(2)  Chronic  Glanders. — A  rare  disease  with  mild  but  vague  general 
symptoms,  as  muscular  and  arthritic  pains,  fever  at  intervals,  asthenia, 
and  progressive  wasting,  and  the  local  features  of  nasal  catarrh,  with  a 
bloody  muco-purulent  discharge.      Cough  may  be  present. 

(3)  Acute  Farcy. — In  this  form  the  virus  is  inoculated  into  the  skin, 
which  presents  the  chief  symptoms,  the  nasal  condition  being  in  abey- 
ance or  absent.  The  primary  lesion  is  of  an  aggravated  type,  accom- 
panied by  numerous  cutaneous  boils  and  abscesses,  often  following  the 
line  of  the  lymphatics.  Their  favorite  seat  is  in  the  vicinity  of  the  joints. 
The  constitutional  symptoms  simulate  those  of  acute  pyemia. 

(4)  Chronic  Farcy. — Granulomatous  tumors,  resulting  in  abscesses, 
constitute  the  chief  clinical  peculiarity.  The  abscessps  are  situated 
primarily  in  the  subcutaneous  tissues,  and  often  near  the  joints.  As  a 
rule  they  open  spontaneously  and  discharge,  first  a  thick,  creamy  pus, 
and  later  a  thin,  fetid  material.  They  sometimes  form  distinct  ulcers, 
extending  in  depth  until  the  bones  are  involved. 

The  general  symptoms  simulate  those  of  chronic  glanders,  the  fever- 
curve  being  of  the  hectic  type.  In  advanced  cases  emaciation  and 
prostration  become  extreme.  The  duration  varies  from  ten  to  eighteen 
months,  though  death  may  result  earlier  from  some  associated  disease. 

Diagnosis. — The  diagnosis  cannot  be  made  without  a  clear  history 
of  contact  with  an  animal  known  to  be  affected  with  the  disease.  In 
doubtful  instances  some  of  the  suspected  material  should  be  injected  into 
the  peritoneal  cavity  of  a  male  guinea-pig.  Pus  is  soon  formed  in  the 
tunica  vaginalis  testis  and  from  it  bacillus  mallei  may  be  recovered 
in  pure  culture.  One  of  the  products  of  the  bacillus  mallei  is  so-called 
"mallein,"  which  has  been  used  by  Nocard  and  others  as  a  diagnostic 
agent  in  animals.  Its  injection  into  horses  suffering  from  glanders  is 
followed  by  a  febrile  reaction.  Schindelke  found  that  a  reaction  of 
3.5°  F.  (2°  C.)  is  almost  positive  proof  of  glanders  ;  while  a  rise  of  1.25°  F. 
(1°  C.)  is  suspicious.^  Wade  recommends  the  complement-fixation  test 
supplemented  by  the  agglutination  test  on  all  negative  serums. 

Differential  Diagnosis. — Cases  of  acute  glanders  have  been  mis- 
taken for  variola;  but  the  history  of  exposure,  the  mode  of  onset, 
nasal  symptoms  and  the  course  of  the  eruption  all  differ  from  those  of 
the  latter  disease.  Pyemia  may  be  eliminated  by  the  history  of  ex- 
posure and  inoculation  experiments.  The  chronic  forms  must  be  dis- 
tinguished from  tuberculosis  and  sypJiilis. 

Prognosis. — Acute  glanders  and  acute  farcy  are  almost  invariably 
1  Saunders'  Year-Book  for  1896,  p.  1013. 


304  INFECTIOUS  DISEASES. 

fatal.  The  chronic  forms,  however,  and  particularly  chronic  ftircy,  end 
in  recoverv,  under  appropriate  treatment,  in  nearly  one-half  the  cases. 
Treatment. — The  primary  lesion  should  be  dealt  with  surgically, 
and  thorough  disinfection  followed  by  cauterization  is  highly  recom- 
mended. Bayard  Holmes  advocates  the  opening  of  fresh  abscesses  and 
the  scraping  out  of  old  ones  under  an  anesthetic.  A  supporting  plan 
of  treatment,  by  generous  feeding  and  judicious  stimulation,  is  to  be 
adopted,  and  the  symptoms  are  to  be  met  as  they  appear.  The  product, 
''mallein,"  has  been  recommended  as  a  specific,  but  its  curative  proper- 
ties have  not  yet  been  demonstrated.  Bristow  reports  a  case  of  human 
glanders  treated  by  an  autogenous  vaccine,  with  recovery. 


ACTINOMYCOSIS. 

( ' '  Big-jaw, "  "  Lumpy-jaw, ' '  etc, ) 

Definition. — An  infectious  disease  of  cattle,  less  frequently  of  man, 
caused  by  the  ray-fungus  (actinomyces),  which  grows  in  the  tissues,  de- 
veloping a  mass  with  secondary  chronic  inflammation  and  metastatic 
growth  as  well  as  a  secondary  pyemic  infection. 

Historic  Note. — In  1877  Bollinger  gave  the  first  description  of 
the  ray-fungus,  which  he  had  observed  in  the  disease-  known  as  "  big- 
jaw  "in  the  ox.  Israel  of  Berlin  discovered  the  fungus  in  man  one 
year  later.  In  1879,  Ponfick  showed  clearly  that  actinomycosis  in  man 
and  cattle  was  one  and  the  same  disease.  Murphy,  who  described  the 
first  case  of  actinomycosis  hominis  in  America,  states  that  up  to  the 
present  date  more  than  500  cases  have  been  reported. 

Pathology. — A  macroscopic  mass  is  produced,  consisting  of  a  cen- 
tral fungous  mass  from  which  threads  of  mycelia  radiate  in  all  directions, 
producing  the  ray  form  of  growth.  Individual  growths  are  of  the  size  of 
a  millet-seed,  but  their  aggregation  may  result  in  masses  as  large  as  an 
orange ;  they  are  of  a  sulphur-yellow  color  and  of  tallowy  consistence. 
Induration  and  infiltration  may  extend  far  into  the  surrounding  tissues. 

3IicroscopicaUi/,  the  little  or  single  ray-like  tumors  show  straight  or 
wavy  branching  filaments  {supi-a).  Their  development  is  accompanied 
by  the  growth  of  dense  adjacent  connective  tissue.  In  addition,  ab- 
scesses containing  yellow  granules  in  the  pus  occur,  but  these  are  sec- 
ondary. In  man  the  lesions  consist  of  nodular  growths  with  secondary 
abscess  f  iriuation.  diff"erini:  from  those  described  as  occurrincr  in  beasts. 

Bacteriology. — The  organism  of  the  disease  belongs  to  the  cladothrix 
variety  of  fungus,  and  may  be  cultivated,  though  with  diflliculty.  The 
finer  threads  may  readily  be  stained  with  anilin  colors.  The  club-shaped 
projections,  however,  do  not  take  these  stains.  Pus  from  whatever  source 
should  be  examined  for  the  actinomyces  even  though  cocci  are  present. 
Rabbits  and  cows  have  been  successfully  inoculated.  Pyogenic  organisms 
are  commonly  in  association. 

Modes  of  Infection. — Infection  generally  takes  place  in  young  subjects 
through  the  mouth,  teeth,  and  pharynx  ;  and  rarely  the  infection  atrium 
is  the  air-passages  or  the  skin.  The  infecting  microbe  is  generally  intro- 
duced with  the  food  or  drink,  and  Bostroem,  from  a  study  of  82  cases, 
concludes  that  the  poison  enters  the  economy  by  means  of  the  ingested 
grains  of  some  cereal  (barley). 

Clinical  History. — (1)  Oral  Actinomycosis. — The  patient  often  com- 


ACTINOMYCOSIS.  305 

plains  of  toothache,  dysj)hagba,  and  of  difficulty  hi  opening  the  javK 
The  latter  symptom  may  be  owing  to  induration  of  adjacent  muscles, 
and  is  a  very  characteristic  sign  (J*artsch).  At  the  angle  of  the  jaw 
a  swelling  appears,  which  quickly  passes  into  suppuration  ;  later  it  opens 
(first  externally,  then  into  the  mouth)  and  discharges  pus  containing 
little  yellow  masses.  If  not  properly  treated,  extension  of  the  process 
takes  place  in  a  downward  direction,  even  to  the  abdominal  organs. 

The  upper  jaw  may  be  the  primary  seat  of  infection,  and  if  so  the 
base  of  the  skull  may  be  perforated  and  the  disease  attack  the  meninges 
and  brain.  Bollinger  has  seen  primary  actinomycosis  of  the  brain.  In 
these  instances  caries  of  the  spine  may  result  from  extension. 

(2)  Pulmonary  Actinomycosis. — I  am  satisfied  that  primary  pulmonary 
actinomycosis  is  comparatively  rare,  although  Karewski  and  Butler  have 
each  recently  reported  an  instance.  In  Butler's  case  the  disease  fol- 
lowed an  injury  by  a  falling  board.  The  disease  begins  with  pain  in 
the  side,  often  the  left,  due  to  pleurisy.  There  are  cough  and  a  pecu- 
liar (fetid)  expectoration,  together  with  general  wasting.  A  microscopic 
examination  of  the  sputum,  if  made  with  care,  reveals  the  actinoniyces. 
In  some  instances  the  symptoms  are  identical  with  those  of  disseminated 
tuberculosis  of  the  lungs  (Brigidi),  though  generally  the  disease  is  unilat- 
eral.    There  is  irregular  fever,  due  to  suppuration. 

The  physical  signs  may  be  those  of  chronic  bronchitis  merely ;  but 
there  are,  in  not  a  few  cases,  extensive  destructive  changes  of  variable 
character  (abscess,  broncho-pneumonia,  etc.),  which  modify  the  signs 
accordingly.  In  primary  pulmonary  actinomycosis  an  extension  to  ad- 
jacent organs  and  also  metastatic  growths  and  abscesses  occur.  Wood 
and  Eshner^  found  the  so-called  sulphur  granules  in  a  pleural  exudate. 

(3)  Intestinal  Acttaomycosis. — The  condition  may  be  primary  or  sec- 
ondary. The  organism  grows  upon  the  mucosa  of  the  intestine  and 
excites  a  proliferation  of  the  underlying  connective-tissue  cells,  and  the 
formation  of  submucous  nodules.  The  latter  ulcerate,  and  perforation 
of  the  serous  coat  of  the  bowel  may  occur,  inducing  peritonitis.  Peri- 
cecal abscesses  have  been  formed  in  like  manner. 

The  symptoms  point  to  intestinal  catarrh,  there  being  some  gastric  dis- 
turbance, with  recurring  attacks  of  diarrhea.  The  actinomyces  has  been 
detected  in  the  stools.  Secondary  metastatic  growths  (rarely)  and  ab- 
scesses may  arise  in  other  organs  (liver,  spleen,  ovaries,  etc.).  The 
viscerae  may  also  be  the  primary  seat  of  infection. 

(4)  Cutaiieons  actinomycosis  rarely  occurs.  The  skin  presents  chronic 
suppurating  ulcers  which  show  the  presence  of  the  ray-fungus,  and  the 
condition  bears  a  close  resemblance  to  a  lupus  patch. 

Diagnosis. — This  rests  solely  upon  the  finding  of  the  actinomyces. 
The  wooden  hardness  of  the  tissues  beyond  the  borders  of  the  ulcers  or 
sinuses,  the  hardness  of  the  neighboring  muscles  in  oral  actinomycosis, 
and  the  yellow  granules  in  the  pus  are  all  significant,  but  merely  cor- 
roborative. To  detect  the  actinomyces,  says  Warren,  sections  may  be 
stained  with  Ziehl's  carbol-fuchsin  from  fifteen  minutes  to  half  an  hour, 
and  then  decolorized  in  a  1  per  cent,  picric-acid  solution  until  the  whole 
section  has  a  yellow  appearance.  Dehydrate  and  mount.  The  fungus 
appears  as  a  brilliant  red  aster,  while  the  surrounding  tissues  are  yellow. 
The  points  mentioned  above  will  serve  to  distinguish  this    disease  from 

^Medical  Record,  June  4,  1910. 
20 


306  INFECTIOUS  DISEASES. 

tubemilosis,  si/philis,  clironic pyemia^  ami  sarcoma.  AVidal  *  diiferentiated 
actinomycopis  hy  the  sero-reaction  in  8  eases. 

Course  and  Progrnosis. — The  course  is  chronic.  Mild  cases  may 
recover  in  from  six  to  nine  months  or  earlier,  the  oral  form  being  per- 
haps the  most  favorable.  Pulmonary  actinomycosis  may  terminate  in 
recovery,  though  rarely.  Death  usually  results  from  pyemia,  amyloid 
degeneration,  and  wasting. 

Treatment. — This  is  mainly  surgical.  The  removal  of  the  parts 
involved  and  disinfection  with  acid-sublimate  solution  are  the  best  meas. 
ures.  Billroth  in  a  case  of  abdominal  actinomycosis  communicating 
with  the  bladder  effected  a  cure  by  the  use  of  fifteen  tuberculin  injec- 
tions. Kinnicutt  and  Mixter  have  used  vaccine  made  from  actinomy- 
cotic pus  in  8  cases  with  encouraging  results.  Internally,  the  potas- 
sium-iodid  treatment,  as  first  recommended  by  Thomassen  in  1885,  and 
recently  emphasized  by  DaCosta,^  is  often  attended  with  success  when 
decided  iodism  is  produced. 


ANTHRAX. 

[Malignant  Pustule;  Splenic  Fever;    Wool-sorter's  Disease,  etc.) 

Definition. — An  acute,  infectious  disease,  caused  by  a  special  ba- 
cillus and  clinically  accompanied  by  the  development  of  a  characteristic 
pustule  (boil)  and  blood-poisoning  {external  anthrax).  The  disease  like- 
wise aifects  the  gastro-intestinal  tract  and  the  lungs  {internal  anthrax). 
Both  forms  are  derived  principally  from  the  herbivora,  it  being  especially 
prevalent  among  sheep  and  cattle.  The  occurrence  of  anthrax  in  the 
United  States  is  much  more  frequent  than  has  been  held  to  be  the  case. 

Pathology. — Post-mortem  rigidity  is  marked.  The  blood  is  dark 
and  thick  and  coagulates  poorly,  and  in  it,  particularly  in  the  spleen, 
as  well  as  in  the  liver,  kidney,  and  lungs,  one  may  find  the  spores. 

Besides  the  local  lesions  of  the  skin  (?'.  e.  ulceration,  gangrene,  edem- 
atous infiltration),  and  besides  the  degeneration  of  the  heart,  kidneys, 
and  liver  that  is  common  to  the  severe  and  rapid  infectious  diseases,  the 
especially  striking  lesion  is  the  constant  and  great  splenic  enlargement. 

The  bowel  may  show  hemorrhagic  infiltration  and  gangrene,  and  the 
mesenteric  and  retroperitoneal  glands  may  be  enlarged  and  hemorrhagic. 

l^tiology. — Bacteriology. — The  special  agent  is  the  bacillus  anthra- 
cia.  Gratia  and  Jonne  give  as  the  microscopic  characteristics  of  anthrax, 
as  seen  in  the  blood,  the  following :  (1)  The  anthrax  bacillus  has  the 
form  of  a  rod  of  a  length  varying  from  bfj.  to  20^,  and  in  breadth  from 
1/i  to  1.5/i.  It  is  broken  up  into  short  articulations  from  1.5/^  to  2^ 
long,  placed  end  to  end  like  the  sections  of  a  tenia,  the  ends  of  each 
articulation  being  slightly  swollen,  giving  the  appearance  of  a  bamboo 
cane ;  (2)  clear  spaces,  appearing  like  a  biconcave  lens,  exist  between 
the  ends  of  the  articulations,  and  result  from  the  slight  concavity  of 
these  ends ;  (3)  a  capsule,  often  distinctly  marked,  surrounds  thp  rod, 
seeming  to  form  a  protoplasmic  support  for  the  individual  articulations. 
These  threads  of  anthrax  bacilli  stain  best  with  Lofiler's  blue.  They 
grow  readily  on  various  media  (agar,  gelatin,  potatoes,  etc.)  into  inter- 

^Bull.  de  I' Acad,  de  Med.,  Paris,  May  10,  1910. 
^  Proc.  of  the  Assoc,  of  American  Physicians,  1900. 


ANTHRAX.  307 

lacing  thread-like  filaments  which  distinctly  show  sporo-formation.  the 
threads  assuming  the  appearance  of  strings  of  beads.  They  resist  desic- 
cation, many  of  the  germicides,  and  boiling  water  even  for  a  few  min- 
utes. Inoculations  are  followed  by  the  production  of  the  pustule  of 
anthrax.  Conradi  ^  affirms  that  it  is  highly  improbable  that  the 
anthrax  bacilhis  produces  a  toxin. 

Modes  of  Infection. — The  virus  (spores)  gains  entrance  into  the  human 
body  through  the  skin  (slight  wounds,  abrasions,  or  scratches),  the  intes- 
tines (with  food),  or  through  the  lungs  (rarely).  The  sting  of  insects 
(mosquitoes,  flies)  may  also  transfer  the  poison  to  man. 

Predisposing  Causes. — Occupation  is  most  influential :  persons  who 
come  into  direct  contact  with  infected  animals  (hostlers,  butchers,  shep- 
herds), and  workers  in  factories  who  handle  the  hair  or  hides  of  such 
animals,  being  liable. 

Immunity. — Pasteur's  well-known  protective  inoculation  with  attenu- 
ated virus  has  been  extensively  practised  in  anthrax  localities,  with  very 
favorable  results.  Peterman,  however,  reinvestigated  the  question  of 
immunity  by  the  albumose  of  anthrax,  and  found  it  without  protective 
action,  except  in  the  case  of  cultures  on  ox-serum,  which,  when  injected 
in  large  quantities  into  the  veins,  conferred  temporary  immunity. 

Clinical  History. — The  period  of  incubation  is  from  one  to  three 
days.     Two  leading  clinical  types  are  distinguished : 

(1)  External  Anthrax. — {a)  Malignant  Pustule. — At  the  point  of 
infection  (the  hand,  arm,  neck,  or  face,  or  other  exposed  part)  a  small 
papule  first  appears,  and  develops  into  a  vesicle  of  considerable  size  with 
bloody  contents.  This  vesicle  breaks,  leaving  a  characteristic  dark- 
bluish  or  black  scab  (anthrax),  and  encircling  the  primary  vesicle  an 
areola  of  miliary  vesicles  may  be  noticed.  The  base  of  the  original  ves- 
icle now  becomes  swollen  and  indurated,  and  this  brawny  edema  spreads 
rapidly  to  the  adjacent  tissues  until  an  extensive  area  is  involved.  The 
neighboring  lymph-glands  may  or  may  not  be  inflamed ;  if  so,  they  are 
apt  to  be  connected  wdth  the  pustule  by  red  lines  (lymph-vessels,  veins). 

Severe  general  disturbances  accompany  the  local  disorder  in  the  course 
of  a  couple  of  days,  and  comprise  fever,  decided  prostration,  sweats,  splenic 
enlargement,  and  delirium  tending  toward  coma.  If  recovery  occur, 
the  edematous  swelling  subsides  and  the  black  scab  is  cast  ofi".  In 
unfavorable  instances  collapse  develops,  and  the  case  ends  fatally  between 
the  fourth  and  eighth  days.  In  such  instances  intestinal  symptoms 
(diarrhea)  or  nervous  phenomena  of  aggravated  type  may  attend. 

(6)  Anthrax  Edema. — In  a  certain  proportion  of  the  cases  the  sys- 
temic infection  is  out  of  proportion  to  the  local  disturbance,  the  latter 
consisting  of  an  edematous  swelling  without  the  presence  of  an  eschar. 
The  eyelids  (commonly),  lips,  tongue,  and  upper  extremities  may  be  the 
seat  of  extensive  swelling,  though  there  is  no  change  in  the  color  of  the 
skin.     This  is  a  dangerous  condition,  and  may  result  in  gangrene. 

(2)  Internal  Anthrax. — (a)  Intestinal  Mycosis. — In  tnis  form  certain 
general,  indefinite  symptoms  are  the  primary  features,  such  as  headache, 
pains  in  the  limbs,  anorexia,  languor.  Soon  acute  gastro-intestinal 
features  supervene,  sometimes  preceded  by  a  chill.  As  a  rule,  vomit- 
ing occurs,  followed  by  abdominal  pains  and  diarrhea,  and  the  stools 
often  become  bloody.      Hemorrhage  may  also  occur  from  other  outlets. 

1  Zeitschri/t  J'iir  Byg.,  June  14,  1899. 


308  IXFF.CTIOUS  DISEASES. 

Other  symptoms,  as  dyspnea,  marked  cyanosis,  and  restlessness,  are 
noted,  followed  sometimes  by  stupor,  general  convulsions,  or  spasms 
of  single  muscles  or  groups  of  muscles.  There  is  moderate  fever,  and 
the  spleen  is  enlarged.     Death  is  preceded  by  collapse. 

Interesting  epidemic  outbreaks  of  internal  anthrax  have  occurred, 
due  both  to  drinking-water  derived  from  infected  wells  and  also  to  dis- 
eased meat.  Murisier  has  related  the  history  of  an  epidemic  in  which 
200  persons  fell  ill  after  eating  meat  from  a  certain  cow.  The  animal 
was  quartered  by  a  butcher  who  had  previously  slaughtered  an  ox 
afflicted  with  anthrax,  and  had  not  disinfected  his  instruments  ;  four 
days  after  this  25  persons  were  attacked  by  the  disease. 

ih)  Wool-sorters'  Disease. — This  occurs  among  the  operatives  in  fac- 
tories in  which  imported  wool  or  hair,  mostly  from  Russia  and  South 
America,  is  sorted,  and  to  produce  the  typical  affection  the  infection 
must  be  swallowed  or  inhaled  in  the  form  of  dust.  Mixed  cases,  or  those 
showing  both  external  and  internal  anthrax,  may  be  met  with  among 
workers  in  curled-hair  establishments  and  the  like.  The  onset  is  sudden, 
with  a  chill  that  is  accompanied  by  pains  in  the  back  and  legs,  prostration, 
and  a  sharp  rise  of  temperature  to  102°  or  103°  F.  (39.4°  C).  The  local 
symptoms  may  either  be  chiefly  pulmonary  or  gastro-intestinal.  The 
former  consist  in  dyspnea,  chest-pains  or  feelings  of  constriction,  cough, 
and  rarely  the  physical  signs  of  bronchitis ;  the  latter  comprise  vomit- 
ing and  a  diarrhea  that  is  followed  by  collapse,  Avith  marked  lividity. 
Nervous  symptoms,  delirium,  convulsions,  or  coma  are  often  prominent 
in  serious  forms  ;  but  a  fatal  ending  may  occur  while  the  mind  is  un- 
clouded.    The  course  ranges  from  one  to  five  days. 

(e)  Rag-pickers'  Disease  ("  Hadernkrankheit "). — This  has  been 
identified  by  Eppinger  as  the  same  form  of  disease  as  "wool-sorters' 
anthrax."  It  occurs  among  the  rag-sorters  in  the  paper-mills  near  Graz. 
Infection  occurs  in  the  respiratory  tract.  The  symptoms  observed  are 
high  fever,  followed  by  collapse,  with  depression  of  the  body-heat,  pain- 
ful and  paroxysmal  cough,  cyanosis,  very  weak  heart,  together  with  the 
signs  of  pleuritic  eflFusion  and  consolidation  of  the  lung. 

Diagnosis. — The  history  (occupation,  etc.)  and  the  appearance  of 
the  malignant  pustule  in  external  anthrax  leave  little  room  for  doubt. 
The  diagnosis,  however,  should  be  confirmed  by  an  examination  of  the 
contents  of  the  pustule  for  the  presence  of  bacilli,  and  if  found  they 
should  be  cultivated  and  inoculated  upon  a  guinea-pig  or  rabbit. 

Internal  anthrax  may  be  suspected  if  the  more  characteristic  pul- 
monary or.  gastro-intestinal  symptoms,  together  with  those  of  systemic 
intoxication,  develop  in  persons  whose  occupation  entails  exposure.  In 
doubtful  cases  the  presence  of  bacilli  in  the  blood  must  be  shown. 

Prognosis. — In  external  anthrax  occurring  in  healthy  persons  the 
disease  often  pursues  a  favorable  course  ;  moreover,  radical  surgical 
measures  have  decreased  the  death-rate  decidedly.  Internal  anthrax, 
however,  is  a  deadly  aff'ection.  As  regards  '' Avool-sorters'  disease," 
those  who  survive  for  one  Aveek  usually  recover  (Bell). 

Treatment. — Prophylactic  measures  embrace  the  sterilization  and 
destruction  of  the  hair,  hides,  wool,  etc.,  of  infected  animals  as  well  as 
the  cremation  of  their  bodies.  Subsequent  disinfection  of  the  infected 
premises  and  the  prohibition  of  grazing  in  infected  pastures  are  matters 
of  the  utmost  importance.     In  the  carbuncular  form,  if  seen  early,  the 


HYDROPHOBIA.  309 

best  treatment  is  excision  of"  the  affected  area,  including  a  considerable 
amount  of  surrounding  skin.  In  the  edematous  variety,  early  excision 
followed  by  cauterization  is  indicated.  If  impossible,  as  is  the  rule, 
injections  of  carbolic  acid  in  a  solution  of  water  and  glycerin  (1: 10)  into 
the  surrounding  tissue  have  given  the  best  results,  llallopeau  recommends 
that  in  order  to  prevent  extension  the  neighboring  structures  be  bathed  with 
a  10  per  cent,  solution  of  carbolic  acid  (first  dissolved  in  alcohol)  in  oil  or  gly- 
cerin. Internally,  stimulants,  antiseptics,  and  nourishing  food  constitute 
our  chief  reliance.  In  internal  anthrax  efforts  at  treatment  avail  nothing. 
Several  sera  have  proved  valuable  in  the  treatment  of  anthrax,  the  best 
being  that  of  Sclavo,  which  is  obtained  from  the  sheep  or  ass  (Emery). 


•      HYDROPHOBIA. 

[Rabies.) 

Definition. — A  specific,  infectious  disease  peculiar  to  carnivora  and 
to  a  less  extent  to  herbivora,  which  may  be  communicated  to  man  by 
direct  inoculation.  It  is  characterized  by  slight  fever,  spasm  of  the 
larynx  and  pharynx,  delirium,  a  short  stage  of  paralysis,  coma,  and,  in 
the  great  majority  of  cases,  a  fatal  termination. 

Pathology. — The  facies,  pharynx,  and  esophagus  may  be  con- 
gested, the  latter  organ  being  sometimes  markedly  edematous ;  pulmo- 
nary congestion  has  also  been  noticed.  The  mucous  membrane  may 
show  here  and  there  points  of  hemorrhage,  and  Fitz  has  observed  blood- 
extravasations  into  the  perivascular  spaces  of  the  brain.  Soft  thrombi 
may  fill  the  cerebral  vessels,  especially  the  veins,  while  the  blood  has  a 
dark  color  and  its  clots  lack  firmness. 

Balzer,  Benedikt,  Kolesnikoff',  and  Schaffer  made  studies  of  the 
changes  in  the  nervous  system.  Later,  Babes  described  the  ^^  tubercles 
rahiques^''  which  consist  of  pericellular  accumulations  of  embryonal  cells, 
the  latter  finally  taking  the  place  of  the  destroyed  cell.  More  recently 
Van  Gehuchten  and  Nelis  discovered  lesions  in  the  cerebro-spinal  and 
sympathetic  ganglia  ;  they  "  consist  in  the  atrophy,  the  invasion,  and 
the  destruction  of  the  nerve-cells  brought  about  by  new-formed  cells 
derived  from  the  capsule,  which  appears  between  the  cell-body  and 
its  endothelial  capsule.  These  new-formed  cells  increase  in  number, 
invade  the  protoplasm  of  the  nerve-cell,  and  finally  completely  occupy 
the  entire  capsule."  Rarely,  the  kidneys  may  show  cloudy  swell- 
ing. 

il^iology. — Pasteur  has  found  the  poison  abundantly  present  in  the 
nerve-centers,  and  has  transferred  the  disease  by  taking  bits  of  brain- 
substance  or  medulla  derived  from  an  infected  animal  and  inoculating 
them  into  healthy  subjects. 

Bacteriology. — The  micro-organism  of  the  disease  has  not  yet  been 
determined,  though  Spenelli,  Rivolta,  Foil,  Ferran,  and  others  have 
described  a  bacillus.  Memmo  ^  believes  he  has  established  its  claims  as 
the  specific  organism,  and  reports  successful  production  of  the  disease  in 
dogs,  rodents,  and  birds,  wuth  the  typical  diff"erences  characteristic  of  each. 

The  usual  mode  of  infection  in  man  is  through  the  bite  of  a  rabid 
animal,  the  virus  being  contained  principally  in  the  saliva,  and  in  an 
immense  majority  of  cases  (about  90  per  cent.)  the  dog  is  the  off"ending 
^Centrcdbl.  f.  Bakt.,  Abt.  i.,  Bd.  xx.,  17,  18. 


310  INFECTIOUS  DISEASES. 

party.  The  cat,  wolf,  cow,  and  horse  also  suffer  from  the  disease,  and 
in  rare  instances  they  communicate  the  disease  to  man.  The  skunk  is 
also  liable,  and  its  bite  has  often  transmitted  rabies,  especially  to  per- 
sons sleeping  in  the  open  air  or  in  tents  which  the  animal  can  enter. 
The  virus  gains  access  to  the  system  through  the  broken  skin. 

Susceptibility  to  the  poison  e.xists  in  about  one-half  the  instances  in 
which  persons  are  bitten  by  rabid  animals,  though  in  some  cases  this  ap- 
parent immunity  may  be  owing  to  slight  or  even  non-infection. 

Clinical  History. — The  incubation-period  lasts  from  six  weeks  to 
three  or  four  months,  though  in  youn^  subjects  and  in  cases  in  which 
the  infection  is  severe  the  symptoms  develop  earlier.  Certain  prodro- 
mal symptoms  are  majiifested,  as  a  rule,  and  generally  last  only  a  day 
or  two ;  I  have,  however,  seen  two  instances  in  which  melancholia,  due 
probably  to  the  dread  of  what  might  follow,  showed  itself  immediately 
after  the  reception  of  the  bite  and  persisted.  The  usual  premonitory 
symptoms  are  headache,  loss  of  appetite,  sleeplessness,  great  depression 
of  spirits,  and  sometimes  darting  pains  that  radiate  from  the  seat  of 
the  bite.  The  adjacent  lymph-glands  may  become  swollen,  and  slight 
difficulty  in  swallowing  is  experienced. 

Following  the  invasion  are  two  stages  :  (1)  The  Stage  of  Excitement. 
— The  patient  wears  an  expression  of  the  most  intense  anxiety.  Hyper- 
esthesia is  present  and  attains  to  a  marked  degree,  and  the  special  senses 
exhibit  the  keenest  vigilance,  a  noise  or  a  draft  of  air  often  causing 
great  psychic  disturbance  or  a  violent  reflex  spasmodic  contraction  of 
the  larynx.  Quite  early  the  mere  sight  of  water  is  dreaded  by  the  pa- 
tient, and  forms  a  characteristic  feature  of  the  disease.  This  symptom 
has  given  the  name  hydrophobia  to  the  disease,  and  springs  from  the 
fear  of  inducing  a  painful  spasm  of  the  larynx.  The  patient  has  thirst 
which  he  cannot  assuage.  There  may  be  maniacal  excitement,  and  the 
spasmodic  contractions  of  the  larynx  may  become  so  strong  as  to  excite 
urgent  dyspnea,  with  the  emission  of  curious  sounds.  The  muscles  of 
the  mouth  may  also  exhibit  convulsive  movements,  causing  the  patient  to 
make  snapping  sounds ;  these,  however,  are  secondary.  There  is  asso- 
ciated great  restlessness,  with  frequent  lateral  rolling  of  the  head,  and 
foaming  saliva  may  be  ejected  from  the  mouth.  The  symptoms  occur 
in  paroxysms,  and  during  the  intervals  the  patient  is  generally  free 
from  excitement.  There  is  fever  as  a  rule,  the  temperature  ranging 
from  100°  to  102°  F.  (37.7°-38.8°  C.)  or  over,  but  it  may  be  absent; 
the  pulse  is  moderately  accelerated  and  is  sometimes  irregular,  and  to- 
ward the  end  of  this  stage  the  reflex  spasms  of  the  respiratory  apparatus 
develop  spontaneously.  Mental  aberrations  and  melancholia  may  ensue, 
and  often  lead  to  suicidal  tendencies. 

(2)  The  Paralytic  Stage. — In  the  concluding  stage  the  patient  passes 
into  actual  unconsciousness  or  coma,  without  spasms.  This  lasts  from 
twelve  to  eighteen  hours,  ending  in  death. 

In  man  there  is  a  paralytic  form  of  rabies,  but  it  is  rare  as  compared 
with  the  delirious  or  psychic  tj^pe.  Thirty  cases  have  been  reported  by 
GamaMia,  and  it  is  apt  to  follow  deep  and  multiple  bites.  The  paral- 
ysis begins  near  the  part  bitten,  and  spreads  until  it  becomes  general, 
finally  involving  the  respiratory  centers.  In  rodents  quiet  madness 
('•  dumb  rabies"),  without  maniacal  excitement,  is  the  rule. 

Diagnosis. — The  hyperesthesia,  the  fear  of  water,  the  reflex  spasms 


HYDE  OPHOBIA .  311 

on  attempting  to  swallow,  accompanied  by  dyspnea  and  great  mental 
agitation,  form  a  very  characteristic  grouping  of  symptoms.  Bits  of 
brain-substance  or  medulla  of  the  rabid  animal  that  has  inflicted  a  bite 
should  be  quickly  obtained,  and  a  subdural  inoculation  of  a  rabbit  be 
made.  If  virulent,  the  paralytic  form  of  the  disease  will  ensue  in  from 
fifteen  to  twenty  days.  Ravenel  and  McCarthy,^  following  the  method  ^ 
of  Van  Gehuchten  and  Nelis,  conclude  that  when  present  the  capsular 
and  cellular  changes  in  the  intervertebral  ganglia,  taken  in  connection 
with  the  clinical  manifestations,  afford  a  trustworthy  means  of  diagnosis 
of  rabies  in  the  animal.  When  these  changes,  however,  are  absent  (as 
happens  in  early  stages  of  the  disease),  rabies  cannot  be  excluded. 
Hysteria  may  be  misleading,  but  here  the  previous  history  suffices. 

The  name  lyssophohia  has  been  given  to  cases  that  simulate,  but  have 
no  relation  to,  hydrophobia,  and  Mills  has  advanced  the  warning  that, 
however  suggestive  the  symptoms  following  a  dog-bite,  the  given  case 
cannot  be  assumed  to  be  a  case  of  hydrophobia  until  other  possibilities 
are  excluded.  It  is  highly  probable  that  there  is  a  form  of  hydrophobia 
which  is  the  result  of  the  wide  publicity  given  to  genuine  and  suspected 
cases  alike.  The  characteristic  symptoms  may  be  present,  but  the  affec- 
tion does  not  develop.  This  so-called  pseudo-hydrophobia  appears  only 
in  neurotic  and  hysteric  subjects.  Recovery  is  the  rule.  Burr  reports 
an  interesting  case  of  the  kind  that  occurred  in  Osier's  clinic,  attended, 
however,  with  recovery. 

Prognosis. — Few  if  any  cases  of  rabies  in  man  recover  if  the  dis- 
ease be  allowed  to  develop. 

Treatment. — Prophylaxis. — Upon  the  reception  of  a  bite  thorough 
disinfection,  followed  by  cauterization  of  the  wound  with  caustic  potash, 
or,  better  still,  excision,  if  important  structures  be  not  involved,  is  a 
measure  that  can  be  quickly  carried  out.  The  wound  is  then  to  be  kept 
open  for  a  period  of  four  or  five  weeks.  Dudley  advises  that  a  tourni- 
quet should  be  applied  if  the  bite  be  on  an  extremity.  Systematic  muz- 
zling of  dogs  is  to  be  encouraged  and  advised. 

Preventive  inoculation  as  perfected  by  Pasteur  is  a  precautionary 
measure  of  the  utmost  importance.  He  showed  that  the  virulence 
of  the  virus  which  is  obtained  from  the  nervous  system  undergoes 
modification  by  passage  through  animals.  Thus  the  potency,  of  the 
virus  is  increased  by  its  inoculation  from  rabbit  to  rabbit  (by  placing 
bits  of  spinal  marrow  beneath  the  dura  mater),  the  period  of  incubation 
at  the  same  time  growing  shorter,  till  at  last  it  is  but  seven  days.  On 
the  other  hand,  the  virulence  is  decreased  or  attenuated  as  the  result  of 
similar  experiments  upon  the  monkey.  Pasteur  also  found  that  if  frag- 
ments of  the  spinal  cord  were  suspended  in  a  dry  atmosphere  they  lost 

'  Proc.  Path.  Soc.  Phila.,  March,  1901. 

*  This  is  as  follows :  The  ganglion  is  put  at  once  into  absolute  alcohol,  in  which  it  is 
left  for  twelve  hours,  the  alcohol  being  changed  once.  It  is  transferred  for  one  hour  to  a 
mixture  of  absolute  alcohol  and  chloroform  ;  next  put  for  one  hour  into  pure  chloroform  ; 
then  for  one  hour  into  a  mixture  of  chloroform  and  paraffin,  and  lastly  in  pure  paraffin  for 
one  hour.  The  sections  are  put  in  the  oven  for  a  few  minutes,  then  passed  through  ivlol, 
absolute  alcohol,  and  90  per  cent,  alcohol,  after  which  they  are  stained  for  five  minutes  in 
methylene-blue  according  to  Nisei's  formula,  diflerentiated  in  90  per  cent,  alcohol,  dehy- 
drated in  absolute  alcohol,  and  cleared  in  essence  of  cajuput  and  xylol.  Ravenel  and 
McCarthy  found  that  the  capsular  changes  were  best  brought  out  in  sections  stained 
by  hematoxylin  and  eosin.  Since  these  latter  changes  are  the  most  essential  diagnostic 
features  in  the  sections,  they  suggest  that  material  unfit  for  the  Nissl  method  will  still 
show  the  capsular  changes  when  stained  by  hematoxylin  and  eosin. 


312  INFECTIOUS  DISEASES. 

gradually  their  virulence  and  finally  became  inert.  From  these  an 
emulsion  is  prepared  which  is  employed  in  the  antirabic  inoculations  in 
man.  In  this  way  he  secured  a  virus  of  known  and  reliable  strength, 
and  with  this  he  could  readily  render  the  dog  refractory  by  inoculating 
with  very  weak  virus ;  then,  by  increasing  from  day  to  day  the  virulency 
of  the  inoculations,  complete  immunity  was  established. 

Protective  Inoculation. — ''  The  patients  are  first  inoculated  with  a 
cord  fourteen  days  old,  and  the  inoculation  is  repeated  daily  for  nine 
days,  each  time  with  a  cord  one  day  fresher.  In  winter  the  oldest  cords 
used  are  five  days  old,  and  in  summer  cords  that  have  been  drying  for 
four  days  are  also  employed  "  (Warren). 

For  patients  who  have  been  bitten  on  the  face,  hands,  or  bare  feet, 
as  well  as  for  those  w  ho  have  been  bitten  long  before  commencing  treat- 
ment, the  special  preventive  method,  the  so-called  "  intensive  treatment," 
is  applicable.  Briefly,  this  consists  in  eliminating  some  of  the  inocula- 
tions of  intermediary  strengths,  thus  lessening  the  number  of  injections, 
and  also  in  administering  the  latter  at  shorter  intervals  than  in  the  usual 
method  of  treatment.  The  success  of  the  Pasteur  method  is  universally 
attested.  Pottevin  gives  the  following  summary  of  figures  from  the 
Pasteur  Institute:  From  1886  to  1894,  13,817  persons  were  bitten,  with 
a  mortality  of  0.5  per  cent.  In  the  New  York  Pasteur  Institute,  313 
West  Twenty-third  Street,  under  the  directorship  of  Paul  Gibier,  of 
1367  cases  treated  during  the  decade  ending  Jan.  1.  1900,  19  died — a 
mortality  of  0.66  per  cent.  The  patients  should  be  sent  to  the  Pasteur 
Institute  at  once,  since  delay  diminishes  the  protective  power  of  the 
inoculation. 

The  established  affection  defies  all  known  methods  of  treatment. 
Our  aim  should  be  to  diminish  the  intensity  of  the  painful  spasms  and 
the  psychic  disturbances.  The  patient  should  be  isolated  from  sounds, 
light,  and  excitement  of  every  sort.  Food,  as  a  rule,  must  consist  of 
nutrient  enemata,  though  by  the  local  application  of  cocain  the  sensi- 
tiveness of  the  throat  may  be  diminished  sufiiciently  to  enable  the 
patient  to  take  liquid  nourishment  (Osier).  For  controlling  the  spasms 
chloroform  by  inhalation  is  most  eflfective ;  chloral  internally  and  mor- 
phin  hypodermically  may  be  of  advantage.  The  patient's  anxiety  is 
best  relieved  by  a  cheerful  demeanor  on  the  part  of  the  attendants'. 


TETANUS. 

{Trismus;  Lockjaw.) 


Definition. — An  acute,  infectious  disease  caused  by  the  tetanus 
bacillus.  It  is  characterized  by  painful  spasms,  affecting  first  and  chiefly 
the  muscles  of  the  jaw  and  neck  {trismus),  and  secondly  those  of  the 
trunk,  especially  the  extensors  of  the  spine  and  limbs  {opisthotonos). 
Two  varieties  are  recognized  :  (a)  idiopathic  C.^) ;  {h)  traumatic.  In  certain 
institutions  and  certain  localities  it  occurs  endemically,  and  among  new- 
born children  and  the  colored  race  it  may  prevail  epidemically  {trismvi< 
neonatorum).     The  incidence  of  the  disease,  however,  is  decreasing. 

Pathology. — No  constant  post-mortem  lesions  have  been  found. 
The  virus   acts  principally  upon  the   nervous   centers  of  the   medulla 


TETANUS.  313 

and  the  cord,  produciiif^  inflarnmntion  ("and  somotiTnes  softenin^r)  of  the 
gray  substance  of  the  cord.  According  to  lirown-SCiquard,  the  charac- 
teristic lesions  are  consecjuent  upon  an  ascendiny  neuritis  starting  from 
the  wound,  and  it  is  true  that  the  nerves  often  present  traumatic  lesions 
with  redness  and  swelling  of  the  neurilemma.  Tetanus  neonatorum  often 
shows  inflammation  of  the  umbilicus. 

l^tiology. — Bacteriology. — In  1884,  Nicolaier  discovered  the  bacil- 
lus of  tetanus,  and  in  1886,  Rosenbach  first  found  it  in  man.  It  is  a 
long,  slender  rod,  at  one  end  of  which  appears  a  swelling  due  to  the  forma- 
tion of  a  spore  in  that  locality,  thus  giving  the  organism  an  appearance 
like  that  of  a  pin  or  drumstick.  The  bacilli  are  easily  stained  by 
Abbott's  method,  and  are  purely  anaerobic.  Pure  cultures  can  be  made, 
but  with  difficulty,  since  they  will  not  grow  in  the  presence  of  the  smallest 
amount  of  oxygen.  If  pure  cultures  are  injected  into  animals,  typical 
tetanus  follows.  Brieger  has  obtained  two  poisons  from  sterilized  cult- 
ures of  the  bacillus  in  the  pure  state,  and  termed  them  "  tetanin  "  and 
"  tetano-toxin  " — both  most  virulent  poisons  in  the  minutest  quantity. 
These  alkaloidal  substances  produce  the  tonic  convulsions  ;  hence  tetanus 
is  purely  toxic  in  nature — an  intoxication.  The  bacilli  are  most  proba- 
bly limited  to  the  point  of  infection,  and  here  develop  the  toxin,  which 
"is  carried  mostly  along  the  nerves  to  the  spinal  cord  "  (Stintzing). 

Tiberti  Avhose  experiments  corroborate  those  of  Meyer  and  Ransom, 
found  that  the  toxin  is  transported  to  the  nerve-centres  through  the 
plasma  of  the  nerve-fibers,  but  that  the  normal  integrity  of  the  axis 
cylinders  to  effect  the  conduction  is  preserved. 

Modes  of  Infection. — In  the  outer  world  tetanus  bacilli  are  found  to 
be  both  numerous  and  widely  distributed.  They  abound  in  the  earth 
(garden-soil  in  particular),  putrefying  liquids,  manure,  in  rubbish,  and 
dust  of  streets  and  houses,  etc.  The  fact  that  the  bacillus  of  tetanus  is 
anaerobic  explains  why  it  is  most  apt  to  follow  punctured  and  contused 
wounds.  An  analysis  of  1201  cases  by  the  writer  and  A.  C.  Morgan  ^ 
affords  convincing  proof  that  every  case  is  the  result  of  the  introduction 
of  the  tetanus  bacillus  through  a  lesion  of  the  skin,  however  minute  it 
may  be,  and  that  so-called  idiopathic  or  "rheumatic"  tetanus  does  not 
exist.  The  presence  of  the  bacillus  in  vaccine  has  apparently  been  the 
cause  of  some  recent  cases.  The  locality/  of  the  injury  is  most  commonly 
on  the  extremities,  particularly  on  the  hands  and  the  feet,  although  the 
figures  of  Anders  and  Morgan  (previously  cited)  indicate  the  great 
susceptibility  of  all  portions  of  the  body  to  the  poison. 

Certain  Prediposiyig  Causes. — 1.  Males  are  more  susceptible  than 
females  [e.  g.,  out  of  981  cases  the  former  sex  made  up  79.3  per  cent.), 
although  males  are  more  exposed  to  infection.  2.  The  robust  are  more 
receptive  than  the  weak,  and  the  nervous  than  the  lymphatic.  3.  Sea- 
son. In  687  cases  the  seasonal  occurrence  was  recorded  by  Morgan  and 
myself  and  indicated  that  tetanus  is  more  prevalent  in  the  hotter  as  com- 
pared with  the  colder  months  of  the  year.  The  maximum  number  of 
cases  occurred  in  July  (4th  of  July  tetanus).  4.  Age.  An  analysis  of 
583  cases,  with  reference  to  liability  according  to  age,  gave  229  cases,  or 
39,3  per  cent,  from  the  fifth  to  the  fifteenth  years  of  life,  145  cases,  or 
24.9  per  cent,  from  the  fifteenth  to  the  twenty-fifth  years,  while  there 
were  86  cases,  or  14.8  per  cent,  between  twenty-five  and  thirty-five 
years.     After  the  fiftieth  year  only  14  cases  occurred, 

^Journal  of  the  Amer.  Med.  Assoc. ^  July  29,  1905. 


314  IXFECTIOUS  DISEASES. 

Immunity. — Behring  and  Kitasato  have  rendered  animals  immune 
by  the  injection  of  cultures  of  the  bacillus  after  the  addition  of  iodin 
trichlorid  to  diminish  their  strength,  and  this  serum  has  been  success- 
fully used  to  protect  others  against  tetanus. 

Clinical  History. — The  duration  of  incubation  depends  upon 
whether  the  given  case  pursues  an  acute  or  a  chronic  course.  In  acute 
tetanus  it  lasts  from  one  to  two  weeks,  while  in  chronic  the  first  symp- 
toms usually  appear  after  the  second  week.  In  so-called  idiopathic 
tetanus  tlie  symptoms  ap]iear  shortly  after  exposure  to  the  special  causes. 

Symptoms  of  Acute  Tetanus. — (1)  Mild  prodromal  symptoms  (languor, 
headache,  etc.)  may  precede  the  more  intense  characteristic  phenomena,' 
which  develop  gradually.  At  first  the  patient  complains  of  stiffness 
and  tension  in  the  muscles  of  mastication  and  back  of  the  neck,  and 
soon  tonic  spasm  of  the  masseters  renders  the  facial  muscles  more  or 
less  immobile  and  locks  the  jaws  {trismus  or  lockjaw).  The  rigidity  of 
the  cervical  muscles  is  shown  by  the  retraction  of,  and  by  attempts  at 
raising,  the  head.  The  physiognomy  is  distinctive ;  it  is  immobile,  the 
forehead  being  often  wrinkled  and  the  corners  of  the  mouth  retracted, 
producing  a  peculiar  smile  {sardonic  grin).  Next  the  muscles  of  the 
body  become  rigid,  first  the  trunk  {orthotonos),  and  then  the  spine  is  bent 
or  bowed  and  the  convexity  presents  anteriorly  {opisthotonos).  Lateral 
arching  of  the  body  also  occurs,  though  rarely  {pleurosthotonos).  The 
belly-muscles  are  hard  and  board-like,  and  their  contractions  may  throw 
the  body  forward  {emprosthotonos).  The  arms  generally  remain  movable, 
but  the  legs  may  be  rigidly  extended.  The  position  of  the  body  is  one 
of  constant  rigidity,  but  from  time  to  time  convulsive  seizures  of  variable 
duration  occur,  causing  most  agonizing  suffering,  thoracic  oppression, 
dyspnea,  and  more  or  less  cyanosis,  due  to  interference  with  the  respira- 
tory function  (especially  spasm  of  the  glottis).  Sharp,  lancinating  pains 
occur  at  the  base  of  the  chest.  "  Convulsive  dysphagia  "  (as  in  hydro- 
phobia) is  rarely  observed.  These  spasms  are  usually  reflex.  The 
reflexes  are  increased.  Rostowzew  thinks  that  Kernigs  symptom  is  an 
early  and  constant  one  in  tetanus.  The  intellect  remains  clear.  Pro- 
fuse perspiration  is  a  significant  symptom. 

Fever  of  a  moderate  degree  is  generally  present.  The  temperature, 
however,  may  suddenly  leap  to  110°  or  11*2°  F.  (43.3°-44.4°  C),  form- 
ing an  ominous  symptom,  these  extreme  elevations  of  temperature  being 
probably  due  to  paralysis  of  the  centers  that  regulate  bodily  heat.  Con- 
versely, fever  may  be  absent  throughout  the  attack,  and  a  brief  post- 
mortem rise  of  temperature  be  seen.  The  pulse  is  quickened,  and  in 
the  worst  cases  may  become  very  rapid  (140  to  160  beats  per  minute), 
small,  and  irregular.  The  urine  may  be  suppressed  or  its  passage  im- 
peded bv  the  muscular  contractions.     The  bowels  are  constipated. 

(2)  Chronic  Tetanus. — The  same  symptoms  are  manifested  as  are  seen 
in  the  acute  form,  but  the  condition  does  not  progress  so  rapidly.  In 
some  instances  the  symptoms  soon  become  aggravated,  to  be  followed, 
however,  by  periods  of  decided  relief  from  the  painful  spasms,  so  that 
during  the  latter  the  patient's  strength  can  be  maintained  by  means  of 
stimulating  food,  and  intervals  of  partial  freedom  from  the  excruciating 
pains  grow  longer  in  favorable  cases,  until  finally  the  period  of  convales- 
cence may  be  reached.     Relapses,  hoAvever,  are  common. 

(3)  Cephalic  tetanus  (first  described  by  Rose)  usually  follows  injuries 
to  the  head  (face).     Its  most  characteristic  symptoms  are  rigidity  of  the 


TETANUS.  315 

masseter  muscles,  spasm  of  tlie  pharyngeal  muscles,  causing  dysphagia, 
chronic  contraction  of  the  muscles  of  the  neck  and  ahdomen  (rare),  and 
paralysis  of  the  facial  nerve  on  the  same  side  as  the  injury.  The  latter 
symptom  is  due  to  local  infection  by  a  toxin.  Recovery  takes  place  in 
about  25  per  cent,  of  the  instances,  according  to  Willard's  statistics. 

Diagfnosis. — In  view  of  the  usual  history,  the  predominating  feat- 
ure— trismus — together  with  the  early  appearance  of  rigidity  at  the 
back  of  the  neck,  will,  as  a  rule,  render  the  diagnosis  a  simple  one. 

Strychnin-poisoning  must  be  eliminated,  in  which  the  following  table 
will  assist  : 

Tetanus.  Strychnin-poisoning. 

Reception  of  a  wound,  generally  followed       Ingestion  of  strychnin,  followed  immedi- 

by  a  period  of  incubation.  ately  by  the  symptoms. 

Begins  with  lockjaw;  later  spreads  down-      Begins    with    gastric    disturbance   or   a 
ward  (the  arms  and  hands  escaping).  tetanic  contraction  of  the  extremities. 

Hyperesthesia  of  the  retina  occurs  and 
objects  look  green. 
Reflex  spasms  not  present  at  the  outset.        Violent  convulsions    present    from    the 

onset. 
Rigidity    is    persistent,    except    in    the      Intervals  of  complete  relaxation  occur. 

chronic  form. 
The   course   is   prolonged   into   days  or      Course  is  brief,  terminating  in  death  or 

weeks.  recovery. 

Cultures    made    from  the  discharges  of       Examination  of  the  gastric  contents  shows 
the  wound  show  the   bacillus    tetani.  strychnin. 

Tetany  gives  rise  to  a  prolonged  spasm  affecting  the  extremities 
(hands  in  particular)  and  the  larynx,  with  intermissions  ;  it  is  also  char- 
acterized by  a  peculiar  posture,  and  occurs  chiefly  in  the  young. 

Mydi'ophohia  is  discriminated  from  tetanus  by  the  history  of  a  bite 
from  an  animal,  by  the  predominance  of  the  reflex  spasm  of  the  respir- 
atory apparatus,  by  the  intensity  of  the  psychic  disturbance,  and  by  the 
absence  of  lockjaw  and  opisthotonos. 

Course  and  Prog"nosiS. — "  Acute  tetanus  or  that  which  developed 
within  ten  days  gave  a  total  of  568  cases  and  a  mortality  of  74  per  cent. 
On  the  other  hand,  211  cases  lasted  over  fifteen  days,  with  only  18 
deaths,  or  8.5  per  cent,  mortality  "  (Anders  and  Morgan).  Death  results 
from  asthenia,  heart-failure,  or  asphyxia  (during  the  paroxysm).  Accord- 
ing to  Richter's  statistics,  88  per  cent,  of  military  cases  are  fatal.  In 
the  so-called  idiopathic  cases  the  mortality-rate  is  under  50  per  cent. 
Chronic  tetanus  gives  a  less  grave  prognosis  than  does  acute.  There  is 
a  direct  relation  between  the  duration  of  the  incubation  period  and  the 
mortality-rate.^  In  the  newborn  recovery  is  so  rare  that  when  it  occurs 
the  diagnosis  may  be  called  into  question. 

Treatment. — In  traumatic  cases  the  wound  must  be  disinfected  and 
thoroughly  cauterized.  The  agents  employed  must  be  brought  in  con- 
tact with  every  portion  of  the  wound,  so  that  punctured  wounds  must  first 
be  laid  open.  Excision  of  the  wound,  and  even  amputation,  may  be  ad- 
visable in  some  cases.  The  fact  that  the  deadly  poison  is  developed  at 
the  site  of  infection  gives  to  the  local  measures  supreme  importance  in 
the  treatment.  The  application  of  lipoid  substances  {e.  g..  Peruvian 
balsam  salve)  is  found  to  delay  the  incubation  period  (Brockenheimer). 

The  patient  should  occupy  a  secluded  room  with  little  light  and  a 
^  Journal  of  the  Amer.  Med.  Assoc,  July  29,  1905. 


316  INFECTIOUS  DISEASES. 

carefully  regulated  temperature.  A  single  nurse  will  suffice,  and  all 
sources  of  external  irritation  should  be  avoided.  A  nourishing  diet  is 
demanded,  and  rectal  feeding  must  be  instituted  as  soon  as  it  is  found 
that  food  cannot  be  administered  per  oram,  or  the  food  may  be  intro- 
duced by  means  of  a  small  stomach-tube  or  catheter  passed  through  the 
nostril.  Stimulants  hypodermically  should  not  be  spared  when  the 
heart's  action  becomes  quick  and  feeble.  The  spasms  are  best  con- 
trolleil  by  chloroform-inhalations,  and  during  the  intervals  the  patient 
should  be  kept  under  the  influence  of  morphin,  administered  sub- 
cutaneously.  Kintzing  ^  reports  excellent  results  from  a  solution  of  pure 
phenol  (10  per  cent,  strength)  in  sterile  water.  Of  this  solution,  the 
adult  dose  employed  was  10  drops  diluted,  by  hypodermic  injection  deep 
into  the  muscles,  and  repeated  every  three  hours  in  the  beginning,  in- 
creasing the  interval  as  improvement  manifested  itself.  Among  other 
capital  remedies  are  chloral  hydrate  and  Calabar  bean.  The  former  may 
be  exhibited  by  rectal  injection  (gr.  xl — 2.59  at  a  dose),  to  be  repeated 
at  intervals  of  six  or  eight  hours  until  the  spasm  is  overcome.  The 
heart,  however,  must  be  carefully  guarded.  Rarely,  chloretone,  potassium 
bromid,  curare,  nitrite  of  amyl.  belladonna,  and  cannabis  indica  are  useful. 

Tetanus-antitoxin  has  been  recommended  for  the  cure  of  the  disease, 
and  is  prepared  in  both  fluid  (antitoxin  serum)  and  dry  form.  A  dried 
preparation  (which  does  not  deteriorate)  is  also  obtainable  from  Merck 
and  his  agents  in  the  form  of  tubes  containing  from  4  to  5  grams  each  ; 
at  the  time  used  it  may  be  dissolved  in  water  or  in  glycerin.  Of  Tiz- 
zoni's  dried  antitoxin  2.25  grams  are  to  be  given  at  the  first  dose,  and 
0.6  gram  at  subsequent  doses.  As  shoAvn  by  recent  experimentation, 
antitetanic  serum  may  prevent  further  invasion,  but  it  cannot  cure  infec- 
tion that  has  already  reached  the  spinal  cord  and  brain.  The  dose,  as 
recommended  by  Copley,^  should  be  large  (30  c.c.  at  once,  to  be  repeated 
at  least  every  six  hours  until  improvement  is  seen).  Behring  insists  upon 
giving  the  serum  not  later  than  twenty-six  hours  after  the  commencement 
of  the  attack.  Hoffmann^  records  recovery  in  14  out  of  16  cases  in- 
jected with  the  serum,  intradurally.  Torres  recommends  the  injection  of 
120  c.c.  of  tetanus  antitoxin  intravenously,  to  be  repeated  twice  in  the 
twenty-four  hours,  a  third  injection  of  100  c.c.  on  the  second  day  and 
this  repeated  on  the  following  days,  if  symptoms  be  still  present.  Mag- 
nesium sulphate  (2  c.c.  of  a  25  per  cent,  solution)  may  be  injected  into 
the  spinal  canal  after  the  removal  of  an  equal  quantity  of  cerebrospinal 
fluid. 

Propfiylatic  injections  of  500  antitoxic  units  should  be  used  at  once 
after  disinfection  of  the  primary  focus.  Baccelli  advises  subcutaneous 
injections  of  carbolic  acid.  The  dejecta  should  also  be  thoroughly  destroyed 
as  the  tetanus  bacillus  has  been  found  in  the  intestinal  tract. 


BERI-BERI. 

{Endemic  Multiple  Neuritis  ;  Kakkc ;  "  Weak  legs.'') 

Definition. — Beri-beri  is  a  specific  disease  characterized  clinically 
by  fever,  muscular  weakness  followed  by  muscular  atrophy,  pain,  tender- 
ness, paresthesia,  gastro-intestinal  disturbance,  tachycardia,  and  often 
general  anasarca.     It  is  not  certainly  contagious. 

i^Yetu  York  Med.  Jour.,  Dec.  23,  1911.  ..^^'■''-  ^ted.Jour.,  Feb.  11,  1899. 

^International  Clinics,  vol.  ii.,  S.  20,  p.  17. 


Plat;.;  11. 


Beei-beei  (Herzog,  in  Philippine  Journal  of  Science). 


BERLBERI.  317 

Historical. — Beri-beri,  first  icco*5ni/e(l  by  Strabo  among  the  soldiers 
in  the  Roman  armies  wiiile  occupying-  Arabia  (24  B.  C),  was  strangely 
enough  not  grouped  with  the  infections  until  the  beginning  of  the  nine- 
teenth century.  At  this  period  the  subject  began  to  receive  the  serious 
attention  of  Dutch  and  (a  little  later)  of  Anglo-Indian  writers,  and  in- 
vestigators. As  stated  by  Osier,  however,  we  may  date  the  modern 
study  of  the  disease  from  Malcolmson's  monograph,  published  in  Madras 
in  1835.  It  remained  for  Sheube  and  Baelz  to  point  out  that  the  prin- 
cipal morbid  lesions  are  those  of  a  multiple  peripheral  neuritis. 

Distribution. — The  disease  is  endemic  in  tropical  and  subtropical 
countries,  but  may  occur  epidemically  on  shipboard,  in  prisons,  and  in 
armies.  Instances  of  epidemic  prevalence  in  armies  are  numerous,  e.  g., 
in  Arabia,  India,  and  the  Philippines.  Birge  has  reported  an  outbreak 
in  which  11  out  of  13  of  a  ship's  crew  were  attacked,  and  Bondurant  de- 
scribed the  epidemic  that  occurred  at  the  State  Hospital  for  the  Insane 
at  Tuscaloosa,  Ala.,  while  J.  J.  Putnam  observed  cases  among  the  New 
England  fishermen.  The  principal  habitats,  however,  are  certain  parts 
of  Asia,  namely,  Japan,  China,  India,  the  Malayan  Archipelago,  the 
Dutch  Colonies,  and  the  Philippines.  In  all  of  these  countries  the  cases 
may  multiply  under  favorable  conditions  into  extensive  and  devastating 
epidemics.  In  England  and  along  the  Pacific  Coast,  among  the  Jap- 
anese and  Chinese,  it  is  not  uncommon  at  the  seaports. 

Pathology. — The  essential  feature  is  the  changes  in  the  nerves ; 
these  are  inflammatory  and  degenerative,  involving  the  medullary  sheaths 
and  axis-cylinders.  In  addition  to  the  peripheral  nerves,  the  pneumo- 
gastric  and  phrenic  may  be  affected.  Degeneration  in  the  muscles  also 
occurs,  and,  not  uncommonly,  serous  effusions. 

!^tiology. — Although  beri-beri  is  most  probably  an  infectious  dis- 
ease, the  specific  cause  still  remains  in  doubt.  Both  the  bacillus  of 
Hamilton  Wright  and  the  coccus  of  Okata  and  Kokubo  have  been  shown 
to  bear  no  causative  relation  to  the  disease.  Beri-beri  is  the  result  of 
a  protozoan  infection  (Hewlett  and  de  Korte  ^).  Davis,  of  Shanghai, 
showed  a  direct  relation  between  the  presence  of  bed-bugs  and  beri-beri 
among  Chinese  prisoners. 

A  second  leading  theory  ascribes  the  disease  to  polished  rice  and  fresh 
fish.  Eraser  and  Stanton's^  experiments  on  chickens  and  human  beings 
indicate  that  polishing  rice  removes  something  (pericarp  ?)  necessary  to 
maintain  health  on  a  strict  rice  diet.  Chamberlain  and  Vedder^  have 
induced  a  disease  somewhat  resembling  beri-beri  in  children  nursing  from 
mothers  suffering  with  beri-beri  by  the  administration  of  rice-polishing 
extract.  The  striking  diminution  in  the  number  of  cases  in  Japan  fol- 
lowing the  introduction  of  an  improved  dietary  would  seem  to  support  the 
food  theory,  but  the  number  of  cases  of  beri-beri  that  developed  during 
the  Russo-Japanese  War  (in  the  Japanese  army)  did  not  exceed  75.000 
to  80,000.* 

Predisposing  Causes. — {a)  The  principal  disposing  condition  is  over- 
crowding, more  particularly  when  combined  with  antihygienic  surround- 
ings. This  fact  explains  the  localized  outbreaks  in  armies,  asylums, 
ships,  and  the  like,  {h)  Certain  climatic  factors  {vide  Distribution,  supra), 

^Journal  of  Tropical  Medicine  and  Hygiene,  October,  1907. 
^  Philippine  Jour,  of  Science,  1910,  v.,  55  to  64. 
s  Editorial,  Jour,  of  the  Amer.  Med.  Assoc,  June  15,  1912. 
*M.  Herzog,  Philippine  Journal  of  Science,  Feb.,  1908. 


318  IXFECTIOUS  DISKASES. 

as  heat  and  humidity,  favoring  the  development  of  beri-beri ;  hence  natives 
of  tropical  countries  and  imported  coolies  sufter  most.  (<•)  Age  and  sex. 
More  cases  occur  amoiiii:  males  than  females,  and  the  decade  from  15  to 
25  \ears  furnishes  a  large  proportion  of  the  cases. 

Symptoms. — The  period  of  incubation  is  not  definitely  known,  but 
is  probably  from  ten  days  to  one  month,  or  even  longer.  Prodromata  are 
commonly  present :  they  are  thoracic  oppression,  epigastric  pains,  anor- 
exia, ]icadac]u\  and  a  slight  febrile  movement.     Rigors  rarely  occur. 

Four  clinical  varieties  are  recognized  : 

1.  Atrophic  Form. — This  is  characterized  by  muscnlar  weakness, 
slowly  developing,  leading  to  paralysis  of  the  lower  limbs  and  trunk, 
rarely  extending  to  the  arms,  head,  and  neck.  Atrophy  of  the  affected 
muscles  quickly  ensues,  with  loss  of  the  deep  reflexes.  The  extensors 
are  more  profoundly  involved  than  the  flexors.  There  are  pain  and 
tenderness  in  the  muscles  and  over  the  nerve-trunks.  The  electrical  re- 
action of  degeneration  is  present.  Sensory  phenomena  are  constant, 
such  as  zones  of  anesthesia  and  paresthesia  over  the  aifected  parts. 
Slight  dropsy  may  arise.  In  cases  of  the  paralytic  form  that  recover, 
convalescence  is  protracted. 

2.  The  Wet  or  Dropsical  Form. — The  earlier  or  later  development  of 
general  anasarca  with  eff"usion  into  the  serous  sacs,  characterizes  the  wet 
form.  The  swelling  may  be  enormous  and  obscure  the  wasting,  which, 
however,  is  less  marked  than  in  the  atrophic  variety.  The  urine  contains 
no  albumin  and  the  edema  is  firmer  than  that  of  nephritis.  Dyspnea,  car- 
diac palpitation,  and  tachycardia  are  commonly  present. 

3.  The  Acute,  Cardiac  (Pernicious)  Form. — This  serious  type  may  de- 
velop acutely  either  as  a  primary  affection  or  secondary  to  a  mild  form 
of  the  complaint.  The  predominating  features  are  cardiac  p)alpitation, 
marked  dyspnea,  and  indications  of  progressive  cardiac  failure.  A  mod- 
erate leukocytosis  is  usually  present ;  this  was  true  of  my  cases.  The 
urine  may  be  scanty  or  suppressed,  while  the  presence  of  indican  in  large 
amounts  may  be  noted.  The  duration  may  be  brief,  not  exceeding 
twenty-four  hours,  but  oftener,  perhaps,  extending  over  several  Aveeks.^ 

4.  The  Mild  or  Rudimentary  Form. — The  initial  symptoms  may  be 
catarrhal  in  nature,  to  which  are  soon  added  the  characteristic  features — 
pain,  u'eakness  iyi  the  legs,  paresthesia,  cardiac  jialpitation,  and  possibly 
malleolar  edana.  Mild  cases  may  be  the  forerunners  of  the  types  pre- 
viously described,  including  acute  pernicious  beri-beri.  The  disease  is 
often  associated  Avith  malaria,  the  result  of  a  blood  examination  in  4  cases 
in  my  care  having  shown  the  plasmodium  in  3.  or  75  per  cent. 

Diagnosis. — This  offers  no  practical  difficulty  except  in  sporadic 
cases,  in  whicii  the  circumstances  under  which  they  arise  {e.  g.,  the 
country  or  region  from  which  the  patient  may  have  come),  are  unknown. 
The  epidemic  form  is  easily  recognized.  The  grouping  of  the  symptoms 
of  peripheral  neuritis  with  edema,  absence  of  deep  reflexes,  and  threat- 
ening cardiac  dilatation,  leave  little  room  for  doubt  in  any  case. 

Differential  Diagnosis. — Other  forms  of  infectious  polyneuritis  are  dis- 
tinguished by  the  absence  of  the  peculiar  endemic  or  epidemic  status,  the 
visceral  symptoms,  the  edema,  and  of  the  transudation  in  the  serous  sacs. 
In  alcoholic  neuritis  the  peculiar  history  and  such  characteristics  as  the 
1"  Beriberi,  with  Report  of  Cases,"  The  Medical  Bulletin,  by  the  writer.' 


MALTA   FEVER.  319 

prevalence  of  painful  features  and  trembling  are  noted ;   in  diphtheritic 
multiple  neuritin  the  velum  palati  is  involved. 

Course  and  Prognosis. — The  course  is  interrupted  by  periods  of 
aggravation  and  apparent  pauses,  and  on  leaving  the  bcri-beric  centres, 
all  symptoms  may  disappear.  The  prognoHia  is  mainly  dependent  on  the 
intensity  of  the  infection,  the  presence  or  absence  of  associated  diseases 
and  the  circumstances  of  the  individual  patient.  The  particular  variety 
present  in  the  case  i'n  hand  influences  greatly  the  outlook,  e.  g.,  the 
cardiac  or  pernicious  form  being  highly  threatening  to  life.  Again,  the 
anatomic  seat  of  the  nerves  implicated  decidedly  aff'ects  the  prognosis. 

The  mortality  diflFers  with  the  seasons,  locality  and  individual  epi- 
demics. In  Japan  the  death-rate  is  only  12.5  per  cent.,  while  among 
the  Chinese  and  Brazilians  it  is  much  higher. 

Treatment. — 1.  Prophylaxis. — It  is  most  probably  a  fact  that  under 
certain  compulsory  conditions — individual  susceptibility,  overcrowding, 
and  a  warm,  moist  climate — the  usual  hygienic  measures  will  not  pre- 
vent the  outbreak  and  spreading  of  this  disease.  Under  these  circum- 
stances, removal  to  a  non-contaminated  locality  alone  suffices.  The  fore- 
going facts  were  strikingly  confirmed  during  the  recent  Russo-Japanese 
War,  when  the  rigid  execution  of  ordinary  sanitary  means  succeeded  in 
limiting  serious  outbreaks  of  typhoid,  typhus,  scorbutus,  and  dysentery  in 
the  Japanese  army,  while  beri-beri  proved  a  veritable  scourge  {vide 
supra).  Removal  of  early  cases  to  special  hospitals,  followed  by  rigor- 
ous disinfection  of  the  houses  and  rooms  in  which  they  have  been  should 
be  systematically  carried  out  during  an  epidemic  season. 

Certain  hygienic  measures,  such  as  systematic  feeding  with  easily 
digestible  proteins,  exposure  to  fresh  air  without  undue  fatigue,  should 
be  advised.  A  change  to  a  milder  and  drier  climate  is  usually  effica- 
cious, if  practicable.     In  severe  cases  rest  must  be  enjoined. 

2.  Medicinal  Treatment. — Various  methods  have  been  advised,  such  as 
the  early  free  use  of  the  salicylates  (Baelz),  venesection,  and  free  purga- 
tion. While  all  of  these  are  useful  in  suitable  cases,  there  is  not  one  that 
is  applicable  in  every  instance.  The  product  known  as  "  oryzanin  "  is 
thought  to  possess  specific  potency  by  certain  Japanese  investigators.  In 
cases  in  which  serious  cardiac  dilatation  supervenes,  venesection  for  its 
immediate  effect  is  often  effective  in  saving  life.  Many  of  the  most  distress- 
ing symptoms  in  acute  forms  (dyspnea,  pain,  nausea,)  are  benefitted  by  the 
use  of  morphin  hypodermically.  The  dropsy  of  the  cardiac  cases  requires 
rest  and  saline  laxatives,  followed  by  digitalis  (Tltv-x,  of  the  tinct.  every 
third  hour).  For  the  so-called  cardiac  seizures,  nitroglycerin  or  inhala- 
tions of  the  nitrite  of  amyl  are  recommended.  The  atrophied  muscles 
should  be  treated  with  electricity  and  massage,  and  strychnin  with  tonics 
is  indicated  for  the  same  condition. 


MALTA  FEVER. 

(^Mediterranean  f&ver  ;    Rock  Fever ;    Undulant  Fever. ) 

Definition. — A  protracted  infectious  disease,  caused  by  the  micro- 
coccus melitensis,  and  characterized  clinically  by  irregular  fever,  copious 
sweats.,  rheumatoid  pains,  and  frequent  relapses. 


320  ISFECTIOUS  DISEASES. 

History. — Malta  fever  Avas  described  clinically  by  Burnett  in  1816 
as  a  type  of  remittent  malarial  fever,  but  it  was  first  depicted  as  a 
specific  disease  by  Marston  in  18r)9.  It  is  endemic  in  Malta,  and  from 
time  to  time  is  encountered  there,  and  at  other  Mediterranean  ports,  in 
epidemic  form.  Owing  to  observations  made  by  Wright  on  the  serum 
reaction,  this  disease  has  been  shown  to  exist  in  India,  Ilong  Kong,  the 
United  States,  the  West  Indies,  and  Brazil.  Kinyonn  first  suspected 
the  presence  of  Malta  fever  on  this  side  of  the  Atlantic,  along  the  coast 
and  in  the  islands  of  the  Gulf  of  Mexico.  Musser  and  Sailer  ^  recognized 
the  afteetion  in  Philadelphia  in  a  soldier  who  had  come  from  Porto  Rico. 
No  essential  pathologic  lesions  have  been  identified  with  the  disease. 
Hughes  ^  noted  an  enlargement  of  the  spleen  and  of  the  mesenteric  glands, 
and  in  grave  cases,  bronchitis  and  broncho-pneumonia. 

Ktiology. — Bacteriology. — The  micrococcus  melitensis  (Bruce)  has 
been  found  in  certain  tissues  (the  spleen  in  all  fatal  cases),  and  is  readily 
recognized  morphologically  and  by  culture.  Bruce,  in  2  cases,  and 
Hughes,  in  4,  reproduced  the  disease  in  monkeys  by  the  inoculation 
of  pure  cultures  of  the  organism.  Antihygienic  conditions  increase. mor- 
bidity. There  is  no  special  liability  according  to  age.  Goat-herders  are 
markedly  predisposed. 

Modes  of  Infection. — (a)  By  the  "  absorption  of  urine  secreted  by  cases 
of  Mediterranean  fever,  and  this  is  one  way  in  which  workers  in  hospitals 
become  infected  "  (Horrocks).  (h)  It  is  extremely  probable  that  human 
beings  are  infected  by  the  bites  of  infected  mosquitoes — culex  pipie7is, 
stegomyia  fasciata.  (c)  By  the  absorption  of  infected  goats'  milk  from 
the  alimentary  canal.  Gentry  and  Ferenbaugh  have  obtained  the  posi- 
tive serum  test  in  3-4  per  cent,  of  the  goats  examined. 

The  incubation-period  lasts  from  a  few  days  to  twenty  or  thirty. 

Symptoms. — The  disease  is  of  sloto  and  gradual  development,  and 
the  features  simulate  those  of  beginning  typhoid  fever.  Headache,  bone- 
ache,  anorexia,  malaise,  and  slight  fever  (often  preceded  by  shiverings) ; 
the  face  may  be  congested,  and  epistaxis  may  be  present.  The  bowels 
are  constipated,  and  the  stools  may  be  blood-streaked.  The  spleen  is 
always  enlarged  and  frequently  painful,  particularly  on  pressure. 

Three  classes  of  cases  are  recognized  :  (1)  K  pernicious  type  which  is 
rare  and  generally  fatal  (Hughes)  and  needs  no  further  description  here ; 
(2)  an  undulant  type,  characterized  by  exacerbations  of  temperature  at 
pretty  regular  intervals  ;  (3)  a  continued  type,  in  which  a  continuous 
fever  persists  for  weeks  and  even  months.  The  fever  is  of  a  remittent 
type,  with  undulating  course,  and  perspirations  lasting  one,  two,  or  three 
weeks ;  this,  after  an  apyrexial  period  of  two  or  three  days,  is  followed 
by  a  relapse,  with  rigors,  high  fever,  delirium,  and  increased  prostration. 

The  relapse  frequently  lasts  from  five  to  six  Aveeks,  and  then,  after  a 
week  or  two,  a  second  relapse  may  ensue ;  symptoms  somewhat  sim- 
ilar to  the  first — rigors,  intermittent  form  of  fever,  extreme  prostration, 
and  general  rheumatoid  symptoms.  The  latter  may  be  so  well  marked  as 
to  prohibit  muscular  movements  of  any  kind.  The  case  now  either  termi- 
nates in  recovery,  or,  after  the  lapse  of  one  or  even  two  months,  there  may 
be  a  repetition  of  the  whole  symptom-complex.  In  grave  cases  the  tem- 
perature is  continuous,  and  death  may  occur  in  hyperpyrexia  (Hughes). 
The  temperature  range  is  often  markedly  irregular,  hence  its  comparative 
1  Phila.  Med.  Jour.,  Dec.  31,  1898.  ^  Annates  de  I'Institut  Pasteur. 


MUSCULAR  lillKUMATLSM.  321 

uselessness,  as  claimed  by  Craig,  from  a  diagnostic  point  of  view.  A 
polynuclear  leukocytosis  is  present  in  Malta  fever.  Certain  cornpliaatl.onH^ 
as  touches  of  pleurisy  and  pneumonia,  rarely  appear-. 

Diagnosis. — From  the  use  of  pure  cultures  of  tlie  special  organism 
in  the  blood  of  Malta  fever  patients  gives  a  typical  agglutination.  Ac- 
cording to  Negre,  this  test  is  only  reliable  for  the  micrococcuH  meJi- 
tensis  when  the  serum  is  heated  to  56°  C.  for  half  an  hour.  Thus  the 
affection  is  with  ease  and  certainty  distinguished  from  typJund  fever  and 
erratic  forms  of  malaria.  In  no  other  manner  can  it  be  discriminated 
from  typhoid  fever  in  the  earlier  stages.  The  presence  or  absence  of  the 
Widal  reaction  will  assist  in  the  differentiation.  If  r)ialaria  is  suspected, 
the  blood  should  be  examined  microscopically.  Many  cases  present 
hacking  cough  and  physical  signs  of  lung  congestion,  or  even  consolida- 
tion, and,  as  a  consequence,  are  confounded  with  incipient  tuberculosis. 
The  serum  test  will  remove  all  doubt.  Malta  fever  not  infrequently,  in 
its  mode  of  onset  and  the  symptoms  present  during  the  first  few  days, 
resembles  lobar  pneumonia  (Craig).  The  absence  of  rusty  sputum,  stab- 
bing chest  pains,  and  the  milder  character  of  the  cases,  however,  are  an  aid 
in  excluding  pneumonia.  The  polyarthritis  with  fever  has  led  to  con- 
fusion with  acute  articular  rheumatism.     Pyemia  must  also  be  excluded. 

Duration  and  Prognosis. — Soldiers  show  an  average  stay  in  the 
hospital  of  ninety  days  (Bruce) ;.  obstinate  cases,  however,  may  last  six 
months.  Most  cases  pursue  a  chronic  course.  The  death-rate  is  low — 
about  2  per  cent.     Death  is  generally  due  to  hyperpyrexia. 

Treatment. — This  should  be  sustentative  or  supportive,  in  view  of 
the  uncertain,  protracted  course.  Nourishing  liquids  and,  usually,  stimu- 
lants are  required.  Dalton  allows  solids,  such  as  eggs,  rice,  and  bread, 
in  addition  to  2  to  3  quarts  of  milk.'  The  bowels  should  be  moved  daily. 
Fever  i^  to  be  combated  by  the  application  of  cold  (cold  bath,  wet  pack, 
or  sponging).  Methylene-blue  (gr.  f — 0.05,  two  or  three  times  daily)  is 
considered  the  best  remedy  available  (Audibert  and  Rouslacroix).  Bas- 
sett-Smith  ^  reports  two  series  of  cases  treated  with  vaccine  prepared  from 
cultures  of  Micrococcus  melitensis.,  freshly  isolated  from  the  spleen  durino^ 
life,  with  gratifying  results.  Tonics,  coupled  with  a  change  of  climate, 
favor  convalescence.  Hematinics  are  especially  indicated  during  this 
period  to  overcome  the  well-marked  secondary  anemia. 


PROBABLE  INFECTIOUS  DISEASES. 

MUSCULAR    RHEUMATISM. 
{Myalgia.) 

Definition. — A  common,  painful  disease  of  the  muscles  and  of  the 
structures  to  which  they  are  attached  (fasciae  and  periosteum),  probably 
due  to  an  attenuated  form  of  the  virus  of  acute  articular  rheumatism. 
Leube  contends — and  very  properly,  I  think — that  muscular  rheuma- 
tism is  a  general  disease  with  local  symptoms.  The  latter  may  be  seated 
in  different  parts  of  the  body,  and  in  this  way  give  rise  to  a  number  of 
leading  sub-varieties,  and  it  may  either  accompany  acute  and  chronic 

^  Journal  of  Tropical  Medicine  and  Hygiene,  May  15,  1907. 
21 


322  INFECTIOUS  DISEASES. 

rheumatism  or  it  may  be  experienced  as  an  independent  disease.  I  have 
also  met  with  several  instances  in  which  it  followed  joint-rheumatism, 
and  Leube  has  seen  it  precede  the  latter.  Certain  authors  believe  that 
the  afFoctinii  is  a  neuralgia  of  the  sensory  nerves  of  the  muscles. 

Pathologfy. — Tn  fatal  cases  (these  are  exceedingly  rare)  the  affected 
muscles  show  a  swelling  of  the  fibers  and  more  or  less  granular  change. 
In  long-standing  cases  there  is  an  atrophy  of  the  muscles,  due  to  trophic 
disturbance.      Strauss  describes  circumscribed  nodules  in  the  muscles. 

The  changes  are  essentially  those  of  myositis.  In  the  acute  form 
there  is  often  an  extensive  round-cell  infiltration  of  the  connective  tissue, 
with  swelling  and  partial  degeneration  of  the  muscular  fibers  and  the 
formation  in  them  of  vacuoles.  In  the  chronic  form  there  is  a  prolifera- 
tion of  the  interfascicular  connective  tissue. 

Htiology. — Among  the  disposing  influences  the  most  important  are 
— (1)  The  rlieumatic  diathesis  (appropriate  soil);  (2)  Heredity ;  (3)  Ex- 
posure to  cold,  damp,  and  strong  air-currents,  especially  after  heavy  ex- 
ercise or  during  free  perspiration  ;  (4)  Sex,  owing  to  the  more  frequent 
exposure  of  men  while  following  their  occupations ;  (5)  Age.  It  is  met 
with  at  all  ages,  but  acute  and  subacute  forms  most  frequently  occur 
among  children  and  young  adults,  while  the  chronic  form  generally  affects 
elderly  persons;  (6)  Previous  attacks  increase  the  susceptibility  to  the 
disease.  (7)  Lumbago  may  be  reflex  in  character,  due  to  hemorrhoids, 
enlarged  prostate,  iind  intestinal  irritation. 

Symptoms. — In  the  majority  of  instances  the  clinical  symptoms 
are  local.  Out  of  200  cases  Leube  found  fei'cr  in  about  one-third,  the 
temperature  rarely  exceeding  102°  F.  (38.8°  C.)  for  two  days  in  dura- 
tion. In  one-sixth  of  Leube's  cases  there  was  a  cardiac  murmur  that 
disappeared  under  treatment  in  one-half  of  this  number.  Pain.,  which 
which  is  sometimes  sharp,  lancinating,  and  pai'oxysmal,  while  in  other 
cases  deeply  seated,  dull,  and  constant,  is  troublesome.  It  is  aggravated 
at  night  by  contraction  of  the  affected  muscles,  by  Aveather-changes,  and 
by  pressure.  In  long-continued  cases  pressure  with  the  broad  side  of 
the  hand  usually  affords  relief.  The  duration  ranges  from  a  few  hours 
to  several  days  or  longer.  The  rheumatic  nodules  are  common  in  the 
shoulder-  and  calf-muscles.  The  cases  in  which  the  symptoms  tend  to 
persist  or  recur  with  changes  in  the  weather  may  be  termed  chronic. 

Leading  Clinical  Varieties. — (1)  Lumbago  [Myalgia  LumhaUs). — This 
is  the  most  common  form,  and  may  be  taken  as  the  type  of  the  myalgias. 
The  onset  is  sudden,  sometimes  intensely  so,  and  the  lumbar  muscles  are 
exceedingly  painful  and  sensitive.  Motion,  such  as  stooping  or  turning 
the  body  or  rising  from  the  sitting  position,  causes  intense  exacerbations 
of  pain.  The  affection  occurs  most  frequently  in  laboring-men,  its  course 
being  brief,  as  a  rule,  and  recurrences  frequent.  Erben,  from  a  study 
of  200  cases  of  lumbago,  finds  that  the  trouble  is  principally  an  affection 
of  the  lumbar  vertebroe,  or  a  neuralgia  of  the  cutaneous  nerves. 

(2)  Pleurodynia. — This  term  implies  involvement  of  the  intercostal 
muscles,  and  less  frequently  of  the  pectorals  and  the  serratus  magnus. 
It  is  unilateral,  and  oftener  affects  the  left  than  the  right  side,  and 
causes  untold  suffering,  since  it  is  constantly  aggravated  by  the  normal 
respiratory  excursions.  The  pain  is  also  intensified  by  pressure,  reach- 
ing, etc.,  and  by  movement  of  the  trunk,  sneezing,  and  coughing. 
Similar  symptoms  may  be  occasioned  by  traumatism  in  Avhich  the  fibers 


muscuJjAr  rheumatism.  ,323 

of  the  thoracic  muscles  are  lacerated,  and  there  is  also  great  danger  of 
confounding  pleurodynia  with  costal  periostitis  and  with  pleurisy. 

(3)  Torticollis  (^Myalcpla  Cervicalis). — Here  the  nnuscles,  some  or  all, 
on  one  side  of  the  neck,  and  at  times  the  throat,  are  implicated.  The 
head  is  held  toward  the  affected  side,  so  as  to  relax  the  group  of  muscles 
involved,  and  on  attempting  to  turn  it  the  patient  rotates  his  entire  body 
in  a  pivot-like  manner.     The  coinplaint  is  fre<}uent  in  young  persons. 

(4)  Cephalodynia. — By  this  term  is  meant  rheumatism  of  the  head- 
muscles  of  the  scalp  and  fasciae.  It  may  be  either  general  or  local., 
being  sometimes  limited  to  the  frontal,  temporal,  or  occipital  muscles. 
The  pain  is  severe  and  greatly  increased  on  motion  of  the  scalp. 

(5)  Other  terms  descriptive  of  localized  forms  of  muscular  rheuma- 
tism are  employed :  (a)  Omodynia  (myalgia  of  the  deltoid) ;  {b)  Dorso- 
dynia  (involvement  of  the  muscles  of  the  upper  part  of  the  back,  etc.) ; 
(e)  Abdominal  rheumatism  (myalgia  of  the  muscles  of  the  abdomen) ; 
(d)  Rheumatic  myositis  of  the  extremities. 

Diagnosis. — This  is  assured  by  the  etiologic  influences  and  the 
presence  of  pain,  which  is  greatly  increased  by  muscular  contraction. 
The  presence  of  fever  does  not  exclude  the  affection.  It  differs  from 
neuralgia  in  that  there  are  no  painful  points,  and  in  that  firm  pressure 
with  the  broad  hand  often  affords  relief.  On  the  other  hand,  in  gonor- 
rheal rheumatism  the  plantar  fascias  are  commonly  involved  and  the 
patient  complains  of  pain  in  the  head.  Dermato-myositis  must  not  be 
confounded  with  muscular  rheumatism.  Unverricht  first  distinguished 
the  former  from  the  latter,  showing  that  there  are  present  pain  and  swell- 
ing of  the  muscles,  as  in  muscular  rheumatism,  but  additionally  redness 
(erythema)  and  hyperesthesia  of  the  skin,  while  the  joints  usually  escape. 
Of  general  symptoms,  the  chief  are  fever  and  physical  prostration.  The 
spleen  is  enlarged,  and  angina  and  hemorrhages  have  been  noted.  The 
disease  is  obviously  infectious,  probably  septic  in  nature,  and  may  rarely 
prove  fatal.  Dermatomyositis,  unlike  muscular  rheumatism,  is  more 
common  among  women,  especially  servants,  than  men.  Abdominal 
rheumatism  has  been  mistaken  for  appendicitis. 

The  prognosis  is  good,  the  disease  never  endangering  life,  though 
a  person  may  be  incapacitated  for  work  by  muscular  rheumatism. 

Treatment. — Severe  and  acute  forms  demand  the  use  of  opiates 
internally  and  anodyne  and  hot  applications  externally.  When  cases 
are  seen  early,  morphin,  administered  hypodermically,  may  serve  to  relieve 
the  pain  and  cut  short  the  disease.  In  acute  cases  the  salicylates  and 
other  antirheumatic  remedies  are  to  be  employed.  Hot  fomentations 
give  comfort,  and  the  Turkish  bath  may  end  the  attack  if  it  can  be  used 
sufficiently  early.  The  hot-Avater  bag,  sponging  with  water  as  hot  as 
can  be  borne,  or  dry  heat  in  the  form  of  bags  filled  Avith  heated  salt  or 
heated  hops,  will  all  do  good  service.  For  the  dull  pain  which  is  so  dis- 
tressing in  some  cases  of  torticollis  the  affected  muscles  may  be  covered 
with  flannel,  over  which  a  warmed  flatiron  may  be  passed  for  a  few 
minutes.  This  is  an  efficient  expedient.  For  lumbago  acupuncture  is 
highly  commended.  Needles  of  from  three  to  four  inches  (7.5-10  cm.) 
in  length  (ordinary  bonnet-needles,  sterilized,  Avill  do)  are  thrust  into 
the  lumbar  muscles  at  the  seat  of  the  pain  and  withdrawn  after  five  or 
ten  minutes  (Osier).      Schmidt  recommends  local  injection  of  5  or  10  c.c. 


324  INFECTIOUS  DISEASES. 

of  physiologic  salt  solution  for  the  relief  of  pain.  Blisters  have  been 
recommended,  but  I  have  tried  them  -without  beneficial  effects.  In  sub- 
acute and  obstinate  cases  I  have  recently  obtained  good  results  from  the 
use  of  a  20  per  cent,  ointment  of  salicylic  acid  freely  rubbed  into  the 
skin.  Active  friction  with  anodyne  and  stimulating  liniments  (the  latter 
when  pain  is  not  great)  is  worthy  of  trial.  Massage  and  electricity  (con- 
stant current)  are  sometimes  efficient,  and  in  chronic  cases  potassium 
icdid,  guaiacum,  and  arsenic  (the  latter  in  small  doses)  should  be  tried. 
The  same  measures  of  prophylaxis  are  to  be  adopted  as  in  chronic  rheu- 
matism. The  general  health  must  also  be  looked  to,  every  endeavor  being 
made  to  nuiintain  the  proper  quality  of  blood  and  perfect  nutrition. 

CHRONIC    ARTICULAR   RHEUMATISM. 

Definition. — An  affection  of  the  articular  structures  which  develops 
slowly  and  gradully  and  may  have  the  same  etiology  as  the  preceding 
forms.      Rarely  it  is  a  sequence  of  acute  or  subacute  attacks. 

Pathology. — The  joints,  as  a  rule,  do  not  show  pronounced  gross 
lesions,  there  being  some  degree  of  synovial  injection  and  also  some, 
though  not  much,  effusion.  Inflammatory  thickening  of  the  articular 
and  periarticular  structures  (capsule,  ligaments,  sheaths  of  the  tendons, 
etc.)  with  contraction,  is  noted,  and  is  a  change  which  deforms  and  stif- 
fens some  joints  to  a  certain  extent.  Superficial  erosions  of  the  carti- 
lages may  also  be  witnessed,  and  muscular  atrophy  supervenes.  The 
probable  causes  of  these  important  changes  have  been  pointed  out  in  con- 
nection with  the  latter  disease.  When  the  shoulder-joint  is  the  seat  of 
chronic  inflammation,  this  muscular  atrophy  (affecting  chiefly  the  deltoid) 
reaches  its  highest  degree  of  development. 

Ktiology. — (a)  Age  predisposes  to  the  affection.  Though  it  may  ap- 
pear at  any  age,  the  greatest  number  of  cases  is  furnished  by  the  years 
from  forty  to  sixty.  (6)  Sex  exerts  a  slight  influence,  the  disease  being 
observed  most  frequently  among  females,  {c)  External  agencies,  as  pov- 
erty and  occupations  which  entail  exposure  to  cold  and  dampness,  {d) 
Hei-edity  may  operate  to  favor  its  development. 

Symptoms. — The  involved  joints  may  not  present  any  visible  evi- 
dences of  disease,  and  perhaps  the  most  prominent  local  symptom  is  pain, 
increased  often  at  night  as  well  as  by  approaching  cold  or  damp  weather. 
Both  the  larger  and  smaller  joints  are  involved,  though  the  former 
to  a  greater  degree,  and  yet,  though  usually  multiple,  the  disease  may 
be  limited  to  one  joint  (knee,  hip.  shoulder,  etc.).  The  joints  are 
somewhat  swollen,  as  a  rule,  at  times  slightly  reddened,  tender  upon 
pressure,  and  their  mobility  is  generally  restricted.  Pain  and  stiffness 
are  most  marked  in  the  morning  hours  (after  rest),  and  often  largely 
disappear  with  each  returning  evening  (after  use).  All  the  local  symp- 
toms are  subject  to  exacerbations  and  remissions.  A  peculiar  crepi- 
tation may  be  elicited  on  applying  the  hand  over  the  affected  joints  dur- 
ing motion,  and  eventually  ankylosis,  with  some  degree  (usually  slight) 
of  distortion  of  the  joints,  may  occur. 

The  general  features  are  usually  conspicuous  by  their  absence.  No 
fever  is  present,  and,  in  most  instances,  there  is  no  serious  impairment 
of  the  general  health.  On  the  other  hand,  as  the  result  of  constant 
suffering,  a  wretched  general  condition  with  marked  anemia  and  debility 


MUSCULAR  lUlEUMATISM.  325 

may  finally  be  reached,  such  patients  often  passinff  sleepless  nif.^hts  ;irirl 
suffering  severely  from  dyspepsia.  Chronic  endocarditis  may  develop 
along  with  the  claronic  articular  changes — a  not  uncommon  association, 
though  frequently  the  history  of  a  previous  attack  of  acute  rheumatism 
is  also  obtainable,  to  which  the  endocarditis  may  be  attributed  (for  the 
differential  diagnosis  of  this  disease  vide  Arthritis  Deformans). 

Prognosis.^ — Full  recovery  is,  with  but  few  exceptions,  out  of  the 
question.  A  cure  may  rarely  be  effected  if  the  case  come  under  appro- 
priate treatment  in  the  incipient  stage.  The  disease,  however,  rarely 
shortens  the  duration  of  life,  though  it  may  do  so  by  interfering  with 
the  nutritive  processes,  the  latter  effect  resulting  from  loss  of  sleep  (due 
to  pain)  and  inability  to  take  active  exercise. 

Treatment. — (a)  The  local  measures  hold  first  place.  The  affected 
joints  should  be  enveloped  in  flannel  at  all  times,  and  underneath  the 
latter  may  be  applied  cold  cloths,  and  the  whole  covered  with  oiled  silk. 
On  the  other  hand,  sponging  the  joints  frequently  with  hot  water  relieves 
the  pain  and  stiffness.  •  Bier,  Reed,  and  others,  employed  a  hot-air  treat- 
ment with  good  effects.  Blisters  are  efficacious  in  removing  effusions. 
In  the  absence  of  synovial  effusion  the  thermo-cautery  is  to  be  preferred 
to  blisters,  and  for  the  swelling  and  stiffness  massage  with  passive  move- 
ment affords  excellent  results.  Massage  is  also  valuable  when  atrophy 
of  the  adjacent  muscles  exists  ;  and  in  these  so-called  "  rheumatic  paral- 
yses "  electricity  is  an  important  help.  lodin  and  stimulating  liniments 
are  more  or  less  serviceable. 

[h)  Hygienic  Measures. — The  diet  should  be  abundant  and  nourish- 
ing; it  may  embrace  milk,  eggs,  the  lighter  forms  of  meat,  fats,  fari- 
naceous articles,  and  cruciferous  vegetables ;  wines  and  alcohol  may  be 
permitted.  Dietetic  abuses,  however,  tend  to  aggravate  the  arthritic 
condition.  The  patient  should  adopt  and  continue  moderately  active 
exercise  until  compelled  to  omit  it  on  account  of  the  advancing  joint- 
lesions.  Cold  spongings  of  the  skin-surface,  followed  by  active  friction, 
have  a  good  effect  in  that  they  lessen  cutaneous  sensitiveness. 

(c)  Internal  remedies  do  not  control  the  morbid  process  directly, 
although  arsenic,  iodin,  potassium  iodid,  guaiacol,  and  other  agents  are 
much  used  for  this  purpose,  but  their  effects  are  usually  limited,  and 
never  brilliant.  It  should  be  our  aim  to  maintain  the  general  health  at 
a  maximum  level  by  the  employment  not  only  of  the  sanitary  means 
before  alluded  to,  but  also  by  tonics  (iron,  quinin,  strychnin,  etc.).  A 
course  of  cod-liver  oil  is  the  most  serviceable  form  of  internal  medication. 

{d)  Hydrotherapy  is  an  important  adjuvant  to  the  treatment. 

The  thermal  springs  whose  waters  are  alkaline  or  contain  sulphur, 
and  of  which  the  hot  springs  of  Arkansas  and  Virginia,  and  the  Rich- 
field Springs,  New  York,  furnish  good  examples,  have  been  strongly 
advocated,  and  sometimes  prove  curative  in  their  effects.  I  have  seen 
excellent  results  from  the  methodic  use  of  hot-water  baths  at  a  constant 
temperature  (100°  to  105°  F.— 37.7°  to  40.5°  C).  combined  with 
passive  motion  and  careful  manipulation  of  the  affected  parts.  Every  pre- 
caution must  be  used  to  avoid  exposure  to  cold  or  draft  during  and  after 
the  baths,  which  should  not  be  prolonged  beyond  ten  minutes. 


326  lyFECTIOUS  DISEASES. 

Mountain  Fever. 

(Moiiniai/i  Sicknejis). 

The  terra  "mountain  fever"  sliould  be  regarded  aB  applicable  only 
to  a  condition  produced  by  the  action  of  a  rarefied  air  upon  the  organic 
functions.  There  is  no  definite  pafhohhiy.  Aron's  investigations  show 
that  the  intake  of  oxygen  is  diniinished  at  high  altitude. 

The  Sjrmptoms  are  a  mneh-quickened  pulse,  urgent  dyspnea,  head- 
ache, vertigo,  and  at  times  nausea  and  vomiting.  There  is  a  subfebrile 
movement,  the  temperature  touching  100'^  F.  (37.7°  C)  or  even  101°  F. 
(38.3°  C).  Thirst  is  present  and  the  appetite  is  lost.  Malaise  and  a 
sense  of  exhaustion  on  attempting  exertion  are  experienced.  Hemop- 
tysis has  been  noted,  but  rarely.  The  effect  upon  the  human  economy 
of  hiffh  altitude  varies  with  the  extent  of  the  differences  in  individual 
reserve  nerve-force.  Rest  and  acclimatization  Avill  almost  invariably 
restore  healthy  function.     Oxygen  inhalations  are  advised  (Ai'on). 

The  "mountain  fever"  of  the  older  writers  is  9,lmost  universally  con- 
ceded at  the  present  day  to  be  typhoid  fever  modified  by  the  effects  of 
extreme  altitude. 

Rocky  Mountain  Spotted  Fever. 

Historic  Note. — This  disease  has  been  known  in  the  valley  of  the 
Bitter  Root  River,  in  Western  Montana,  during  the  past  twenty  years. 
Rock  Creek  and  Bonito,  nearly  twenty  miles  disrant  from  Bitter  Root 
Valley,  have  furnished  a  limited  number  of  cases. 

Mountain  spotted  fever  has  also  appeared  in  the  valleys  of  streams 
situated  in  the  mountainous  sections  of  Northwestern  Nevada,  Southern 
and  Western  Idaho,  and  in  Northern  Wyoming. 

Predisposing  Causes. — Climate. — Mountain  spotted  fever  has  not 
been  observed  south  of  40°  or  north  of  47°  N.  lat.,  and  epidemics  are 
most  prevalent  at  elevations  ranging  from  3000  to  4000  feet. 

Season. — The  disease  prevails  exclusively  during  spring  and  early 
summer  months. 

Ocaqjatioii,  Age,  and  Sex. — Persons  who  are  compelled  to  be  in  the 
open  air  and  among  the  woodlands  and  farming  districts  are  most  likely 
to  become  infected. 

In  Anderson's  ^  analysis  of  121  reported  cases,  76  were  males  and  45 
females.  Most  of  the  cases  occurred  between  the  fifteenth  and  fiftieth 
years  of  age. 

Parasitic  Origin. — A  series  of  investigations,  conducted  by  Ander- 
son, showed  that  the  Pyroplasma  hominis,  a  parasite  closely  allied  to  the 
Pyrosoma  bigeminum  (known  to  cause  Texas  fever  in  cattle)  and  found 
within  the  body  of  the  red  blood-corpuscles,  is  the  infecting  parasite. 
He  further  believes  that  the  disease  is  transmitted  to  man  through  the 
bite  of  ticks  (Dermacentor  reticulatus)  common  to  infected  districts. 

Incuhafion. — The  period  of  incubation  varies  from  three  to  ten 
days,  seven  days  being  the  rule.  During  three  or  four  days  of  this  period 
the  patient  experiences  slight  chilly  sensations,  malaise,  and  nausea. 

Clinical  History. — The  disease  is  ushered  in  by  a  distinct  chill, 
which  is  followed  by  a  rapid  and  continuous  elevation  in  the  temperature, 

*  Hyqifivir,  lAihorntory  Bulletin,  No.  14.  "Public  Health  and  Marine-Hospital  Service 
of  the  United  States,"  p.  8. 


ROCKY  MOUNTAIN  SPOTTED  FEVER.  827 

with  slight  morning  remissions,  until  the  tentli  to  the  twelfth  day,  and  in 
fatal  cases  it  reaches  104°  to  106°  F.  In  favorable  cases  the  tempera- 
ture reaches  the  maximum  from  the  eighth  to  the  tenth  day,  after  which 
there  is  a  gradual  decline  to  the  normal  by  the  fourteenth  day. 

Following  the  chill  the  patient  experiences  pain  in  the  back  and  loins, 
soreness  of  the  muscles,  the  limbs  are  moved  with  difliculty,  and  there  is 
always  slight,  and  at  times  severe,  nose-bleed  after  the  fiist  week  of  fever; 
the  tongue  is  heavily  coated  at  the  center  and  base,  Avliile  its  edges  and 
tip  are  red;  nausea  and  vomiting  are  common,  and  persistent  constipa- 
tion is  the  rule.  The  conjunctivae  are  at  first  congested  and  later  assume 
a  yellowish  tinge;  the  urine  is  febrile  in  character,  being  diminislied  in 
quantity  and  containing  a  moderate  amount  of  albumin  and  also  renal 
casts;  the  respirations  range  from  25  to  60  per  minute,  and  it  is  not 
uncommon  for  the  patient  to  develop  bronchitis  from  the  third  to  the 
sixth  day  of  the  fever;  the  liver  and  spleen  are  enlarged.  The  pulse  is 
weak  and  rapid,  being  out  of  proportion  to  the  temperature.  The  mind 
is,  as  a  rule,  clear  even  in  the  severer  forms. 

Eruption.— ^he  eruption  is  rather  characteristic ;  it  appears  on  the 
third  to  the  fourth  day,  on  the  wrists  and  ankles,  from  which  points  it 
spreads  to  the  arms,  legs,  forehead,  back,  chest,  and,  lastly,  to  the  abdomen. 

The  spots  are  at  first  bright-red  maculge,  varying  from  the  size  of  a 
pin's  point  to  that  of  a  pea.  In  the  severer  forms  of  the  disease  these 
maculse  become  dark  and  later  assume  a  purplish  tinge.  They  begin  to 
fade  at  about  the  sixth  day,  and  lose  their  petechial  character  with  the 
decline  of  the  fever  at  or  about  the  fourteenth  day. 

Blood. — During  the  course  of  the  disease  the  red  blood-cells  show 
evidence  of  destruction,  and  the  white  cells  may  be  slightly  increased  in 
number.     The  hemoglobin  may  gradually  fall  to  50  per  cent. 

Diagnosis. — Mountain  spotted  fever  is  to  be  differentiated  from 
cerebrospinal  meningitis.,  peliosis  rheumatica,  malaria,  typJioid  fever, 
mountain  fever,  and  purpura  hemorrhagica.  The  eruption  is  similar  to 
that  of  typhus  fever,  but  the  spleen  is  less  habitually  enlarged,  and  it 
runs  a  shorter  course  with  a  more  abrupt  onset  and  termination  of  the 
fever. 

Prognosis. — Of  121  cases  occurring  in  the  Bitter  Root  Valley  dis- 
trict, 84  were  fatal  (Anderson).  In  other  districts  the  rate  of  mortality 
may  reach  90  per  cent.  Death  usually  occurs  betAveen  the  fourteenth 
and  eighteenth  days  of  the  disease,  and  may  result  from  complications, 
among  which  pneumonia  deserves  special  mention. 

Treatment. — The  treatment  is  ordered  to  meet  the  indications  pre- 
sented by  each  individul  case.  L.  B.  Wilson  and  Anderson  have  sug- 
gested the  use  of  quinin  hypodermically.  Morphin,  in  the  form  of  Dover's 
powders,  is  usually  required  to  relieve  the  intense  pain  and  soreness.  Hot 
sponge-baths  are  of  value  in  relieving  the  temperature.  The  diet  should 
consist  of  milk,  broths,  soft-boiled  eggs,  and  soft  toast.  H.  T.  Ricketts 
recommends  the  eradication  of  the  tick  in  infected  areas  as  a  prophylactic 
measure.  Heinemann  and  Moore  found  that  serum  from  horses  recovered 
from  spotted  fever  has  a  protective  value;  it  can  be  concentrated  as  in 
the  case  of  diphtheritic  antitoxin. 


328  INFECTIOUS  DISEASES. 


WEIL'S  DISEASE. 
{Acute  Febrile  Jaundice :  FHedler's  Disease.) 

Definition. — An  acute  febrile  disease,  probably  specific  in  origin, 
and  characterized  by  jaundice,  remittent  fever,  and  muscular  pains.  It 
usually  runs  a  definite  course  and  terminates  by  lysis. 

Pathology. — During  the  comparatively  recent  studies  of  the  post- 
mortem lesions  occurring  in  this  disease  very  little  has  been  noted.  The 
liver  and  spleen  are  sometimes  the  seat  of  an  active  hyperemia,  and 
occasionally  some  gastro-intestinal  irritation  is  present.  The  cortical 
substance  of  the  kidneys  is  swollen  and  mottled,  and  the  epithelium  of 
the  tuliules  and  glomeruli  shows  cloudy  swelling. 

!^tiology. — The  special  organism  of  the  disease  is  unknown  ;  indeed, 
it  may  be  an  acute  febrile  jaundice  of  varied  etiology.  Jaeger  claims 
that  it  is  due  to  infection  by  the  bacillus  proteus  jiuorescens.  Cockayne 
believes  that  it  may  be  due  to  some  biting  insect.  Certain  French  authori- 
ties consider  the  disease  a  ptomain  poisoning. 

Predisposing  Causes. — Among  these  may  be  mentioned  the  following : 

(a)  Age. — The  age  of  the  patient  usually  varies  from  twenty  to  forty 
years.     A.  Holz  records  a  case  in  a  woman  fifty-one  years  old. 

(h)  Occupation. — Butchers  are  most  commonly  aifected.  Workers  in 
ditches  and  sewers  or  those  exposed  to  foul  water  are  particularly  prone 
to  infection. 

(c)  Sex  and  Season. — Most  of  the  recorded  cases  occurred  in  males 
asnd  during  the  summer  months. 

{d)  Locality. — The  cases  have  appeared  in  groups,  in  both  rural  and 
urban  localities. 

Symptoms. — The  disease  is  usually  ushered  in  by  a  chill.,  followed 
by  fever,  headache,  and  pain  in  the  muscles,  joints,  and  epigastrium. 
Jaundice  usually  appears  on  the  second  day,  and  may  either  be  slight 
or  very  intense ;  if  it  be  due  to  obstruction,  the  stools  are  gray-colored, 
showing  the  absence  of  bile.  The  fever  is  of  the  remittent  type,  run- 
ning from  ten  to  fourteen  days  and  terminating  by  lysis.  Nausea, 
vomiting,  and  diarrhea  may  rarely  occur.  The  liver  and  spleen  are 
often  enlarged,  the  latter  being  tender  on  pressure.  The  urine  is  febrile, 
high-colored,  and  often  shows  the  presence  of  albumin,  with  tube-casts, 
and  sometimes  blood  (hemoglobinuria).  In  grave  (but  rare)  cases  cere- 
bral symptoms,  such  as  delirium,  convulsions,  and  coma,  may  occur  and 
prove  fatal. 

The  diagnosis  rests  on  the  acute  onset,  fever,  pains  in  the  muscles, 
joints,  and  epigastrium,  nephritis,  and  icterus.  Schlarnmfieber,  which 
prevailed  mainly  among  young  persons  who  had  worked  in  the  recently 
flooded  districts  near  Breslau  during  the  summer  of  1891,  and  assumed 
epidemic  proportions,  has  not  been  satisfactorily  classified.  Miiller 
shows  its  resemblance  in  many  respects  to  Weil's  disease,  which  may 
occur  at  times  without  jaundice  (?). 

Prognosis. — The  prognosis,  both  as  to  life  and  recovery,  is  good. 
W.  E.  Hughes,  notwithstanding,  records  two  cases  that  proved  fatal 
within  forty-eight  hours  of  the  onset. 


FEBRWULA.  329 

The  treatment  is  purely  symptomatic.  The  diet  shouhl  be  fluid, 
such  as  milk,  broths,  and  the  like.  Hydrotherapy  is  indicated  in  the 
more  toxic  cases.  The  muscular  pains  may  be  relieved  by  warm  stupes 
and  fomentations. 

FEBRICULA. 
{Simple   Continued  Fever ;  Ephemeral  Fever.) 

Definition. — A  brief  febrile  attack,  unattended  with  definite  local 
lesions,  and  of  varied,  often  indeterminate  etiology.  A  true  ephemeral 
fever  is  one  that  lasts  about  twenty-four  hours,  while  the  term  simple 
continued  fever  or  febricula  is  given  to  cases  lasting  a  longer  period. 

The  cases  are  diversified  with  reference  to  their  etiology  and  clinical 
relations,  but  may  be  roughly  grouped  under  several  heads : 

(a)  A  large  group  of  cases  in  which  a  g astro-intestinal  disturbance  is 
the  only  assignable  cause.  The  latter  may  be  due  to  cold  or  more  often 
to  errors  in  diet  (particularly  the  use  of  tainted  food-stuffs),  accompanied 
by  absorption  of  ptomaines,  or  it  may  assume  the  form  of  gastro-intes- 
tinal  catarrh  met  with  in  young  children. 

(b)  Undeveloped  or  abortive  forms  of  the  infectious  diseases  (typhoid, 
influenza,  rheumatism).  These  affections,  particularly  during  times  of 
epidemic  prevalence,  may  run  a  brief  course  without  manifesting  any 
of  their  distinctive  characters.  This  is  particularly  true  of  the  abortive 
types  of  typhoid,  and  other  acute  infections.  Again,  diseases  that 
ordinarily  manifest  a  characteristic  eruption  {e.  g.,  scarlet  fever,  measles, 
erysipelas)  may  run  their  course  without  doing  so,  or  the  eruption  may 
escape  observation. 

(c)  It  may  follow  exposure  to  the  summer  sun  or  excessive  heat  (?), 
or  exhaustion  of  the  7iervous  system. 

(d)  It  is  not  infrequently  the  result  of  a  slight  and  unnoticed  local- 
ized inflammation  (tonsillitis,  bronchitis,  lymphadenitis,  etc.). 

(e)  The  inhalation  of  sewer-gas  or  other  noxious  vapors  (such  as  em- 
anations from  decomposing  organic  matter)  may  produce  an  aberrant 
form  of  the  fever  (vide  Septicemia). 

Symptoms.— It  is  to  be  remembered  at  the  outset  that  a  single 
symptom,  peculiar  to  all  cases,  is  the  fever.  The  onset  is  generally 
sudden,  and  especially  in  ephemeral  fever,  but  it  may  be  gradual ;  if 
sudden,  there  is  rarely  either  a  chill  or  vomiting,  while  in  neurotic  chil- 
dren a  convulsion  may  occur.  The  temperature  ascends  quickly  to 
102°-103°  F.  (39.4°  C.)  or  over,  pursues  the  continued  type,  and  at 
the  end  of  one,  two,  or  more  days  subsides  abruptly  by  crisis.  There 
are  accompanying  symptoms,  many  of  which  are  due  to  the  fever,  such 
as  headache,  hebetude,  mild  delirium,  flushed  countenance,  a  full,  rapid 
pulse,  anorexia,  constipation,  scanty,  high-colored  urine,  and,  not  rarely, 
herpes  labialis.  Defervescence  may  be  attended  with  critical  sweats, 
diarrhea,  or  a  copious  flow  of  urine.  Special  types  {e.  g.,  cerebral,  gas- 
tric, gastro-intestinal)  may  be  observed,  due  to  the  predominance  of  the 
symptoms  presented  by  individual  organs  or  systems. 

In  another  class  of  cases  the  access  of  simple  fever  may  be  less  sud- 
den, the  maximum  level  attained  being  somewhat  low^er  and  the  attend- 
ing phenomena  less  acute  and  pronounced.     Da  Costa  ^  has  described 
cases  belonging  to  this  category.      The  course  is  more  protracted,  though 
1  Transactions  of  the  Associatioi  of  American  Physicians,  vol.  xi.,  1896. 


330  INFECTIOUS  DISEASES. 

rarely  exceeding  a  week  or  ten  days,  and  the  defervescence  is  not  so 
abrupt.  So-called  thermic  fever  is  at  the  present  "writing  believed  by 
Guit^ras,  who  first  described  it,  to  be  due  to  a  special,  though  as  yet 
unknown,  oriranism. 

The  diagnosis  necessitates  the  exclusion  of  other  acute  fevers.  The 
affections  from  which  it  is  most  difficult  to  distinguish  febricula  are 
typhoid  fever ^  remittent  fever,  scarlet  fever,  incipient  tuhercxdosis,  larval 
pneumonia,  and  vieninf/itis  (in  children).  In  febricula,  however,  there 
is  an  absence  of  local  manifestations  and  of  physical  signs  pointing  to 
consolidation  of  the  lungs ;  characteristic  skin-eruptions  are  also  absent. 
Tyson  points  out  that  in  cases  in  which  there  is  splenic  enlargement 
(rare)  the  resemblance  to  typhoid  is  close,  and  the  diagnosis  may  have 
to  remain  in  doubt  until  settled  by  the  Widal  test  or  by  time.  The 
cases  must  also  be  discriminated  from  the  fever  which  sometimes  attends 
chlorosis  and  certain  nervous  disorders. 

The  prognosis  is  good. 

Treatment. — Few  cases  require  treatment  other  than  rest  in  bed 
and  liquid  nourishment  for  several  days.  Cooling  drafts  internally,  and 
mild  forms  of  hydrotherapy  (spongings,  ice-caps)  externally,  are  indi- 
cated. If  traceable  to  gastro-intestinal  disturbance,  a  laxative  usually 
proves  beneficial  and  eifective.  It  should  be  followed  by  intestinal 
antiseptics.  Unless  it  is  clear  that  the  given  case  is  non-infectious  and 
non-contagious,  isolation  of  the  patient  should  be  ensured. 

MILK-SICKNESS. 

Definition. — A  peculiar  infectious  disease,  occurring  both  in  man 
and  in  the  loAver  animals,  when  it  is  known  as  "  trembles."  The  dis- 
ease is  unknown  east  of  the  Alleghany  Mountains,  but  throughout  many 
of  the  Western  and  South-western  States  it  formerly  prevailed  very  ex- 
tensively, with  fatal  effect.  It  has,  however,  been  almost  exterminated 
as  the  result  of  denudation  of  the  forests  and  the  advancing  cultivation 
of  the  virgin  soil.  It  still  prevails  in  parts  of  North  Carolina  (Osier), 
and  until  very  recent  times  has  been  seen  in  certain  parts  of  Illinois. 

No  peculiar  pathologic  lesions  have  been  described. 

Ktiology. — It  is  believed  to  be  due  to  a  special  poison  derived  from 
the  earth,  but  as  yet  we  are  ignorant  of  its  exact  nature.  Phillips 
claims  to  have  found  a  spirillum  in  the  blood. 

Modes  of  Infection. — The  disease  attacks  cattle  most  frequently  (espe- 
cially unweaned  calves),  horses,  sheep,  goats,  and  less  often  many  undo- 
mesticated  animals ;  wherever  trembles  prevails  among  cattle,  milk-sick- 
ness is  met  Avith  in  man.  It  is  thought  that  the  poison  is  communicated 
to  man  in  the  milk,  butter,  and  cheese,  or  in  the  flesh  of  infected  animals. 

Among  disposing  factors  are  the  seasons,  the  disease  being  most  fre- 
quent in  the  late  summer  and  autumn.     It  is  most  common  in  adult  life. 

Symptoms. — The  period  of  incubation  may  be  short  or  long  in 
duration,  and  prodromata,  such  as  headache,  anorexia,  languor,  and 
oncoming  fatigue,  may  be  noted.  These  symj)toms  increase  in  severity, 
and  are  soon  eclipsed  by  the  more  characteristic  features — nausea  and 
vomiting,  a  hot  pain  in  the  stomach,  and  a  peculiar  fetor  of  the  breath. 
There  is  an  unquenchable  thirst,  a  swollen,  tremulous  tongue,  and  abso- 


MILIARY  FEVKIi.  331 

lute  constipation.  Fever  is  present,  but  it  is  sliglit,  and  the  surface- 
temperature  is  often  below  the  normal.  The  nervous  symptoms  include 
restlessness,  merging  into  mental  dulness  witli  marked  indifference,  and 
the  latter  condition  passing  in  grave  cases  into  a  stupor  that  may  deepen 
into  actual  coma.  Convulsions  may  arise  or  the  patient  may  drop  into 
a  fatal  typhoid  state. 

The  diagnosis  rests  chiefly  upon  the  history  (particularly  upon 
the  coexistence  of  "  trembles  "  in  cattle)  and  the  exclusion  of  other  acute 
intoxications. 

The  prognosis  is  generally  favorable,  though  a  fatal  termination 
due  to  asthenia  may  occur  within  a  few  days  of  the  time  of  the  onset. 

Treatment. — Prophylaxis  consists  in  the  avoidance  of  those  foods 
that  act  as  bearers  of  the  disease.  Apart  from  the  use  of  supporting 
measures  (appropriate  diet  and  stimulants),  we  can  attend  only  to  the 
symptomatic  indications.      Medicated  enemata  should  not  be  omitted. 

MILIARY  FEVER. 

(^Sweating  Sickness.) 

Definition. — An  infectious  disease,  characterized  by  copious  sweats 
and  a  vesicular  (miliary)  eruption.  In  certain  countries  it  has  prevailed 
epidemically  (France,  England,  Italy,  Germany),  and  in  1887  a  severe 
epidemic  occurred  in  France.  Schaffer  ^  reports  the  occurrence  of  a  re- 
cent epidemic  in  an  Austrian  province  in  the  spring  of  1893,  lasting  for 
nearly  three  months.  Out  of  5079  persons  (the  total  population  of  the 
district),  159  suifered,  as  follows :  17  men,  14  women,  and  128  children. 
At  the  present  day  it  seems  to  be  met  with  only  in  Picardy,  in  a  few 
other  French  provinces,  and  throughout  a  limited  area  in  Italy. 

Neither  have  definite  pathologic  lesions  nor  the  specific  exciting  cause 
been  found.  Among  predisposing  infi,uences  the  following  have  been 
noted :  (a)  Most  epidemics  occur  in  spring  and  summer ;  (6)  It  is  more 
common  among  women  than  men,  and  most  frequent  during  the  middle 
period  of  life.  A  large  percentage  of  the  entire  population  of  an  in- 
vaded district  (usually  limited  in  area)  is  attacked. 

The  SjTtnptoms  that  characterize  miliary  fever  are  fever  with  its 
usual  accompaniments,  irritation  of  the  skin,  epigastric  oppression, 
copious  and  persistent  sweating,  followed,  on  the  third  or  fourth  d-av 
of  the  disease,  by  an  eruption  (due  to  profuse  sweatings)  of  miliary 
vesicles.  A.  Weischelbaum  ^  has  shown  by  serial  sections  through 
sudaminse  that  the  fluid  in  the  latter  is  not  due  to  retained  secretions  In 
the  sweat  glands,  but  is  always  of  an  inflammatory  nature. 

The  vesicles  burst,  and  within  forty-eight  hours  scaly  desquamation 
is  generally  completed.  In  severe  types  the  nervous  phenomena  (delir- 
ium, etc.)  are  grave  in  character  ;  hemorrhages  may  occur,  and  at  times 
fatal  collapse  may  follow.      Relapses  are  not  uncommon. 

The  prognosis  is  aff"ected  largely  by  the  character  of  the  epidemic, 
the  average  death-rate  being  8  or  9  per  cent. 

Quinin  has  met  with  almost  universal  favor  as  a  remedy,  but  the 
expectant  plan  of  treatment  is  the  most  appropriate,  the  indications 
being  fulfilled  as  they  arise.     The  sweating  may  demand  atropin. 

1  Wiener  med.  Bldtler,  1893,  No.  32,  ^  Zeit.  f.  Klin.  Med.,  1907,  Ixii.,  21. 


332  IXFECTIOUS  DISEASES. 


FOOT-AND-MOUTH  DISEASE. 

(Epidemic  Stoinatiiis  :  Aphihous  Feva:) 

Definition. — An  acute  infection  of  certain  lower  animals  (cattle, 
sheep,  pigs,  goats),  caused  by  a  micro-organism  as  yet  undiscovered, 
although  Klein  has  described  a  micrococcus.  It  is  characterized  by  fever, 
by  the  appearance  of  vesicles  and  ulcers  in  the  mucosa  of  the  mouth,  in 
the  furrows  about  the  feet  and  on  the  udder,  and  by  the  rapid  develop- 
ment of  asthenia  and  marked  emaciation.  Though  a  disease  of  mild 
character,  its  territorial  range  is  so  vast  as  to  entail  untold  loss  to  Euro- 
pean countries.  Young  animals  or  sucklings  perish  in  great  numbers  on 
account  of  the  deteriorated  quality  of  the  milk,  which  assumes  a  yellowish- 
white  appearance  and  has  a  bitter,  nauseating  taste. 

During  epidemics  of  foot-and-mouth  disease  the  poison  may  be  trans- 
ferred to  man,  in  whom  the  disease  is  known  as  epidemic  stomatitis, 
the  poison  generally  being  transferred  by  means  of  milk.  Boiling  the 
latter  destroys  the  virus,  but  rarely  the  infection  may  be  transmitted 
through  butter  and  cheese  made  from  the  milk  of  infected  cattle.  Com- 
munication by  inoculation  (while  milking)  may  also  occur.  The  disease 
does  not  seem  to  be  transmissible  through  the  meat  of  diseased  animals.^ 
In  America  a  few  instances  only  of  transference  from  animals  to  man 
are  recorded. 

Symptoms. — The  incubation-period  lasts  from  three  to  five  days, 
A  rigor  may  mark  the  onset  or  merely  slight  shiverings,  followed  by 
fever  and  malaise,  and  soon  vesicles,  such  as  are  described  under  Aph- 
thous Stomatitis,  appear  upon  the  tongue  and  inner  surface  of  the  lips. 
The  mouth  is  hot,  the  mucosa  reddened  and  swollen,  and  salivation  is 
present.  A  form  of  miliary  eruption  that  may  become  pustular  may 
also  appear  on  the  skin-surface,  and  particularly  on  the  fingers  and 
hands.      Hemorrhages  have  been  observed  in  severe  epidemics. 

The  diagnosis  is  made  with  ease  if  the  disease  be  prevailing  at  the 
same  time  among  lower  animals.  The  peculiar  coincidence  of  the  erup- 
tion in  the  mouth  and  extremities,  sparing  the  rest  of  the  body,  has  not 
been  noticed  in  any  other  eruptive  disease  (Whittaker). 

Course  and  Prognosis. — The  course  is  mild  and  ends  in  about 
one  week,  the  disease  being  very  rarely  fatal. 

Treatment. — Prophylaxis  requires  the  use  of  milk  from  healthy 
animals  (cows  or  goats),  together  with  measures  looking  to  the  care  of 
the  stables  and  isolation  of  diseased  cattle.  A  reliable  method  of  immu- 
nization against  foot-and-mouth  disease  has  not  as  yet  been  discovered.* 
For  treatment  the  reader  is  referred  to  the  article  on  Aphthous  Stoma- 
titis. 

GLANDULAR  FEVER. 

Definition. — By  this  term  is  meant  an  acute  infectious  disease  of 
children,  characterized  by  adenitis   affecting  the   lymph-glands  of  the_ 
neck,  especially  the  anterior  cervical. 

'  Zuell's  translation  of  Friedberger  and  Frohner's  Pathology  and  Therapeutics  of  the 

Donwjilic  AnimaU.  _       _  .  ,      -r,  •  i.  t>-  j  c  i       .. 

'  Sie^el,  "Experiments  in  Immunization  against  the  Foison  oi  Jiites  and  bcratcnes. 
Quoted  fn  the  Fhiladelph-ia  Med.  Jour.,  January  28,  1899. 


GLANDULAR  FEVER.  833 

History. — A  detailed  description  of  ^liindidar  fever  was  first  given 
by  E.  Pfeiffer,  in  1889,  under  the  name  of  Drasenfieber,  but  it  had  jjrob- 
ably  been  previously  described  by  Filatow,  of  Moscow.  Donkin,  Fischer 
and  Dawson  Williams,  in  England,  and  J.  l^ark  West  have  given  excel- 
lent descriptions  of  the  disease. 

Pathology. — The  anterior  cervical  lymphatic  glands  are  involved 
first,  and  it  is  "  probable  that  the  infection  finds  its  point  of  entrance 
through  either  the  tonsils  or  the  pharyngeal  mucous  membrane  "  (Wil- 
liams).    The  adenitis  may  also  aflect  the  inguinal  and  axillary  glands. 

etiology. — The  special  micro-organism  of  the  disease  is  unknown, 
although  Burns  has  isolated  the  staphylococcus  aureus.  The  complaint 
occurs  usually  in  the  form  of  house-epidemics.  West,  of  Ohio,  however, 
has  described  the  most  widespread  epidemic  hitherto  recorded.  There 
were  96  cases  in  43  families,  and  rarely  did  a  child  exposed  to  the  infec- 
tion escape.  The  disease  usually  occurs  during  childhood  ;  the  ages  of 
West's  cases  ranging  from  seven  months  to  thirteen  years.  A.  E.  Rous- 
sell  has  reported  four  cases,  one  occurring  in  an  adult.  Most  cases  occur 
between  the  months  of  October  and  May,  inclusive.  According  to  Hand, 
the  weight  of  clinical  evidence  tends  to  variation  in  the  etiology  in  differ- 
ent cases  (e.  g.,  it  is  often  one  of  the  protean  manifestations  of  influenza). 

The  incubation-period  lasts  usually  from  five  to  eight  days. 

Sytaptoms. — The  onset  is  sudden.  The  child  holds  the  neck  stiffly, 
since  movement  causes  pain ;  there  are  anorexia,  nausea,  and  less  com- 
monly vomiting,  the  bowels  are  constipated,  and  often  there  is  abdominal 
pain.  The  child  may  complain  of  pain  and  swelling ;  an  examination 
of  the  pharynx  may  show  some  chronic  enlargement  of  the  tonsils,  and 
in  some  cases  injection  of  the  pharyngeal  mucosa,  actual  pharyngitis 
being  rare.  The  temperature  oscillates  from  101°  to  108°  F.  (88.3°- 
89.4°  C).     Nervous  symptoms  (delirium,  hebetude)  are  rarely  observed. 

The  glandular  enlargement  becomes  obvious  on  the  second  or  third 
day,  and  in  most  cases  is  observed  first  on  the  left  side,  then,  after  a  few 
days,  on  the  other  side  of  the  neck  also.  The  glands  vary  in  size  from 
a  bean  to  a  hen's  egg,  and  are  painful  on  palpation.  They  rarely  suppu- 
rate. Other  groups  of  glands  (axillary,  inguinal)  may  be  successively 
involved.  Cough  and  dyspnea  may  point  to  involvement  of  the  bron- 
chial and  tracheal  glands.  The  mesenteric  glands  were  enlarged  in  38.5 
per  cent,  of  West's  cases.  Splenic  enlargement  occurs  in  50  per  cent. 
of  the  cases,  while  the  liver  is  increased  in  size  in  almost  all  cases.  There 
is  a  leukocytosis  varying  from  18,000  to  25,000.  The  average  duration 
is  sixteen  days  (West).  Among  complications  may  be  mentioned  hem- 
orrhagic nephritis,  bronchitis,  and  otitis  media. 

Diagnosis. — The  recognition  of  glandular  fever  embraces  the  exclu- 
sion of  such  affections  as  tonsillitis,  pharyngitis.,  and  influenza,  in  the 
course  of  which  adenitis  might  arise.  Griffith^  has  reported  cases 
resembling  glandular  fever  in  which  influenza  was  probably  the  sole  dis- 
ease present. 

Prognosis. — Recovery  is  the  rule. 

Treatment. — The  course  of  the  disease  is  probably  uninfluenced  by 
treatment.  Locally,  cold  compresses  and  fomentations  are  useful.  Inter- 
nally, West  advises  castor-oil  in  the  early  stage,  followed  by  minute 
doses  of  calomel  (gr.  -jL  to  -jlg-)  twice  or  thrice  a  day. 

*  Univ.  Med.  Magazine,  October,  1900. 


PART   II. 

ANIMAL  PARASITIC   DISEASES. 


PARASITES  OF  MAN. 

The  human  species  furnishes  a  habitat  for  many  varieties  of  parasites. 
Protozoa,  including  the  Amebas  and  Infusoria,  Plathelminthes,  Nema- 
todes, Leeches,  Arachnoids,  and  Insects.  Some  infest  the  body  surface, 
while  others  find  their  locus  in  the  intestines,  bone  marrow,  vascular  sys- 
tem, muscles,  brain,  genital  apparatus,  or  solid  viscera. 


AMEBIC  DYSENTERY. 

(Amebiasis.) 

Definition. — A  colitis,  usually  chronic,  though  it  may  be  acute, 
caused  by  the  Entamoeba  di/ sentence,  often  leading  to  abscesses  of  the  liver. 

Etiology. — This  disease  is  caused  by  the  amceba  dysenterice  (Council- 
man and  Latieur)  or  the  entamoeba  hystolytica.  The  amoeba  dysenteriae 
is  a  unicellular,  motile  organism,  in  size  3  to  7  times  the  diameter  of  a 
red  blood-corpuscle  (15  to  30  micromillimeters).  Its  protoplasm  con- 
sists of  two  zones — an  outer  colorless  (ectosarc)  and  an  inner  granular 
zone  (endosarc),  with  a  visible  nucleus  and  one  or  more  vacuoles.  This 
micro-organism  was  first  described  by  Lambl  (1859),  but  it  remained  for 
Losch,  and  especially  Kartulis,  to  show  its  close  association  with  dysen- 
tery. The  amoeba  dysenteriae  is  occasionally  found  in  healthy  individuals, 
and  also  in  other  bowel  affections  than  dysentery  (mucous  enteritis,  simple 
diarrhea,  proctitis  due  to  engorgement),  and  two  species  are  recognized 
— a  virulent  entamoeba  hystolytica  and  a  benign  form,  entamoeba  coli. 
Walker's  studies,  however,  indicate  not  less  than  ten  species.  The 
ameba  is  found  not  only  in  the  discharges,  but  also  in  the  pus  from  the 
secondary  liver-abscesses.  Flexner^  affirms  that  bacterial  association 
probably  has  much  influence  on  the  pathogenic  powers  of  the  amebas. 
The  principal  causative  role  in  the  production  of  this  form  of  dysentery 
has  been  ascribed  to  the  pyogenic  cocci  by  Tancarol,  Ascher,  and  others. 
The  disease  is  much  more  prevalent  in  adult  males. 

The  mode  of  transference  of  the  ameba  is  not  definitely  known,  though 
the  principal  source  of  the  dysenteric  germs  is  most  probably  the  drink- 
ing-water.    The  disease  is  feebly  communicable  by  contact. 
^  Jour.  Amer.  Med.  Assoc,  Jan.  -5,  1901. 
334 


AMEBIC  DYSENTERY.  ?j?,o 

Pathology. — The  lesions  are  almost  always  situated  in  the  large 
intestine,  although  rarely  the  ileum  is  also  invaded.  The  first  visible 
change  is  a  hyperemia  of  the  mucosa,  most  marked  in  the  descending 
colon  and  rectum  ;  but  the  changes  which  produce  the  characteristic 
dysenteric  ulcer  begin  with  infiltration  and  swelling  of  the  submucosa, 
followed  by  necrosis,  which  involves  the  overlying  mucosa  with  its  epi- 
thelium (Kruse  and  Pasquale).  How  the  amebse  reach  the  submucosa 
has  not  yet  been  observed.  The  infiltrated  circumscribed  areas  are  oval 
or  hemispheric  in  shape,  and  project  above  the  level  of  the  surrounding 
mucosa.  The  submucosa  presents  a  grayish-yellow  appearance,  and  is 
soon  thrown  off  in  the  form  of  a  slough. 

The  ulcers  take  various  shapes — chiefly  irregular,  and  less  frequently 
round  or  oval.  Their  edges  are  ragged  and  undermined,  and  the  floor, 
which  is  more  or  less  covered  with  pultaceous  material,  is  rough  or 
crater-like,  and  formed  by  the  musculature  or  the  outer  serous  coat  of  the 
intestine.  From  the  manner  in  which  the  ulcers  are  formed  it  is  obvious 
that  cellular  infiltration  (followed  by  necrosis)  may  occupy  the  sub- 
mucosa for  a  greater  or  less  distance  beyond  the  borders  of  the  ulcers. 
In  this  way  fistulous  channels  may  be  produced  beneath  the  mucosa  and 
connect  two  or  more  ulcers.  Usually  this  ulcerative  process  affects  only 
certain  portions  of  the  large  gut,  especially  the  flexures — hepatic  and 
sigmoid — and  the  rectum ;  but  it  may  be  general,  and  I  have  seen  an 
instance  of  this  kind.  Cases  are  not  uncommon  in  which  the  ulcers  are 
so  numerous  as  to  include  almost  the  entire  mucosa  of  the  colon. 

Healing  is  attended  with  the  development  of  fibrous  tissue  along  the 
edges  and  in  the  base  of  the  ulcer,  and  secondary  contraction  of  this 
new  connective  tissue  is  often  productive  of  colonic  stricture,  which  is 
usually  either  partial  or  irregular.  The  cases  that  come  to  autopsy  often 
show  diphtheritic  inflammation  as  a  secondary  or  terminal  condition. 

The  microscope  reveals  proliferation  of  the  fixed  connective-tissue 
cells  (rarely  pus),  and  the  presence  of  amebas  in  the  walls  and  the  base 
of  the  ulcers,  in  the  lymph-spaces,  and  rarely  in  the  blood-vessels. 

The  liver  may  be  the  seat  of  prominent  lesions.  These  are  (a)  ab- 
scesses, which  may  be  single  or  multiple.  The  single  or  large  solitary 
abscess  is  usually  situated  near  either  the  upper  convex  or  the  lower 
concave  surface,  while  the  abscess-cavity  is  formed  in  a  manner  similar 
to  the  intestinal  ulcers.  The  area  affected  is  at  first  infiltrated ;  it  then 
becomes  necrotic,  and  finally  more  or  less  liquefied.  Upon  the  full  de- 
velopment of  the  first  stage  the  part  invaded  is  a  grayish-yellow  pulta- 
ceous mass,  but  in  the  second  or  necrotic  stage  the  abscess  contains  a 
yellowish  or  greenish-yellow,  spongy  material  with  beginning  liquefac- 
tion. The  contents  of  the  mature  abscess  consist  of  a  greenish-  or 
reddish-yellow  purulent  material  and  of  remnants  of  liver-tissue.  The 
walls  of  the  recent  abscess  are  irregular  and  ragged,  those  of  an 
old  abscess  being  dense  and  fibrous,  and  a  section  of  the  abscess-wall 
shows  an  inner  necrotic  zone,  a  middle  zone  (in  which  there  is  great 
proliferation  of  the  connective-tissue  cells,  compression  and  atrophy  of 
the  liver-cells),  and  an  outer  zone  of  intense  hyperemia  (Osier).  The 
contents  of  the  abscess  show  either  few  or  many  amebge,  and  onlv  rarely 
pus.     When  pus  is    present   it  is  due  to  a  secondary  infectioa'by  the 


336  ANTMAL   PARASITW  DISEASES. 

pyogenic  germs.  The  amebfe  probably  gain  access  to  the  liver  by  met- 
astasis from  the  intestinal  foci.      Cultures  are  generally  sterile. 

(b)  The  parenchyma  of  the  liver  may  be  the  seat  of  circumscribed 
necrotic  spots,  due  to  the  action  of  the  toxins  formed  by  the  amebae. 

The  lungs  sometimes  show  changes  similar  to  those  in  the  liver ;  they 
are  the  result  of  direct  extension  of  the  hepatic  abscess  through  the  dia- 
phragm into  the  lower  lobe  of  the  right  lung.  The  kidneys  often  present 
the  lesions  of  acute  parenchymatous  nephritis  (Craig). 

Clinical  History. — The  mode  of  onset  is  gradual  except  in  a  small 
proportion  of  the  cases,  in  which  it  is  sudden  with  Avell-marked  symp- 
toms. When,  as  generally  happens,  it  is  insidious,  the  initial  symptom 
is  often  a  trivial  diarrhea.  The  affection  is  then  characterized  prin- 
cipally by  intermissions  and  an  exacerbating  diarrhea,  the  liquid 
stools  containing  necrotic  tissue  of  a  grayish-brown  and  sometimes 
yellowish-gray  color.  The  latter  are  often  bloody  and  mucoid,  later  be- 
coming fluid.  I:\xenumher  of  discharges  per  day  is  exceedingly  variable, 
although  in  most  instances  they  range  from  six  to  eight  or  ten  daily. 

Microscopic  examination  of  the  feces  during  the  exacerbations  dis- 
closes amebse  that  are  almost  invariably  endowed  with  motion,  though 
usually  not  Avhen  the  stools  have  become  formed.  Tenesmus  is  not  a 
prominent  feature  in  most  cases,  and  may  be  entirely  absent.  Colicky 
abdominal  pains,  nausea,  and  vomiting  are  rare. 

General  Symptoms. — Fever  is  usually  present,  but  it  is  slight  and 
exhibits  marked  variations.  In  certain  instances,  however,  the  tempera- 
ture is  below  the  normal.  From  the  time  of  onset  there  is  gradual,  pro- 
gressive loss  of  flesh  and  strength,  and  anemia  becomes  well  marked. 

Complications. — The  most  common  is  hepatic  abscess,  and  as  the 
result  of  perforation  of  the  diaphragm  may  arise  secondary  abscess  of  the 
right  lung.  Authors  are  not  agreed  as  to  the  frequency  of  occurrence 
of  liver-abscess  (see  p.  922)  in  amebic  dysentery,  but  it  is  certainly  com- 
paratively rare  in  this  country,  not  exceeding,  perhaps,  3  per  cent,  of  the 
cases.  In  the  tropics  it  occurs  in  20-25  per  cent,  of  the  cases.  Peri- 
tonitis may  result  from  perforation  of  a  dysenteric  ulcer,  causing  death. 
The  point  of  perforation  may,  however,  be  in  the  rectum,  when  peri- 
proctitis is  the  result ;  or  it  may  be  in  the  cecum,  when  perityphlitis  is 
the  sequel.  In  tropical  or  subtropical  countries  the  disease  is  often 
complicated  with  malaria.  The  presence  of  an  intermittent  fever  is  not, 
however,  sufficient  to  warrant  the  assumption  that  malaria  complicates 
dysentery  ;  we  must  be  able  to  demonstrate  the  presence  in  the  blood  of 
the  Plasmodium  malarice.  In  pyemia  and  in  suppurative  processes  gen- 
erally— conditions  sometimes  met  with  in  dysentery — the  temperature- 
curve  is  often  distinctly  intermittent.  Typhoid  fever  is  a  rare  compli- 
cation. The  typhoid  state  is  met  with,  and  pyemia  and  septico-pyemia 
may  appear  late.  Pylephlebitis,  pericarditis,  endocarditis,  pleuritis, 
nephritis  (common),  and  rheumatoid  pains  in  the  joints  are  observed. 

Diagnosis. — The  slow  course,  marked  by  intermissions  and  exacer- 
bations of  the  bloody,  fluid  stools,  the  mild  general  symptoms,  apart 
from  emaciation  and  debility,  are  salient  features,  but  an  assured  recog- 
nition of  the  aflfection  demands  a  microscopic  examination  of  the  stools. 
Cases  have  been  recorded  by  Councilman  and  Lafleur  in  which  the 
diagnosis  rested  upon  amebte  being  found  in  the  sputa ;  this  was  ex- 
plained   by  the  existence  of   an  hepato-pulmonary  abscess,  which  had 


AMEBIC  DYSENTERY.  337 

discharged  through  a  bronchus;  the  intestinal  symptoms  were  negative. 
Simihir  cases  have  been  reported  by  L.  Napoleon  Boston  ^  and  others. 

Prognosis. — The  mortality-rate  in  certain  epidemics  has  been  fright- 
ful, particularly  among  soldiers  in  the  field  (amounting  to  70  per  cent.). 
In  sporadic  cases  the  danger  to  life  is  less,  the  mortality-rate  in  temper- 
ate climates  being  not  over  5  or  6  per  cent.  The  complications  which 
render  the  prognosis  unfavorable  are, — peritonitis,  hepatic  and  pulmonary 
abscess,  pyemia,  broncho-pneumonia,  malaria ;  death  may  be  due  to 
hemorrhage  or  peritonitis,  but  in  a  preponderating  proportion  of  the  cases 
to  asthenia.  A  dangerous  degree  of  debility  is  indicated  by  great  ner- 
vous depression  ;  a  cool,  clammy  skin ;  a  sunken,  pinched  facies ;  a  dry 
tongue;  a  feeble,  rapid  pulse;  and  by  Ioav  muttering  delirium. 

Course  and  Duration. — The  average  duration  ranges  from  eight 
to  ten  weeks  in  uncomplicated  cases;  the  disease  can,  however,  be  cut 
short  by  appropriate  treatment.  It  manifests  an  innate  tendency  to 
pursue  a  chronic  course,  interrupted  by  frequent  exacerbations  or  true 
relapses,  and  convalescence  occupies  a  long  period  of  time  in  conse- 
quence of  the  profound  anemia  and  debility  that  supervene. 

Treatment. — The  diet  should  consist  of  easily  digestible  and  nutri- 
tious solids,  as  raw  oysters,  eggs,  rice,  fowl,  fish,  and  the  like,  in  small 
quantities.  Milk  should  also  be  freely  allowed.  It  may  be  necessary  to 
restrict  the  diet  to  fluids  if  diarrhea  be  well  marked.  During  convales- 
cence  a  return  to  a  mixed  dietary  is  to  be  adopted  in  a  gradual  manner. 

A  judicious  hygienic  regimen  calculated  to  maintain  assimilation  is 
especially  valuable.  Kest  in  bed,  combined  with  gentle,  systematic 
massage,  may  be  necessary  in  severe  cases ;  in  other  and  lighter  cases 
graduated  exercise  in  the  open  air  and  rest  are  serviceable.  The  medi- 
cal treatment  is  by  ipecacuanha,  in  the  form  of  salol-coated  pills.  Not 
less  than  30  grains  at  a  single  dose  are  to  be  given  on  the  first  day. 
"  Subsequently  the  amount  is  to  be  diminished  by  5  grains  per  diem, 
so  that  by  the  sixth  day  only  5  grains  of  the  drug  are  administered. 
During  the  next  week  or  ten  days  a  nightly  dose  of  five  grains  must  be 
allowed."^  Rogers^  recommends  the  subcutaneous  injection  of  J-grain 
doses  of  emetin  hydrochlorid.  Beck  advises  the  treatment  of  dysentery 
with  ipecac  through  the  Einhorn  duodenal  tube,  especially  in  acute  cases, 
as  much  as  1  to  2  drams  being  introduced  at  one  sitting.  Colonic 
injections  of  warm  solutions  of  quinin  hydrochlorid  (strength  1  :  1000 
to  1 :  5000)  have  proved  effective  in  the  hands  of  most  clinicians.  Leroy, 
of  Memphis,  has  used  formalin  similarly  (1 :  1000),  with  almost  specific 
effects.  Copper  arsenite  internally  (gr.  j^^  ^-0.00067)  and  hot  instilla- 
tions of  copper  sulphate  solution  (1 :  10,000  to  1 :  6000)  have  been  found 
valuable  (Storck  *).  Musgrave^  prefers  thymol,  which  he  gives  by  enema. 
A  small  class  of  cases  do  not  yield  to  either  the  ipecacuanha  treatment  or 
rectal  lavage ;  they  demand  "  appendicostomy  and  systematic,  thorough 
irrigations  through  the  appendix."  Recurrences  will  yield  to  the  same 
means,  and  they  can  sometimes  be  prevented  by  promoting  the  repair  of 
the  blood  and  tissues  during  the  intervals. 

^  Jour.  Amer.  Med.  Assoc,  April  26,  1902. 

2 "  The  Treatment  of  Amebic  Dysentery,  Especially  bv  Appendicostomv,"  bv  J.  M. 
Anders  and  W.  L.  Eodman,  Jour.  Amer.  Med.  Assoc,  February  12,  1910. 
3  Brit.  Med.  Jour.,  1912,  2695,  405. 
*Jour.  Amer.  Med.  Assoc,  Jan.  6,  1912. 
^  New  Orleans  Med.  and  Surg.  Jour.,  May,  1911. 
22 


338  ANIMAL  PARASITIC  DISEASES. 

FLAGELLATA. 

MASTIGOPHORA. 

During  the  motile  period  of  their  existence  these  organisms  possess 
one  or  more  flagella  attached  to  either  or  both  ends  in  the  various  forms, 
and  some  of  them  also  possess  an  undulating  membrane,  the  trypan- 
osomee  being  the  best  exemplars  of  this  latter  group.  The  body  of  these 
parasites  is  very  small,  many  with  rounded  anterior  portion,  pointed  pos- 
teriorly ;  others,  spindle-shaped.  They  are  nucleated,  often  have  vacu- 
oles, and  some  contain  chlorophyl. 

Trichomonas  var/inalis  lives  in  an  acid  medium.  It  is  not  found  in 
normal  vaginal  secretion,  but  in  vaginal  catarrh  with  acid  secretion ;  it 
may  occur  at  any  age  from  childhood  to  advanced  life.  It  is  a  specific 
parasite  of  the  female  generative  tract,  though,  rarely,  it  has  been  found 
in  the  urine  of  men,  probably  introduced  through  coitus.  It  is  not 
known  how  they  gain  entrance  to  a  woman.  Alkaline  solutions  destroy 
them,  as  does  cold. 

Trichomonas  i7itestinalis  and  jmlmonaUs  are  met  Avith  in  stools,  urine, 
sputum,  secretions  from  mouth ;  but  these  forms  are  not  pathogenic. 

Lamhlia  (Oercomonas)  i)itestinalis — a  monad  commonly  met  with  in 
intestinal  discharges ;  not  believed  to  be  pathogenic.  Cercomonads  have 
been  found  ((7.  hominis)  in  discharges  of  cholera  patients  and  {Bodo 
urinarius)  in  urine. 

Balantidium  coli  {Paramoecium  call)  is  found  in  discharges  from  obsti- 
nate cases  of  colitis ;  also  in  mucosa,  and  even  submucosa,  of  rectum  and 
colon.  Stokvis  has  found  it  in  the  sputum  of  a  case  of  pulmonary 
abscess.    The  pig  is  believed  to  be  the  source  from  which  man  is  infected. 

Trypanosomiasis. 

sleeping  sickness. 

The  trypanosoma  is  a  flagellated  hematozoon  common  to  the  lower 
animals,  and  has  been  found  in  man.  Trypanosoma  hominis  is  a  minute, 
colorless,  translucent,  active  protozobn,  tapering  toward  its  extremities, 
the  anterior  of  which  displays  a  long  flagellum.  The  body  of  the  organ- 
ism is  finely  granular.  It  is  found  free  in  the  plasma.  Trypanosomes 
have  been  known  for  over  sixty  years,  but  their  pathologic  import  was 
first  pointed  out  by  Evans  in  surra,  a  disease  of  horses  and  cattle  in 
India,  trypanosoma  Evansii.  In  May,  1901,  Forde  found  the  organism 
in  the  blood  of  an  Englishman  suffering  from  an  irregular  chronic  fever, 
at  first  thought  to  be  malaria.  Six  months  later  Dutton  found  and 
recognized  the  nature  of  the  organism  in  the  blood  of  this  same  patient, 
though  about  ten  years  before,  Nepven,  a  French  observer,  had  seen  the 
same  or  a  similar  parasite  in  man,  this  being  the  first  time  that  man  was 
found  to  be  subject  to  infection  from  trypanosomes.  Dutton  suggested 
the  name  trypanosoma  gamhiense  for  the  parasite,  and  trypanosomiasis 
for  the  disease.  Trypanosomiasis  is  engrossing  a  large  proportion  of 
the  professional  attention  at  the  present  day  of  Europe,  Asia,  Africa, 
Australia,   and  even  America.      Castellani  ^  found   the    trypanosoma  in 

'  Lancet,  June  20,  1903. 


SLEEPING  SICKNESS.  339 

the  spinal  fluid,  obtained  by  lumbar  puncture,  in  20  out  of  34  cases  of 
sleeping  sickness,  but  Bruce  first  showed  the  pat}iohj;^ic  relationshi)) 
between  sleeping  sickness  and  trypanosonia,  and  that  the  agent  of  trans- 
mission is  the  tsetse  fly  of  the  genus  Glosnina  paljjaltH.  This  fly  is  not 
found  in  America. 

Trypanosoraes  have  been  found  associated  with  many  diseases  of  man 
and  animals,  and  Manson  believes  that  three  of  these — i.  <?.,  the  trypan- 
osoma  Brucei,  a  tsetse-fly  disease,  causing  nagana  in  horses  and  cattle ; 
trypanosoma  Uvansii,  and  the  trypanosome  of  mal  de  caderas — are  closely 
allied  species,  if  not  identical.  Recently  Broeden  discovered  in  the 
Congo  country  a  trypanosome  which  is  pathogenic  for  cattle,  rats,  guinea- 
pigs,  and  monkeys,  and  the  infection  is  essentially  like  that  produced  by 
other  trypanosomes. 

Symptoms  and  DiagrnosiS. — Early  the  skin  may  appear  nearly 
normal,  but  Ford  and  Manson  have  described  blotches  of  erythema,  iso- 
lated areas  of  edema,  especially  of  the  eyelids,  and,  later,  general  edema 
and  cachexia.  The  tongue  is  red  and  raw.  There  are  wasting,  general 
malaise,  and  decided  weakness  of  the  lower  limbs.  The  pulse  may  reach 
120  beats  per  minute.  Tachycardia  and  muscular  weakness  are  the  rule. 
Fever  may  develop  at  intervals  or  may  occur  daily  for  an  indefinite  time, 
ranging  from  100°  to  104°  F.  (87.7°-40°  C).  Lethargy  is  the  domi- 
nating feature  of  these  cases.  In  addition  to  the  cutaneous  symptoms, 
which  may  resemble  leprosy,  there  are  restlessness,  difficulty  in  speech, 
delirium,  Cheyne-Stokes  respiration,  and  coma.  /Splenic  enlargement 
and  tenderness  were  present  in  Ford's  case.  The  lymphatic  glands  are 
enlarged  and  contain  trypanosomes.  An  irregular  remitting  fever  is  a 
leading  symptom  of  the  first  stage.  There  is  general  anemia  of  the 
simple  chlorotic  type.  Ophthalmoscopic  examination  may  show  mottling 
of  the  fundus.  The  Liverpool  School  of  Tropical  Medicine  maintains 
that  gland  palpation  is  the  most  efficient  means  of  diagnosis  of  human 
trypanosomiasis,  other  causes  for  the  glandular  enlargement  being 
absent.^  The  parasites  {trypanosoma  hominis)  are  numerous  in  the 
blood  during  the  febrile  periods.  (For  technique  necessary  for  its  recog- 
nition and  staining,  see  Malaria.)  Sleeping  sickness,  which  is  due  to  a 
lymphatic  infiltraton  of  the  brain  with  small  mononuclear  cells,  probably 
constitutes  the  second  or  final  stage  of  human  trypanosomiasis.  There  is 
a  marked  rise  of  temperature  in  the  evenings.  There  are  mental  dulness, 
headache,  general  weakness,  and  somnolence,  merging  into  coma  later. 

Treatment. — Koch  advises  the  sacrifice  of  every  animal  whose  blood 
is  found  to  contain  the  parasite.  He  has  found  arsenic  to  be  a  specific 
in  the  treatment.  The  methods  adopted  by  Great  Britain  and  Germany 
to  prevent  trypanosomiasis  are :  segregation,  notification,  and  measures 
for  dealing  with  animals  serving  as  carriers.  Dr.  Daniels  informs  me 
that  atoxyl  in  ascending  doses  has  been  found  efiective.  Commencing 
with  gr.  j,  every  second  day,  the  dose  is  increased  to  gr.  iss  at  the  end 
of  one  week,  to  gr.  ij  at  the  end  of  another  week,  then  gr.  iiss  to  gr.  iij 
every  second  day  for  a  year  or  more  after  all  trypanosomes  have  disap- 
peared. This  treatment  may  be  followed  by  a  course  of  mercury.  Ex- 
cellent reports  from  the  use  of  Ehrlich's  remedy  (arseno-phenyl-glycin) 
have  been  received,  but  is  still  on  trial. 

^  J.  L.  Todd,  The  Journal  of  Tropical  Medicine  and  Hygiene,  October  15,  1908. 


340  ANIMAL  PARASITIC  DISEASES. 

FEBRILE    TROPICAL    SPLENOMEGALY. 

(l>iim(li(m  Fertr,  Kala-azur,  Piroplasvioxia.) 

Definition. — It  is  a  chronic  disease,  characterized  by  anemia,  irreg- 
ular fever,  emaciation,  pigmentation  of  the  skin,  enlarged  spleen,  and 
by  a  {)rotozoon  organism,  whicli  is  found  in  the  spleen,  liver,  bone-niar- 
row,  lymph-glands,  adrenals,  testicles,  intestinal  and  cutaneous  ulcers, 
and  intlammatory  exudates,  and  only  very  rarely  in  the  blood. 

Tropical  splenomegaly,  known  also  by  its  native  Indian  name,  kala-azar 
(black  fever),  from  the  pigmentation  of  the  skin,  has  also  been  termed  Dum- 
dum fever  in  Indian  medical  circles,  after  Dumdum,  a  military  station  near 
Calcutta.  The  disease  is  met  Avith  in  India,  Assam.  China,  Egypt,  and  Af- 
rica. Epidemics  move  forward  very  slowly — about  14  miles  a  year — the 
disease  clinging  to  a  place  for  almost  five  years  and  then  disa})pearing. 

Ktiology. — In  1885  Cunningham,  and  in  1901,  Firth,  called  atten- 
tion to  certain  minute  bodies  to  be  found  in  the  protoplasm  of  the  cell 
exudate  of  the  base  of  the  Oriental  sore  or  Delhi  boil.  In  November, 
1900,  Leishman  found  these  bodies  in  smears  from  the  spleen  of  a  case  of 
Dumdum  fever  in  a  soldier  invalided  home  from  India.  In  the  winter  of 
1902—3  Major  Leishman  noted  these  same  organisms  in  smears  of  blood 
and  internal  organs  from  a  trypanosome-infected  rat.  In  May,  1903,  he 
published  these  observations,  and  suggested  that  the  organisms  were  try- 
pan oeomes.  Soon  after  Donovan  found  them  in  fluid  obtained  by  splenic 
puncture  from  an  Indian,  hence  the  name,  Leishman-Donovan  body.  Low. 
Manson,  Rogers,  Bentley,  and  others  have  since  found  them.  They  are 
minute,  oat-shaped,  oval,  or  round  bodies,  with  faintly  staining  protoplasm, 
but  deeply  staining  chromatin  masses,  usually  placed  at  opposite  poles  of 
the  cell.  Rogers  succeeded  in  cultivating  these  bodies  in  citrate  of  soda 
solution,  typical  flagellated  organisms  resulting — the  proof  of  their  nature. 
Unlike  the  usual  type  of  trypanosomes,  the  flagellum  is  attached  to  the 
end  of  the  body  at  Avhich  the  micronuclous  is  situated,  and  it  does  not  pos- 
sess an  undulating  membrane.  It  probably  escapes  from  the  body  of  the 
infected  individual  in  the  discharges  from  cutaneous  or  intestinal  ulcera- 
tion, and  in  all  likelihood  the  intermediate  host  is  some  biting  insect. 

Predisposing"  Causes. — One-third  of  the  cases  occur  under  twenty 
years  of  age,  and  the  Hindus  were  more  fre(iuently  afl'ected  by  the  disease 
than  the  Mohammedans,  the  proportion  being  about  4  to  1  (Brahmachari). 

The  Oriental  sore — Delhi  or  Bagdad  boil,  a  local  infection,  without 
constitutional  symptoms — is  apparently  due. to  the  same  trypanosome  as 
tropical  splenomegaly,  but  it  is  not  fatal,  and  one  attack,  as  a  rule,  gives 
immunity.  Manson  says  it  has  been  noted  that  Oriental  sore  is  peculiar 
to  camel-usino-  countiies,  and  if  this  really  be  due  to  the  same  Leishman- 
Donovan  body  as  kala-azar,  that  a  reduction  in  virulence  of  the  organ- 
ism has  been  attained  by  j^assage  through  the  camel,  as  is  the  case  with 
small-pox  in  its  passage  through  the  cow.  The  inference  is,  therefore, 
that  the  virus  of  Oriental  sore  should  be  employed  in  an  attempt  to  protect 
against  kala-azar.  The  disease  prevails  at  all  ages,  in  both  sexes,  and 
shows  a  predilection  for  the  natives  and  old  residents.  ►. 

Symptoms. — There  is  fever,  irregular  in  type,  generally  remittent, 
often  comparatively  long  intermittent  periods,  the  whole  extending  over 
some  months.  The  fever  may  occur  in  ague-like  attacks.  A  dirt}-,  sal- 
low, anemic  appearance  of  the  cutaneous  surface  is  noted,  and  occa- 
sionally areas  of  pigmentation.      Enlargement  of  the  spleen  and  liver 


PSOROSPERMIASrS.  .'Ml 

occur  early,  the  former  being  an  invariable  accompaniment,  wliile  the 
latter  is  less  constant.  Dyspnea,  emaciation,  progressive  and,  finally, 
extreme  weakness,  and  more  or  less  edema  are  present.  Leucopenia,  in 
which  the  proportion  of  white  or  red  corpuscles  may  be  less  than  one  to 
one  thousand  with  relative  low  polymorphonuclear  counts,  is  almost  diag- 
nostic of  the  disease.  Cutaneous  and  intestinal  ulceration  devehjp  various 
hemorrhages  or  purpura,  and  these,  in  an  extremely  emaciated  individual 
with  a  large  protuberant  belly,  make  a  picture  fairly  characteristic. 
Death  often  results  from  some  intercurrent  affection,  Amon^  the  cora- 
moner  complications  are  pneumonia,  pulmonary  tuberculosis,  abscesses, 
and  splenalgia  due  to  infarcts  in  the  spleen. 

Prognosis. — Manson  regards  the  disease  as  absolutely  hopeless  ;  he 
has  never  seen  a  case  recover.  Rogers  places  the  mortality  at  96  per 
cent.     Donovan  gives  an  equally  gloomy  prognosis. 

Treatment. — Tonic  and  hygienic.  Quinin  is  of  no  special  value, 
but  may  be  employed  with  iron  and  arsenic.  When  possible,  segregate 
infected  cases,  since  no  other  known  method  of  prevention  exists,  and,  as 
we  have  seen,  once  developed,  it  proceeds  to  a  fatal  issue. 


PSOROSPERMIASIS. 


Psorosperms  belong  to  the  lowest  form  of  pjrotozoa.  They  are  also 
known  as  sporozoa,  and,  because  of  their  parasitic  relation  to  cells,  as 
cytozoa.  A  common  form  occurs  in  the  muscles  of  the  pig  {sareocystis 
Miescheri).  The  amoeba  coli  of  amebic  dysentery  belongs  to  the  protozoa. 
Various  coccidia  may  occur  in  man  (e.  g.,  sarcocystis  hominis)  to  produce 
the  disease  indicated  by  this  heading. 

{a)  Internal  J*so7-ospermiasis. — In  man,  hepatic  disease  similar  to  that 
found  in  the  rabbit  is  produced  by  the  coccidium  oviforme.  The  tumors 
formed  by  the  coccidia  may  be  palpable,  and  the  liver  may  be  quite  tender. 
Some  chilliness  and  fever,  malaise,  and  stupor  passing  into  coma  have  been 
observed.  Death  was  caused  on  the  fourteenth  day  in  a  case  admitted  to 
St.  Thomas's  Hospital  (Osier).  The  necropsy  showed  whitish  neoplasms 
in  the  peritoneum,  omentum,  kidneys,  pericardium,  liver,  and  spleen. 

In  the  intestinal  variety  of  internal  psorospermiasis  nausea  and  vom- 
iting, diarrhea,  and  the  typhoid  state  may  be  manifested.  Involvement 
of  the  kidneys  has  caused  hematuria  and  frequency  of  urination. 

{h)  External  Psorospermiasis. — Cutaneous  psorospermiasis,  one  form 
of  which  was  formerly  called  keratosis  follioiclaris,  is  characterized  by 
lesions  at  first  of  a  hard,  crusty,  papular  type,  later  becoming  confluent, 
and  situated  on  the  fiice,  lumbo-abdominal,  and  inguinal  regions.  These 
papillomatous  growths  contain  either  parasitic  sporozoa,  or,  as  suggested 
by  Montgomery  and  others,  parasites  that  belong  to  the  blastomyces. 

In  carcinoma,  epithelioma,  and  Paget's  disease  of  the  nipple  coc- 
eidia  are  readily  found  in  and  between  the  pathologic  epithelial  cells, 
but  whether  they  have  an  etiologic  bearing  upon  these  malignant  affec- 
tions is  still  a  matter  of  uncertainty. 

Prophylaxis  consists  in  cleanliness  and  care  in  preparing  such  food  veg- 
etables as  spinach,  lettuce,  cabbage,  and  other  greens  that  may  possibly  be 
contaminated  by  the  excreta  of  the  lower  animals  liable  to  psoroform-in- 
fection.  The  treatment  of  psorospermiasis  is  symptomatic,  though  rectal 
injections  of  a  solution  of  quinin  (1 :  5000  to  1 :  1000)  may  be  tried. 


342  ANIMAL  PARASITIC  DISEASES. 


MALARIAL  FEVER. 

{■Chills  and  Fever;  Fever  and  Ague;  Swamp  Fever.) 

Definition. — An  infectious,  non-contagious  disease  caused  by  the 
liematozoon  of  Laveran.  It  is  characterized  by  splenic  enlargement, 
brief  febrile  attacks  which  recur  periodically,  melanemia,  and  a  ten- 
dency in  protracted  cases  to  irregular  fever  and  extreme  anemia.  The 
following  sub-varieties  will  be  discussed :  (I.)  Intermittent  fever ;  (II.) 
Pernicious  intermittent ;  (III.)  llemittent  fever ;  (IV.)  Malarial  ca- 
chexia ;  (V.)  Masked  inter niittents ;  and  (VI.)  Malarial  hematuria. 

Historic  Note. — There  are  few  diseases  with  which  the  profes- 
sion has  been  acquainted  longer  than  with  malaria,  and  chief  among 
the  earliest  known  hotbeds  of  this  disease  were  the  city  of  Rome,  the 
Pontine  marshes  about  the  latter,  and  the  swamps  along  the  lower 
Danube.  It  is  pretty  generally  believed  that  the  prevalence  of  the 
disease  long  has  been,  and  still  is,  diminishing.  This  view  is  fully 
corroborated  by  my  own  observations  upon  the  cases  from  four  leading 
hospitals  of  Philadelphia.  The  drying  of  marshy  districts  of  a  malarious 
character,  thereby  rendering  them  unsuited  to  the  development  of  the 
mosquito,  is  the  cause  of  this  decreased  prevalence. 

New  England,  once  a  region  in  which  the  disease  was  very  preva- 
lent, now  aftbrds  few  cases.  Again,  in  the  southern  portion  of  the  United 
States,  where  the  severer  forms  of  malaria  prevailed  extensively  in  the 
past,  a  marked  tendency  to  progressive  reduction  in  the  number  of  cases 
has  also  been  observed.  In  foreign  lands  (England  and  Continental 
Europe)  the  constantly  decreasing  prevalence  and  virulence  of  this  dis- 
ease have  been  noted  by  numerous  careful  observers.  The  relation  be- 
tween malaria  and  the  mosquito  is  suggested  in  the  wn-itings  of  such 
ancient  authors  as  Columella  and  Varro.  The  peasants  say  "  in  such 
a  place  there  is  much  fever  because  it  is  full  of  mosquitoes."  Shep- 
herds returning  from  the  European  mountains  to  their  cabins  smoked 
them  to  drive  out  the  mosquitoes.  The  sheep  occupied  the  cabins  at 
periods  Avhen  the  famished  mosquitoes  inflicted  their  bites  upon  these 
animals,  after  which  they  showed  little  tendency  to  bite  man  (an  ancient 
prophylaxis).  Mbu  is  the  term  used  in  Eastern  Africa  for  both  malaria 
and  the  mosquito. 

In  1848  Noth,  of  America,  maintained  that  both  yellow  fever 
and  malaria  were  transported  by  the  mosquito,  and  King,  in  1883, 
showed  that  malaria  was  transmitted  in  this  manner.  In  1891  Laveran 
recognized  the  mosquito  as  an  intermediary  host  of  this  parasite. 
Similar  views  were  held  by  Pfeiffer  and  Koch  in  1892  and  Bignami  in 
1894. 

Pathology. — The  chief  and  most  constant  morbid  lesions  are 
attributable  to  the  direct  effect  of  the  malarial  parasites  upon  the  blood. 
The  symptomatic  anemia  (often  quite  pronounced)  results  from  the  de- 
struction of  red  corpuscles  by  the  parasites.  There  is  a  marked  ten- 
dency to  an  accumulation  of  pigment  in  the  blood  and  in  certain  of  the 
internal  organs,  particularly  the  spleen  and  liver.      To  account  for  this 


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DESCRIPTION   OF  PLATES   III.  and  IV.» 


The  drawings  were  made  with  the  assistan  of  the  camera  lucida  from  specimens  of  fresh 
blood.  A  Winckel  microscoiw,  objective  '^  (oil  immersion),  ocular  1.  was  used.  Figures  4,  13,  23, 
24,  and  4'2  of  I'late  III.  were  drawn  from  fresh  blood,  without  the  camera  lucida. 

PLATE  III. 
The  Parasite  of  Tertian  Fever. 

1. — Normal  red  corpuscle. 

2,  3,  4.— Youni;  hyaline  forms.    In  I.  a  corpuscle  contains  three  distinct  parasites. 

5,  L'l. — 13eginnini:'(if  nisnientation.  The  parasite  was  observed  to  form  a  true  ring  by  the  con- 
fluence of  two  iistudoiMKlia.  During  observation  the  body  burst  from  tlie  corpuscle,  which  became 
decolorized  and  ilisaiijieared  from  view.  The  parasite  became,  almost  immediately,  deformed  and 
motionless,  as  shown  in  Fig.  21. 

6,  7,  8.— Partly  developed  pigmented  forms. 
9.— Full-grown  body. 

10-14. — Segmenting  bodies. 

15. — Form  simulating  a  segmenting  body.  The  significance  of  these  forms,  several  of  which 
have  been  observed,  was  not  clear  to  Drs.  Thayer  and  Hewetson,  who  had  never  met  with  similar 
bodies  in  stained  specimens  so  as  to  be  able  to  study  the  structure  of  the  individual  segments. 

16,  17. — Precocious  segmentation. 

18,  1'.),  20.— Large  swollen  and  fragmenting  extracellular  bodies. 

22.— Flagellate  Dody. 

23,  24.— Vacuolization. 

The  Parasite  of  Quartan  Fever. 

25.— Normal  red  corpuscle. 
26.— Young  hyalinL-  form. 

27-34.— Gradual  development  of  the  intracorpuscular  bodies. 

35.— Full-grown  b(jdy.  The  substance  of  the  red  corpuscle  is  no  more  visible  in  the  fresh 
specimen. 

36-39.— Segmenting  bodies. 

40.— Large  swollen  extracellular  form. 

41.— Flagellate  body. 

42. — Vacuolization. 

PLATE  ]V. 
The  Parasite  of  ^stivo- autumnal  Fever. 

1,  2. — Small  refractive  ring-like  bodies. 

3-6. — Larger  disk-like  and  ameboid  forms.       .       , 

7.— Ring-like  body  with  a  few  pigment-granules  in  a  brassy,  shrunken  corpuscle. 

8,  9,  10,  12.— Similar  pigmented  tjodies. 

11.— Ameboid  body  with  pigment. 

13.- Bodywith  a  central  clump  of  pigment  in  a  corpuscle,  showing  a  retraction  of  the  hemo- 
globin-containing substance  about  the  parasite. 

14-20. — larger  bodies  with  central  pigment  clumps  or  blocks. 

21-24.— Segmenting  bodies  from  the  spleen.  Figs.  21-23  represent  one  body  where  the  entire 
process  of  segmentation  was  observed.  The  segments,  eighteen  in  number,  were  accurately 
counted  before  separation,  as  in  Fig.  23.  The  sudden  separation  of  the  segments,  occurring  as 
though  some  retaining;  membrane  were  ruptured,  was  observed. 

2V33.— Crescents  and  ovoid  bodies.  Figs.  30  and  31  represent  one  body,  which  was  seen  to 
extrr.de  slowly,  and  later  to  withdraw,  two  rounded  protrusions. 

34,  35.— Round  bodies. 

36. — "  Gemmation,"  fragmentation. 

37.— Vacuolization  of  a  crescent. 

38-40.— Flagellation.  The  figures  represent  one  organism.  The  blood  was  taken  from  the  ear 
at  4.15  p.  m. :  at  4.17  the  body  was  as  represented  in  Fig.  38.  At  4.27  the  flagella  ap])eared  ;  at  4.:i3 
two  of  the  flagella  had  already  broken  away  from  the  mother  body. 

41-15. — Phagocytosis.    Traced  with  the  camera  lucida. 

'  These  illustrations  are  reproduced  by  permission  from  the  article  by  Drs.  Thayer  and  Hewet- 
son in  The  Johns  Hopkinit  Hoxpital  Reports,  vol.  v.,  1895. 


The  Parasite  of  Tertian  Fever. 


I'LATK    III. 


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MALARIAL   FKVKR.  343 

is  the  fact  mentioned  in  the  description  of  the  amebic  (infra)  that  the 
hemoglobin  of  the  blood  is  converted  into  melanin  (pigment)  by  the 
organisms.  The  phenomena  of  the  disease  are,  at  least  in  part,  referable 
to  the  toxic  action  of  this  pigment.  The  malarial  parasite  also  engenders 
a  toxin  which  may  be  in  part  responsible  for  the  morbid  lesions  of  the 
disease. 

The  spleen  is  engorged  with  blood,  and  at  first  is  swollen  (chiefly 
during  the  febrile  paroxysm),  but  it  soon  becomes  permanently  enlarged 
("  ague-cake  ").  A  rare  accident  in  intermittent  fever  is  rupture  of  the 
spleen.     Hemorrhagic  infarcts  are  occasionally  presented  by  this  organ. 

The  liver  is  also  engorged,  but  not  to  the  same  extent  as  the  spleen. 

The  heart-chambers  may  be  found  to  be  acutely  dilated.  Neuritis 
has  been  observed  by  Gowers,  Bamstark,  Ewald,  and  V.  P.  Gibney. 
W.  G.  Spiller^  reported  a  case  that  showed  partial  sclerosis  of  the 
motor  tracts,  and  recent  hemorrhages  within  the  left  internal  capsule 
{vide  Pernicious  Malarial  Intermittent,  also  Remittent  Malarial  Fever). 

!^tiologfy. — Parasitology. — Our  knowledge  of  the  malarial  parasite 
may  be  discussed  under  five  heads :  (1)  Discovery  of  the  Plasmodium 
malarise  in  the  blood  of  persons  suffering  from  the  disease.  (2)  Its 
developmental  cycle  in  man  (sporulation),  as  shown  by  Golgi,  in  1885. 
(3)  The  discovery,  by  MacCallum,  of  its  method  of  sexual  fertiliza- 
tion. (4)  Its  fertilization  and  development  in  an  intermediate  host  (the 
mosquito),  as  first  pointed  out  by  Surgeon-Major  Ross.  (5)  The  obser- 
vations of  the  Italian  school,  showing  its  method  of  re-entering  the 
tissues  of  man. 

(1)  In  1880  Laveran  discovered  the  malarial  parasite,  but  it  was  not 
until  1883,  Avhen  Marchiafava,  Colli,  and  Golgi  published  their  confirma- 
tory investigations,  that  the  parasitic  origin  of  the  disease  was  accepteil. 

(2)  Laveran  and  Golgi  observed  that  certain  parasites,  especially 
those  found  in  estivo-autumnal  fever,  developed  into  peculiar  crescentic 
bodies  (gametocytes).  Other  more  rounded,  ring-like  bodies  were  seen 
to  display  abnormal  agitation  in  from  ten  to  fifteen  minutes  after  being 
withdrawn  from  the  body,  followed  by  the  discharge  from  the  protoplasm 
of  several  filamentous  bodies  or  flagella  (microgametocytes).  The  latter 
wei'e  seen  to  separate  from  the  parent-cell,  after  which  they  were  observed 
swimming  independently  in  the  blood. 

(3)  The  significance  of  both  the  crescentic  and  flagellated  bodies  was 
first  described  by  W.  G.  MacCallum,  of  the  United  States,  in  1897. 
While  studying  the  life-history  of  the  "  halteridium,"  it  was  noted  that 
a  limited  number  of  ellipsoid  bodies  were  produced,  corresponding  to  the 
crescentic  bodies  seen  in  human  malaria.  Certain  of  these  bodies  were 
hyaline,  others  granular,  and  it  was  the  former  variety  only  that  de- 
veloped flagella.  A  flagellum,  on  swimming  away  from  the  mother-cell, 
was  seen  to  display  peculiar  agitation  on  approaching  one  of  the  granular 
bodies  (crescentic).  One  of  the  flagella  was  seen  to  enter  the  granular 
body  and  effect  a  symbiosis  with  it  {sexual  fertilization).  Fertilization 
was  followed  by  a  short  rest,  after  which  the  granular  body  assumed  a 
worm-like  form,  and  then  swam  slowly  away,  its  pointed  end  directed 
foremost  and  trailing   behind  it  pigment  particles,  which  had  been  situ- 

'  Amer.  Jowr.  Med.  Sci.,  Dec,  1900. 


344  ANIMAL   PARASITIC  DISEASES. 

ated  within  its  protoplasm.  Later  MacCallum  was  able  to  confirm  these 
investigations  by  a  microscopic  study  of  the  blood  from  a  case  of  malaiia 
(eativo-autumnal)  in  man,  the  flagella  being  formed  after  exposure  to  the 
air.  In  human  malaria  sexual  fertilization  takes  place  in  the  mosquito's 
stomach  or  middle  intestine  within  the  first  twelve  hours. 

(4)  Manson  correctly  supposed  that  the  mosquito  sucked  blood  from 
malarial  subjects.  Surgeon-Major  Ross,^  of  Liverpool,  began  his  investi- 
gations in  India,  in  1895,  by  endeavoring  to  determine  what  became  of 
the  parasite  after  fertilization  in  the  mosquito's  stomach.  During  August 
and  September,  1897,  two  members  of  the  species  Anopheles  maculipennis, 
bred  from  the  larvje,  were  fed  on  the  blood  of  patients  containing  cres- 
cents, and  he  found  that  peculiar  spheroidal  cells  developed  on  the  walls 
of  their  stomachs,  which  convinced  him  that  ''these  cells  constituted  the 
long-sought  mosquito  stage  of  the  parasite"  {zytjote). 

In  1898  Ross  studied  the  "  zygotes  of  protozoma "  of  birds.  He 
found  that  they  attached  themselves  to  the  outer  coats  of  the  mosquito's 
stomach.  The  zygote  grows  rapidly,  without  movement  or  change  in 
form,  protruding  into  the  insects  body-cavity.  Later  its  capsule  be- 
comes easily  perceptible  and  the  cell-substance  is  seen  to  divide  into 
from  ten  to  twelve  ''meres.  "  In  from  one  to  three  weeks,  depending  on 
the  external  temperature,  the  zygote  matures,  when  each  mere  contains 
a  number  of  delicate,  "thread-like"  blasts. 

The  next  step  in  the  development  of  the  parasite  is  the  rupture  of  its 
capsule,  setting  free  these  "thread-like"  blasts  within  the  insect's  body; 
they  are  then  carried  by  the  blood's  currents  to  all  its  tissues,  more  par- 
ticularly into  the  insect's  salivary  gland.  The  common  duct  of  the  sal- 
ivary gland  of  the  mosquito  (genus  Anopheles)  passes  along  the  middle 
stylet  of  the  proboscis,  opening  at  its  extremity,  and  a  portion  of  the 
secretion  of  this  gland  is  poured  into  the  Avound  caused  by  the  insect's 
bite.  In  the  human  body  the  blasts  return  to  the  amebulae,  with  which 
the  life-history  of  this  parasite  began. 

(5)  In  1898  Grassi  found  three  chief  species  of  the  mosquito  in  mala- 
rious localities,  the  Anopheles  claviger  being  constantly  present.  Manson 
gives  32  members  of  the  family  Anophelinfe,  which  have  been  shown, 
with  more  or  less  precision,  to  be  hosts  of  the  malarial  parasites.  Banks 
has  shown  conclusively  that  Myzomyia  ludhwi  should  be  added  to  the 
list. 

In  Nov.,  1898,  Bastianelli,  Bignami,^  and  Grassi  conducted  a  series 
of  experiments,  by  feeding  mosquitoes  the  blood  from  persons  suffering 
from  estivo-autumnal  fever,  confirming  the  findings  described  by  Ross, 
in  Aug.,  1897.  These  investigations  showed  the  mode  of  infection ;  that 
healthy  mosquitoes  become  infected  by  sucking  blood  from  malarial  pa- 
tients, and  that  in  from  eight  to  twenty-one  days  such  insects  may  infect 
healthy  men  by  their  bites.  One  mosquito  may  infect  many  persons, 
and  may  possess  this  power  for  an  indefinite  period,  "  since  not  all  of  the 
germinal  threads  escape  from  the  venomosalivary  gland."  ^  Neither  the 
common  house  mosquito  (genus  Culex)  nor  the  Anopheles  nigripinee 
takes  part  as  an  intermediary  host  for  this  parasite.     The  fact  that  mos- 

'  Brii.  Mfid.  Jour.,  Dec.  18,  1897. 

^  "Malaria  and  Mosquitoes,"  Lancet,  Jan.  13,  1900. 

^  Jour.  Amer.  Med.  Assoc.,  Feb.  3,  1900,  A.Woldert. 


MALARIAL  FEVER.  345 

quitoes  (Anopheles  claviger)  are  known  to  occupy  non-malarious  districts 
proves  the  innocence  of  the  uninfected  insects.  A  single  case  of  malaria 
transported  to  such  territory  often  results  in  an  epidemic. 

The  malarial  parasite  of  Laveran  belongs  to  a  subclass  of  the  pro- 
tozoa known  as  hematozoa  {hoemameha).  Of  the  latter,  three  varieties, 
corresponding  with  the  three  leading  clinical  forms  of  the  affection,  have 
been  distinguished  in  man,  and  the  evolution  of  two  of  these  parasites 
at  least  takes  place  within  the  red  blood-corpuscles.  Manson  describes 
five  species  which  he  classifies  as  follows : 


Benign  {  ^       .        )>  do  not  form  crescents. 


'&' 


r  Quotidian — pigmented        ^ 
Malignant <  Quotidian — unpigmented    Vform  crescents. 
( Tertian  J 

They  enter  the  red  cells  in  the  form  of  small,  non-pigmented  plasmodia, 
exhibiting  ameboid  motion,  and  then  feed  upon  their  host,  transforming, 
at  the  same  time,  the  hemoglobin  of  the  latter  into  dark  pigment-granules 
as  they  develop.  The  special  varieties  of  the  malarial  parasite  as  ob- 
served in  microscopic  studies  of  the  blood  of  human  beings  will  be 
described  separately. 

(1)  The  Hcemameha  Causing  Tertian  Intermittent  Fever. — This  begins 
its  asexual  cycle  of  evolution  in  the  red  blood-corpuscles  as  a  small  hyaline 
ameba.  Its  development  is  attended  with  the  appearance  in  its  inte- 
rior of  fine,  brown,  motile  granules  in  the  form  of  pigment,  and 
when  matured  it  about  equals  the  size  of  a  normal  red  corpuscle.  It 
now  assumes  a  spheric  form,  the  pigment  collecting  centrally,  and 
sporulation  into  fifteen  to  twenty  or  more  segments  follows.  The  tertian 
parasites  are  exceedingly  numerous  in  the  blood,  and  pass  through  the 
various  stages  of  their  life-cycle  almost  simultaneously,  the  sporulation 
of  an  entire  generation  occurring  Avithin  the  space  of  a  few  hours 
(Golgi).  The  occurrence  of  the  malarial  paroxysm  follows  the  process 
of  sporulation,  which  is  attended,  most  probably,  with  the  development 
of  a  toxin,  and  the  symptoms  of  the  disease  may  be  attributable  chiefly 
to  the  effects  of  the  latter.  The  red  corpuscle  that  includes  the  parasite 
becomes  enlarged  and  decolorized  as  the  latter  develops.  The  parasite 
of  tertian  intermittent  runs  its  cycle  in  about  forty-eight  hours.  Hence 
infection  by  a  single  generation  would  result  in  sporulation  every  second 
day,  followed  by  the  malarial  paroxysm.  Quite  commonly,  infection  bv 
two  groups  of  parasites  occurs  on  successive  days,  and,  since  each  has  a 
definite  period  of  evolution,  a  daily  malarial  paroxysm  is  the  result 
(quotidian  intermittent).  Multiple  infection  with  this  parasite  may 
occur,  but  Avith  great  rarity. 

(2)  The  Hoemameba  Causing  Quartan  Fever. — This  cannot  be  distin- 
guished from  the  tertian  parasite  at  the  beginning  of  its  asexual  career, 
but  later  differences  are  clearly  perceptible.  Its  ameboid  movements  are 
more  deliberate,  and  its  pigment-granules  are  coarser,  darker,  and  also  less 
motile  than  those  of  the  tertian  organisms.  Unlike  the  latter,  it  does 
not  attain  the  size  of  the  red  corpuscles,  and  during  sporulation  the  seg- 
ments (five  to  ten  in  number)  encircle  in  an  orderly  way  the  central 
pigment-mass  or  clump,  "rosettes"  of  great  beauty  thus  being  formed. 


346  ANIMAL  PARASITIC  DISEASES. 

The  red  blood-corpuscle  that  harbors  the  quartan  parasite  contracts 
upon  its  destioyer,  appears  shrivelled,  and  its  color  changes  at  the  same 
time  from  the  normal  to  a  deep  greenish  or  bronzed  tint.  It  sporulates 
about  seventy-two  hours  after  it  enters  the  red  corpuscle ;  hence,  if  only 
one  group  of  parasites  be  present,  febrile  attacks  occur  every  fourth  day 
— quartan  intermittent.  On  the  other  hand,  double  quartan  infection 
results  in  paroxysms  on  two  successive  days,  followed  by  an  intermission 
lasting  one  day,  while  trijde  infection,  or  the  presence  of  three  groups, 
causes  daily  paro.xysms — the  quotidian  intermittent.  Infection  by  more 
than  three  groups  of  the  quartan  parasite  may  occur,  but  is  very  rare. 

(3)  The  Rcemameha  Causing  Estivo-autumnal  Fevers. — The  endogen- 
ous cycle  of  this  variety  is  evolved,  chiefly,  in  certain  of  the  internal  vis- 
cera, and  the  microscopic  examination  of  the  blood  in  the  various  stages  of 
the  disease  does  not  always  give  a  positive  result,  as  in  benign  tertian  and 
quartan.  The  organism  invades  the  red  blood-corpuscle,  but  to  what  extent 
is  questionable.  It  is  a  quite  small  hyaline  body,  its  size  at  maturity 
scarcely  equalling  one-half  the  dimensions  of  the  red  corpuscle,  and  it 
accumulates  a  few  fine  pigment-granules.  The  parasite  may  be  found  in 
the  later  stages  in  the  blood  from  certain  internal  viscera,  as  the  spleen. 
After  the  condition  has  lasted  a  time  characteristic  oval  and  crescentic 
bodies,  which  are  more  or  less  refractive,  may  be  observed  in  the  fresh 
blood.  These  so-called  ''sickle-form  bodies"  show  central  rods  and 
clumps  of  coarse  pigment,  and  are  connected  "with  the  malignant  type  of 
malarial  fevers.  Kino;-form  bodies,  and,  at  times,  the  sigJiet-ring  forms, 
are  observed.  The  red  corpuscle,  at  whose  expense  the  parasite  develops, 
assumes  a  brassy-green  hue,  becoming  shrivelled  and  crenated. 

It  would  appear  from  the  studies  of  Manson,  Marchiafava,  Big- 
nami,  and  Surgeon  Craig  ^  that  two  varieties  of  parasite  are  concerned — 
quotidian  and  tertian  forms  of  autumnal  fevers  {vide  table,  p.  345). 

The  parasites  of  tertian  estivo-autumnal  fever  are  larger  than  the 
quotidian  parsisite,  and  during  the  hyaline  stage  the  signet-ring  form, 
slugcrish  ameboid  movement,  clear-cut  refractive  outline,  and  the  occur- 
rence  of  one  organism  in  a  blood-cell  which  is  not  wrinkled  are  observed; 
during  the  pigmented  stage,  the  ameboid  movement  and  fine  granular 
motile  pigment.  Segmentation  takes  place  outside  the  corpuscle.  Cres- 
cents are  large,  slender,  and  deeply  pigmented  (see  Plate  IV.,  p.  346), 

The  quotidian  parasite  is  smaller,  at  times  actively  ameboid,  and  more 
than  one  parasite  may  occupy  a  single  red  cell,  which  is  usually 
wrinkled.  Their  pigment  is  motionless,  and  usually  in  the  form  of  short 
rods.  Unpigmented  parasites  also  occur  (Manson).  Crescents  are  small, 
plump,  and  often  present  a  double  outline.  Segmentation  occurs  within 
the  red  corpuscle. 

Development  of  Flagella. — Some  of  the  crescents  become  ovoid  with 
scattered  pigment ;  this  in  turn  becomes  more  or  less  spherical,  the  pig- 
ment forming  a  central  ring ;  ''  this  finally  approaches  the  periphery,  the 
whole  parasite  becomes  violently  agitated,  throwing  out  flagella,  which 
have  a  wave-like  motion,  many  of  which  break  away  "  (Wright). 

Predisposing  Causes. — (1)  Soil. — Fresh- water  marshes  favor  the  de- 
velopment of  malaria,  and  are  most  fruitful   in   influencing   its  growth 

1  New  York  Med.  Jour.,  Dec.  23,  1899. 


MALARIAL  FEVER.  ?A1 

when  located  near  the  coast  and  tainted  with  salt  water.  Again, 
marshy  districts  affording  luxuriant  vegetation  are  notorious  as  malarial 
foci.  Keeping  in  remembrance  the  foregoing  facts,  we  can  readily  see 
why  malaria  is  unusually  prevalent  in  certain  countries  (chielly  tropicalj, 
and  why  it  is  chiefly  confined  to  the  low-lying  estuaries  and  the  deltas 
of  rivers.  The  same  facts  explain  satisfactorily  why  certain  districts 
which  were  very  liable  to  the  affection  should  have  become,  as  the  result 
of  denudation  of  the  virgin  soil  and  its  subsequent  drainage  and  culti- 
vation, entirely  free  from  the  complaint.  Epidemics  following  the 
upturning  or  the  removal  of  the  surface  of  the  virgin  soil  are  probably 
due  to  importation  of  the  disease  (or  infected  mosquitoes),  and  are  com- 
mon on  the  frontier  of  the  South  and  West. 

(2)  Climate. — Malaria  is  more  prevalent  in  tropical  and  subtropical 
than  in  temperate  climates,  and  more  common  in  the  latter  than  in  the 
polar  zones.  Hence  it  occurs  more  frequently  in  the  southern  than  in 
the  northern  States  of  our  own  country. 

(3)  Rapidly  growing  trees  dry  the  soil  by  absorbing  enormous  quan- 
tities of  water.  In  the  Roman  Campagna  extensive  experiments 
have  been  made  with  the  eucalyptus  tree,  and  districts  protected  in  this 
manner  becoming  almost  entirely  free  from  malaria  in  a  few  years,  the 
environment  being  unsuited  to  the  mosquito. 

(4)  Seasons. — In  temperate  latitudes  most  cases  are  developed  in  the 
autumn,  the  maximal  period  corresponding  with  the  month  of  Septem- 
ber. This  dictum  is  based  upon  4841  cases  of  malaria  gathered  by  the 
author  from  the  records  of  the  leading  Philadelphia  hospitals.^  Cases 
that  develop  before  the  "Anopheles  claviger "  makes  its  appearance 
(in  June)  are  possibly  relapses.  In  the  tropics  the  case  seems  to  be 
different,  and  two  maximum  periods — spring  and  autumn — obtain. 
Statistics  from  the  hospitals  of  Rome,  collected  from  1864  to  1898,  show 
the  maximum  number  of  cases  to  occur  in  August,  September,  October, 
November,  and  July,  respectively,  and  in  June  the  minimum  number. 

(5)  Persons  occupying  the  upper  stories  of  a  house  or  living  on 
elevations  are  affected  with  relative  infrequency,  for  the  reason  that  mos- 
quitoes are  always  found  near  the  earth's  surface,  where  the  air-currents 
are  feeble.     This  fact  also  explains  nocturnal  infection. 

(6)  Race  exerts  little  influence,  but  in  the  United  States  negroes  are 
slightly  less  susceptible  than  are  the  whites. 

(7)  Sex  is  without  effect  when  men  and  women  are  equally  exposed. 
Cases  are,  however,  vastly  more  frequent  among  males  because  of  their 
increased  liability  to  mosquito  bites  while  following  certain  occupations 
(agriculture,  marsh-draining).  The  5J44  cases  collected  by  me  gave  the 
numerical  proportion  of  6  to  1  in  favor  of  males. 

(8)  Age. — Children  are  more  susceptible  than  adults. 

(9)  The  disease  may  flare  up  after  either  an  accident  or  surgical 
operation. 

Immimity. — There  are  individuals  immune  from  malaria  and  experi- 
mental malaria.  An  individual  may  present  this  property  after  a  mild 
fever  has  been  cured  by  quinin.  Maurel  has  shown  that  when  living  in 
a  malarious  district  whites  may  in  time  show  marked  immunity.  By  the 
use  of  methylene-blue  and  euchinin  an  immunity  may  be  established 
against  the  inoculation  of  from  1  to  2  grams  of  estivo-autumnal  blood. 
1  Univ.  Med.  Mag.,  May,  1897. 


348  ANIMAL   PARASITIC  DISEASES. 

Incubation. — According  to  Bignami  and  Bastianelli,  the  period  of 
incubation  for  experimental  malaria  is :  Quartan,  15  days ;  spring 
tertian,  12  days  ;  estivo-autumnal  tertian,  5  days.  The  administration 
of  potassium  bromid,  potassium  iodid,  arsenic,  carbolic  acid,  antipyrin, 
and  phenocoll  may  result  in  a  longer  period.  Angelo  Celli  has  seen 
spring  tertian  show  incubation  of  22,  and  the  estivo-autumnal  tertian  17 
days. 

Hpidemiology. — Estivo-autumnal  fevers  are  rare  in  their  recur- 
rence, while  mild  tertian  and  quartan  prevail  with  each  new  spring,  and 
the  first  cases  of  tertian  are  noted  to  occur  in  the  same  houses  in  which 
the  last  recurrences  of  these  fevers  appeared.  After  the  first  cases  there 
is  a  lapse  of  from  seventeen  to  eighteen  days,  after  which  the  epidemic 
spreads.  The  life  and  habits  of  the  Anopheles  have  a  direct  bearing 
upon  epidemics — ''  either  the  first  cases  of  these  fevers  in  July  are  recur- 
rences of  a  previous  infection,  or  the  very  first  cases  of  tliese  fevers  in 
July  are  primary"  (Celli).  "Both  hypotheses  are  possible.  In  both 
we  have  to  deal  with  a  contagion  circulating,  so  to  speak,  between  the 
temporary  host  (man)  and  the  definitive  host  (mosquito),  a  contagion 
which,  by  means  of  the  blood  of  the  relapsing  cases  of  the  preceding 
year,  is  transmitted  by  the  agency  of  mosquitoes,  and  starts  the  epi- 
demic of  the  following  year."  There  are  many  interesting  (juestions  not 
yet  explained. 

(I.)  Intermittent  Fever. — Symptoms. — The  clinical  history  pre- 
sents itself  under  two  heads :  (a)  the  paroxysms,  and  {b)  the  manner 
in  which  the  paroxysms  recur. 

(fl)  The  Paroxysms. — There  may  be  premonitions  lasting  from  one  to 
several  days,  and  most  significant,  yet  not  distinctive,  are  headache, 
pain  in  the  nape  of  the  neck,  yawning,  a  yellowish  complexion,  and  a 
slight  splenic  enlargement.  In  a  large  proportion  of  the  cases,  how- 
ever, the  onset  is  abrupt.  Typical  paroxysms  present  three  stages — 
chill,  fever,  and  sweating.  The  chill  is  intense,  causing  shivering,  and 
often  chattering  of  the  teeth.  Malaise  is  marked,  the  skin  is  cool  and 
pale,  face  slightly  cyanotic,  and  limbs  painful.  This  stage  usually  occurs 
in  the  morning  houi^s,  but  the  time  of  onset  is  not  constant ;  its  duration, 
also,  varies  greatly,  generally  lasting  from  one  to  two  hours.  The 
internal  temperature  rises  rapidly ;  the  pulse  is  small,  rapid,  and  of  high 
tension. 

The  hot  stage  succeeds  the  chill,  and,  in  striking  contrast  with  the 
first  stage,  the  face  wears  a  decided  flush  and  the  skin  is  burning  hot  to 
the  touch.  The  temperature  continues  to  rige,  but  not  so  rapidly  as  in 
the  first  stage.  Its  maximum  level,  usually  from  104°  to  106°  F.  (40° 
to  41°  C),  is  soon  reached,  and  may  either  be  maintained  uniformly  for 
several  hours,  or  the  curve  may  show  two  small  summits  if  the  tempera- 
ture be  recorded  frequently  (Fig.  26).  The  pulse  is  full  and  bounding, 
except  in  the  rare  instances  in  wliich  acute  dilatation  of  the  heart  en- 
sues, when  it  is  quite  feeble  and  sometimes  irregular.  The  length  of  the 
second  stage  is  from  three  to  six  hours.  The  temperature  generally 
begins  to  decline  before  the  close  of  the  febrile  stage. 

When  sweating,  which  soon  becomes  profuse,  sets  in,  the  symptoms 
of  the  hot  stage  are  promptly  relieved.  The  temperature  falls  by  crisis, 
touching  the  normal  level  in  a  few  hours  ;  the  decline,  however,  is  less 


MA  LARFA  L   FE  VKR. 


349 


rapid  than  the  rise  at  the  bo_o;inning  of  tlie  paroxysm,  'ilie  fall  may  be 
unbroken  by  any  fresh  elevations  of  temperature,  though  more  often  the 
latter  occur.  Less  frequently  defervescence  occurs  by  stops,  the  temper- 
ature falling  one  or  more  degrees,  and  remaining  at  the  new  level  for 
a  short  period  ;  then  dropping  again  about  an  equal  distance,  and  so  on 
until  the  normal  is  reached.  Usually,  following  the  paroxysm,  the  tem- 
perature becomes  subnormal  (about  97°  F. — 36°  C).  The  length  cf  *he 
typical  malarial  paroxysm  ranges  from  eight  to  twelve  hours. 


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(5)  The  Manner  in  which  the  Paroxysms  Recur. — The  special  cha- 
racteristic of  this  form  of  intermittent  is  the  regularity  with  which  the 
paroxysms  recur  in  cases  that  are  not  under  treatment.  The  intermis- 
sion, or  time  between  two  successive  paroxysms,  is  most  frequently 
twenty-four  hours  (quotidian  intermittent  fever) ;  almost  as  often  it  is 
forty-eight  hours  (tertian  intermittent) ;  and  less  frequently  it  is  sev- 
enty-two hours  (quartan  intermittent).     If  there  be  two  paroxysms  on 


350  AyiMAL  PARASITIC  DISEASES. 

one  (iav — a  rare  occurrence — the  term '' double  quotidian"  is  used  to 
designate  the  case.  Of  the  above  types,  as  stated  in  the  life-history  of 
the  parasite,  three  only — the  quotid/an  (malignant),  the  tertian,  and  the 
quart(7n — have  been  clearly  distinguished.  The  cjuotidian  ague  (the  most 
frequent  clinical  variety)  is  generally  due  either  to  double  infection  by  the 
tertian  parasite  or  the  (juotidian  parasite  (single  infection),  and  rarely  is 
it  to  be  attributed  to  the  presence  of  three  groups  of  the  quartan  para- 
site, resulting  in  daily  sporulation.  It  sometimes  happens  that  the  par- 
oxysms recur  a  couple  of  hours  later  each  successive  day,  when  it  is 
called  a  '■'■  retardhui "  intermittent  fever,  or  they  may  recur  a  little 
earlier,  when  the  term  "-anticipating''  is  employed. 

Other  More  or  Less  Characteristie  Symptoms. — Apart  from  the  par- 
oxysms and  the  regularity  with  which  they  recur,  splenic  enlargement  is 
almost  always  present,  and  hence  is  of  considerable  clinical  import. 
After  the  first  paroxysm  or  two  the  swelling  is  usually  marked  and 
demonstrable,  especially  by  palpation.  The  organ  can  be  shown  to  in- 
crease in  size  with  each  succeeding  paroxysm.  Tenderness  is  elicited 
on  pressure,  and  commonly  outlasts  the  course  of  the  aftection  for  a  con- 
siderable length  of  time.  Moderate  enlargement  of  the  liver  may  be 
present,  but  this  is  not  so  constant  as  enlargement  of  the  spleen. 

Connected  with  the  skin  are  two  symptoms  of  considerable  diagnostic 
value:  (1)  a  yellotoish-hroivn  discoloration,  the  so-called  "malarial  com- 
plexion," due  to  the  deposition  of  pigment;  and  (2)  herpes.  The  latter 
occurs  usually  on  the  prolabia  or  on  the  nose,  though  rarely  elsewhere. 
Other  skin-eruptions,  as  urticaria  and  purpura,  have  been  described  by 
authors,  but  they  have  no  real  clinical  worth. 

As  stated  under  Pathology,  acute  dilatation  of  the  heart  may  develop, 
attended  with  the  usual  physical  signs  of  this  condition,  but  it  rarely  lasts 
longer  than  the  brief  febrile  paroxysm.  Murmurs  of  functional  origin 
may  also  be  heard  in  the  heart  during  the  attack,  and  the  lungs  upon 
auscultation  sometimes  present  the  signs  of  a  dry  bronchitis. 

The  urine  may  contain  a  small  amount  of  albumin,  and  rarely  there 
is  acuce  nephritis — a  rather  common  sequel  in  the  negro.  There  is  a 
temporary  increase  in  the  amount  of  urea  eliminated,  and  this  may  be 
observed  from  two  to  six  or  eight  hours  before  the  chill  (Jaccoud). 

Gastro-intestinal  syniptoms  may  be  present,  as  diarrhea,  which  is 
sometimes  considerable,  catarrhal  Jaundice,  and  paroxysmal  vomiting, 
but  these  are  limited  to  the  graver  forms  of  intermittent. 

There  is  a  rapid  diminution  in  the  number  of  both  red  and  white  cor- 
puscle^, proportionate  "  to  the  severity  and  the  number  of  the  attacks  " 
(W.  W.  Johnston).  The  leukopenia  is  associated  with  an  increase  of 
large  mononuclear  leukocytes.  Thomson  emphasizes  leukocytic  variation 
at  different  times  of  day,  correlating  these  with  the  stage  of  development 
of  the  parasites  ;  he  also  found  that  the  more  numerous  the  parasites,  the 
greater  the  leukopenia,  whereas  a  small  number  on  sporulating  cause  a 
leukocytosis.  The  hemoglobin  is  reduced  and  granules  of  pigment  are 
found  in  the  plasma. 

Clinical  Varieties. — Besides  the  typical  attacks,  mild  or  rudimentary 
forms  are  met  witii,  these  either  being  due  to  slight  infection  or  appear- 
ing as  the  remnant  of  cases  of  usual  severity  after  active  treatment.  The 
separate  stages  of  the  febrile  attacks  are  not  well  marked,  and  one  or  more 
may  be  missing ;   thus  the  chill  may  be  absent  (dumb  ague). 


MALARIAL  FEVER.  351 

In  children  there  is  no  rigor  noticcctblc.  "^I^licy  grow  pale,  tlie  mucous 
membranes  often  being  slightly  livid  during  the  chill,  and  the  paroxysmn 
may  be  initiated  by  a  convulsion  or  other  nervous  phenomena.  Acute 
nephritis  is  a  ratlier  fref|uent  sequel  in  white  children. 

(II,)  Pernicious  Malarial  Intermittent. — This  truly  serious  form 
occurs  chiefly  in  highly  malarial  districts,  and  rarely  also  in  the  wide- 
spread regions  in  which  the  simple  variety  prevails.  In  the  United 
States  it  is  encountered  most  frequently  in  the  Southern  and  Southwest- 
ern States.  In  this  form  of  malaria  the  parasites  of  estivo-autumnal 
fever  are  constantly  associated.  The  paroxysms  do  not  recur  with  strict 
regularity,  and  the  primary  paroxysms  are  rarely  pernicious  in  character. 

Pathology. — This  type  of  malaria  may  arise  (1)  as  a  fresh  infection, 
and  (2)  as  a  reinfection. 

(1)  Infection. — The  blood  is  more  or  less  hydremic,  and  the  blood- 
disks  are  in  all  stages  of  disintegration.  The  spleen  is  considerably 
swollen,  soft,  and  its  parenchyma  is  turbid  and  lake-colored,  all  its  tissue 
elements  being  more  than  naturally  pigmented.  Upon  microscopic  ex- 
amination pigment-granules  and  red  corpuscles  containing  parasites  and 
phagocytes  are  observed,  particularly  in  the  pulp  adjacent  to  the  arte- 
rioles. The  liver  is  enlarged,  soft,  and  turbid,  and  pigmentation  occurs, 
but  it  is  also  microscopic.  In  the  minute  vessels  phagocytes  and  para- 
sites containing  pigment  are  perceptible  within  the  red  corpuscles,  and 
numerous  small  necrotic  areas  have  been  observed.  The  kidneys  show 
microscopic  pigmentation,  most  marked  in  the  vicinity  of  its  blood-sup- 
ply. Minute  areas  of  cell-death  are  sometimes  seen.  The  brain  may 
be  abnormally  colored,  assuming  in  severe  cases  a  chocolate  tint,  and 
in  mild  types  a  lighter  hue.  The  brain-tissue  is  often  anemic,  and 
more  rarely  edematous.  Occasionally  there  is  congestion.  The  capilla- 
ries are  literally  blocked  with  phagocytes  and  blood-disks  more  or  less 
disintegrated  (containing  parasites),  and  perivascular  infiltration  and 
minute  hemorrhages  may  rarely  occur,  producing  a  focal  lesion. 

(2)  Reinfection. — The  blood  is  often  extremely  hydremic.  The  spleen 
may  or  may  not  be  much  enlarged,  and  is  usually  quite  firm,  with  a 
well-marked  pigmentation  that  is  obvious  to  the  naked  eye.  The  liver 
is,  as  a  rule,  moderately  increased  in  size,  and  is  somewhat  indurated, 
while  macroscopically  it  is  seen  to  be  deeply  pigmented.  The  changes 
presented  by  the  kidneys  diifer  in  no  essential  manner  from  those  of  the 
liver.  The  microscopic  appearances  of  the  liver,  spleen,  and  kidneys, 
apart  from  the  fact  that  the  amount  of  pigment  present  is  relatively 
greater,  are  entirely  analogous  to  those  met  with  when  a  fresh  infection 
occurs.     Pigmentation  of  the  lung  is  also  common. 

Clinical  Varieties. — Three  varieties  merit  description  : 
(a)  Congestive  Chills  (Algid  Form). — These  are  accompanied  by 
raging  gastro-intestinal  symptoms  (vomiting,  purging,  etc.),  inducing 
systemic  collapse,  which  simulates  to  a  nicety  the  algid  stage  of  cholera. 
The  temperature  of  the  interior  of  the  body  is  much  elevated.  True 
dysenteric  symptoms  may  arise,  and  sometimes  jaundice,  followed  by 
grave  nervous  symptoms,  may  be  a  secondary  development.  The  intel- 
lect is  unclouded,  as  a  rule.  This  condition  is  to  be  discriminated  from 
yellow  fever,  with  which  it  has  frequently  been  confounded.  The  para- 
sites in  this  affection  center  in  a  special  manner  in  the  gastro-intestinal 


352  A^'I^IAL  parasitic  diseases. 

mucosa,  in  the  vessels  of  ■which  they  may  be  seen  in  unusual  numbers, 
sometimee  forming  distinct  thrombi.  In  the  United  States  this  is  the 
most  common  among  the  pernicious  forms. 

(b)  Hemorrhagic  Peryiicinus  Malarvt. — In  this  form  the  chill  is  severe 
and  prolonged,  and  during  the  hot  stage  the  urine  is  bloody  and  scanty, 
containing  considerable  albumin,  with  bloody,  epithelial  and  granular 
casts.  Hemorrhages  from  other  outlets  of  the  body  (mouth,  rectum, 
vagina,  nares,  stomach)  may  also  occur,  together  with  larger  and  smaller 
cutaneous  ecchymoses,  and  the  yellowish-brown  malarial  complexion  is 
intensified.  The  mind  may  renuiin  clear,  although  the  patient  is  restless 
and  anxious.  Urinary  suppression  may  ensue,  and  uremic  toxemia  be 
superadded ;  the  greatest  dangers  being  cardiac  failure,  uremia,  and  de- 
lirium (or  coma  independently  of  the  latter).  Death  is  rarely  the  direct 
consciiuence  of  hemorrhage.  Brem  believes  this  form  to  be  due  to  an 
hemolysin  produced  by  the  malarial  parasite. 

((?)  Comatose  Form. — The  chill  may  be  absent.  Grave  cerebral 
symptoms,  as  acute  delirium  or  sudden  coma,  seize  the  patient  violently. 
The  hot  stage  is  attended  with  high  fever,  and  if  the  patient  survives  the 
paroxysm,  the  violent  nervous  symptoms  either  disappear  suddenly  with 
the  appearance  of  the  sweating  stage,  or  may  outlast  the  latter  by  several 
hours.  Primary  paroxysms  rarely  prove  fatal,  but  recurrences  bring  im- 
minent danger.  This  variety  is  due  to  an  inordinate  localization  of  the 
malarial  parasites  in  the  brain,  where  they  form  complete  thrombi,  and 
induce  pathologic  lesions  in  the  adjacent  structures. 

(III.)  Remittent  or  Continued  Malarial  Fevers  (Kstivo- 
antuninal  Fever). — On  account  of  the  intensity  of  the  gastro-intes- 
tinal  symptoms  this  variety  is  also  termed  bilious  remittent  fever.  Its 
severity  exceeds  that  of  intermittent  malarial  fever.  It  prevails  for  the 
great  part  in  warm  and  truly  tropical  climates,  though  it  is  also  seen  in 
its  milder  forms  in  temperate  climates.  The  estivo-autumnal  parasites 
previously  described  are  the  specific  cause  of  the  disease. 

Pathology. — Melanosis  of  the  spleen,  liver,  and  brain  is  generally 
observed;  on  the  other  hand,  in  rare  instances  in  which  the  specific 
parasite  had  even  been  demonstrated  during  life,  the  internal  organs 
were  found  to  be  non-pigmented  on  autopsy.  The  degree  of  th«  pig- 
mentation depends  upon  the  length  of  time  that  the  patient  has  been 
infected,  as  well  as  upon  the  frequency  of  reinfection.  The  spleen,  if 
it  be  a  fresh  infection,  becomes  swollen,  but  is  soft ;  in  protracted  cases 
it  becomes  permanently  enlarged  and  firm.  Microscopically  the  pigment 
is  seen  to  be  most  abundant  in  the  splenic  pulp  and  within  and  around 
the  splenic  veins.  The  liver  is  enlarged  in  like  manner.  The  pigment 
that  is  found  in  the  form  of  granular  masses  in  all  tiie  hepatic  tissue- 
elements  (especially  Kupffer's  cells,  vessels,  vessel-walls,  and  perivascular 
tissue)  gives  to  the  organ  a  bronzed  appearance  ("  bronze  liver"). 

As  in  pernicious  malaria,  so  in  this  affection,  the  brain,  and  particu- 
larly the  gray  matter,  is  in  long-standing  cases  of  a  dark  brown  or  almost 
black  color.  The  arterioles  are  often  found  stuffed  with  phagocytes  and 
blood-disks  which  contain  pigmented  parasites.  Punctate  hemorrhages 
may  occur  in  the  brain.  The  kidneys  are  pigmented  and  may  show  "  a 
severe  acute  degeneration  of  the  cortical  tubule  cells  "  (Ewing).  Mass- 
ing of  the  parasites  in  the  renal  capillaries  may  occur.  Other  organs 
and  tissues  of  the  body,  including  the  lymphatic  glands  and  the  skin, 


MALAUrAL  FEVER.  353 

become  more  or  less  deeply  pigmented.  The  hlood  sliows  mai-ketl  hydre- 
mia, Avith  partly  or  wholly  degenerated  red  blood-disks  in  abundance. 

Symptoms. — There  may  be  prodromal  symptoms,  such  as  headache, 
anorexia,  and  epigastric  oppression,  lasting  a  day  or  two,  but  these  signs 
are  variable.  There  may  be  daily  or  bi-daily  paroxysms  of  fever  which 
resemble  the  ordinary  quotidian  and  tertian  intermittent  forms,  with  this 
difference,  however,  that  the  febrile  paroxysms  are  of  longer  duration 
(twenty  hours  or  more).  Both  the  rise  at  the  onset  and  the  decline  at 
the  end  of  the  paroxysm  are  more  gradual  than  in  true  intermittent 
malarial  fever,  and  the  initial  chill  may  even  be  wholly  absent.  The 
febrile  attacks  are  often  "anticipating,"  the  succeeding  paroxysm  be- 
ginning before  the  elevated  temperature  of  the  preceding  touches  the 
normal  level,  giving  rise  to  a  remittent  type  of  fever  which  often  exhibits 
considerable  irregularity.  The  remissions  may  become  shorter,  producing 
finally  a  continued  type  of  curve — continued  malarial  fever. 

In  typical  cases  of  remittent  fever  a  chill  generally  occurs  at  the  on- 
set, but  is  less  severe  than  in  malarial  intermittents.  Shortly  after  the 
chill  the  temperature  rises  rapidly,  so  that  in  ten  or  twelve  hours  it  may 
reach  104°  or  105°  F.  (40.5°  C).  The  pulse  is  full  and  accelerated  to 
100  or  120,  and  there  is  rending  headache.  Nausea  and  vomiting  are 
common ;  oppression  in  the  epigastrium  is  intense,  and  there  is  well- 
marked  tenderness  in  the  latter  region.  The  spleen  is  found  to  be  en- 
larged on  palpation.  Nervous  symptoms  (delirium,  coma,  etc.)  may 
develop  speedily,  and  rarely  a  mild  bronchitis  may  also  arise. 

About  midnight  the  remission  in  the  temperature  and  sweating 
begin,  in  consequence  of  which  the  headache  and  gastric  symptoms 
largely  disappear.  The  temperature  usually  drops  to  100°  F.  (37.7° 
C)  by  the  next  morning,  to  be  followed  by  a  new  exacerbation  of  fever, 
which  commences  about  noon  of  the  second  day.  The  same  symptoms 
now  repeat  themselves.  The  affection  has  usually,  by  this  time,  reached 
its  acme,  and  the  temperature  may  have  risen  to  106°  F.  (41.1°  C). 
Grave  nervous  symptoms  may  also  have  appeared.  The  urine  is  dimin- 
ished in  amount,  often  slightly  albuminous,  and  acute  nephritis  is  ob- 
served in  4.7  per  cent,  of  the  cases  (Thayer) ;  while  either  a  slight  or 
marked  hepatogenous  jaundice  may  appear.  Urriola^  states  that  the 
presence  of  malarial  pigment  in  the  urine  is  a  pathognomonic  sign.  A. 
C.  Smith  ^  reports  instances  of  bubo  (inguinal)  as  a  complication.  Herpes 
lahialis  is  quite  common.  The  nocturnal  remission  again  ensues,  and  in 
the  mild  types  or  in  those  brought  promptly  under  suitable  treatment  the 
febrile  paroxysms  grow  briefer,  resulting  in  an  intermittent  form  of  fever. 
The  course  of  light  cases  is  run,  usually,  within  two  weeks. 

In  severe  types  or  in  neglected  cases  the  separate  febrile  paroxysms 
grow  longer  until  the  remissions  become  slight  and  simulate  continued 
fevers.  These  are  the  cases  that  are  distinguished  by  the  same  symp- 
toms as  those  that  mark  typhoid  fever,  save  only  the  eruption  and  the 
Widal  reaction.  The  course  of  the  attack,  if  not  properly  treated,  pro- 
longs itself  to  three,  four,  or  more  weeks,  and  the  salient  features  of 
pernicious  intermittent  may  suddenly  appear  and  the  disease  mav  ter- 
minate life.  On  the  other  hand,  mild  forms  of  the  continued  type  also 
occur,  and  these  yield  promptly  to  the  specific — quinin. 

1  Interstate  Med.  Jour.,  Jan.,  1912.  ^ New  York  Med.  Jour.,  June  22,  1901. 

23 


35-4  ANIMAL  PARASITIC  DISEASES. 

(IV.)  Malarial  Cachexia. — This  is  an  exceedingly  chronic  condi- 
tion, and  is  usually  a  remnant  of  one  of  the  acute  forms.  AVhen  the 
latter  are  not  properly  treated,  they  are  apt  to  drag  on,  and  assume  the 
characteristic  features  of  chronic  malarial  cachexia.  The  condition  may, 
however,  be  chronic  from  the  start  in  truly  malarial  localities. 

The  symptoms  are  varied  both  in  character  and  in  intensity.  There 
is  fever  at  intervals,  but  chills  do  not  occur,  and  the  temperature-curve  is 
typical  neither  of  remittent  nor  intermittent  fever,  although  it  may  approx- 
imate either  the  one  or  the  other.  Again,  the  fever  is  sometimes  wholly 
irregular,  though  its  range  is  not  high,  and  it  seldom  exceeds  103°  F. 
(39.4°  C).  The  skin  often  presents  the  dirty  yellowish-brown  com- 
plexion to  a  marked  degree.  The  spleen  is  enormously  enlarged  and 
indurated,  and  hypertrophy  with  hardening  of  the  liver  may  also  be 
pronounced.  The  blood  is  profoundly  anemic,  the  count  in  one  of  my 
cases  showing  but  1,300,000  red  corpuscles  per  cubic  millimeter. 

Many  of  the  local  and  general  symptoms  are  dependent  upon  the  well- 
marked  anemia.  Among  general  features  may  be  mentioned  debility, 
frequent  sweatings,  and  dropsy.  Nervous  symptoms  may  also  be  notice- 
able, and  chief  among  these  are  tremors,  neuralgia,  palsies,  vertigo, 
wakefulness,  and  nervous  palpitation  of  the  heart.  Among  the  rarest 
concomitants  of  this  condition  is  paraplegia.  Malarial  neuntis  is  met 
with  and  presents  most  of  the  features  common  to  other  toxic  forms  of 
neuritis.  Slight  cough  and  dyspnea  evidence  the  presence  of  mild  hro7i- 
chitis ;  and  anorexia,  nausea,  diarrhea,  and  other  symptoms  of  chronic 
gastro-intestinal  catarrh  are  observed.  The  joints  and  voluntary  mus- 
cles may  be  painful.  Hemorrhages  from  the  various  mucous  surfaces 
and  into  the  retina  are  common  ;  and  I  have  seen  one  case  in  which 
spongy,  bleeding  gums,  with  numerous  petechias,  pointed  to  the  existence 
of  associated  scorbutus.  Tuberculosis  finally  developed  and  carried  ofiF 
the  patient.  Chronic  dysentery,  fatty  degeneration  of  the  heart,  and 
chronic  nephritis  may  develop  and  prove  serious  sequelae.  These  cases 
do  well,  generally,  if  the  patient  can  be  removed  permanently  from  the 
malarial  district.  In  long-standing  cases  the  spleen  does  not  return  to  its 
natural  dimensions.      Complete  recovery,  however,  may  be  expected. 

(V.)  Masked  Intermittent. — This  presents  itself  in  much  the  same 
forms  as  chronic  malarial  cachexia,  but  with  the  important  diflference  that 
there  is  no  fever.  This  type  comprises  a  long  list  of  conditions,  at  the 
head  of  Avhich  stands  neuralgia,  most  frequently  involving  the  supraor- 
bital branch  of  the  trigeminus.  Often  a  striking  periodicity  is  observed, 
the  painful  paroxysms  usually  beginning  in  the  morning  and  terminating 
in  the  late  afternoon  hours,  the  patient's  sufferings  increasing  steadily 
in  intensity  until  just  before  the  close  of  the  attack,  when  they  sud- 
denly abate.  Among  other  nerves  implicated  with  relative  frequency 
are  the  occipital,  the  intercostal,  and  the  sciatic.  Except  the  blood- 
appearances  be  characteristic  or  unless  the  attacks  yield  promptly  to 
quinin,  a  certain  diagnosis  of  malarial  neuralgia  should  not  be  ventured. 
Craig,'^  out  of  395  cases  of  latent  and  masked  malaria,  found  the  estivo- 
autumnal  parasite  in  275 ;  they  appeared  as  a  small  hyaline  disc  or  ring- 
form  within  the  red  blood-corpuscle.  The  parasites,  however,  have  been 
observed  in  all  stages  of  growth,  even  undergoing  segmentation.  Craig 
»  Amer.  Med.,  Oct.  29,  1904. 


MALARIAL  FEVER.  355 

believes  that  the  latency  can  be  accounted  for  by  the  fact  that  the  few 
organisms  present  do  not  generate  sufficient  toxin  to  provoke  character- 
istic symptoms.  Masked  intermittents  may  assume  the  forms  of  pares- 
thesia, anesthesia,  convulsions,  or  paralysis;  tliey  may  also  appear  under 
the  guise  of  edema,  hcmorrliages  from  the  various  mucous  outlets  of  the 
body  or  into  the  skin,  diarrhea,  dysentery,  dyspepsia,  bronchitis,  pneu- 
monia, appendicitis,  etc.  But,  since  these  affections  may  all  obey  th(; 
law  of  periodicity,  we  should  not  pronounce  in  favor  of  malarial  infection 
unless  they  yield  readily  to  the  therapeutic  specific,  or  the  parasite  is  found. 

(VI.)  Malarial  Hematuria  and  Hemoglobinuria. — I  have  pre- 
viously described  a  hemorrhagic  form  of  pernicious  intermittent  in  many 
cases  of  which  hematuria  is  a  prominent  symptom.  Boisson,^  in  3  cases 
of  hemoglobinuric  fever,  occurring  in  soldiers  attacked  with  malaria  in 
Madagascar,  found  great  reduction  in  the  erythrocytes,  while  7  out  of 
10  red  cells  contained  parasites.  I  have  observed  several  instances  of 
malarial  hematuria  in  the  Kensington  district  of  Philadelphia,  where  the 
milder  forms  of  malaria  prevail.  Hematuria  in  its  severest  form  is  seen 
with  the  approach  of  cold  weather  (Jones).  It  is  rare  in  the  negro. 
Young  in  both  sexes  and  males  over  puberty  are  .most  apt  to  suffer.  The 
blood  shows  pigmented  parasites  (forming  rosettes),  and  sometimes  cres- 
cents and  pigmented  leukocytes. 

The  symptoms  consist  of  a  mild  cold  stage,  a  subfebrile  temperature 
to  which  is  added  hematuria,  or  more  often  hemoglobinuria.  The  par- 
oxysms may  recur  daily,  bi-daily,  or  at  longer  intervals,  and  in  severe 
forms  the  hemoglobinuria  may  be  continuous,  with  aggravations  at 
definite  intervals.  Suppression  of  urine  may  appear  early,  accompanied 
by  ui-emic  features,  e.  g.,  coma,  nausea,  vomiting,  diarrhea.  The  lumen 
of  the  renal  tubules  may  be  occluded  by  plugs  of  granular  material  de- 
rived from  the  hemoglobin.  The  diagnosis  demands  the  demonstration 
of  the  malarial  parasites  in  the  blood,  and  of  the  hemoglobin  in  the  urine. 
Tyson  recommends  Teichmann's  (hemin  crystals)  test  to  show  the  pres- 
ence of  hemoglobin.  The  earthy  phosphates  are  precipitated,  filtered 
out,  and  a  small  portion  placed  on  a  glass  slide  and  carefully  dried.  A 
minute  granule  of  common  salt  is  carried  on  the  point  of  a  knife  to  the 
dried  mass  and  thoroughly  mixed  with  it.  Any  excess  of  salt  is  then  re- 
moved, the  mixture  is  covered  with  a  thin  glass  cover,  a  hair  interposed, 
and  a  drop  or  two  of  glacial  acetic  acid  allowed  to  pass  under.  The  slide 
is  then  carefully  warmed  until  bubbles  begin  to  make  their  appearance. 
After  cooling,  hemin  crystals  can  be  seen  by  the  aid  of  the  microscope, 
and  are  easily  recognizable  by  an  amplification  of  800  diameters.  Chemi- 
cally they  are  hydrochlorate  of  hematin. 

The  so-called  blackwater  fever  is  an  intoxication  due  to  repeated  at- 
tacks of  malaria,  in  which  "  some  exciting  cause  produces  a  sudden 
hemolysis  "  (Prout),  and  quick  spontaneous  disappearance  of  the  malarial 
parasites  (Plehn).  Other  observers  (Sambon,  Macay)  regard  hemoglobin- 
uria as  a  specific  disease.  Bass  and  Johns  found  that  calcium  salts  added 
to  culture-mediums  caused  hemolysis  of  the  infected  as  well  as  the  non- 
infected  cells  of  the  blood  of  the  sufferer.  The  leading-  characteristics 
are  irregular  paroxysms  of  fever  wuth  rigor,  bilious  vomiting,  jaundice, 
hemoglobinuria,  and  nephritis.  This  form  occurs  in  the  Philippines,  in 
Germany,  and  other  countries. 

1  Rev.  de  Med.,  May  10,  1896. 


356  ANHfAL  PARASITIC  DISEASES. 

According  to  Frank  A.  Jones,  obesity  occurs  among  persons  coming 
from  a  climate  free  from  malaria  to  the  Mississippi's  delta.  They  neither 
have  chills  nor  manifestations  of  chronic  malaria.  ''  The  obesity  sub- 
sides rapiilly  by  changing  from  a  malarious  to  a  non-malarious  climate." 

Complications. — The  author's  analysis  of  178U  cases  of  malaria 
(intermittents  and  remittents)  showed  complications  in  about  10  per  cent. 
The  more  common  among  these  were:  Enteritis  (16),  nephritis  (14), 
rheumatism  (10),  typhoid  fever  (S),  lobar  pneumonia  (5),  jaundice  (5), 
and  dysentery  (4).  The  opinion  of  the  ])r()fession  is  divided  upon  the 
question:  "lias  pneumonia  any  special  connection  with  malaria?" 
According  to  the  results  of  my  collective  investigations,  pneumonia  is 
rarely  associated.  Craig  affirms  that  malaria  may  present  typical  symp- 
toms of  pneumonia,  prol)ably  owing  to  a  localization  of  the  malarial  para- 
site in  the  capillaries  of  the  lungs.  Thayer's  studies  show  that  the  fre- 
quency of  albuminuria  and  nephritis  in  malarial  fever  is  somewhat  below 
that  observed  in  the  more  severe  acute  infections. 

Typhoid  fever  is  a  complication  of  malaria,  according  to  these  re- 
searches, but  the  relationship  between  these  afiections  cannot  be  close. 

Diagnosis. — (1)  Of  Intermittents. — This  is  difficult,  unless  the  brief 
febrile  paroxysms,  with  their  characteristic  stages  and  other  diagnostic 
features  (enlarged  spleen,  malarial  complexion,  herpes),  together  with 
the  rigid  periodicity  of  the  paroxysms,  be  present.  Eesidence  in  a  mala- 
rial district  is  confirmatory.  The  only  unquestionable  method  of  diag- 
nosis is  provided  by  a  microscopic  examination  of  the  fresh  blood.  If 
this  cannot  be  made  an  early  diagnosis  is  rarely  possible  until  the  peculiar 
manner  of  recurrence  of  the  paroxysms  is  established. 

Differential  Diagnosis. — Xon-malarial  affections,  exhibiting  an  inter- 
mittent form  of  fever,  are  often  mistaken  for  malarial  intermittents.  Of 
these,  (a)  pyeviia  is  very  apt  to  be  thus  confounded.  It  will  be  observed, 
however,  that  the  chills  occur  at  more  irregular  intervals,  and  that  pros- 
tration is  more  profoun<l  during  the  intervals  between  the  febrile  ex- 
acerbations. The  etiologic  factors  and  place  of  resirlence  are  also  to  be 
considered.  The  blood  should  be  examined  microscopically,  and,  if 
this  be  impossible,  the  therapeutic  test  will,  as  a  rule,  remove  any  doubt. 
Leukocytosis  is  common  in  pyemia  and  absent  in  malaria. 

(6)  Acute  tuberculosis  and,  more  rarely,  incipient  chronic  tuberculosis 
may  present  a  febrile  movement  in  no  way  differing  from  quotidian 
intermittent,  except  that  in  the  former  the  pyrexia  develops  in  the  after- 
noon instead  of  the  forenoon,  as  in  the  latter.  A  clear  history,  the 
associated  local  and  general  symptoms,  along  with  the  results  of  a  care- 
ful physical  examination,  usually  render  tuberculosis  probable  and  dis- 
tinguish it  from  malarial  intermittents.  In  tuberculosis  the  chills  recur 
despite  the  use  of  quinin,  and  this  is  not  the  case  in  malaria. 

(c)  Ulcerative  endocarditis  may  exhibit  an  intermittent  pyrexia,  but 
the  history  is  different,  and  the  associated  features  are  more  numerous 
and  decidedly  more  grave.  A  blood-examination  reveals  leukocytosis — 
a  distinguishing  feature.  Again,  (|uinin  is  without  effect.  The  irregular 
forms  of  intermittents  are  difficult  in  the  extreme  to  diagnosticate.  If, 
in  suspected  cases  of  "erratic"  malaria,  quinin  is  resisted,  we  cannot 
feel  certain  of  our  diagnosis  unless  we  obtain  the  microscopic  evidence 
of  the  presence  of  the  malarial  parasite  in  the  blood. 


MALARfAL   FEVER.  'Z'il 

(2)  The  diagnosis  of  remittent  fever  would  be  eawily  made  if  it  did  not 
sometimes  bear  a  strong  resemblance  to  typhoid  fever.  Its  certain 
recognition  demands  the  detection  in  the  blood  of  the  estivo-antuninal 
parasite.  In  typhoid  fever  the  history  points  to  a  more  gradual  onset, 
the  remissions  are  less  marked,  and  epigastric  opj)ression  is  wanting. 
Again,  typhoid  has  its  characteristic  eruption  and  gives  the  sero-reaction. 
(For  diagnosis  from  hepatic  abscess,  vide  p.  926)  Chronic  malaria  must 
be  differentiated  from  chronic  biliousness  or  enter o genie  intoxication. 

Method  of  Examining  the  Blood  for  the  Malarial  Parasite. — ']'he 
finger  or  lobe  of  the  ear  is  carefully  cleansed,  and  then  slightly  cut 
with  a  sharp  lancet.  The  first  drop  of  blood  is  wiped  away  and  the 
second  collected  on  the  center  of  a  clean  cover-glass,  which  is  imme- 
diately placed  upon  a  clean  slide  and  the  blood  allowed  to  spread  in  a 
thin  film,  and  examined  immediately  through  an  oil-immersion  objec- 
tive. It  is  all-important  that  the  blood  be  perfectly  spread  between  the 
surfaces  of  the  slide  and  cover-glass,  in  order  that  the  corpuscles  do  not 
rest  one  against  the  other.  In  the  fresh  specimen  one  is  able  to  detect 
the  parasite  during  all  its  developmental  stages  seen  in  man,  but  the  best 
time  is  either  just  before  or  during  the  chill.  If  the  blood  of  estivo- 
autumnal  fever  be  exposed  to  the  air  a  short  time  and  then  mounted 
in  this  manner,  it  is  likely  to  display  flagella.  If  desirable  to 
preserve  the  specimen  or  if  impossible  to  make  the  microscopic  ex- 
amination at  once,  smears  should  be  prepared  by  laying  another 
cover  upon  the  first,  allowing  the  blood  to  spread  in  a  thin  layer,  and 
then  sliding  them  apart  quickly  and  drying  in  the  air.  If  permanent 
specimens  are  desired,  Wright's  modification  of  Romonowski's  stain  is  to 
be  preferred.  The  specimen  should  be  covered  with  the  solution  and 
allowed  to  stand  two  minutes.  To  stain,  add  3  or  4  drops  of  distilled 
water  and  allow  to  remain  two  or  more  minutes,  when  the  specimen  is 
washed  with  water,  dried,  and  mounted  in  Canada  balsam.  The  organ- 
isms appear  as  small  blue  bodies,  often  containing  pigment.  For  the 
crescent  and  oval  forms,  often  diflScult  to  find,  it  may  be  advantageous 
to  allow  a  drop  of  blood  to  dry  upon  the  cover-glass  without  spreading, 
fix,  and  then  wash  with  dilute  acetic  acid  ;  wash  thoroughly  with  water 
and  stain  as  before.  The  hemoglobin  of  the  red  cells  is  dissolved,  and 
only  the  white  cells  and  the  parasites  remain  visible. 

Prognosis. — Uncomplicated  cases  of  intermittent  fever  under  proper 
treatment  generally  recover.  In  certain  malarious  regions  and  seasons 
pernicious  types  are  prevalent.  Primary  'pernicious  attacks  are  moder- 
ately dangerous,  while  recurrences  are  highly  so.  The  mortality-rate  in 
this  variety  is  between  20  and  25  per  cent.  In  remittent]  fever  death 
inay  be  due  to  asthenia,  particularly  when  the  type  is  severe  and  when 
wrong  notions  as  to  treatment  prevail.  Suppression  of  urine,  followed 
by  uremic  symptoms,  hemorrhages,  and  intense  jaundice  are  grave  com- 
plications. 

Treatment. — Prophylaxis. — The  investigations  cited  above  show- 
that  an  individual  ill  of  malaria  is  a  source  of  danger  in  a  community, 
and  should  be  promptly  protected  from  mosquitoes,  and  then  treated. 
The  homes,  and  more  particularly  the  sleeping-apartments,  of  persons 
residing  in  paludal  regions,  should  be  protected  against  invasion  by 
mosquitoes.  The  use  of  wire  netting  is  to  be  advised  for  this  pur- 
pose.    Caps  to  which  the  same  material  is  attached  may  be  worn  out 


358  ANIMAL  PARASITIC  DISEASES. 

of  doors.  Methods  for  destroying  the  mosquito  (adult  female  and  larvfe) 
should  be  adopted.  In  rooms  this  is  best  accomplished  by  fumigation  ; 
in  the  outer  world  the  breeding-places  (e.  q.,  marshes)  must  be  found 
and  then  removed  by  thorough  drainage  and  covering  water-barrels 
and  privies.  The  larv:\i  are  most  effectually  suffocated  by  sprinkling 
petroleum  upon  the  water,  to  the  surface  of  which  they  rise  to  get  air. 

Koch  states  that  gametes  are  often  found  in  children  and  that  many 
persons  harbor  the  parasite  Avithout  manifesting  active  symptoms  ;  he 
advises  prophylactic  doses  of  quinine  in  malarial  localities. 

1.  For  intermittent  malarial  fever  there  is  an  almost  infallible  remedy 
in  quinin.  "  ^Vllen  shall  its  use  be  commenced  ?  "  is  a  pertinent  question. 
It  would  certainly  seem  highly  desirable  to  check  the  course  of  the 
disease  as  soon  as  possible,  and  especially  since  transmission  of  the  sim- 
ple intermittents  into  the  pernicious  forms  may  occur  if  the  disease  be 
not  arrested.  At  the  present  day  specific  treatment  is  often  delayed  in 
order  to  give  full  opportunity  for  making  a  blood-examination  with  a 
view  to  completing  the  diagnosis.  There  is  no  decided  advantage  in 
commencing  the  use  of  quinin  during  the  first  paroxysm,  when  the  blood 
may  be  examined ;  but  on  finding  the  case  to  be  one  of  malaria,  quinin 
should  be  administered  after  the  paroxysm,  so  as  to  prevent  a  recurrence. 
For  like  reason,  if  the  history  at  the  physician's  first  visit,  combined  with 
the  symptoms  presented,  make  the  diagnosis  of  intermittent  malaria 
reasonably  certain,  and  there  is  no  opportunity  to  examine  the  blood 
microscopically,  the  principal  antiperiodic  remedy  should  be  commenced 
at  the  close  of  the  paroxysm.  The  quinin  cures  malaria  by  acting  directly 
upon  the  intracorpuscular  hematozoa  (the  young  forms). 

During  the  paroxysm  we  should  aim  to  make  the  patient  comfortable. 
He  is  to  remain  in  bed,  is  to  be  well  covered,  and  external  heat  applied 
during  the  cold  stage  ;  and  he  is  to  be  lightly  covered,  given  cooling 
drinks  and  cold  spongings  during  the  hot  stage. 

During  the  apyrexial  intervals  the  patient  may  leave  his  bed,  pro- 
vided that  he  feel  strong  enough,  and,  as  before  intimated,  the  specific 
remedy  is  given  during  the  afebrile  period.  Certain  authors  recommend 
that  the  entire  daily  quanitity  be  given  at  one  dose  from  four  to  six  hours 
before  the  succeeding  paroxysm  is  expected,  the  object  being  to  surcharge 
the  blood  at  the  time  when  the  hematozoa  sporulate.  The  total  amount 
per  day  required  to  destroy  both  the  asexual  and  sexual  parasites  is  from  16 
to  20  grains  (1.030  to  1.296)  for  a  period  of  three  weeks,  in  most  temperate 
climates.  When  this  fails,  more  may  be  given — 24  to  30  grains  (1.555- 
1.944).  My  own  practice  has  been  to  administer  immediately  after  the 
close  of  the  sweating  stage  gr.  iv  or  v  (0.259  or  0.324),  repeating  the 
same  dose  a  few  hours  later,  and  the  remaining  8  or  10  grains  (0.518  or 
0.648)  (or  one-half  the  daily  dose)  six  hours  before  the  time  for  the  next 
paroxysm.  I  have  thus  escaped  the  slight  toxic  symptoms  (tinnitus, 
deafness,  nausea,  etc.)  which  are  apt  to  follow  single  large  doses.  The 
remedy  should  be  administered  in  the  form  of  the  hydrochloride,  in  cap- 
sules. After  the  attacks  cease  to  recur  quinin  should  be  continued  in 
amounts  of  6  to  8  grains  (0.388  to  0.518)  daily  for  several  days.  If 
quinin  cannot  be  taken  per  os  it  may  be  tried  l)y  enema  or  by  supposi- 
tories in  appropriately  large  doses.  In  young  subjects  I  administer  the 
quinin  by  suppository. 


MALARIAL   FEVER.  359 

The  physiolo^i^ic  effects  of  tlie  drug  can  be  quickly  obtained  by  admin- 
istering it  hypodermically.  Hence,  if  there  be  no  time  for  absorption 
from  the  stomach  (four  hours  being  the  shortest  period  it  is  safe  to  allow), 
the  drug  should  be  thus  employed.  For  this  purpose  the  more  soluble 
salts  (hydrobromide,  hydrochloride)  of  quinin  are  to  be  preferred  to  the 
ordinary  and  more  insoluble  sulphate. 

Many  preparations  of  cinchona  other  than  the  salts  of  quinin  may 
be  tried,  and  among  these  cinchonin  administered  in  the  same  manner 
as  the  latter  is  the  best  substitute.  Some  contend  that  the  sulphate  of 
quinidin  has  antiperiodic  power,  almost  equal  to  quinin.  In  prolonged 
cases  the  salts  of  quinin  and  other  preparations  of  cinchona  sometimes 
lose  their  specific  influence,  and  arsenic  is  then  to  be  employed,  either 
alone  or  in  combination  with  the  former  agents.  The  dose  of  the 
arsenic,  beginning  with  IfTLiv  (0.266)  t.  i.  d.  of  Fowler's  solution,  must 
be  increased  until  its  physiologic  effects  are  produced.  Arsenious  acid 
often  does  even  better  service  than  Fowler's  solution.  Administered  as 
above  indicated,  this  remedy  is  most  efficacious  in  malarial  cachexia  and 
masked  forms  of  intermittents ;  it  may  be  combined  with  iron  and 
quinin.  Atoxyl,  either  alone  or  associated  with  quinin,  is  capable  of 
bringing  about  rapid  improvement  in  health,  especially  in  cachexia  and 
chronic  forms  of  malaria.  In  cases  of  malaria  that  are  resistant  to  quinin 
(often  the  quotidian  forms),  methylene-blue  has  been  found  extremely 
active  and  serviceable.  Cardamates  believes  that  it  is  indicated  only 
when  quinin  is  contraindicated,  as  in  hemoglobinuria  or  in  pregnancy, 
when  abortion  is  feared.  It  attacks  the  adult  forms  of  the  parasite. 
Werner  recommends  salvarsan  (0.6  to  0.7  gram)  in  cases  in  which  the 
parasite  is  resistant  to  quinin.  While  in  charge  of  the  out-patient  ser- 
vice of  the  Episcopal  Hospital,  Philadelphia,  I  employed  in  chronic  ma- 
larial cachexia,  with  very  satisfactory  results,  the  sulphate  of  cinchonidin 
in  daily  doses  of  gr.  xxx-xl  (1.944^2.592).  In  this  class  of  cases  War- 
burg's tincture  §ss  (16.0),  three  times  a  day,  has  been  warmly  recom- 
mended. Splenectomy  has  been  recommended  in  intractable  forms,  but 
it  is  to  be  performed  only  as  a  dernier  ressort. 

2.  The  Treatment  of  Pernicious  Intermittents. — (a)  Prophylaxu. — By 
treating  all  ordinary  intermittents  actively  after  the  first  paroxysms  the 
occurrence  of  pernicious  forms  can  be  obviated.  Not  to  pursue  this 
course  in  malarial  seasons  and  localities  is  next  to  criminal. 

(b)  The  first  pernicious  attach  must  be  treated  immediately,  and  there 
is  not  a  moment  to  be  lost.  Hence  in  all  varieties  of  pernicious  inter- 
mittents quinin  should  be  administered  hypodermically  until  the  patient 
is  fully  cinchonized — a  condition  that  must  then  be  maintained  for  sev- 
eral days.  In  all  varieties  stimulants  are  to  be  used  freely  if  the  heart's 
action  becomes  feeble,  and  the  patient  is  to  be  well  nourished  through- 
out. There  are  other  details,  though  of  relatively  minor  importance, 
and  they  vary  with  the  individual  forms.  Thus  in  "congestive  chills  " 
external  warmth  is  useful,  and  morphin  combined  with  atropin  should 
be  given  hypodermically,  this  combination  tending  to  allay  gastro-intes- 
tinal  symptoms  as  well  as  to  warm  the  extremities,  and  meeting  really 
important  indications.  Rectal  feeding  must  be  resorted  to  should  the 
stomach  refuse  to  retain  nourishment.  In  the  comatose  form  the  ner- 
vous symptoms  are  most  successfully  combated  by  prompt  and  energetic 


360  AXLVAL    PAJRASITIC  DISEASES. 

antiperiodic  treatment,  together  Avith   viiroroiis  stimulation  and  feeding, 
since  they  are  due  to  the  intensity  of"  the  infectious  process. 

(c)  During  the  apyrexial  period  every  effort  must  be  made  to  prevent 
a  recurrence  of  the  paroxysm,  and  to  this  end  the  patient  must  be  kept 
fully  einchonized  until  the  time  for  the  next  paroxysm  is  over. 

3.  Treatment  of  Remittent  Fever. — The  mode  of  treatment  in  this  form 
differs  somewhat  from  that  api)ropriate  for  intermittents.  At  the  onset 
a  mild  mercurial  is  advantageous  (calomel  gr.  }  (0.0162)  every  hour  for 
three  doses),  followed  by  a  saline  hixative  (Kochelle  salts,  .^ij  ;  8.0). 
During  the  febrile  exacerbations  cool  spongings  of  the  body,  coupled 
with  the  use  of  the  ice-cap,  are  serviceable.  The  gastric  symptoms 
demand  chipped  ice  by  the  mouth  or  small  doses  of  cocain,  and  a  mus- 
tard plaster  externally.  Immediately  after  the  first  remission  sets  in 
quiniu  must  be  exhibited,  and  large  doses  are  now  indicated  (^r.  xv 
(0.972),  to  be  repeated  at  8  or  9  a.  m.).  A  third  and  even  a  fourth  dose 
of  the  same  size  maj^  be  required.  The  exacerbations  of  fever  gener- 
ally yield  to  this  remedy,  but  if,  as  rarely  happens,  they  do  not,  then 
small  doses  of  pilocarpin  (gr.  -|-  to  |- ;  0.008  to  0.010)  may  be  adminis- 
tered hypodermically  during  the  height  of  the  fever.  This  causes  free 
sweating  in  many  instances,  and  in  consequence  renders  the  remission 
more  marked  and  more  prolonged;  thus,  in  short,  rendering  the  course 
of  the  affection  speedily  favorable.      The  heart  must  be  guarded. 

A  case  that  has  been  allowed  to  run  on  for  one,  two,  or  more  weeks 
is  often  greatly  benefited  by  the  use  of  Warburg's  tincture,  as  before 
recommended,  for  several  days,  when  quinin  may  be  re-employed.  The 
patient,  especially  if  the  case  be  protracted,  must  be  vigorously  fed,  and 
per  rectum  if  it  cannot  be  accomplished  by  the  mouth.  In  typical 
cases,  which  are  promptly  controlled  by  quinin,  stimulants  are  rarely 
needed,  or  at  least  not  until  the  convalescent  stage  is  arrived  at.  In 
severe  and  neglected  cases  the  indications  for  their  employment  may 
be  presented  early,  and  they  should  then  be  given,  the  physician  con- 
forming to  the  same  rules  as  in  typhoid  and  other  acute  infectious  dis- 
eases. The  renal  congestion  and  anuria  are  to  be  met  by  internal  dia- 
phoretics (pilocarpin,  etc.)  and  by  saline  laxatives.  Most  efficacious, 
perhaps,  is  a  combined  hot-water  and  steam  bath.  The  patient  is  placed 
in  hot  water,  and  then  a  blanket  is  put  around  the  neck,  its  free  ends 
being  allowed  to  extend  over  the  edges  of  the  tub. 

4.  Treatment  of  Malarial  Hematuria. — Whether  or  not  (juinin  is  to  be 
employed  in  hemorrhagic  pernicious  malaria  is  a  (juestion  involved  in 
doubt.  The  statistics  of  M.  Brady  indicate  a  tremendous  advantage  in 
discontinuing  quinin  as  soon  as  blood  shows  in  the  urine — a  reduction 
of  mortality  from  24  to  6  per  cent.  Foicheimer  also  holds  that  if  in 
an  attack  of  black-water  fever  the  administration  of  quinin  is  followed 
by  hemoglobinuria,  the  quinin  should  be  withheld.  Under  these  cir- 
cumstances the  use  of  methylene-blue  has  given  favorable  results.  This 
remedy  is  best  administered  in  doses  of  gr.  iss-iiss  (0.097-0.162)  every 
third  hour,  and  it  should  be  continued  in  somewhat  diminished  dosage 
for  a  week  or  longer  after  the  cessation  of  fever.  Cholesterin  has  been 
found  to  arrest  paroxysmal  hemoglobinuria.  Pringsheim  advises  five  in- 
tramuscular injections  of  5  c.c.  each  of  a  10  per  cent,  emulsion  of  choles- 
terin in  eleven  days. 


DLSTOM/ASIS.  361 

DISTOMIASIS. 

( Trematodiaisis.) 

Various  forms  of  trcmatodes,  including  the  distomata,  may  become 
parasitic  in  man. 

Distoma  Hepaticum  (Liver-fluke). — Among  the  more  common  va- 
rieties of  trematodes  or  flukes,  is  the  distoma  hepaticum  or  liver-fluke, 
a  parasite  found  in  animals  (horse,  goat,  ass,  sheep,  rabbit)  and  acci- 
dentally ingested  by  man. 

It  is  almost  30  millimeters  (1.1  inches)  in  length,  and  inhabits  the 
biliary  passages  of  the  animal,  and  from  them  is  discharged  into  the 
intestinal  tract  and  evacuated  with  the  feces.  Under  certain  conditions 
of  temperature  and  moisture,  a  ciliated  embryo  escapes  from  the  egg, 
and  is  ingested  by  a  gasteropod  or  snail  {limncea  truncatula),  in  "vvhich 
it  undergoes  development  into  a  sporocyst,  that  in  turn  gives  origin  to 
radice  or  parent  nurses.  These  give  birth  to  daughter-radise  or  cerearice, 
which  leave  the  gasteropod  or  snail  and  attach  themselves  to  aquatic 
plants,  where  they  are  in  turn  eaten  by  animals. 

Symptoms. — When  present  in  sufiicient  numbers  in  the  bile-passages 
the  liver  becomes  greatly  enlarged,  with  the  occurrence  of  jaundice  and 
ascites  that  may  prove  fatal.  Other  symptoms  may  also  be  present ; 
thus  pain  was  prominent  in  41  out  of  100  cases  reported  by  Kurimato 
in  Japan,  and  heart-murmurs  were  present  in  42  of  those  cases. 

Late  in  the  disease  the  liver  may  become  nodulated  and  terminate 
in  atrophy. 

On  inspection  in  well-marked  cases,  a  peculiar  barrel-shaped  bulging 
is  sometimes  seen,  extending  over  the  hepatic  area,  with  tense  abdom- 
inal walls  over  the  enlarged  liver.  This  is  a  pathognomonic  symptom 
of  hepatic  distoma.  An  endemic  form  occurring  in  Japan  has  been  de- 
scribed ;  it  is  characterized  by  marked  emaciation,  diarrhea,  hepatic 
enlargement,  and  often  by  ascites. 

The  prognosis  of  distoma  hepaticum  is  absolutely  fatal  and  the  treat- 
ment is  merely  palliative,  though  it  may  run  a  course  extending  through 
many  years,  often  with  intermissions,  even  apparent  recovery,  later  to 
relapse. 

Among  other  trematodes  may  be  mentioned  (a)  distoma  lanceolatum 
(found  also  in  cattle) ;  (b)  distoma  crassum,  which  is  larger  in  size  than 
the  preceding ;  (c)  distoma  sihiricum  ;  {d)  distoma  pulmonale  (D.  Rin- 
geri)  ;  (e)  distoma  spatulatum  (endemieum)  ;  (/)  amphistomum  hominis  ; 
\g)  distoma  hematobium  (Bilharz).  Two  of  these  deserve  extra,  though 
brief,  mention. 

Parasitic  Hemoptysis  {Distoma  Puhnonale). — This  is  caused  by 
the  ParagonimiiS  Westermanii  first  described  by  Mansou  (1880)  and 
Baily  (1880)  in  man.  The  lung  fluke  worm  has  also  been  found  in  the 
tiger  (originally  by  Kerbert),  hog,  dog,  and  cat.  The  disease  is  ex- 
tremely prevalent  in  certain  provinces  of  Japan  and  China.  Elsewhere 
it  is  usually  mistaken  for  pulmonary  tuberculosis.  Stiles  and  Has- 
salP  have  discussed  the  whole  subject.  The  parasite  is  8  to  16  mm. 
long,  4  to  6  mm.  broad,  and  2  to  5  mm.  thick.  It  is  found  encysted. 
^  Annual  Report  vj  tlie  Bureau  of  Animal  Indusf)-y,  1899. 


362  ANIMAL  PARASITIC  DISEASES. 

usually  two  iiulividuals  in  each  cyst,  with  eggs,  and  its  habitat  is  the 
lungs  of  mammals.  It  enters  its  final  host  (man,  etc.)  either  encysted 
or  as  a  free-swimming  cercaria.  The  mode  of  infection. — Eastern  writei-s 
look  upon  the  drinking-water  supply  as  the  source  of  infection,  and  this 
view  has  much  in  its  favor.  The  disease  has  been  found  in  hogs  through- 
out various  sections  of  the  United  States  by  Stiles  ;  this  suggests  the 
possibility  of  widespread  infection  in  America. 

Predisposition. — Most  cases  occur  between  the  ages  of  eleven  and 
thirty  years.      Out  of  bd>  sufferers,  38  were  farmers  (Stiles). 

Symptoms, — In  the  usual  form  (lung  infection),  cough,  is  common  but 
not  constant;  the  sputa  are  similar  to  those  of  lobar  pneumonia,  although 
they  may  be  absent  from  time  to  time.  Free  hlood-sjntting  often  occurs 
at  intervals.  Jacksonian  epilepsy  may  supervene  from  metastasis  to 
the  brain. 

Diagnosis. — This  rests  upon  the  detection  of  the  eggs  in  the  sputum. 
Place  a  drop  of  the  bloody  sputum  on  a  slide,  and  upon  it  a  cover- 
glass.  On  microscopic  examination  the  red  color  will  be  found  due  to 
both  red  blood-cells  and  large  dark-broAvn,  thick-shelled,  operculated 
ova.  which  vary  from  80  to  100  jj.  in  length,  and  from  40  to  60  a  in 
breadth. 

The  prognosis  depends  upon  the  number  of  the  parasites  present,  the 
age  of  the  patient  (the  young  and  the  old  bearing  the  disease  badly)  and 
the  presence  or  absence  of  complications.  Pulmonary  tuberculosis  is  an 
unfavorable  complication. 

Treatment. — Prophvlaxis  embraces  care  reo;ardinor  the  drinkino;- 
water,  and  the  collection  and  disinfection  of  the  sputum  as  in  pulmonary 
tuberculosis.  The  patient  should  be  sent  to  healthy  non-infected  areas. 
There  is  no  special  medical  treatment. 

Distoma  Hematobium  (Bilharzia  hematohia ;  Blood-fiukes). — 
This  hematode  is  a  narrow  worm  with  anterior  abdominal  sucking-disks. 
The  male  is  shorter  and  thicker  than  the  female ;  the  former  being  4—15 
mm.  (|— f  in.)  long ;  the  latter,  about  20  mm.  (i  in.).  It  prevails 
mostly  in  Egypt,  Cape  Colony,  and  other  parts  of  Africa,  and  its  en- 
trance into  the  human  body  is  now  believed  to  be  through  the  skin  of 
those  who  bathe  frequently  in  the  African  rivers,  in  many  of  which  it 
abounds.  It  is  not  unlikely  that,  as  formerly  held,  infection  may  also 
occur  in  many  cases  from  drinking  the  impure  water  of  the  rivers.  The 
parasites  or  their  ova  are  found  in  the  bladder,  the  pelvis  of  the  kidney, 
and  the  veins  (portal,  mesenteric),  most  rarely  the  pulmonary. 

The  symptoms  are  hematuria,  with  some  pain  during  urination.  The 
last  few  drops  of  urine  voided  only  contain  blood,  although  rarely 
hemorrhage  is  more  extensive  and  then  the  entire  bulk  is  blood-tinged. 
Cystitis  often  occurs,  with  resultant  thickening  of  the  bladder  wall.  The 
ova  become  nuclei  for  vesical  stone-formation. 

Proctitis  may  result  when  the  parasites  lodge  in  the  rectum,  in  which 
case  mucous  and  bloody  stools  wath  tenesmus  result.  Ova  of  the  para- 
sites are  found  in  the  urine.  No  serious  systemic  disturbances  occur  in 
bilharziosis  except,  rarely,  profound  anemia  from  loss  of  blood.  There  is 
slight  leukocytosis  with  increase  in  the  eosinophile  and  large  mononuclear 
cells.  Prophylaxis  as  regards  drinking  and  bathing  in  African  waters 
should  be  exercised.  Fouquet  affirms  the  value  of  the  extract  of  male 
fern  internally  in  this  form  of  distomiasis. 


ECIHNOCOOOUS  DISEASE.  363 

OESTODES. 

ECHINOCOCCUS    DISEASE. 
(Hydatid  or  Bladder-vwrm  Disease.) 

The  taenia  echinococcus  is  the  smallest  tape-worm  of  our  domestic 
animals,  and  lives  between  the  villi  in  the  small  intestine,  especially  in 
the  larger  breeds  of  dogs.  It  has  a  length  of  from  4  to  9  mm.  (|-  to  1 
in.),  and  consists  of  only  three  or  four  sections,  the  last  one  of  which  is 
mature.  The  rostellum  projecting  from  the  small  head  has  thirty  or 
forty  booklets  arranged  in  a  double  row  and  a  quadruple  sucking  appa- 
ratus. Thousands  of  eggs  are  contained  in  the  mature  segment.  The 
intermediary  hosts  for  the  larvae  are  rarely  man,  the  horse,  and  the  sheep, 
but  more  often  the  hog  and  ox. 

I/ife  History. — The  ova,  embryos,  or  the  proglottides  even,  of  the 
adult  tenia  are  voided  by  the  dog,  and  in  various  ways,  later,  are  ingested 
by  man.  The  dog  first  becomes  infected  by  eating  the  echinococcus 
cysts  of  some  animal  that  harbors  the  larval  form  of  the  tenia,  and  the 
matured  teniae  appear  in  from  eight  to  ten  weeks.  The  liberated  six- 
hooked  embryos  burrow  through  the  intestinal  wall  or  enter  the  portal 
vein  ;  they  pass  into  the  solid  viscera  and  muscles.  There  they  develop 
into  the  larval  form  and  cause  the  formation  of  echinococcus  cysts. 

In  the  development  of  echinococcus  cysts,  about  four  weeks  after  the 
ingestion  of  the  bladder-worm  eggs,  small  nodules  appear,  about  1  mm. 
(^  in.)  in  size.  In  about  five  months  the  cyst-walls  consist  of  two 
layers,  an  external  layer  and  an  inner,  granular,  parenchymatous  layer 
(or  endocyst),  containing  a  clear  liquid.  As  the  reaction  to  the  irritation 
caused  by  the  parasite  and  its  cyst  increases,  a  fibrous  investment  forms 
around  them.  At  this  time,  also,  small  daughter-cysts,  or  vesicular  buds, 
form  the  minor  granular  layer  of  the  mother-cyst,  and  contain  the  heads 
of  the  larvae.  They  are  soon  set  free,  and  may  themselves  give  rise  to 
other  or  granddaughter-cysts  in  a  similar  way.  These  really  become  the 
breeding  capsules  of  little  cellular  outgrowths  that  form  the  scolices  or 
heads  of  future  teniae.  They  show  the  four  sucking  disks  and  a  circle  of 
booklets.  Each  scolex,  when  taken  into  the  intestine  of  the  dog,  de- 
velops into  an  adult  bladder-worm  or  taenia  echinococcus.  This  endogenous 
mode  of  cystic  growth  is  common  in  man  (^.  hydatidosus).  In  animals 
the  so-called  exogenous  cyst  development  is  the  more  common  in  which 
the  primary  cyst-buds  push  out  between  the  cyst  wall  and  then  develop 
externally.  A  third  variety  is  the  multilocuiar  echinococcus  {E.  alve- 
olaris.  Buhl),  affecting  principally  the  liver.  A  large,  hard  tumor  is 
seen  that  on  section  shows  a  firm  connective-tissue  framework  surround- 
ing alveoli  that  average  a  small  pea  in  size.  These  alveoli  contain  small 
echinococcus  cysts  with  thick,  laminated  walls.  They  may  contain  scol- 
ices or  booklets,  and  sometimes  they  are  sterile.  The  echinococci  may  be 
situated  in  the  lymph-channels  and  bile-ducts  (Zenker). 

The  pure  hydatid  fluid  is  colorless,  limpid,  neutral  in  reaction,  and 
has  a  specific  gravity  of  1005  to  1012.  About  96  to  98  per  cent,  is 
water,  and  sodium  chlorid,  carbonate,  and  sulphate :  traces  of  sugar 
(dextrose) ;  cholesterin  and  uric  acid  are  found  among  the  constituents. 

Among  the  changes  that  an  echinococcus  cyst  may  undergo  the  com- 
monest is  that  of  the  death  of  the  echinococci,  as  from  diminished  nour- 
ishment due  to  intense  proliferation  of  daughter-  and  granddaughter- 


564  ANLVAL   PARASITIC  DISEASES. 

cysts.  The  contents  become  thickened,  putty-like,  or  granuhir,  and  even 
calcified.  Remnants  of  these  obsolete  cysts,  such  as  the  chitinous  sub- 
stance of  the  old  and  outer  wall-layer  and  booklets,  may  be  found. 
Sometimes  rupture  of  the  cyst  occurs,  with  serious  consequences  to  the 
patient ;  or  the  peritoneum  daughter-cysts  or  free  scolices  may  be  dis- 
seminated and  grow.  Or  perforation  into  the  respiratory,  digestive,  or 
urinary  tracts  and  discharge  of  daughter-cysts  and  hydatid  fluid  may 
take  place.  Lastly,  suppuration  and  the  formation  of  large  hepatic 
abscesses  may  ensue,  either  spontaneously  or  on  account  of  septic  instru- 
ment? used  for  tapping  the  cysts. 

Ktiology. — Carelessness  in  the  feeding  and  the  keeping  of  dogs  is 
the  primary  source  of  hydatid  disease,  and  the  preparing  of  food  where 
dogs  are  allowed  ro  roam  about,  and  so  on,  accounts  for  the  majority  of 
cases.  Females  are  more  often  aftected  than  males,  and  childi-en  and 
young  adults  seem  to  be  oftener  aftected  than  those  older  in  years. 

As  regards  the  geographic  distribution,  echinococcus  disease  prevails 
most  extensively  in  Iceland,  where  man  and  dog  live  closely  together. 
In  Australia,  also,  many  persons  are  affected.  It  is  not  so  common  in 
Europe,  Asia,  or  Africa,  and  in  America  it  is  rare. 

Organs  Affected. — The  tenia  echinococcus  has  an  undoubted  predi- 
lection for  the  liver.  "'  Of  1806  organ-infections,  the  following  organs 
were  the  most  frequently  aff"ected:  liver  (1011),  lung  (147),  and  kid- 
ney (126)  "  (Stiles).  The  brain  and  spinal  cord,  spleen,  bones,  muscles, 
the  heart,  and  blood-vessels  are  involved  with  uncertain  frequenc3^ 

Symptoms. — Hydatids  of  the  Liver. — Unless  the  cystic  tumors  com- 
press the  portal  area  or  the  biliary  passages,  or  invade  the  neighboring 
viscera,  subjective  symptoms  may  be  entirely  wanting.  Not  infrequently 
echinococcus  sacs,  partly  calcified,  have  been  found  postmortem,  not 
having  produced  any  symptoms  during  life.  Grradual  but  progressive 
loss  of  flesh  and  strength  with  the  presence  of  a  fluctuating  tumor  may 
be  the  only  symptoms  present  until  late  in  the  disease.  If  the  cysts  attain 
a  large  size,  a  sensation  of  dragging,  and  of  pain  even,  is  often  present ;  as 
a  rule,  however,  pain  is  absent  throughout  the  course  of  the  disease.  If 
the  tumor  displaces  the  diaphragm  upward  and  compresses  the  lung,  cough 
and  dyspnea  result.  In  some  cases  the  sac  has  ruptured  into  the  bronchi, 
and  given  rise  to  cough  and  to  expectoration  of  the  fluid  and  vesicles. 

If  the  portal  veins  and  bile-duct  are  compressed,  splenic  enlargement 
from  passive  congestion,  ascites,  and  jaundice  will  occur,  these  symptoms 
being  more  common  when  the  cysts  are  multilocular.  Rupture  may 
occur  into  the  intestines  (colon),  into  the  pleura  or  pericardium,  causing 
pyothorax  or  pyo-pericardium,  or  into  the  inferior  vena  cava,  causing 
fatal  pulmonary  embolism. 

Fever  is  usually  absent  throughout,  unless  the  contents  of  the  sac  become 
converted  into  an  abscess;  then  rigors  or  chills,  fever  (hectic  in  type),  and 
sweatings  occur,  with  jaundice  (more  or  less  intense)  and  rapid  emaciation. 

Not  infrequently  the  cyst-wall  becomes  partly  calcified  and  the  con- 
tents are  reabsorbed. 

When  rupture  occurs,  unless  the  contents  be  evacuated  through  the 
respiratory,  alimentary,  or  urinary  tracts  or  externallv,  svmptoms  of 
collapse  develop  and  are  followed  by  death.  Toxic  erythema  or  urticaria 
may  follow  rupture  of  cyst. 

The  physical  signs  give  on  inspection  fulness  or  bulging  in  the  right 


ECHINOGOOOUS  DISEASE.  365 

hypochondriac  region,  especially  if  the  cyst  be  single,  of  large  size,  and 
Bituated  anteriorly. 

Palpation  confirms  inspection  and  shows  a  fluctuating  mass  or  masses. 
A  trembling  impulse  is  felt  sometimes  on  deep  palpation,  aided  by  light 
percussion  over  the  opposite  side  of  the  cyst,  constituting  the  so-called 
"  hydatid  thrill."  This  sign  cannot  always  be  elicited,  but  when  present 
is  pathognomonic  of  the  disease.  The  remainder  of  the  liver  shows  uni- 
form enlargement.  The  spleen  is  often  palpably  increased  in  size  from 
passive  congestion. 

Percussion  reveals,  in  addition  to  the  hydatid  fremitus,  an  increased 
area  of  dulness  to  the  left  or  posteriorly,  depending  on  the  location  and 
extent  of  the  growths.  If  the  left  lobe  be  involved,  the  line  of  flatness 
may  extend  across  the  sternum  to  the  left  hypochondriac  region.  If  the 
cysts  are  multiple  and  on  the  antero-inferior  surface,  the  stomach  may  be 
displaced  toward  the  left  and  dulness  may  extend  across  the  epigastrium; 
if  posteriorly,  the  pleural  cavity  may  be  encroached  upon,  causing  an 
increased  area  of  flatness  upward  in  the  postero-axillary  line.  Frerichs 
claims  the  line  of  dulness  posteriorly  in  hydatid  disease  to  be  a  curved 
one,  whose  convexity  is  upward. 

Auscultation  gives,  according  to  Santoni  and  others,  a  short  sharp 
booming  sound  when  the  tumor  is  percussed,  that  may  be  likened  to  one 
produced  by  striking  a  membrane  stretched  over  a  metallic  frame. 

Diagnosis. — In  the  entire  absence  of  subjective  symptoms  and  of 
characteristic  physical  signs,  the  diagnosis  is  impossible.  If  the  cyst 
be  of  sufficient  size  to  give  fluctuation  and  the  liver  be  irregularly  en- 
larged, with  an  absence  of  fever,  pain,  and  marked  emaciation,  the  dis- 
ease may  be  strongly  suspected.  The  only  certain  demonstration  of  the 
condition  is  the  discovery  of  the  characteristic  booklets  or  heads  in  the 
aspirated  or  discharging  contents  of  the  cyst.  Among  the  conditions  that 
may  be  misdiagnosed  for  hydatid  disease  are — {a)  Dilatation  of  the  gall- 
bladder, {h)  hydronephrosis,  (c)  right-sided  pleurisy  with  eifusion,  (cZ) 
syphilis  of  the  liver,  (e)  carcinoma,  (/)  abscess,  and  {g)  cirrhosis. 

Hydatid  Cyst.  Dilatation  of  the  Gall-bladder. 

Previous  history  negative,  except  the  com-      A  previous    history    of    having    passed 

panionship  of  dogs.  biliary  calculi  is  often  present. 

Pain  and  jaundice  usually  absent.  Attacks  of  biliary  colic  followed  by  jaun- 

dice   either  are  present  or  enter  into 
the  previous  history. 
Enlargement  in  any  direction,  depending      Enlargement  is  always  in  one  direction — 

upon  the  location  of  the  cysts.  downward  and  posteriorly. 

Hydatid  thrill  may  be  present.  "Hydatid  fremitus"  never  present. 

Less  so.  The  tumor  is  somewhat  movable. 

Hydatid  Cyst.  Hydronephrosis. 

The  history  is  negative  {vide  supra).  There  is  a  history  of  renal  calculi  or  of 

vesical  inflammation. 
Urinalysis  is  negative.  Urinalysis    reveals    evidences    of    renal 

disease. 
The  tumor  is  most  prominent  over  the      The   tumor   is   most   prominent   in    the 
hepatic   area,   and   is    associated  with  flank  and  iliac  fossa.     If  extending  to 

enlargement  of  the  liver.  .  the  right  hypochondriac  region,  it  does 

not  move  with  the  liver. 
The  duration   is  indefinite  and   uremia      The  duration  is  short;  a  termination  in 
rare.  uremia  is  common. 


366  ANIMAL  PARASITIC  DISEASES. 

Hydatid  Cyst.  Pleurisy  with  Effusion. 

The  onset  is  slow ;  pain  and   fever  are  The  onset  is  sudden,  and  violent  pain  is 

absent.  present,  with  fever  and  dyspnea. 

The  presence  of  a  fluctuating  mass  in  the  The  presence  of  eflusion,   beginning  at 

hepatic  area,  7ioi  changing  with  the  po-  the   base  of  the   chest  and    gradually 

sit  ion  of  the  patient.   Hydatid  fremitus  extending  upward — changing  with  the 

is  present,  but  no  bulging  of  the  inter-  po.'^ition  of  the  patient  and  accompanied 

costal  spaces.  by  bulging  of  the  intercostal  spaces. 

Aspiration  reveals  a  clear  yellow  liquid  Aspiration  gives  a  cloudy,  turbid  liquid, 

of  low  spocifio  gravity  witliout   albuiiiiii,  containing  albumin  and  flakes  of  lymph 

but  chlorids,  sugar,  and  hooklots.  with  high  specific  gravity. 

The  disease    invariably    runs    a    chronic  The   disease    generally    runs    an    acute 

coui'se.  course. 

For  a  differential  diagnosis  from  (d),  (c),  (/),  and  [g)  I  would  refer  the 
reader  to  the  discussion  of  the  several  diseases  (_vide  Diseases  of  the  Liver). 

Echinococcus  of  the  Respiratory  Organs. — The  lung  has  been  the  seat 
of  the  larvne  quite  frequently,  and  instances  have  been  noted  especially 
in  North  Germany  and  Australia.  The  right  lower  lobe  has  been  the 
seat  of  predilection,  though  sometimes  the  pleura  is  the  primary  source 
of  trouble.  There  are  pain  in  the  chest,  cough,  dypsnea,  perhaps  arching 
of  the  overhanging  thoracic  region,  signs  of  a  pleural  effusion,  a  tym- 
panitic note  above  the  prominence,  hemoptysis,  and  the  pathognomonic 
expectoration  of  Iiydatid  disease.  The  general  condition  may  or  may  not 
be  seriously  affected.  Perforation  into  the  pleural  sac  by  pulmonary 
eehinococci  may  be  followed  by  empyema,  and,  later,  by  perforation  of 
the  chest  wall.  The  heart  may  be  dislocated.  Compression  of  the  lung 
may  produce  gangrene. 

The  diagnosis,  in  the  absence  of  the  characteristic  sputum,  is  to  be 
made  from  phthisis  and  a  pleural  effusion.  Their  location  at  the  base  of 
the  chest  may  serve  to  differentiate  hydatid  cysts  from  phthisis,  as  well 
as  the  absence  of  marked  emaciation.  The  characteristic  curved  upper 
boundary  of  dulness  in  pleural  effusion  and  the  change  of  the  boundary 
upon  changing  the  patient's  position  will  serve  to  distinguish  this  affec- 
tion. Pleural  eehinococci  sometimes  cause  great  compression  of  the  lung 
and  a  barrelling  of  the  chest  on  one  or  both  sides.  The  pain  may  be  quite 
sharp,  and  the  respiratory  murmur  either  distant  or  altogether  absent. 

EcMnococcus  of  the  Mediastinum. — Hare  has  collected  6  cases  of 
hydatid  disease  among  520  cases  of  mediastinal  tumors. 

Echinococcus  of  the  Heart. — Most  of  the  cases  have  shown  involvement 
principally  of  the  right  side  of  the  heart. 

Echinococcus  of  the  brain  and  spinal  cord  should  not  be  confounded 
with  cystic  degeneration  of  the  choroid  plexuses.  J.  H.  Lloyd  found  19 
distinct  cysts  in  the  lateral  ventricles  and  one  occupying  the  fourth  ven- 
tricle. The  symptoms  of  cerebral  hydatids  are  those  of  tumor,  persistent 
and  intense  cephalalgia,  vomiting,  psychical  disturbances,  convulsions, 
amblyopia,  and  "choked  disk,"  and  sometimes  paralysis.  Hydatid  dis- 
ease may  develop  inside  the  dura  mater,  or  it  may  penetrate  from  with- 
out and  destroy  the  vertebrae  before  they  compress  the  cord  to  a  great 
degree.      The  symptoms  are  those  of  a  compression  myelitis. 

Echinococcus  of  the  Spleen. — About  40  cases  of  involvement  of  the 
spleen  have  been  described.  The  organ  may  become  greatly  enlarged 
and  be  mistaken  for  that  due  to  malaria,  leukemia,  etc.  The  hydatid 
thrill  may  be  detected. 


TAPE-WOBMS.  367 

Echinococcus  of  the  Kidneys. — More  than  100  casew  have  been  ob- 
served, mostly  in  Germany  and  France.  The  cyst  may  be  as  large  as  in 
hydronephrosis.  Many  of  the  cysts  arc  of  the  exogenous  form  of  growth. 
As  a  rule,  one  kidney  only  is  affected,  and  generally  the  left  one.  Ab- 
dominal and  thoracic  compression  symptoms  may  be  caused,  and  bulging 
is  often  present  in  the  lumbar  region  in  marked  cases.  This  may  be 
punctured  as  an  aid  in  the  diagnosis.  Rupture  into  the  pelvis  of  the 
kidney  and  the  discharge  of  the  smaller  cysts  may  give  rise  to  renal  colic 
and  to  the  discharge  of  the  cysts  with  the  urine.  More  rarely,  rupture 
of  a  suppurating  cyst  may  take  place  in  the  loin. 

Echinococcus  of  the  peritoneum  is  rare  as  a  primary  condition. 
Echinococci  have  also  been  located  in  the  bladder,  prostate,  testicle, 
ovary,  uterus,  great  omentum,  mesentery,  pancreas,  arteries,  lymphatics, 
thyroid  gland,  muscles,  bones,  joints,  parotid  gland,  orbit,  and  mamma. 

A  peculiar  complication  of  echinococcus  cysts  is  the  occasional 
development  of  urticaria.  It  has  been  noted  especially  shortly  after 
the  puncture  of  a  cyst,  and  this  is  somewhat  diagnostic  when  it  appears. 

The  prognosis  is  generally  grave  both  as  to  life  and  cure,  although 
some  cases  of  hydatid  disease  of  the  liver  have  lasted  for  more  than  ten  y  ear<. 

The  character  of  the  changes  in  the  cysts  and  their  mode  of  termina- 
tion influence  the  prognosis.  Thus,  the  occurrence  of  suppuration  is  to 
be  dreaded.      Spontaneous  cures  have  been  noted  in  a  few  instances. 

Treatment. — As  in  most  of  the  other  parasitic  diseases,  prevention 
is  more  or  less  effectual,  and  a  cure  is  difficult  or  impossible.  Infection 
of  the  dog  should  be  avoided  by  preventing  its  gaining  access  to  possible 
sources  of  hydatid  disease,  as  the  raw  flesh  of  animals,  especially  in  the 
form  of  meat-scraps  around  slaughter-houses.  In  order  that  human 
beings  may  not  be  affected,  dogs  should  not  be  carelessly  handled  or 
allowed  to  be  where  they  may  come  in  contact  with  food  and  drink  in 
any  way,  whether  meat  or  eggs,  vegetables,  fruits,  or  cereals.  Cleanli- 
ness in  keeping  dogs  and  in  the  proper  preparation  of  food  are  essential 
in  regions  where  hydatid  disease  is  prevalent. 

Medicines  cannot  reach  the  parasites  in  man,  situated  as  they  are  in 
larval  form  encysted  in  the  various  tissues  and  organs  of  the  body. 
Whenever  the  cyst  becomes  large,  accessible,  and  the  cause  of  trouble- 
some symptoms,  surgical  measures  may  be  resorted  to.  Among  these 
are,  simple  tapping,  tapping  with  aspiration,  and  with  the  subsequent 
injection  of  various  substances  (as  iodin  and  zinc-chlorid  electrolysis), 
and  incision  with  drainage.  Excision  of  the  liver  cysts  has  been  practised 
by  Raggi,  Pozzi,  Tansini,  and  others,  but  its  practical  value  is  still 
undetermined.      Should  suppuration  occur,  treat  as  an  abscess. 

T^NI^   OB   TAPE- WORMS. 

Natural  History. — Tape-worms  are  found  in  the  intestine  of  man, 
and  are  the  matured  or  completely  developed  larvae  or  cysticerci  from  the 
muscles  and  solid  viscera  of  animals.  Different  varieties  of  cysticerci 
develop  from  the  ova  of  the  respective  varieties  of  tenise.  These  tape- 
worm eggs,  after  having  passed  out  of  the  bowel,  may  be  taken  into  the 
systems  of  various  animals  by  various  modes,  entering  the  circulation, 
it  may  be,  and  becoming  fixed  within  the  solid  tissues,  especially  the 
muscles.  In  about  two  or  three  months  pea-sized  cysts  develop,  and 
from  the  cyst-walls  there  gradually  forms  a  new  tenia-head,  called  a 


368  ANIMAL  PARASITIC  DISEASES. 

scolt'.r.  or  nurse.  The  ■worm-cysts,  popular!)^  termed  "measles,"  con- 
stitute the  cysticerci.  Remaining  in  the  tissues,  they  die  and  become 
calcified  in  from  three  to  six  years  (Striimpell).  But,  if  taken  into  the 
stomach  by  the  eating  of  raw  or  partially-cooked  meat,  a  tape--\vorm  de- 
velops from  the  scolex.  The  maturation  of  the  segments  of  the  tape- 
worm commences  several  months  after  the  fixation  of  the  scolex  in  the 
intestine.  In  the  natui-al  life-cycle  of  a  tape-worm  the  usual  order  of 
lodgement  may  be  reversed.  Thus  man  instead  of  a  lower  animal  may 
become  the  host  of  the  tenia  eggs,  which  in  turn  may  find  their  way  into 
the  solid  viscera  and  muscles  to  develop  into  cysticerci.  Again,  this 
same  order  may  be  brought  about  by  "  auto-infection."  The  tape-wonr 
has  a  ribbon-like  form  ;  although  it  has  a  number  of  segments  and  joints, 
giving  it  a  link-belt  appearance.  When  matured,  these  segments,  or 
proglottides^  develop  male  and  female  generative  organs. 

Varieties. — Taenia  Solium  [Pork  Tape-worm). — This  worm  is  rarer 
in  America  and  also  in  Europe  than  formerly.  It  develops  in  the  small 
intestine  after  the  ingestion  of  raAv  or  underdone  "  measly  "  pork.  This 
worm  does  not  necessarily  exist  singly,  as  its  name  would  indicate, 
although  such  is  usually  the  case.  It  ranges  from  2  to  4  meters 
(6  to  13  feet)  in  length.  The  head  is  rounded,  pin-head  in  size,  and  is 
succeeded  by  a  thread-like  neck  and  by  gradually  shortening  and 
widening  segments.  Four  suckers  and  a  projecting  circle  of  twenty-six 
long  and  short  booklets  arm  the  head  of  the  tenia.  The  mature  ones 
become  detached,  and  are  passed  with  the  feces.  They  are  about  1  centi- 
meter (|-  in.)  in  length  and  from  6  to  8  millimeters  (5—^  in.)  in  breadth,  and 
about  1  meter  (39.36  in.)  from  the  head  they  are  "approximately  quad- 
rilateral" in  shape.  These  proglottides  are  bisexual.  The  female  mat- 
rix occupies  the  middle  of  each  proglottis,  and  is  provided  with  from 
eight  to  fourteen  irregular,  tree-like  branches  on  each  side.  The  male 
generative  organs  are  small  vesicles  in  the  anterior  portion  of  the  seg- 
ment. The  sexual  opening  is  situated  on  one  side,  near  the  middle. 
The  ovarian  or  uterine  apparatus  of  a  mature  segmient  contains  myriads 
of  thick-shelled  eggs,  each  one  of  which  has  an  embryo  with  six  booklets. 

Taenia  Mediocanellata  {Saginata). — The  beef  tape-worm  is  some- 
times called  the  ''unarmed  tape-worm,"  since  the  head  possesses  suck- 
ing disks,  but  no  booklets.  It  is  more  common  in  this  country  and  even 
in  some  of  the  European  countries,  as  England.  Longer  than  the  tenia 
solium,  being  4  to  10  meters  (12  to  80  feet)  in  length,  its  segments  are 
also  thicker  and  larger,,  measuring  from  16  to  88  mm.  (|^  in.)  long,  and 
from  8  to  10  mm.  {^  in.)  broad.  The  head  of  the  worm  as  well  as  the 
ripe  ovum  is  also  slightly  larger  and  proportionately  thicker.  The  ova- 
rian branches  are  more  numerous  (eighteen  to  thirty  in  number)  and  di- 
vide more  dichotomously  than  those  of  tenia  solium.  Proglottides  are 
also  found  in  the  stools,  where  they  sometimes  exhibit  a  crawling  motion 
that  has  caused  them  to  be  mistaken  for  individual  parasites.  Cysti- 
cercus  saginata  has  never  been  observed  in  ma,n. 

Bothriocephalus  latus  [Fish  tape-worm,  Tcenia  lata)  occurs  most  com- 
monly in  Russia,  Switzerland,  Holland,  and  the  German  Baltic  prov- 
inces. It  is  the  longest  cestode,  measuring  from  6  to  10  meters  (20  to 
30  feet).  The  head  is  club-shaped,  unarmed,  and  has  two  lateral  longi- 
tudinal grooves  as  suckers.      The  segments  may  be  distinguished  from 


TAPE-WORMS.  369 

those  of  tlie  preceding  varieties  named  by  their  marked  breadth  and 
shortness,  also  by  the  centrally  situated,  tortuous  ovarian  rosette,  and 
the  sexual  orifice  near  the  center  of  the  abdominal  surface  of  each  pro- 
glottis. The  ova  are  larger  than  those  of  the  pork  and  beef  tape-worms, 
though  thinner-shelled  and  with  a  sort  of  lid  at  on(!  end.  They  develop 
only  in  fresh  water.  From  them  is  formed  an  embryo  with  vibrating 
cilia  and  six  booklets.  Pike  and  other  fish  swallow  these  embryos, 
which  develop  into  cysticerci  in  the  muscles,  peritoneum,  and  solid  vis- 
cera. The  eating  of  measly  fish,  raw  or  partially  cooked,  thus  favors 
the  development  of  this  tape-worm  in  the  human  intestine. 

Symptoms. — Tape-worms  may  develop  in  man  at  any  period  of  life. 
D.  J.  Milton  Miller  met  with  one  in  a  child  a  few  months  old 
who  had  been  fed  on  expressed  beef-juice.  Contrary  to  what  has  been 
supposed  in  days  gone  by,  there  are  no  absolutely  diagnostic  symptoms 
of  the  presence  of  tape-worm  that  can  be  relied  upon.  Indeed,  the  ex- 
istence of  a  tape-worm  in  the  bowel  may  not  be  suspected  even  because 
of  the  total  absence  of  indicative,  subjective  sensations.  On  the  other 
hand,  teniae  may  cause  considerable  local  distress  and  impairment  of  the 
general  health.  Because  of  this  fact  a  knowledge  of  the  existence  of 
tape-worm  in  certain  neurotic  subjects  leads  to  an  inordinate  description 
of  symptoms  that  exist  mainly  in  the  workings  of  a  morbid  imagination. 

Alimentary  symptoms  of  tape-worm  may  be  as  follows:  anorexia  alter- 
nating with  a  voracious  appetite,  constipation  alternating  with  diarrhea, 
colicky  pains  in  the  abdomen,  indigestion,  nausea,  and  vomiting.  Cer- 
tain foods  (herring,  garlic,  sour  foods)  increase  the  colic-like  pains,  others 
decrease  them,  as  milk,  eggs,  and  oils. 

Greneral  symptoms  of  the  teniae  may  be  added,  as  lassitude,  inappe- 
tence,  mental  uneasiness,  worry  and  irritability,  depression  of  spirits, 
some  physical  prostration,  and  even  emaciation.  Various  reflex  symptoms^ 
such  as  pruritus  of  the  nose  and  anus,  vertigo,  migrain,  tinnitus  aurium, 
palpitation,  visual  disturbances  (even  temporary  amaurosis),  unequally 
dilated  pupils,  chorea,  and  epileptiform  convulsions  have  been  attributed 
to  these  parasites.  But,  on  careful  inquiry,  adequate  causes  for  some  of 
these  symptoms  may  be  found  in  other  associated  morbid  conditions. 
The  bothriocephalus,  however,  may  cause  anemia,  often  very  grave,  even 
fatal.  The  blood-picture,  in  fact,  is  identical  with  that  of  pernicious 
anemia,  as  Schaumann's  study  of  38  cases  has  shown,  and  as  was  the  case 
in  three  Finnish  sailors  seen  by  W.  E.  Robertson.  This,  in  all  likeli- 
hood, is  due  to  some  toxin  elaborated  by  the  worm.  The  blood-findings 
are  otherwise  unique  among  the  verminous  parasitic  diseases  in  that  they 
are  the  only  class  in  which  eosinophilia  does  not  occur. 

Diagnosis. — This  is  always  to  be  made  by  the  discovery  of  tenia 
segments  or  ova  in  the  underclothing  or  stools.  The  doubtful  presence 
of  suspected  tape-worm  may  be  cleared  by  the  administration  of  a  suitable 
purgative,  which  will  usually  suffice  to  bring  away  portions  of  the  worm 
in  the  dejections.  I  would  here  add  a  special  warning  lest  mucous  casts 
or  shreds  or  vegetable  structures  (as  of  onion)  be  mistaken  for  tape-worm. 

The  diagnosis  of  the  variety  of  the  tape-worm  is  made  by  a  careful 
scrutiny  of  the  segments.  Those  of  the  tenia  saginata  are  larger  and 
fatter  than,  and  their  generative  apparatus  is  unlike  that,  of  tenia  solium. 

Hypochondriasis  can  be  excluded  by  repeated  examinations  of  the 

24 


370  .4.V/.l/-li.   PARASITIC  DISEASES. 

Stools,  especially  after   the  exhibition  of  cathartics,  and  by  the  uniform 
failure  to  detect  portions  of  tape-worm  or  tenia  eggs. 

Prognosis  is  favorable.  Indeed,  teniae  saginata  may  exist  at  all  ages  and 
for  years  -without  any  danger  to  the  patient.  Tenia  solium,  however,  is  at- 
tended with  danger  on  account  of  the  possibility  of  its  causing  cysticercosis. 

Treatment. — Prophylaxis. — The  way  to  avoid  acquiring  a  tape- 
worm is  to  use  none  but  well-cooked  meats ;  this  applies  to  beef  and 
pork  in  particular.  The  use  of  pure  drinking-water  is  of  no  little  im- 
portance also.  The  pi'oglottides  of  the  tenia  should  always  be  burned, 
and  not  thrown  where  they  may  be  taken  into  the  bodies  of  other  animals, 
as  the  cow  or  hog,  and  then  be  allowed  to  propagate.  Governmental 
inspection  of  the  meat-supply  in  abattoirs  should  be  rigidly  enforced. 

Curative. — Before  administering  the  chosen  anthelmintic,  the  patient 
needs  to  undergo  a  "preparatory  treatment."  This  has  for  its  object 
the  starvation  of  the  parasite,  so  as  to  weaken  its  hold  upon  the  intesti- 
nal mucosa.  This  is  specially  necessary  in  the  case  of  ta?nia  solium, 
in  Avhich  the  cephalic  booklets  are  obstinately  and  firmly  fixed  to  the 
membrane,  and  since  a  cure  cannot  be  said  to  have  been  effected  unless 
the  head  be  dislodged  with  the  dejecta.  For  about  two  days  prior  to 
giving  the  remedy  the  patient  should  be  restricted  in  diet  to  milk,  light 
soups,  a  little  white  bread,  and  the  like.  Meanwhile,  the  bowels  should 
be  purged  gently  once  or  twice,  after  a  simple  enema. 

In  the  evening  preceding  the  day  on  which  the  drug  is  to  be  exhibited, 
a  saline  cathartic  should  be  given  to  empty  the  bowel  as  completely  as 
possible.  The  following  morning  no  breakfast  should  be  allowed,  and 
before  noon  the  selected  anthelmintic  should  be  administered.  If  the 
worm  does  not  come  away  in  a  few  hours,  and  an  intense  sense  of  pressure 
is  felt  in  the  abdomen,  a  brisk  purge  is  indicated.  The  worm  should  be 
passed  into  a  bowl  containing  warm  water. 

There  are  several  very  efficacious  anthelmintic  drugs  to  choose  from. 
Prominent  among  them  is  male  fern.  Given  to  an  adult  in  doses  of  \  to 
1  dram  (2.0-4.0)  of  the  ethereal  extract,  and  followed  in  several  hours 
by  a  calomel  and  a  saline  purge,  it  usually  succeeds  in  bringing  away 
the  tenia.  Schilling  gives  in  the  morning,  fifteen  minutes  after  a  break- 
fast of  coffee  with  Zweiback,  this  formula  : 

I^,    Fresh  ethereal  extract  of  male  fern,  sij  ; 

Powdered  jella,  gr  viiss  ; 

Simple  syrup,  q.  s.  ad  3j. 

Sisr.     Shake  well  and  take  at  one  dose. 

If  evacuation  of  the  bowels  be  delayed,  an  enema  of  warm  water  is 
indicated.  Another  valuable  remedy  is  pelletierin,  the  active  principle  of 
pomegranate  ;  the  tannate  may  be  prescribed,  dose  1  to  1.5  gm.,  in  cap- 
sules ;  or,  a  decoction  of  the  pomegranate  bark  may  be  used,  in  combi- 
nation with  male  fern,  as  in  the  Leipsic  formula  (Striimpell): 

!^.   Granati  radicis  corticis,  ^iv-v  (128.0-160.0); 

Aquge,  Oij  (1  liter). 

Mix  and  macerate  for  twenty-four  hours, 

and  boil  until  reduced  to  f  ^v  (148.0). 

Add  :   Oleoresinse  aspidii,  3j  (4.0). 

Sig.   To  be  taken  in  three  or  four  doses,  at  short  intervals. 


TAPJ^-WOJiMS.  ;j71 

Pepo  in  eraulsion  or  in  a  sugary  paste  (a?jout  two  ounces — 04.0 — and 
deprived  of  the  envelopes)  is  at  once  a  useful  and  iiarmless  remedy. 

Another  effective  vermifuge  is  kousso  (Brayera  anthelmintica).  An 
infusion  of  half  an  ounce  (10. 0)  of  the  flowers  to  one  pint  of  water  and 
mucilage  of  acacia  is  made,  a  wineglassful  of  which  may  be  taken  every 
half  hour.  The  Germans  recommend  sometimes  the  agreeable,  though 
more  expensive,  Rosenthal's  "  kousso  tablets."  Enough  of  the.se  to 
make  15  grains  (0.972)  may  be  taken  within  one  hour,  with  cafe  noir  or 
lemonade.  Koussin  (the  active  principle)  in  doses  of  80  to  40  grains 
(1.94-2.592)  has  also  been  recommended,  but  should  not  be  given  to 
pregnant  women,  as  abortion  may  be  produced.  Among  other  remedies 
of  value  as  vermifuges  may  be  mentioned  kamala  (1  to  3  drams — 4.0- 
12.0 — of  the  powder  and  hairs,  in  wine  or  water),  oil  of  turpentine  (^  to 
2  ounces — 16.0—64.0 — in  emulsion  or  milk),  and  thymol.  The  combined 
use  of  such  drastics  as  croton  oil  renders  the  action  of  the  anthelmintic 
drug  more  certain  at  times. 

Although  the  head  of  the  tenia  may  not  be  detected  in  the  stools 
along  with  the  body  of  the  worm  (and  such  is  usually  the  case),  a  cure 
usually  follows  nevertheless,  since,  on  account  of  its  smallness,  it  may 
easily  escape  notice,  and  also  from  the  fact  that  the  head  often  dies  and 
thus  loses  its  hold  upon  the  membrane,  being  carried  away  with  the  feces. 
On  the  other  hand,  if  after  the  lapse  of  several  months  from  the  removal 
of  a  tape-worm,  segments  again  appear  in  the  stools,  it  may  be  inferred 
that  the  head  was  not  dislodged  or  that  another  worm  has  developed.  In 
cases  where  the  tenia  seems  to  redevelop  with  remarkable  frequency  and 
obstinacy  it  may  happen  that  the  head  and  neck  are  well  protected 
beneath  one  of  the  valvulse  conniventes. 

After  the  removal  of  the  tape-worm — a  weakening  procedure,  as  a 
rule — the  condition  calls  for  supportive  measures.  The  diet  should  not 
be  too  heavy  for  a  time,  but  nutritious  and  easily  digestible. 

T^NIA   NANA. 

This  is  the  smallest  tape-worm  in  man  (v.  Siebold).  It  varies  from 
8  to  20  mm.  (-g— f  in.)  in  length  and  from  0.5  to  0.7  mm.  [-^^  in.)  in 
width.  The  head  has  four  suckers,  a  rostellum,  and  booklets.  The  seg- 
ments are  yellowish,  short,  and  broad.  It  is  more  common  than  is  sup- 
posed. It  is  believed  by  some  observers  that,  occurring  in  children,  as 
it  commonly  does,  this  parasite  is  the  cause  of  epileptiform  convulsions 
and  enuresis  nocturna.  Thousands  of  worms  may  be  found  within  a  cubic 
centimeter  of  fecal  matter.  Hymenolepis  nana  fraterna,  which  develops  in 
rats  without  intermediate  host,  is  regarded  as  being  identical  with  the  T. 
nana.  Persons  infected  should  occupy  separate  beds  until  cured.  Male 
fern  is  the  only  remedy  which  has  thus  far  been  useful  in  expelling  this 
worm  (Stiles). 

T^NIA   PLAVOPUNCTATA. 
[Taenia  Diminuta ;   Tcenia  Leptocephalata.) 

Taenia  diminuta  is  a  very  small  cestode,  20  to  60  mm.  (f— 2i  in.)  in 
length,  with  a  small  club-shaped  head  and  nearly  a  thousand  segments. 
The  cysticerci  inhabit  such  insects  as  the  asopia  familiasis  (caterpillar  and 
cocoon) ;  the  anisolabis  annuli  (belonging  to  the  orthoptera) ;  and  the 
coleoptera  axis  spinosa  and  scaurus  siriatus.     Man  has  been  infested  a 


372  ANIMAL  PARASITIC  DISEASES. 

number  of  times,  probably  by  taking    food    containing    these   infested 
insects. 

Tcenia  MadagadoaHeinsis  and  Taniia  serrata  are  other  forms  rarely 
found  in  man. 

NEMATODES. 

HELMlNTHOLoaiSTS  inohide  in  this  chiss  the  cvlindric  worms,  certain 
varieties  of  which  are  among  the  most  common  entozoa  that  infest  the 
human  body  and  inhabit  the  intestines. 

ASCARIASIS. 

Ascaris  I/Umbricoides  (Bound-worm). — Natural  History. — This 
species  resembles  the  common  earth-worm,  and  is  the  most  frequent 
in  occurrence  of  all  the  parasites.  It  usually  appears  in  children  be- 
tween the  ages  of  three  and  ten  years.  The  round-worm  inhabits  the 
upper  portion  of  the  small  intestine,  and  occurs  singly  or  in  numbers. 
Its  body  is  round,  fusiform,  and  marked  with  fine  transverse  striae.  It 
has  a  yellowish  or  reddish-brown  color,  and  measures  in  the  female  from 
7  to  14  inches  in  length  (17.5—35  cm.),  and  from  4  to  8  inches  in  the 
male  (about  20  cm.),  its  thickness  being  about  that  of  an  ordinary 
goose-quill.  The  cephalic  extremity  of  the  worm  has  three  oval  papillae, 
furnished  with  fine  teeth  ;  the  caudal  extremity  is  straight  in  the  female 
and  curved  in  the  male. 

Lumbricoid  worms  develop  from  ova,  which  are  about  .05  to  .06  mm. 
long,  elliptic,  dark-reddish  in  color,  and  have  a  thick,  resisting  envelope  ; 
they  occur  in  the  feces.  The  eggs  obtain  entrance  into  the  human  intes- 
tine most  probably  through  drinking-water  and  food. 

The  round-worm  sometimes,  though  rarely,  migrates  from  the  small 
intestine.  It  has  been  vomited,  and  it  has  also  crawled  into  the  pharynx, 
mouth,  and  nares,  and  has  been  withdrawn  thence  by  the  patient's 
fingers.  It  has  even  passed  into  the  larynx  and  trachea,  causing  fatal 
asphyxia  or  pulmonary  gangrene.  The  Eustachian  tube  and  biliary  ducts 
may  be  invaded  with  such  serious  symptoms  as  perforation  of  the  mem- 
branum  tympani  and  hepatic  abscess. 

Symptoms  may  be  absent,  and  yet  the  worms  be  found  repeatedly  in 
the  stools.  Existing  symptoms  are  indefinite,  and  point  simply  to  an 
irritative  condition  of  the  boAvels.  Some  writers  ascribe  them  to  toxins 
elaborated  by  the  worms.  Serious  symptoms  may,  however,  result  from 
the  migration  of  the  worm,  as  into  the  biliary  passages.  Eustachian  tube, 
or  larynx.  Fever  is  not  a  necessary  concomitant.  Lumbricoid  worms 
may  give  rise  to  any  or  all  of  the  following  symptoms  :  colicky  pains, 
nausea,  vomiting,  indigestion,  diarrhea  (sometimes),  restlessness,  irrita- 
bility, anorexia,  itching  of  and  picking  at  the  nose,  disturbed  sleep  with 
grinding  of  the  teeth,  salivation,  and  nervous  twitchings.  Very  nervous 
children  may  manifest  epileptiform  convulsions,  choreic  movements,  dilated 
pupils,  vertigo,  cephalalgia,  mental  disturbances,  and  even  contractures. 

Complications. — The  development  of  jaundice  will  indicate  obstruc- 
tion of  the  bile-duct,  in  cases  in  which  the  worms  have  been  found  in 
the  feces.  Intestinal  obstruction  from  coiled  -worms  has  occurred.  So 
also,  suffocative  symptoms  coming  on,  especially  at  night,  in  a  child 
with  worms,  may  be  due  to  a  migrating  lumbricoid.     Perineal  abscesses 


ASCARIASIS.  373 

and  inflamed  herniae  that  have  perforated  externally  sometimes  diseharge 
the  ascaris  lumbricoides. 

Diagnosis. — This  is  positively  determined  only  by  discovering  the 
worms  or  ova  in  the  stools. 

The  prognosis  is  good,  unless  serious  complications  arise  {vide  supra), 
when  it  should  be  guarded  accordingly. 

Treatment. — Prophylaxis. — The  water  used  for  drinking  purposes 
should  be  obtained  from  the  purest  sources. 

Before  giving  an  anthelmintic,  it  should  be  borne  in  mind  tliat  no 
good  result  can  be  certainly  obtained  unless  the  gastro-intestinal  tract 
be  nearly  deprived  of  food  for  from  twelve  to  thirty-six  hours,  so  that 
the  toxic  action  of  the  drug  used  may  be  exerted  directly  upon  the  un- 
protected worm. 

Santonin  is  at  once  the  most  efficient  and  the  most  easily  administered 
remedy.  It  may  be  given  in  doses  of  gr.  ;|^  to  1  (0.0162-0.0648)  of  the 
crystals  to  a  child,  or  from  gr.  ij  to  iv  (0.1296-0.2592)  to  an  adult,  in 
the  form  of  a  troche,  before  breakfast.  A  little  milk  or  other  light 
nourishment  may  be  allowed,  the  troches  being  continued  once  or  twice 
daily  for  two  or  three  days.  This  treatment  is  to  be  followed  by  a  brisk 
purge,  preferably  gr.  j  to  iij  (0.0648-0.1944)  of  calomel.  I  have 
sometimes  combined  small  doses  of  calomel  with  the  santonin  in  a 
troche,  and  with  good  effect.  Xanthopsia  or  yellow  vision,  spasms,  and 
even  convulsions,  and  saffron-colored  urine  may  follow  the  use  of  san- 
tonin in  cases  of  idiosyncrasy  or  overdose  of  the  drug.  Oil  of  worm- 
seed  (chenopodium)  in  doses  of  five  to  ten  drops,  in  emulsion,  capsules, 
or  on  sugar,  may  also  be  used  with  benefit.  Another  favorite  remedy 
with  some  is  the  unofficial  fluid  extract  of  spigelia  and  senna,  to  be  given 
in  from  1-  to  3-dram  (4.0-12.0)  doses.  Finally,  the  fluid  extract  of  spi- 
gelia alone  (1  to  2  drams — 4.0-8.0),  followed  by  a  brisk  purge,  may 
bring  away  dead  worms. 

Oxyiiris  Vermicularis  {Seat-,  Fin-,  Thread-,  or  Maw-ivorm). — 
Natural  History. — The  ascaris  vermicularis,  as  this  worm  is  also  called, 
inhabits  the  colon  and  especially  the  rectum.  It  is  a  small  worm,  as 
several  of  the  commonly-used  terms  signify,  and  frequently  it  occurs  in 
great  numbers,  sometimes  agglutinated  with  mucus  into  feculent  balls. 
It  is  most  common  in  children,  though  found  not  rarely  at  any  period  of 
life.  The  female  oxyuris  is  whitish  in  color  and  about  ten  or  twelve 
millimeters  (one-half  inch)  long,  the  male  being  about  three  or  four 
millimeters  (about  one-sixth  of  an  inch)  in  length.  Oxyures  develop 
from  ova  in  about  two  weeks  after  the  ingestion  of  the  latter.  The 
eggs  are  irregularly  ovoid,  about  -^  in.  (0.05  mm.)  in  length,  and  tena- 
cious of  life.  By  the  time  the  embryos  have  reached  the  cecum,  they 
are  sexually  mature,  and  when  the  female  arrives  in  the  rectum,  im- 
mense numbers  of  eggs  are  deposited  that  mature  into  great  numbers 
of  worms,  the  latter  being  discharged  with  the  feces.  Sometimes  the 
worms  crawl  out  of  the  anus. 

Infection  with  the  ova  may  take  place  through  water  and  food 
(green,  uncooked  vegetables  and  fruit)  that  have  come  in  contact  with 
the  hands  of  infected  persons.  Scratching  the  anus  will  permit  of  the 
reception  of  oxyuris  eggs  under  the  finger-nails  (Zenker  and  Heller), 
and  in  careless,  ignorant,  and  uncleanly  persons  the  possibility  of  such 
an  auto-  or  re-in/ection  should  be  recognized  and  avoided. 


374  ANIMAL  PARASITIC  DISEASES. 

Symptoms. — Priin'his  avi  (itchini;  of  the  anus),  sometimes  burning 
pain,  and  tenesmus,  with  restlessness  and  disturbed  sleep,  are  the  com- 
monest symptoms  of  the  presence  of  this  parasite.  The  itching  is 
always  woi-se  at  night,  and  may  be  paroxysmal.  An  herpetic  or  eczem- 
atous  eruption,  around  the  anus  should  arouse  suspicion,  particularly 
in  children,  of  the  presence  of  the  oxyuris  in  the  rectum,  and  it  ac- 
counts for  the  intense  itching.  Anorexia  and  anemia,  rectal  irritability, 
and  ''nervousness"  may  be  associated.  It  is  believed  that  the  migra- 
tion of  the  worms  into  the  vagina  may  excite  vulvo-vaginitis,  pruritis, 
and  leukorrhea,  and  that  habits  of  masturbation  may  be  induced  in  both 
girls  and  boys  by  the  sexual  irritation  caused  by  the  Avorm.  Inspection  of 
the  stools  will  reveal,  in  positive  cases,  the  whitish,  thread-like  parasites. 

Diagnosis. — The  pruritus,  indicating  rectal  trouble,  will  direct  the 
physicians  attention  to  the  anus,  where  the  oxyures  may  be  seen;  if 
not  found,  their  discovery  in  the  feces  or  the  discovery  of  the  eggs  by 
microscopic  examination  will  suffice. 

The  prognosis  is  good,  and  proper  treatment  is  always  effective,  though 
occasionally  exceedingly  refractory  cases  are  encountered. 

Treatment. — The  exhibition  of  anthelmintics  and  purgatives,  such  as 
recommended  for  destroying  and  removing  the  lumbricoid  worm,  may  be 
effective  against  seat-worms  also,  in  reaching  those  lodged  in  the  bowel 
above  the  rectum.  C.  W.  Stiles^  states  that  the  adult  worm  lives  in  the 
small  intestine  and  should  be  driven  into  the  large  intestine  by  an  an- 
thelmintic before  local  injections  are  given.  Ashford  recommends  beta- 
naphtol  in  2-dram  doses.  The  larval  forms  may  be  killed  by  methylene- 
blue  in  pills — 18  to  24  one-grain  pills  daily  for  five  days.  This  treat- 
ment is  to  be  taken  three  times,  ten  days  apart.  Attacking  the  oxyures 
directly,  however,  by  means  of  enemata  is  rational  treatment. 

The  rectum  should  be  well  emptied  of  feces,  so  that  the  worms  may  be 
exposed  to  the  action  of  the  medicament  injected,  and  for  this  purpose 
enemata  of  cold  water,  either  simple  or  with  salt  or  soap,  may  be  resorted 
to.  Injections  containing  the  decoction  of  quassia  (1  or  2  ounces — 32.0 
to  64.0 — of  the  powder  or  chips  to  the  pint — ^  liter — of  water)  are  nearly 
always  curative.  Other  useful  remedies  are  carbolic  acid,  turpentine,  tan- 
nin, vinegar,  canijjhor,  potassium  sulphid,  and  the  oil  of  eucalyptus.  The 
injections  should  be  repeated  once  or  twice  daily  for  at  least  ten  days. 

Rectal  irritation  may  be  allayed  by  injections  of  laudanum  and 
starch-water  (gtt.  iij-v  to  the  ounce — 32.0).  Anal  itching  is  often 
amenable  to  carbolized  vaselin,  at  bed-time,  or  to  belladonna  ointment. 

Ascaris  Alata. — This  is  another  name  for  the  ascaris  vi^stax,  a 
species  of  worm  found  in  the  intestines  of  the  dog  and  cat,  and  occa- 
sionally in  man.  It  is  a  slender  worm,  with  a  closely-rolled  spiral  tail 
and  a  wing-like  projection  on  either  side  of  the  head.  The  female  is 
about  6-7  centimeters  (2.7  inches),  the  male  about  4  centimeters  (1.75 
in.)  in  length.  Scarcely  ten  instances,  however,  have  been  recorded 
in  which  this  parasite  has  occurred  in  man. 

Trichocephalus  Dispar  (Ascaris  trichiura). — Natural  History. — 
This  so-called  whip  worm  measures  about  four  or  five  centimeters  (2 
inches)  in  length,  and  is  characterized  by  the  very  slender,  hair-like 
appearance  of  the  anterior  two-thirds  of  its  body,  in  contrast  to  the 
1 "  Proceedings  of  the  Araer.  Soc.  of  Tropical  Medicine,"  N.  Y.  Med.  Jour.,  Apr.  18,  1908. 


UNCINABIASrS.  375 

thick  posterior  portion,  wliicli  is  more  or  less  straiglit  and  blunt-pointed 
in  the  female,  but  rolled  into  a  spiral  in  the  male.  Its  particular  habitat 
seems  to  be  the  cecum,  though  sometimes  it  is  also  found  in  the  colon. 
It  may  exist  in  great  numbers.  Enroponns  appear  to  be  infected  with 
the  parasite  more  commonly  than  Americans. 

Propagation  is  effected  by  the  microscopic  eggs,  which  are  ovoid, 
hard,  nodular,  brownish,  and  about  0.05  mm.  {-^]^  in.)  in  length. 

Symptoms. — It  is  not  certain  that  the  parasite  causes  any  symptoms. 

The  diagnosis  is  made  by  detecting  the  microscopic  ova  in  the  feces. 

The  prognosis  and  treatment  are  not  called  for. 

UNCINARIASIS. 
{.Ankylostomiasis  ;  Hookworm  Disease. ) 

Ankylostomutti  Duodenale  (Dochmius  Duodenalis). — Natural 
History. — This  parasite  belongs  to  the  family  of  strongylidce  of  the 
nematoid  worms.  It  was  discovered  in  Milan,  in  1838,  by  Dubini. 
The  length  of  the  female  is  from  8  to  18  mm.  (^  inch),  and  of  the  male 
from  6  to  10  mm.  {^  inch).  Its  body  is  thread-like,  with  a  conical- 
shaped  head,  and  a  large,  bell-shaped  mouth  surrounded  by  a  horny 
capsule,  and  possessing  four  hook-like  teeth,  ventrally  situated,  and  two 
smaller,  vertical  teeth  on  the  dorsal  side,  by  which  the  worm  fixes  itself 
to  the  raucous  membrane.  A  bulbous-like  swelling  exists  at  the  tail  end 
of  the  male  worm.  It  inhabits  the  jejunum  and  duodenum.  The  eggs 
are  found  in  muddy  water,  or  in  warm  moist  earth,  and  there  liberate  the 
embryos.  These  develop  into  larvse,  which  soon  enter  the  dormant 
state,  remaining  quiescent  for  an  indefinite  period  until  they  are  taken 
into  the  human  stomach  through  drinking-water,  food,  dirt  ("  dirt-eaters  "), 
or,  more  commonly,  dirt  that  has  collected  upon  the  hands  and  about  the 
nails.  Probably  direct  infection  through  the  skin,  as  first  shown  by  Loos, 
is  the  usual  mode  of  infection,  however,  and  Allen  J.  Smith  and  others 
have  regarded  the  subtropical  dermatitis  known  as  "ground  itch  "  as  an 
expression  of  this  mode  of  infection.  Loos  has  shown  that  on  the  com- 
pletion of  the  exogenous  phase  of  the  embryo,  the  parasite  enters  through 
the  skin,  generally  of  the  feet  and  legs,  by  contact  with  soil  contaminated 
with  the  ova  of  the  ankylostoma.  Carried  by  the  blood  stream  to  the 
lungs  it  passes  into  the  air  vesicles,  then  into  a  bronchus,  to  the  trachea, 
esophagus,  and  stomach,  and  finally  to  the  small  intestine.  Here  sexual 
characters  develop  in  the  parasites,  reproduction  ensues,  and  the  ova  are 
deposited  in  the  bowel.     They  do  not  multiply  within  the  intestine. 

Predisposing  Causes. — (a)  Geographical  Distribution. — The  par- 
asite is  found  in  Italy,  Egypt,  India,  Philippines,  Germany,  Belgium. 
Switzerland,  and  in  England  was  found  by  Haldane  in  miners  in  Corn- 
wall. B.  K.  Ashford^  (U.  S.  Army)  has  shown  that  a  large  percentage 
of  all  cases  of  anemia  occurring  in  Porto  Rico  are  induced  by  this  para- 
site. H.  F.  Harris  has  found  the  ankylostoma  prevalent  along  the  Gulf 
of  Mexico  and  in  the  southeastern  section  of  the  United  States.  The 
Rockefeller  Sanitary  Commission,  after  a  survey  made  to  determine  the 
degree  and  extent  of  hookworm  infection,  show^ed  that  hookworm  disease 
belts  the  earth  in  a  zone  about  6Q  degrees  wide,  extending  from  parallel 
36  north  to  parallel  30  south  latitude.  Not  less  than  58  per  cent,  of  the 
earth's  estimated  population  is  in  the  infected  area.  The  importation  of 
1  New  York  Medical   Jour.,  April  14,  1900. 


376  AXIMAL  PARASITIC  DISEASES. 

infected  Italian.  Hun<Tarian,  and  Polisli  laborers  may  be  accountable  for 
the  propagation  of  the  parasite  in  the  United  States.  Stiles  has  studied 
the  parasite  of  American  origin  correlatively  Avitli  that  kno^vn  to  foreign 
observers,  and  suggests  the  term  Necator  Americanus.  (b)  Sex. — 
Males  and  females  are  infected  to  the  same  extent,  (c)  Age. — Tlie 
greatest  infection  occurs  between  the  age  of  six  and  sixteen  years  (Wells). 

Pathology. — The  ankylostomum  is  probably  nourished  Dy  the  plasma 
of  the  blood  it  sucks  from  the  intestinal  vessels,  though  this  is  denied  by 
Loos.  It  is  found  postmortem,  sometimes,  in  the  mucous  or  even  sub- 
mucous coat,  rolled  up  in  a  little  blood-cavity.  Ecchymoses,  containing 
a  central  opening  through  Avhich  blood  can  ooze,  are  the  usual  result  of 
the  worm's  action.  Chronic  catarrhal  enteritis  is  usually  associated. 
Hypertrophic  dilatation  of  the  heart  is  observed. 

Symptoms. — The  chief  symptom  of  the  condition  is  progressive  anemia 
(secondary),  and  the  skin  is  a  pasty  yellow  or  dirty  gray  color,  called  in 
the  southern  part  of  the  United  States  "  Florida  complexion."  When 
the  number  of  ankylostoma  embryos  introduced  into  the  intestine  is  large, 
the  anemia  may  develop  acutely  ;  when  but  a  few  are  introduced,  the 
Avithdrawal  of  blood  is  more  gradual,  and  clironic  anemia  develops.  I 
think,  however,  it  may  be  safely  affirmed  that  the  anemia  is  not  wholly 
due  to  blood-sucking,  but  that  some  poisonous  substance  is  given  oft"  by 
the  worm,  of  the  nature  of  a  hemolytic  toxin.  The  impoverishment  of 
the  blood  has  been  so  profound  as  to  simulate  a  pernicious  anemia. 

Ashford  found  the  red  cells  to  vary  between  700,000  and  3,525,000 
per  cmm.,  and  the  hemoglobin  between  10  and  55  per  cent.  Leukocytosis 
is  not  a  feature  of  uncomplicated  cases  ;  the  polymorphonuclear  cells  may 
show  slight  reduction,  and  the  lymphocytes  a  moderate  increase.  Eosino- 
philia  is  common  iu  this  as  in  many  parasitic  diseases,  and  may  reach  40 
per  cent,  or  more.  In  mild  cases,  however,  eosinophilia  may  not  be 
available  for  diagnosis,  in  which  case  the  feces  should  be  examined  for 
eggs.  The  red  cells  are  pale,  of  irregular  size  and  outline ;  normoblasts 
ai'e  plentiful,  and  less  often  megaloblasts  are  found.  This  parasite  is  the 
cause  of  "Egyptian  chlorosis,"  first  described  by  Griesinger.  Ankylos- 
tomiasis is  not  uncommon  in  tropical  countries.  In  Italy  it  has  been 
termed  tunnel  or  mountain  anemia ;  in  Belgium  it  is  known  as  brickmaker  s 
anemia  ;  again,  it  occurs  among  w^orkers  in  coal  mines — miner  s  cachexia. 

There  may  be,  in  addition,  slight  gastro-intestinal  disorder  (anorexia, 
colicky  pains,  nausea  and  vomiting,  and  constipation  alternating  with 
diarrhea).  In  cases  marked  by  an  acute  development  of  anemia  consid- 
erable general  weakness,  dyspnea,  and  dropsy  may  ensue.  There  is  no  loss 
in  weight ;  but  swelling  of  the  feet  and  ankles,  sleeplessness,  headache, 
faintness,  palpitation,  and  scanty  perspiration  are  common  symptoms. 
The  renal  function  is  maintained  and  slight  fever  may  develop.  Corneal 
ulcer  is  not  uncommon.     Lemann  ^  describes  infantilism  in  uncinariasis. 

Physical  Signs. — The  areas  of  the  apical  cardiac  impulse  and  of  car- 
diac dulness  are  increased.  Various  murmurs — hemic — may  be  heard, 
and  palpitation  and  dyspnea  are  common.  In  those  affected  the  face  is 
peculiarly  dull,  expressionless,  and,  owing  to  the  marked  metabolic  disturb- 
ance, the  growth  of  young  subjects  is  greatly  hindered. 

Diagnosis. — This  is  made  by  finding  the'  eggs  or  mature  worms  in  the 
feces.  The  former  are  oval-shaped,  about  0.05  mm.  {-^\-^  in.)  in  length, 
^Archives  of  Internal  Medicine,  Chicago,  August,  1910. 


TRICTIINrASIS.  -.Ml 

and  have  a  much  thinner  shell  than  the  ova  of  the  round  worm.  Ova 
are  seen  with  a  \  objective  and  are  commonly  entangled  in  the  mucus 
that  escapes  with  the  feces.  Suspicious  specimens,  if  negative,  should  be 
centrifuged,  Bass' ^  method  being  preferable  for  the  purpose.  "If  in 
doubt  as  to  the  diagnosis  of  the  eggs,  they  may  be  hatched  out  in  twenty- 
four  to  forty-eight  hours  and  the  characteristic  larvKi  h)oked  for  "  (JJock 
and  Bass).  In  cases  of  pronounced  anemia,  in  which  the  cause  is  obscure, 
the  patient's  dejections  should  be  carefully  examined. 

Duration. — The  disease  may  last  for  months  or  for  several  years. 

Prognosis. — If  left  untreated,  the  affection  may  end  fatally.  Intense 
anemia,  obstinate  diarrhea,  and  profound  nutritive  disturbances  constitute 
symptoms  of  grave  import.  Properly  treated,  the  prognosis  is  fsivorable, 
although  the  subject  remains  a  carrier. 

Treatment. — Prophylactic. — Workmen  in  mines,  tunnels,  and  brick- 
yards, and  in  tropical  localities  especially,  should  be  warned  not  to  drink 
the  water  close  at  band  without  previous  boiling  and  then  cooling.  Stools 
infected  with  ankylostoma  ova  should  be  carefully  disposed  of  and  efforts 
at  prevention  of  further  pollution  of  the  soil  be  made.  The  feet,  legs, 
and  hands  should  be  protected  against  contamination  with  infected  soil. 

Medicinal. — Anthelmintics  to  kill  the  ankylostoma  and  purgatives  to 
remove  it  from  the  intestine  are  indicated.  The  "Permanent  Commission 
for  the  Suppression  of  Uncinariasis  in  Porto  Rico  employ  repeated  doses 
of  thymol  and  betanaphtol,  preceded  and  followed  by  a  saline.  Branch^ 
administers  30  gr.  (2.0  gm.)  of  thymol  in  powder  at  4,  6,  8,  and  10 
A.  M.,  on  an  empty  stomach,  followed  by  an  ounce  of  castor  oil  at  6  P.  M. 
The  State  Board  of  Health  of  Florida  recommends  the  following  dosage  : 
Under  5  years  of  age,  up  to  8  grains ;  5  to  10  years  of  age,  8  to  15 
grains;  10  to  15  years  of  age,  15  to  30  grains;  15  to  20  years  of  age, 
30  to  45  grains ;  20  to  60  years  of  age,  45  to  60  grains  ;  over  60  years 
of  age,  45  grains.  The  condition  of  the  heart,  the  degree  of  debility  and 
anemia  should  also  be  considered.  Manson  sounds  a  note  of  warning 
concerning  the  use  of  thymol.  He  says  alcohol  should  never  be  given  at 
the  same  time  nor  for  some  hours  after  a  dose  of  thymol,  as  the  drug  is 
soluble  in  alcohol  and  may  then  exercise  its  toxic  action  on  the  host  as 
well  as  on  the  parasite.  After  this  routine,  nourishing  food,  fresh  air. 
iron,  and  tonics  are  to  be  given. 

TRICHINIASIS. 
{Trichinosis.) 

The  parasite  that  gives  rise  to  this  affection  is  tricliina  spiralis. 

Natural  History. — The  mature  male  worm  is  0.8  to  1.5  mm.  (Jg- 
in.)  long  and  the  female  2  to  4  mm.  (^^2 — \  in-)-  ^^®  head  is  pointed  and 
unarmed,  and  the  neck  is  long  and  more  slender  than  the  body,  which 
has  a  round  blunt  end.  The  worm  is  viviparous.  It  inhabits  the  intes- 
tines of  such  animals  as  the  rat,  dog,  cat,  hog,  and  man. 

The  embryo  or  muscle  trichina  is  about  0.6  to  1  mm.  (2^  in.)  long,  and 
lies  coiled  up  in  a  spiral  form  within  an  ovoid  capsule  in  the  sarcolemma- 
sheath  of  muscle-fiber.  The  life-history  begins  with  the  larval  state  of 
the  trichinae  encysted  in  the  muscles.  When  this  flesh  is  eaten  by  another 
animal,  or  by  man,  the  larvae  are  liberated  during  the  digestive  process. 
Passing  into  the  intestines,  they  reach  the  adult  stage  in  from  two  to  four 
'  "  Hookworm  Disease,"  Dock  and  Bass,  pp.  175, 176.       -  Brit.  Med.  Jour.,  March  5, 1904. 


378  ANIMAL  PARASITIC  DISEASES. 

days,  being  then  sexually  mature,  and  in  five  to  seven  days  more  they 
produce  hundreds  of  living  embryos. 

The  intestinal  trichinae  become  fully  grown,  and  then  usually  die  in 
from  four  to  tive  weeks.  The  female  trichina  may  bring  forth  several 
broods  of  embryos  during  her  life-period  in  the  intestine.  The  living 
embrvos  leave  the  intestine  at  once,  and  invade  the  muscles  through 
various  channels — principally  along  the  connective-tissue  routes — so  that 
the  symptouis  of  muscular  irritation  develop  in  from  seven  to  ten  days 
after  eating  the  trichinous  meat.  The  embryos  attain  to  maturity  (larval 
form)  in  about  two  weeks  after  entering  the  muscular  tissues.  Their 
presence  causes  a  mechanical  irritation  that  results  in  the  formation  of  a 
fibrous  capsule  in  from  four  to  six  weeks.     In  man  it  probably  becomes 

encysted  at  a  later  period  than 
in  the  lower  animals,  as  shown 
by  the  accompanying  illustration, 
taken  from  a  case  under  the  im- 
mediate observation  of  Dr.  L.  Na- 
poleon Boston  (Fig.  27).  Usually 
but  a  single  worm  is  found  within 
one  capsule,  though  occasionally 
three  or  four  are  seen.  The  en- 
capsulated trichinte  may  live  many 
years  in  the  muscles.  With  in- 
creasing age  the  capsules  become 
thicker  and  may  be  the  seat  finally 

Fig.  27.— Trichina  spiralis  from  the  head  of  ^f  rnlpnrpnnsj  infiltvq+inn  Tn    fVia 

the  right  gastrocnemius  muscle  three  weeks  after  X     ^^^^^^^^^^  mmiiation.  in    tUB 

the  first  symptoms  appeared  (Queen  obj.  |;  eye  hocr,   CalcareOUS  infiltration  of  the 

piece  No.  II).                                                                                  1        •       4.1,                    J.-  1 

capsule  IS  the  exception,  hence 
the  difficulty,  even  impossibility  of  seeing  them  with  the  unaided  eye. 

Pathology. — The  diaphragm  is  most  thickly  infested  with  the  larval 
trichinae.  Next  in  order  are  such  trunk-muscles  as  the  intercostals  and 
abdominals,  then  the  muscles  of  the  neck,  including  the  larynx,  head, 
eyes,  and  extremities.  Up  to  the  seventh  week  of  the  disease  the  intes- 
tinal trichinae  may  be  very  numerous.  Microscopically,  the  muscles 
show  "the  changes  characteristic  of  acute  myositis  "  (Fitz)  after  the  fifth 
week.  The  trichinous  cysts  in  the  muscles  may  be  seen  with  the  naked 
eye  as  small,  grayish-white,  opaque,  "oat-shaped"'  specks,  longitudinally 
disposed  in  the  meat-fibers. 

Sources  of  the  Trichina. — The  trichina  was  first  found  in  pork — 
the  usual  source  of  trichiniasis  in  man — by  the  late  Joseph  Leidy.  Recent 
investigations  show  that  the  live  trichinae  may  be  found  in  the  fatty  as 
well  as  the  fleshy  portion  of  pork.  The  pig  is  infested  by  eating  tri- 
chinous rats,  trichinous  pork,  or  human  or  porcine  excrement  containing 
the  embryos  of  propagating  intestinal  trichinae.  The  rat  maj^  be  the 
original  host  of  the  parasites,  or  it  may  itself  become  infected  by  older 
rodents  eating  their  fellows,  or  by  eating  trichinous  pork  or  human  or 
porcine  excrement. 

As  to  the  frequency  of  the  infection  of  hogs,  it  may  be  said  that  about 
2  per  cent,  were  found  to  be  tricliinous,  according  to  Salmon's  report 
(1884),  of  nearly  300,000  examinations  of  American  pork.  In  Prussia, 
according  to  Eulenberg's  statistics,  the  ratio  is  decidedlv  less  varying — 
from  1  to  2160  hogs  (1876)  to  1  to  1817  (1889).     "  The  dissecting-room 


TRICHINIASIS.  379 

and  postmortem  statistics  show  that  from   J   to  2  per  cent,  of  all  bodies 
contain  trichinge  "  (Osier). 

Of  course,  man,  as  a  rule,  becomes  infected  by  eating  raw  or  partially 
cooked  pork  containing  living  muscle-trichinse  (larvae).  Eating  raw  liam 
and  sausages,  a  habit  common  among  the  Germans  of  Prussia  (particu- 
larly during  picnics),  and  in  some  parts  of  the  United  i*^tates  where 
German  emigrants  have  settled  in  large  numbers,  explains  the  compara- 
tive frequency  of  this  disease  in  such  localities.  About  900  cases  have 
been  reported  in  the  United  States  in  the  past  forty-five  years  (Beecher). 
Trichiniasis  has  occurred  in  epidemic  form  in  North  Germany,  France, 
Spain,  Russia,  the  Scandinavian  countries,  and  in  several  of  the  north- 
western United  States. 

Symptoms. — Postmortem  examination  often  reveals  the  presence 
of  unsuspected  muscle-trichinae. 

In  well-marked  cases  of  infection  g astro-intestinal  disturbances  appear 
on  the  second  or  third  day  after  the  ingestion  of  the  aifected  meat.  Vom- 
iting, diarrhea,  and  colicky  pains  in  the  abdomen  may  be  present.  The 
diarrhea  sometimes  takes  on  the  characteristics  of  a  choleraic  attack  or 
may  be  followed  by  obstinate  constipation. 

Extreme  "muscular  weariness"  and  bodily  fatigue  often  occur  for 
several  days  before  the  embryonic  parasites  can  have  begun  to  wander 
into  the  muscles.  On  about  the  tenth  to  the  fifteenth  day,  when  migra- 
tion usually  commences,  chills,  followed  by  a  temperature  of  101.5°  to 
104°  (38.6°  to  40°  C.)  and  marked  myositis,  come  on.  The  muscles  are 
stiff,  tense,  painful  on  pressure  and  motion,  and  somewhat  swollen.  The 
flexors  of  the  extremities  are  particularly  sore  and  often  firmly  con- 
tracted, causing  the  knees  and  elbows  to  be  acutely  bent.  3Iastication^ 
deglutition,  and  ])}tonation  may  be  difiicult  and  painful  because  of  the 
involvement  of  the  muscles  of  the  jaws,  pharynx,  larynx,  and  tongue.  In- 
tense dyspnea  is  frequent  on  account  of  the  involvement  of  the  diaphragm 
and  intestinal  muscles.  The  temperature  shows  marked  remissions  in  most 
cases,  and  may  even  be  subnormal.    The  pulse  varies  with  the  temperature. 

Edema  is  characteristic  in  nearly  all  of  the  cases.  It  appears  on 
about  the  seventh  day  after  the  infection,  and  begins  in  the  face  (frontal 
region),  usually  being  noted  first  in  the  eyelids,  and  extending  thence  to 
the  extremities  and  trunk  during  the  height  of  the  muscular  symptoms. 
It  may  last  for  several  days,  then  disappear  for  several  days  or  a  week, 
and  reappear.  Ascites  even  has  been  observed.  Oedema  of  the  larynx 
and  bronchial  catarrh,  the  latter  rarely  leading  to  broncho-pneumonia, 
may  also  supervene  and  add  to  the  gravity  of  the  dyspnea.  Profuse 
sweating  may  last  for  several  weeks.  Miliaria,  urticaria,  acne,  furuncu- 
losis,  herpes,  and  pruritus  may  occur  as  skin-manifestations.  Insomnia, 
headache,  a  temporary  loss  of  the  tendon-reflexes,  and  dilatation  of  the 
pupils  (Rupprecht)  have  been  noted  among  the  nervous  symptoms.  Pro- 
longed cases  show  a  marked  degree  of  emaciation  and  anemia.  T.  R. 
Brown  ^  found  a  decided  increase  of  the  eosinophiles  in  the  blood,  amount- 
ing to  37  per  cent.  This  discovery  has  been  confirmed.  W.  T.  Howard, 
Jr.,^  noted  eosinophiles  in  the  muscle-lesions,  but  failed  to  find  an  increase 
of  these  cells  in  the  circulating  blood.  Opie"*  administered  trichina 
spiralis   to   the   guinea-pig,  and  found  that   a   resulting  mild   infection 

1  Johns  Hopkins  Hospital  Bulletin,  1897,  vol.  viii. 

2  Phila.  Med.  Jour.,  December  2,  1899.  ^  Amer.  Jour.  Med.  Sci.,  March,  1904. 


380  ANIMAL  PARASITIC  DISEASES. 

stimulates   the  eosinophile  cells  to  active  multiplication,  but  severe  infeo- 
tion  causes  their  destruction.    A  marked,  absolute  leukocytosis  is  the  rule. 

There  is  little  doubt  that  the  ''muscle  symptoms,"  varying  with  the 
site  of  the  muscle  attacked,  can  be  explained  on  the  basis  of  a  reaction- 
ary inflammation,  a  true  myositis  existing  about  the  parasitic  cysts  as 
Brown  has  shown,  but  the  general  symptoms  are  probably — in  part  at 
least — due  to  some  toxic  emanation  from  the  parasite  itself. 

Complications,  as  a  typhoid  state,  hypostatic  pneumonia,  and  pleurisy 
may  appear.     Albumin,  with  casts,  are  found  in  the  urine. 

Recovery  is  effected  in  mild  cases  within  two  weeks,  while  in  the 
severe  ones  from  six  weeks  to  several  months  may  be  occupied. 

Diagnosis. — The  following  symptoms  are  regarded  as  pathogno- 
monic :  sudden  swelling  of  the  face,  coming  on  after  the  patient  has 
suffered  for  several  days  from  muscular  soreness ;  loss  of  appetite,  fever, 
and  profuse  sweats  (Bohler)  ;  painful,  tender,  and  "rubber-like"  hard- 
ness of  the  muscles,  with  difficulty  in  movement ;  semiflexed  extremities ; 
gastro-intestinal  catarrh,  with  a  red,  dry,  coated  tongue ;  dyspnea,  diar- 
rhea, and  edema  of  the  extremities  following  the  subsidence  of  that  first 
noticed  in  the  face.  Friedreich  emphasizes  hoarseness,  and  the  late  Dr. 
Packard  rapidity  of  respiration  without  evident  cause. 

Differential  Diagnosis. — Meat-  and  sausage-poiso^iing  may  be  distin- 
guished from  trichiniasis  by  the  more  rapid  course  of  the  former,  the 
dry  throat  and  skin,  jaundice,  visual  disturbances,  and  the  absence  of 
edema  and  muscular  symptoms. 

Direct  examination  of  the  passages  and  of  the  muscles  may  be  resorted 
to.  The  discovery  of  the  parasites  in  the  pork  a  portion  of  which  has 
been  eaten  by  the  sick  establishes  the  diagnosis.  A  low-power  micro- 
scope should  be  used  to  examine  the  intestinal  mucus  for  the  trichinae. 
Light  purgation  should  precede  this  endeavor.  Harpooning  such  muscles 
as  the  biceps  for  the  purpose  of  removing  some  muscle-fiber,  or  directly 
incising  a  small  portion  under  Schleich's  method  of  infiltration-anes- 
thesia, may  permit  of  a  positive  diagnosis. 

Acute  rheumatism,  cholera,  typlioid  fever,  and  acute  polymyositis 
(pseudo-trichiniasis)  may  at  times  resemble  trichiniasis.  Epidemics  of 
the  parasitic  disease  are  more  readily  diagnosed  than  an  isolated  case. 

Prognosis. — This  depends  upon  the  number  of  parasites  ingested 
and  upon  the  number  of  embryos  generated  in  the  intestines.  Marked 
early  diarrhea  is  favorable.  The  prognosis  should  be  guarded,  as  death 
may  occur  as  late  as  from  the  fourth  to  the  sixth  week.  Of  357  cases 
collected  by  Packard,  the  mortality  Avas  24.07  per  cent. 

Treatment. — Prophylaxis  is  of  supreme  importance,  both  as  to  the 
infection  of  the  hog  and  the  danger  of  eating  infected  pork.  Care  should 
be  exercised  in  the  feeding  of  swine,  and  the  destruction  of  rats  should 
be  made  as  complete  as  possible  in  and  about  the  styes.  Pig-excrement 
should  be  removed  and  burned,  and  feeding  with  milk,  bran,  grain,  and 
vegetables  should  be  forced  upon  all  keepers  of  swine. 

Rigid  inspection  of  the  meat-supply,  as  is  done  in  Germany,  should 
be  carried  out  by  government  sanitary  officers.  Decidedly  the  safest  and 
most  efficient  way  to  prevent  ti'ichinosis  is  to  thoroughly  salt,  smoke,  and 
cook  the  pork  that  is  to  be  used.    Putrefaction  does  not  kill  the  parasites. 

The  treatment  of  thpse  who  have  eaten  trichinous  meat  should  be  by 
a  prompt  evacuation  of  the  bowel,  especially  within  the  first  twenty-four 


FILABIASIS. 


381 


hours,  as  after  tho  embryo  young  have  been  brougbt  forth  and  have 
passed  into  the  muscles  no  known  treatment  is  successful  in  attacking 
them.  Calomel  is  one  of  the  best  drugs,  and  active  purgation  usually 
follows  its  use  in  large  doses,  succeeded  by  salines ;  rhubarb,  senna,  sul- 
phur, aloin,  and  large  doses  of  oil  or  glycerin  may  also  be  tried.  In 
combination  with  the  purgatives  some  anthelmintic  (male  fern,  santonin, 
thymol)  should  be  used.  The  encysted  or  larval  parasites  are  not  acces- 
sible to  treatment,  although  picric  acid  has  been  recommended.  The 
symptoms  to  be  met  are  the  great  muscular  pains,  insomnia,  anfl  weak- 
ness; which  is  often  severe  in  protracted  cases.     Prolonged  hot  baths. 


"7^ 

^ 


Fig.  i!S.— The  movement  of  a  single  tilaria  during  a  series 
of  four  successive  instantaneous  exposures.  The  length  of 
each  exposure  was  one-fifth  of  a  second,  the  entire  series 
occupying  less  than  five  seconds.  The  magnification  is  to 
eight  hundred  diameters,  with  a  Zeiss  one-twelfth  homoge- 
neous immersion  lens  (F.  P.  Henry). 


Fig.  2y.— Filaria  alive  in  the 
blood.  Instantaneous  photomi- 
crograph. Four  hundred  diam- 
eters magnification.  Four  milli- 
meters Zeiss  apochromatic  (F.  P. 
Henry). 


anodyne  embrocations,  with  hypodermics  occasionally,  may  prove  useful 
for  the  first ;  bromids,  chloralamid,  and  the  like  for  the  second  symptom ; 
and  a  concentrated  liquid  diet,  strychnin,  peptonoids,  and  the  like  for  the 
last.  Massage,  electricity,  and  stimulating  applications,  as  chloroform 
liniment,  may  be  required  during  convalescence  and  for  some  time  there- 
after to  combat  the  muscular  weakness,  soreness,  and  stiffness. 

FILABIASIS. 

{Filaria  Sanguinis  Hominis.) 

There  are  several  varieties  of  filarife  that  may  be  found  in  human 
blood.  The  two  principal  ones  are  t\iQ  filaria  sanguinis  liominis  nocturna 
and  filaria  sanguinis  hominis  diitrna.  But  two  other  distinct  species 
of  nematode  worms  infest  the  blood  of  tropical  man  according  to  Man- 
son.  These  are  filaria  perstans  and  filaria  demarquai.  Of  these 
various  forms  the  filaria  yxocturna  is  the  most  important  and  the  best 
known.  The  adult  forms,  male  and  female,  found  only  in  the  lymphatics,  are 


382  AXI.VAL  PARASITIC  DISEASES. 

calletl  aiaria  Baivroffi :  the  embryos,  wliich  alone  are  found  in  the  cir- 
culating blood,  are  termed  tilaria  uocturna.  Tiie  first  is  a.  white,  opaline 
thread-like  worm,  tapering  toward  the  ends,  which  latter,  however,  are 
blunt.  The  male  is  83  mm.  (3.2  inches),  the  female  155  mm.  (6.1  inches) 
long.  The  second  worm  is  known  only  in  embryonic  form,  and  is  dis- 
tinguished by  granulations  in  the  axis  of  the  body.  This  is  the  filaria 
diurna,  of  which  the  adult  form  is  said  to  be  the  Jihtria  hui,  now  known 
to  be  the  cause  of  Calabar  swellings.  Manson  found  them  in  the  blood 
of  Congo  negroes,  but  only  during  the  daytime.  On  the  other  hand,  the 
nocturnal  filaria  is  found  only  at  night,  or,  if  the  host  be  either  by  habit, 
necessity,  or  choice,  a  day  sleeper,  during  this  time,  showing,  then,  that 
there  is  some  condition  <if  the  body  during  quietude  that  is  conducive  to 
the  appearance  of  the  (ilaria  in  the  blood  (Granville).  Manson  observed 
that  during  the  diurnal  temporary  absence  of  the  filari;«  from  the  cutaneous 
circulation  they  are  found  principally  in  the  larger  arteries  and  the 
lungs.  This  ''  filarial  periodicity  "'  is  a  striking  characteristic.  Inversion 
cannot  be  induced  in  cases  of  filaria  diurna. 

Filaria  phih'ppiyiensis  is  also  worthy  of  mention.  Ashburn  and  Craig 
conclude:  ('/)  That  the  complete  development  of  Filaria  jjJnUppinmsis, 
discovered  l)y  them  in  1906,  has  been  followed  in  the  mosquito,  Culex 
fatic/ans ;  (h)  that  the  Filaria  philipjnnensis  is  distinguishable  from 
other  filaria  "  both  in  the  blood  and  during  the  developmental  cycle 
within  the  mosquito";  (c)  that  as  regards  the  time  of  its  occurrence  in 
the  blood,  the  organism  presents  no  periodicity. 

The  embryos  of  filaria  sanguinis  hominis  are  produced  by  the  female 
in  great  numbers,  and  are  so  small  that  they  readily  pass  through  the 
capillaries.  According  to  Manson,  who,  in  1877,  found  the  larvae  in  the 
stomach  of  a  female  mosquito,  it  is  probable  that  after  filling  itself  with 
the  blood  of  an  infested  man  during  sleep,  the  mosquito  seeks  stagnant 
water,  dies,  and  the  larvne  are  set  free.  In  this  way  it  may  happen  that 
man  takes  in  the  embryos  through  the  drinking-water.  More  recently 
it  has  been  shown  that  the  filaria.  once  in  the  stomach  of  the  mosquito, 
sheds  its  delicate  envelope,  then  pierces  the  wall  of  the  mosquito's 
stomach  and  lodges  in  the  thoracic  muscles.  Here  it  undergoes  further 
developmental  changes  during  two  weeks,  then  finds  its  way  into  the 
proboscis,  to  be  discharged  into  the  blood  of  the  human  host.  They  find 
a  permanent  seat  in  the  lymphatics  of  the  human  host,  mature,  and  bring 
forth  young.  Avhich  may  again  infest  the  blood  by  ]iassing  through  the 
lymph-ducts  into  the  thoracic  duct  and  general  circulation. 

The  geographic  distribution  of  filariasis  is  limited  mainly  to  the  tropics 
and  sub-tropics.  It  is  most  common  in  Brazil,  the  West  Indies,  Mexico, 
the  Southern  States.  Southern  China.  India,  Egypt,  a  part  of  Australia, 
and  the  southern  Pacific  islands,  where  it  is  endemic. 

The  symptoms  of  filariasis  are  in  abeyance  until  some  obstruction 
and  inflammation  <>f  the  lymjih-channels  is  caused  by  the  ])arasite.  There 
are  several  conditions  or  endemic  diseases  produced.  Elephantiasis  arabum 
is  believed  by  Manson  to  be  the  eft'ect  of  these  parasites,  in  a  certain  pro- 
portion of  cases  at  least.  In  specimens  of  night-blood  from  88  Cochin 
Chinese  he  found  filarire  in  21  ;  14  specimens  came  from  patients  with  ele- 
phantiasis, and  oidy  1  showed  filarite.  This  latter  fact,  he  explains,  is  to  be 
expected,  since,  in  order  to  give  rise  to  elephantiasis  (due  to  an  infarction  of 
the  lymphatic  glands  connected  with  the  diseased  areas),  the  adult  filariae 


BRAC'ONTIASIS.  .383 

must  lie  on  the  distal  side  of  the  glands,  which  rnukes  it  impossible  for 
the  young  filariae  to  pass  into  the  general  circulation,  "  '^i'herefore  the 
person  least  likely,  in  a  filarial  district,  to  have  filariye  in  his  hlood  is  one 
who  is  the  subject  of  elephantiasis."  ^  Embryos  can  be  demonstrated  in 
the  blood  as  soon  as  the  adult  filarite  reach  maturity  and  begin  to  dis- 
charge them,  ^.  e.,  before  the  usiuil  obstructive  symptoms  appear  (Jtivas 
and  Smith  ^). 

Hematochyluria  and  Chyluria, — The  patient  passes  a  white,  opaque, 
milky  urine,  occasionall}'  bloody,  with  a  clotty  sediment.  This  may  be 
intermittent,  and  normal  urine  may  be  passed  for  many  weeks  before 
chyluria  or  hematochyluria  reappears.  There  may  be  at  the  same  time  a 
slight  degree  of  polyuria.  Under  the  microscope,  fat  granules  and  Avhite 
and  red  corpuscles  are  seen.  The  lively,  wriggling  embryo  filarise  may 
also  be  discovered  in  the  urine,  as  well  as  in  the  blood  at  night.  There 
is  a  dilatation  of  the  lymph-vessels  in  the  kidneys  alongside  of  the 
tubules,  and  in  the  abdominal  lymph-plexuses.  Sometimes  a  little  vesical 
irritation  and  straining  during  urination  may  be  caused  by  the  endeavor 
to  pass  chylous  blood-clots.  The  thoracic  duct  above  the  diaphragm  has 
been  found  impervious  (Stephen  Mackenzie). 

Lymph-scrotum  and  lymph-vulva  have  been  caused  by  the  filarise.  The 
parts  are  greatly  swollen,  thickened,  and  contain  distended  lymphatics 
filled  with  a  turbid  and  either  milk-white,  salmon-colored,  or  blood-red 
coagulable  liquid  that  is  discharged  upon  puncturing  the  varices.  The 
filaria  is  not  always  found  in  the  exuded  lymph.  The  inguinal  and 
femoral  regions  are  often  enlarged.  An  erysipelatous  inflammation  of 
the  parts  is  not  infrequent  in  these  cases,  and  may  be  ushered  in  b}'  a 
chill  and  high  fever,  lasting  a  day  or  two,  and  ending  with  a  profuse  sweat. 

The  filarise  have  been  found  in  ascites  (Winckel),  in  hemoptysis,  and 
in  the  feces  (Yamane,  Japan).  Worms  killed  by  blows  or  other  injuries 
are  often  absorbed,  but  may  act  as  an  irritant  and  cause  abscesses. 

Treatment. — Healthy  subjects  must  protect  themselves  against 
mosquito  bites.  Filtering,  boiling,  and  storing  the  drinking  water  in 
mosquito-proof  receptacles  are  important  measures.  Thymol,  in  from  1- 
to  5-grain  (0.0648-0.324)  doses,  given  for  from  two  to  eight  weeks,  has 
caused  the  disappearance  of  the  larval  filarise  in  several  cases.  Methylene- 
blue  appears  also  to  have  produced  a  cure  in  a  case  of  chyluria  reported 
by  Flint.  Henry,  however,  states  that  he  has  "given  this  drug  in  larger 
doses  than  were  used  in  the  case  reported  by  Flint,  and  for  a  much  longer 
period,  without  the  slightest  effect  upon  the  parasite."^  The  adult  filaria 
seems  to  be  beyond  the  reach  of  any  known  medication  that  will  not 
prove  dangerous. 

DRACONTIASIS. 

( Guinea-worm  Disease.) 

The  parasite  is  the  Jilaria  or  dracunculus  medinensis  or  persarum, 
common  in  the  tropics  of  Asia,  Africa,  and  America.  It  is  usually  solitary, 
and  measures  from  50  to  100  cm.  (20  to  40  in.)  in  length  and  about  2  mm. 
[-^  in.)  in  diameter.  It  is  cylindric,  w'hitish,  with  blunt  papillated  head, 
and  a  sharp,  curved  tail.  The  body  is  nearly  filled  by  the  uterus,  which 
contains   innumerable   embryos,  which,   after   maturation   of  the  worm, 

^Bvilish  Med.  Jou.r.,  June  2,  1894.  ^Southern  Med.  Jour.,  October,  1912. 

3  Med.  News,  May  2,  1896. 


384:  ASIMAL  PARASITIC  DISEASES. 

escape  shortly  after  contact  with  -water  in  the  form  of  a  milky  fluid. 
The  process  of  emptying  the  uterus  takes  from  two  to  three  weeks.  This 
accomplished,  the  worm  dies.  It  is  then  taken  into  the  stomach  and  in- 
testines of  man  through  the  contaminated  drinking-water.  The  female 
enters  the  intestines  by  way  of  the  mesentery  and  brings  forth  its  young, 
which  pass  into  the  connective  tissue  of  its  human  host.  The  male 
worm  is  unknown.  The  worm  has  an  inexplicable  afiinity  for  the  sub- 
cutaneous and  intermuscular  tissues  of  the  feet  and  legs,  where  it  attains 
full  development. 

Symptoms. — Wherever  the  parasite  is  situated,  it  may  often  be  felt 
coiled  up  under  the  skin,  which  at  that  point  becomes  red  and  fluctuating 
like  an  abscess.  When  opened,  either  surgically  or  naturally  by  the 
worm,  the  head  appears  through  the  aperture.  The  favorite  spot  for 
perforation  is  the  dorsum  of  the  foot,  though  sometimes  it  extrudes  from 
the  legs,  rarely  the  thighs,  and  very  rarely  from  the  thorax  and  abdomen. 

Treatm.eiit. — Prophylaxis  in  regard  to  the  drinking-water  and  as  to 
bathing  where  the  intermediary  host  of  the  dracunculus — the  cyclops — 
has  its  habitat  is  essential  for  safety. 

The  treatment  embraces  the  surgical  measures  necessary  to  remove 
the  worm  and  to  promote  the  healing  of  the  irritated  tissues.  Roth  claims 
that  after  incision  the  application  of  carbolic  acid  (1  :  15)  causes  the  worm 
to  be  removed  in  two  or  three  days.  Native  Indian  physicians  commend 
highly  the  local  a.pplication  of  the  leaves  of  the  '"  amarpattee  "  plant. 

OTHER    PILARIS. 

Among  other  filarite  that  have  been  found  in  man  are  the  following : 
The  Jilaria  immitis,  which  causes  hematuria  and  has  been  found  in  the  por- 
tal vein,  whilst  the  ova  were  discovered  in  the  ureteral  and  vesical  walls ; 
jilaria  labiaUs,  found  in  a  lip  pustule ;  filaria  loitis.  found  in  a  cataract ; 
Jilaria  trachealis  and  bronchialis,  seen  in  the  trachea,  bronchioles,  and 
lungs  ;  filaria  hominis  oris,  observed  by  Leidy  in  the  mouth  of  a  child  ; 
filaria  loa,  noticed  in  the  tropics  among  negroes,  its  habitat  being  beneath 
the  conjunctiva.  Recently  L.  N.  Boston  found  filaria  mermus  (ac- 
cording to  Wardell  Stiles,  to  whom  he  referred  them)  in  a  cavity  in 
the  centre  of  an  apple.  They  are  believed  to  be  parasites  of  the  apple 
worm,  but  whether  pathogenic,  is  not  known. 

OTHER   AND   UNCOMMON   NEMATODES. 

Eustrongylus  Gigas. — This  parasite  is  exceedingly  rare  in  man,  but 
has  been  found  in  many  of  the  carnivora  and  in  some  herbivora.  It  is 
supposed  that  fish  act  as  the  intermediary  host  for  the  larvae.  The  worm 
is  enormous  in  size,  the  female  being  from  25  to  100  cm.  (10  to  40  in.) 
in  length.  It  is  a  red,  cylindric  parasite  with  blunt-pointed  ends.  Its 
seat  is  the  kidney,  which  it  may  destroy,  causing  hematuria  and  the 
presence  of  the  eustrongylus  ova.  Dr.  John  McKenna  has  recovered  an 
adult  eustrongylus  from  a  child  whose  urine  had  long  contained  ova. 

Anguillula  stercoralis  or  strongyloides  intestinalis  occurs  in  the  stools 
of  certain  tropical  endemic  diarrheas.  It  is  common  along  the  Gulf  of 
Mexico.  The  parasites  are  oviparous,  and  the  eggs  may  be  taken 
through  the  drinking-water.  They  have  been  found  in  the  biliary  and 
pancreatic  ducts,  as  well  as  in  various  parts  of  the  intestines.  The  ad- 
ministration of  thymol  or  male-fern  is  to  be  recommended. 


OTHER  PARASITIC  INSECTS.  385 

Echinorhynchus  moniliformis  occurs  in  rats,  and  in  one  ca?«e,  that  of  a 
Sicilian,  reported  by  Calandruccio,  the  ova  were  found  in  the  feces. 

PARASITIC  ARACHNIDA. 

Pentastoma  Tenioides. — This  parasite  is  an  inhabitant  of  the  nasal 
fossae  of  the  dog  or  horse,  though  it  may  also  occur  in  man  both  in  this 
and  in  the  larval  form.  The  ova  are  ejected  during  sneezing,  and  are 
then  ingested  by  man.  The  larvae  are  found  in  the  liver,  lungs,  and 
kidneys. 

Sarcoptes  (Acarus  Scahiei). — This  insect  produces  the  skin  affection 
known  as  "  the  itch,"  or  scabies,  an  affection  more  common  in  Europe 
than  in  America,  where  it  constitutes  only  about  4  or  5  per  cent,  of  all 
cases  of  skin  disease.  It  is  most  prevalent  among  the  poor  and  the  un- 
clean. The  female  is  visible  to  the  naked  eye,  and  is  about  0.5  mm. 
(^  in.)  in  length ;  the  male  is  about  0.25  mm.  (y^  in.).  Both  are 
nearly  as  broad  as  they  are  long. 

The  parasite  penetrates  the  skin  and  lives  in  a  burrow  or  cuniculus 
that  it  makes  for  itself.  The  female  lives  in  the  end  of  the  burrow,  which 
may  contain  a  number  of  ova,  and  appears  as  a  minute,  brownish-black, 
dotted,  sinuous  line,  situated  chiefly  in  the  cutaneous  folds,  where  the  skin 
is  mostly  delicate,  as  between  the  fingers.  Secondary  skin  lesions,  due  to 
scratching,  are  common.  Sulphur  ointment,  well  rubbed  in  after  hot 
bathing,  is  usually  quite  efiicacious. 

Sarcoptes  scabiei  hominis  is  a  variety  of  the  preceding  that  infests 
other  animals  (cat,  dog,  cow,  horse,  wolf,  goat,  camel,  etc.).  Occasionally 
it  may  gain  an  entrance  into  man's  skin,  but  dies  simultaneously  in  the 
human  host,  although  many  invasions  may  occur. 

Leptus  Autumnalis  (Harvest  Bug). — The  most  comjnon  of  several  va- 
rieties is  a  mite  of  a  reddish  color,  having  six  legs  armed  with  claws  and 
sharp  mandibles.  It  arises  among  low  bushes  and  thus  appears  about  the 
ankles  and  legs.  It  partially  penetrates  the  skin,  boring  only  far  enough 
with  its  short,  thick  head  to  procure  nourishment.  Artificial  dermatitis 
may  be  produced  by  the  irritation  of  scratching.  Mercury,  sulphur,  and 
naphthol  ointments  suffice  to  destroy  the  parasite. 

Demodex  Folliculorum  (Comedo  Mite). — This  minute  parasite  may 
be  expressed  from  swollen  sebaceous  follicles  of  the  nose,  cheek,  and 
other  parts  of  the  face.  It  has  a  worm-like  body  with  very  short  legs, 
and  is  only  about  0.2  to  0.4  mm.  (-^  in.)  in  length.  It  is  not  known  to 
produce  acne,  as  was  formerly  supposed. 


OTHER  PARASITIC  INSECTS. 

PEDICULOSIS. 
(Phthiriasis.) 

Lice  or  pediciili  live  on  and  attack  the  skin.  Three  forms  are  found 
on  man  r  pediculus  capitis,  pedieulus  corporis,  and  pediculus  pubis. 

The  pediculus  capitis  is  whitish  or  grayish  in  color,  about  1  mm.  {-^ 
in.)  long  (male),  and  has  six  legs  under  the  front  part  of  the  body.     The 

25 


386  ANIMAL  PARASITIC  DISEASES. 

oviparous  female  is  nearly  twice  as  long  as  the  male,  and  lays  from  fifty 
to  eighty  eggs  on  the  hairs  within  a  week.  These  ova,  or  "nits,"  ma- 
ture in  from  three  to  eight  days.  Itching  is  the  most  prominent  symp- 
tom, and  an  eczematous  eruption  above  and  behind  the  cars  and  in  the 
neck  is  often  associated.  '■  Plica  polonica  ''  was  a  phrase  once  used  to 
designate  the  matted  condition  of  the  hair  in  extremely  dirty,  crusty, 
and  lung-neglected  cases  of  head-lice.  Secondary  adenojjathy  of  the 
cervical  lymphatic  glands  is  a  common  feature  in  neglected  cases. 

Pediculus  Vestimentorum  {Corporis). — This  louse  inhabits  more  often 
the  clothing  tiian  the  body  itself  It  is  larger  than  the  head  louse,  and, 
like  the  latter,  moves  slowly.  The  nits  are  found  with  difficulty  on  the 
fibers  of  the  underclothing.  It  sucks  blood  through  a  proboscis  inserted 
into  the  sweat  pores,  and  after  withdrawing  leaves  a  minute  hemorrhagic 
speck.  Irritation  of  the  skin  is  produced,  and  in  old  cases,  as  in  filthy 
tramps,  the  skin  becomes  scaly  and  quite  pigmented  (vagabonds  disease). 
The  efforts  at  scratching  are  almost  frantic,  and  after  a  cure  is  effected 
parallel  white  lines,  the  remains  of  scratch-marks,  followed  by  atrophic 
changes,  may  be  visible,  as  in  a  case  that  I  reported.^ 

Pediculus  or  Phthiriasis  Pubis  (Crab-louse). — This  parasite  is  not  limited 
to  the  pubis,  but  attacks  also  the  hairy  region  in  the  axilla,  on  the  chest, 
and  may  even  reach  the  beard  and  eyebrows.  It  clings  firmly  to  one  or 
two  hairs  close  to  the  skin.  Its  six  legs  with  strong  claws  are  placed 
closely  together  at  the  anterior  part  of  the  ovoid  body. 

Treatment. — The  hair  should  be  cut  short  where  the  head-lice  and 
nits  are  abundant.  Saturating  the  hair  and  scalp  with  kerosene  oil  for 
twenty-four  hours  usually  kills  the  parasites.  Body-lice  may  be  destroyed 
by  scalding  the  underclothing  and  hot-ironing  carefully  about  the  seams. 
A  hot  soap-and-water  bath  is  sufficient  for  the  body,  and  sedative  and 
antiseptic  ointmerjits  may  be  useful  adjuvants.  Mercurial  and  beta- 
naphthol  unguents  usually  suffice  in  treating  for  pediculus  pubis.  Prof. 
J.  V.  Shoemaker  affirms  that  naphtol  is  a  remedy  that  meets  the  indica- 
tions presented  by  all  forms  of  the  disease  ;  he  prepares  it  as  follows : 

I^.  Beta-naphtol,  3J  (4.0) ; 

Cologne  water,  fgiv-vi  (120.0-178.0).— M. 

Cimex  Lectularius  or  Bed-bug. — This  too  well-known  parasite  is  flat, 
brownish-red  in  color,  and  from  2  to  5  mm.  {-^-\  in.)  in  length.  It  in- 
fests beds  and  public  vehicles,  emitting  a  disagreeable  odor.  It  is  a 
blood-sucker,  and  causes  considerable  itching,  local  irritation,  and  urti- 
caria even  in  some  persons,  while  others  are  unmindful  of  their  attacks. 
Sulphur  fumigation  and  mercuric  chlorid  applications  to  the  harboring 
places  of  the  bed-bugs  are  effectual  destructive  agents.  Saturated  sodium 
bicarbonate  solution  will  relieve  the  burning  and  itching. 

Pulex  Irritans  (Common  Flea). — This  "ubiquitous"  parasite  is  from 
2  to  4  mm.  {y^-\  in.)  in  length,  black  or  (when  filled  with  blood)  brown- 
ish-red in  color,  having  six  legs,  the  hind  ones  of  which  are  relatively 
very  large  and  powerful,  enabling  it  to  jump  many  times  its  own  height. 
A  flea's  bite  causes  a  sharp  sting,  and  leaves  a  slightly  raised  red  spot 
with  a  dark,  pin-point  center,  the  site  of  penetration  of  the  biting  appa- 
ratus of  the  insect.  Treatment  is  the  same  as  for  the  preceding  insect. 
'  International  Clinics,  vol.  iii  ,  third  series,  p.  769. 


OTHER  PARASITIC  INSECTS.  'i87 

Pulex  Penetrans  ['■'■  Ji/ifjer''). — This  parasite,  also  called  "sand-flea," 
is  indigenous  to  the  West  Indies,  South  America,  and  the  Southern 
States.  The  impregnated  female  penetrates  the  skin,  and  especially  that 
of  the  feet,  for  purposes  of  ovulation.  As  the  distention  with  tiie  eggs 
occurs,  swelling,  pain,  and  even  ulceration  may  appear.  The  sand-flea 
is  a  small,  egg-shaped  insect,  about  half  the  size  of  an  ordinary  flea, 
brownish  in  color,  and  exceedingly  resistant  to  crushing  force.  Prophy- 
laxis in  regard  to  foot-wear  is  necessary.  Essential  and  antiseptic  oils 
may  also  be  put  on   the  feet  or  stockings. 

Ixodes  ( Wood-tick). — There  are  several  varieties  of  tick-  or  wood- 
louse  that  may  attack  the  human  skin,  among  which  ixodes  albipictus  is 
supposed  to  be  the  most  common.  Ixodes  rieinus  and  ixodes  bovis  are 
found  on  horses  and  cattle.  They  are  blood-suckers,  adhering  to  the 
skin  very  firmly,  and  wheals  may  be  produced  by  them.  A  drop  of  tur- 
pentine, or  of  some  such  essential  oil  as  anise  or  rosemary,  will  cause 
them  to  loosen  their  hold. 

Dermanyssus  Avium  et  Gallinse. — These  bird-  and  fowl-insects  are 
small  and  grayish-white  in  color,  and  may  attack  the  human  skin  and  cause 
eczematous  eruptions,  owing  to  the  scratching  induced  by  the  irritation. 

Culicidse  [Mosquitoes  and  Gfnats). — The  blood-sucking  mosquito  [culex 
auxifer),  so  well  known,  may  also  transfer  to  human  beings  the  filaria 
sanguinis  hominis  and  the  plasmodium  malarise. 

The  gnat  (culex  pipiens)  is  very  troublesome  during  certain  seasons, 
particularly  along  water-courses  and  in  wooded  districts.  Its  bite  is 
quick,  sharp,  and  stinging. 

The  hirudo  (leech)  is  a  parasite  that  sometimes  attaches  itself  to 
bathers.  In  the  tropics  it  has  been  known  to  cause  severe  bites  and 
inflammation.  A  remarkable  case  of  hemoptysis  is  on  record  in  which 
a  leech  was  found  attached  to  the  larynx,  below  the  cords. 

The  bites  and  stings  of  bees,  wasps,  spiders,  and  ants  have  been 
known  to  cause  considerable  inflammation,  edema,  and  blood-poisoning. 

Estridae  {Bot-flies). — These  may  become  parasitic  in  man  in  the  larval 
form.  Species  of  the  hydoxerma  and  dermatobia,  that  infest  the  skin 
of  the  horse,  ox,  goat,  etc.,  have  also  been  observed  among  the  Central 
and  South  American  Indians.  They  burrow  beneath  the  skin  of  the 
abdomen,  scrotum,  and  other  regions. 

Muscidse  (Common  Flies). — Common  flies  affect  the  skin  of  man  by 
depositing  eggs  in  wounds.  The  ova  hatch  within  twenty-four  hours 
sometimes,  and  the  dipterous  larvae  may  swarm  to  make  the  so-called 
*' living  "  wound  or  sore  (myiasis  vulnerum).  The  larvae  or  maggots  do 
not  penetrate  the  tissues,  however.  The  principal  flies  that  infest  wounds 
are  the  flesh-fly  (sareophila  carnaria),  the  blow-fly  (ealliphora  vomitoria), 
the  screw-worm  fly  (compsomyia  maeellaria),  and  the  ordinary  house-fly 
(musca  domestica). 

Internal  myiasis  may  also  be  caused  by  swallowing  the  ova  of  these 
flies.     The  larvae  may  thus  be  vomited  or  defecated. 

Epidemic  urticaria  is  often  caused  by  the  migration  of  the  caterpillar 
(cnethocampa).'  Among  other  parasites  that  attack  man  and  inhabit  par- 
ticular regions  are  the  following :  The  simulium  reptans,  or  creeping 
gnat  of  Sweden  ;  the  seroot-fly  (zimb)'  of  Abyssinia  ;  tne  ixodes  carapato, 
a  virulent  bed-bug  in  Brazil;  the  hcematopota  pluvialis  (Clegg)  of  the 
West  Highlands. 


388  ANIMAL  PARASITIC  DISEASES. 


SYPHILIS. 


Definition. — A  chronic  infectious  disease  communicable  from  per- 
son to  person  by  direct  or  indirect  contact  ■with  a  specific  virus,  or  by 
heredity.  According  to  its  clinical  course,  it  is  characterized  by  five 
periods  :  (1)  Period  of  primary  incubation — the  time  which  elapses  be- 
tween contact  with  the  poi:?on  and  the  appearance  of  the  chancre. 
(2)  Period  of  secondary  incubation — the  time  which  elapses  between  the 
appearance  of  the  initial  lesion  of  the  disease  (the  chancre)  and  the  de- 
velopment of  its  cutaneous  manifestations.  (3)  Period  of  secondary 
symptoms  (skin  eruptions).  (4)  Intermediary  period  characterized  by 
the  absence  of  lesions,  although  evidences  of  existing  dyscrasia  can  still 
be  found.  (5)  Period  of  tertiary  symptoms.  The  hereditary  form  of  the 
disease  is  transmitted  at  the  time  of  procreation  by  the  sperm  virile,  by 
the  ovum,  or  by  both.  Prince  Morrow '  points  out  that  the  important 
lesions  of  the  disease  are  those  that  occur  in  the  internal  organs — visceral 
syphilis. 

General  Pathology. — {a)  Primary  Lesion  of  Chancre. — This  ap- 
pears at  the  sit-e  of  inoculation,  an<l  is  characterized  by  infiltration  of  the 
connective  tissue  chiefly  with  round  cells  of  the  same  type  as  those  seen 
in  recent  granulations.  There  is  sclerosis  of  the  small  blood-vessels, 
chiefly  involving  the  adventitia  of  the  arterioles.  The  neighboring 
lymphatic  glands  soon  undergo  hyperplasia  and  induration. 

(6)  Secondary  Lesions. — Macular  and  maculo-papular  eruptions  are 
frequent,  and,  with  the  mucous  patch,  show  round-cell  infiltration  of  the 
connective  tissue  and  blood-vessels  similar  to  that  found  in  the  chancre, 
■\vith  plasma  cells  and  leukocytes.  The  favorite  sites  for  mucous  patches 
are  the  mucocutaneous  junctions  (mouth,  anus.  etc.).  Other  lesions  of 
this  stage  are  general  adenopathy,  alopecia,  and  pharyngitis. 

(c)  Tertiary  Lesions. — These  are  circumscribed  inflammatory  prod- 
ucts known  as  gummata.  They  appear  in  the  connective  tissue,  bones, 
periosteum  ("nodes  "),  skin,  muscles,  brain,  liver,  lungs,  kidneys,  heart, 
testes,  etc.  The  gummata,  though  usually  sharply  circumscribed,  may 
take  the  form  of  diffuse  infiltrations  and  vary  in  size — from  a  pin's  point 
to  a  hen's  egg.  Usually  firm,  they  maybe  soft,  and  tend  to  form  ulcers. 
Their  color  is  grayish,  and  on  section  they  show  a  caseous,  semi-opaque 
center,  with  a  fibrous,  translucent  periphery. 

Microscopirally ,  the  gumma  consists  of  lymphoid  cells,  plasma  cells, 
leukocytes,  and  epithelioid  cells,  in  Avhich  fatty  degeneration  and  soften- 
ing result  in  the  formation  of  a  pasty  mass.  The  mass  thus  formed  may 
either  be  absorbed  or  persist ;  but  in  most  instances  coagulation-necrosis 
occurs  in  the  center,  with  conversion  of  the  peripheral  zone  into  fibrous 
tissue.  Gummata  of  certain  structures  (skin,  mucous  membrane,  bones, 
and  cartilages)  often  lend  to  destructive  ulceration  and  sloughing. 

General  Ktiology. — Parasitology. — Schaudinn  and  Hoff'man^  de- 
scribed two  spiral  micro-organisms  ;  one,  from  the  deeper  layers  of  the 
chancre,  condylomata,  and  lymph-glands,  the  specific  organism,  or  the 
treponema  pallidum  ;  while  from  the  superficial  part  of  the  lesions,  the  non- 
specific gpirochceta  refringens.     The  treponema  pallidum  in  length  varies 

*  Deulsch.  med.  Wochenschr.,  May  4,  1905. 
1  Medkai  News,  March  23,  1901. 


SYPHILIS.  389 

from  one  to  six  times  the  diameter  of  a  red  blood-cell,  in  width  from 
unmeasurable  thinness  to  ^  //.  Metchnikoflt"  and  Jloux  '  hav(;  demon- 
strated this  organism  in  ac(iuired  syphilis  of  man  and  in  experimental 
lues  in  the  monkey  and  ape. 

Predisposing  Causes. — Since  acquired  syphilis  originates  only  by  in- 
oculation, it  is  obvious  that  a  break  in  the  cutaneous  or  mucous  surfaces 
is  essential  to  infection,  such  as  a  slight  abrasion,  fissure,  or  laceration, 
etc.,  particularly  of  the  genital  mucosae.  Other  surfaces  may  also  be 
the  seat  of  infection,  as  the  lips,  hands,  etc. 

Susceptibility  to  the  virus  is  universal,  and  no  age  is  exempt.  Re- 
infection is  exceedingly  rare,  but  does  occur. 

Contagion  of  Syphilis. — The  blood  of  a  syphilitic  during  the  second- 
ary period,  and  the  secretion  from  the  chancre  or  any  of  the  secondary 
lesions,  are  contagious,  the  lesion  at  the  point  of  inoculation  always  being 
a  chancre.  The  physiologic  secretions,  saliva,  sweat,  milk,  and  semen, 
do  not  convey  the  virus,  unless  contaminated  with  the  discharges  from 
some  of  the  lesions  of  the  primary  or  secondary  stage.  The  semen  is 
able  to  infect  the  embryo  and,  in  turn,  the  mother.  There  is  experi- 
mental evidence  to  show  that  the  gumma  is  infectious. 

Modes  of  Infection. — (1)  In  a  great  proportion  of  the  cases  (about  70 
per  cent.)  syphilis  is  transferred  by  illicit  sexual  intercourse. 

(2)  Accidental  Inoculation. — This  is  not  uncommon,  (a)  Most  fre- 
quently it  is  accomplished  through  the  pernicious  custom  of  indiscrim- 
inate kissing  (lip-chancre),  and  I  have  personal  knowledge  of  not  less 
than  8  instances  in  which  infection  has  occurred  through  labial  contact. 
In  Russia  from  75  to  80  per  cent,  are  acquired  in  this  manner  from  pop- 
ular customs. 

(h)  The  site  of  inoculation  may  also  be  the  mouth  and  tonsils,  the 
virus  being  conveyed  during  the  low  practices  of  sexual  perverts  or  by 
kissing.  The  wet-nurse  may  infect  the  mouths  of  suckling  babes,  or,  vice 
versa,  the  infant  may  infect  the  nipple  of  the  nurse. 

((?)  The  obstetric  finger  may  become  infected.  Three  instances  of 
the  sort  have  come  under  my  oAvn  observation,  and  Fournier  gives  the 
details  of  40  cases  of  primary  syphilitic  infection  of  the  hand.  In  30 
of  these  the  malady  was  acquired  in  medical  practice  (4  obstetricians. 
20  general  practitioners,  3  students,  and  3  midwives).  Montgomery  ^ 
states  that  chancre  of  the  finger  is  peculiarly  frequent  in  physicians. 

(d)  Humanized  vaccine  virus  may  rarely  transmit  the  disease. 

(e)  Accidental  infection  has,  at  times  (though  very  rarely),  taken  place 
in  a  variety  of  other  ways — e.  g.^  handling  foul  rags  from  the  hospital 
ward,  by  bed-clothing,  drinking-cups,  the  pipe  and  cigar,  tattooing,  etc. 

Krafft-Ebing  found  that  out  of  3455  cases  15-^q  per  cent,  were  of 
extra-genital  origin.      The  lesion  was  upon  the  lips  in  51  per  cent. 

(3)  Hereditary  Transmission. — Paternal  transmission  (through  the 
semen)  is  much  more  common  than  is  maternal,  the  period  of  greatest 
danger  being  immediately  after  the  father  has  become  infected  or  dur- 
ing the  time  of  the  secondary  manifestations.  The  first-born,  if  the 
father  be  syphilitic,  is  apt  to  show  well-marked  lesions.  Appropriate 
treatment  of  a  syphilitic  parent  lessens  the  danger  of  transmission  very 

'  Bulletin  de  I'Academie  de  Mederin,  Paris,  May  16,  1905. 
^  Jour.  Cuian.  Diseases,  April,  1905. 


390  ANIMAL  PARASITIC  DISEASES. 

materially,  however,  and  in  such  instances  there  is  little  tendency  to 
Vransmission  shown  after  the  third  year.  On  the  other  hand,  a  syphi- 
litic father  or  mother  may  beget  healthy  offspring,  the  infant  having 
acquired  some  immunity  which  protects  it  from  its  mother  (Profeta's 
law).  Syphilitic  children  are  also  common  to  infected  women.  In  the 
majority  of  instances  of  hereditary  transmission,  however,  both  parents 
are  syphilitic,  and  under  these  circumstances  the  liability  to  infect  the 
offspring  is  much  augmented.  A  woman  who  has  become  infected  after 
conception  may  bear  a  syphilitic  child  ;  though  the  latter  may,  on  the 
other  hand,  escape  infection. 

Allusion  may  here  be  made  to  Colless  law — that  a  woman  who  bears 
a  syphilitic  child  enjoys,  owing  to  a  sort  of  protective  vaccination  with 
the  specific  virus,  perfect  immunity,  and  this  in  the  absence  of  all  signs 
of  the  affection.      Coutts  ^  dissents  from  this  opinion. 

Clinical  History  of  Acquired  Syphilis. — [a)  Primary  Stage. — 
The  typical  initial  lesion  (chancre)  appears  about  three  weeks  after  in- 
fection, and  is  followed  soon  by  swelling  and  induration  of  the  nearest 
lymphatic  glands.  The  primary  sore  begins  as  a  red  papule,  which 
rapidly  reaches  its  maximum,  and  then  undergoes  a  central  necrosis 
with  the  formation  of  a  small  ulcer.  The  adjacent  structures  become 
hard  or  cartilage-like — a  characteristic  to  which  the  lesion  owes  its 
name  of  "  hard  chancre."  A  small  chancre  may  often  escape  detec- 
tion, especially  if  it  be  situated  inside  the  meatus.  When  situated  upon 
a  mucous  membrane  it  is  always  a  chancrous  erosion,  which  may  be  so 
mild  and  of  such  brief  existence  as  to  come  and  go  without  the  knowl- 
edge of  its  bearer.  Particularly  is  this  the  case  in  the  female.  The 
general  symptoms  are  negative  in  this  stage. 

(6)  Secondary  Stage. — This  is  announced  about  six  weeks  after  the 
appearance  of  the  infecting  chancre  by  moderate  fever  (100°— 101°  F. — 
37.7°-38.3°  C),  exceptionally  higher,  accompanied  by  languor,  head- 
ache, bone-pains,  impaired  digestion,  and  a  slight  degree  of  prostration. 
There  is  angina,  with  hyperemia  of  the  fauces  and  hard  palate.  The 
blood  shows  a  marked  reduction  in  hemoglobin  with  some  diminution  in 
the  number  of  red  cells.  General  lymphatic  enlargement  is  seen,  espe- 
cially significant  in  the  post-cervical  and  epitrochlear  glands. 

tSkin  eruptions  are  of  many  forms.  The  erythematous  or  roseolar  is 
the  earliest  and  most  common,  coming  out  abundantly  upon  the  trunk 
(especially  the  chest),  buttocks,  thighs,  and  forehead.  Another  early 
variety  is  the  papular.  The  papules  are  small  or  large,  hard,  and 
appear  on  the  face,  trunk,  and  flexor  surfaces  of  the  extremities. 

Mucous  patches  may  appear  on  the  visible  mucous  surfaces  (angles  of 
mouth,  tongue,  tonsils,  pharynx,  vulva,  vagina,  penis,  and  around  the 
anus),  and  are  among  the  early  and  constant  lesions.  The  distribution 
of  these  early  syphilids  is  symmetric  :  their  outlines  are  rounded ;  their 
color  like  that  of  a  slice  of  raw  ham  (''coppery");  they  are  polymor- 
phous ;  and,  as  a  rule,  they  excite  neither  pain  nor  itching. 

Other  and  later-appearing  eruptions  may  be  pustular,  and  tuber- 
cular. These  show  a  tendency  to  bunch  in  certain  areas,  and  hence 
are  less  diffuse  than  the  afore-mentioned  eruptions  ;  and  are  not  sym- 
metrically distributed  on  the  body. 

'  "  Hunterian  Lectures,"  Lancet,  1896,  No.  3889. 


SYPHILIS.  391 

Other  frequent  symptomatic  conditions  arise  during  this  secondary 
period,  such  as  alopecia,  hiryngitis,  iritis,  choroiditis,  retinitis,  and  epi- 
didymitis (more  rarely).  The  hairs  of  the  eyelids  and  eyebrows  may  fall 
ofiF  and  the  finger-nails  become  brittle. 

The  secondary  symptoms  last  from  two  to  three  months  (the  usual 
duration)  to  a  year  or  more,  and  are  followed  by  a  period  of  apparent 
good  health  lasting  for  an  exceedingly  variable  interval  (from  a  few 
months  to  many  years)  before  the  tertiary  stage  sets  in.  During  the 
secondary  stage  the  symptoms  may  be  severe,  mild,  or  even  absent.  There 
is  a  late  secondary  syphilis,  the  symptoms  appearing  a  variable  number 
of  years  after  the  primary  lesion.  Fournier  states  that  late  secondary 
phenomena  occur  most  often  in  cases  that  have  been  well  treated. 

(c)  Tertiary  Stage. — As  I  have  already  stated,  the  secondary  period 
is  generally  followed  by  a  variable  interval  of  freedom  from  symptoms, 
but  to  this  rule  there  are  numerous  exceptions,  and  among  not  uncom- 
mon occurrences  may  be  witnessed  the  appearance  of  tertiary  symptoms 
during  the  secondary  stage.  As  stated  by  R.  W.  Taylor,  "  By  far  the 
most  potent  and  frequent  cause  of  tertiary  syphilis  is  the  absence  or  in- 
suflficiency  of  treatment  during  the  secondary  stage."  Belonging  to  the 
third  stage  are  certain  skin-eruptions,  especially  the  characteristic  rupia, 
which  first  appears  in  the  form  of  pustules  that  break  and  form  ulcers 
that  are  covered  with  dry,  laminated  crusts  "like  an  oyster-shell."  To 
this  stage  also  belongs  the  tubercular  variety,  aifecting  the  face,  back, 
and  legs,  and  very  commonly  the  elbows,  and  rarely  other  portions  of 
the  bodily  surface.  These  eruptions  involve  the  true  skin,  and  in  heal- 
ing leave  scars,  but,  unlike  the  secondary  cutaneous  lesions,  they  are 
neither  infectious  nor  contagious,  are  not,  as  a  rule,  symmetric,  and  are 
more  liable  to  be  attended  by  itching.  A  purpuric  syphilid  (blood-extrava- 
sation form)  is  also  met  with  in  this  stage.  True  gummata  may  develop  in 
the  skin  and  subcutaneous  tissue,  and  these  break  down  and  form  kidney- 
shaped  ulcers  which  tend  to  spread  in  a  serpiginous  manner.  On  healing  (a 
process  that  is  accomplished  with  difficulty),  scars  result.  Gummata  may 
occur  in  the  mucous  membrane  and  pass  through  the  stages  of  ulceration 
and  cicatrization.  When  situated  in  the  larynx  or  trachea,  their  healing 
is  attended  with  narrowing  of  the  organ,  and  when  in  the  lower  bowel  or 
the  rectum,  dysenteric  symptoms,  followed  by  actual  stenosis,  may  result. 

In  the  muscles  gummata  occur  and  form  small  hard  tumors.  They 
may  also  cause  periostitis  and  death  of  the  bones,  especially  of  the  nose, 
palate,  and  skull;  "nodes"  are  thus  formed,  which  are  situated  chiefly 
upon  the  tibia  and  the  skull  in  larger  or  smaller  numbers,  and  also, 
though  less  frequently,  upon  other  bones.  These  are  exceedingly  pain- 
ful, particularly  at  night,  and  are  very  tender.  They  may  be  true  gum- 
mata, but  more  often,  if  not  absorbed,  they  either  become  ossified  or 
undergo  fibi'oid  change,  while  in  rarer  cases  they  suppurate.  Chronic  en- 
largement of  the  lymphatics  and  of  the  testicle,  with  little  tendency  to 
suppuration,  may  be  noticed.  The  pregnant  female  is  apt  to  abort  or 
miscarry.     Fever  of  any  type  may  attend  this  stage. 

Gummata  also  occur  in  the  internal  organs  [visceral  syphilis),  and  of 
the  latter  I  shall  speak  presently,  taking  up  separately  some  of  the 
various  organs  and  systems  of  the  body.  Amyloid  degeneration  is 
frequently  caused  by  the  acquired  form,  particularly  syphilis  of  the  rec- 
tum in  women,  but  very  rarely  by  the  congenital. 


392  jyiMAL  PARASITIC  DISEASES. 

Malignant  Syphilis. — By  this  term  is  meant  a  virulent  and  a  fatal 
form  of  the  malady  which  is  fortunately  rare.  The  various  stages 
manifest  themselves  e^irly,  and  especially  the  tertiary,  as  on  the  forty- 
fifth  day  in  a  case  of  Mauriac.  The  course  is  rapid  and  the  condition 
resists  all  forms  of  treatment.  Roussel  narrates  a  case  in  which  death 
occurred  about  one  year  after  the  comnioncement  of  the  disease. 

Clinical  Symptoms  of  Hereditary  Syphilis. — These  may, 
though  rarely,  be  identical  with  those  of  acquired  syphilis,  if  we  except 
the  chancre.'  Occasionally  the  characteristic  symptoms  are  present  at 
birth.  On  the  other  hand,  in  the  vast  majority  of  instances,  they  appear 
between  the  first  and  fourth  months  of  life  [infra).  The  symptoms  of 
inherited  si/philis  may  be  grouped  according  to  the  time  of  appearance. 
Kassowitz  ^  states  that  one-third  of  all  children  procreated  of  syphilitic 
parents  are  born  dead,  and  of  those  born  living  24  per  cent,  die  within 
the  first  six  months  of  life. 

(1)  In  the  New-born. — There  is  a  lack  of  physical  development. 
The  babe  may  be  greatly  emaciated,  it  has  snuffles,  and  singultus  occa- 
sionally sets  in  soon  after  birth.  Skin-eruptions  are  rare,  except  pem- 
phigus neonatorum,  which  appears  as  bullae  on  che  palms  and  soles; 
among  exceptional  cutaneous  phenomena  are  gummata  around  the  radio- 
carpal articulations,  palmar  psoriasis,  and  a  fleeting  roseola.  Ulcers 
and  fissures  {I'hagades)  may  be  noticed  around  the  outlets  of  the  body 
(mouth,  anus,  etc.) ;  the  osseous  system  may  show  hyperostoses  of  the 
long  bones ;  and  the  liver  and  spleen  are  enlarged.  Comby  reports  8 
cases  of  pseudo-paralysis  due  to  syphilis  in  the  new-born. 

(2)  Early  Post-natal  Symptoms. — Most  subjects  of  syphilis  heredi- 
taria are  born  plump  and  without  taint.  Symptoms  appear  in  the  ma- 
jority of  cases  not  later  than  the  third  month. 

The  first  symptom  is  generally  coryza  (syphilitic  rhinitis),  which  is 
betrayed  by  a  sero-purulent  or  bloody  discharge  and  a  peculiar  form  of 
obstructed  breathing  (snuffles),  rendering  nursing  difficult.  The  coryza 
may  in  some  cases  be  preceded  by  singultus  lasting  ten  or  twenty  days 
(Carini),  and  ulcers  may  form  in  the  nose,  leading  to  necrosis  of  the 
bones  and  producing  at  last  a  sunken  and  deformed  nose  which  is  highly 
significant.  The  coryza  may  extend  to  the  middle  ear  and  cause  otitis 
media,  with  deafness  and  otorrhea  as  the  chief  symptoms.  The  skull 
may  approach  the  natiform  in  shape,  and  the  signs  of  diaphyso-epiphys- 
eal  inflammation  develop. 

The  cutaneous  symptoyns  appear  early.  The  skin  has  a  tawny  hue, 
and  an  erythematous  eruption  of  the  nates  and  genitals  is  frequently 
seen;  this  is  patchy,  with  well-defined  margins,  and  has  the  character- 
istic coppery  color.  In  the  same  localities  papules  may  appear,  while 
pemphigus  may  attack  the  palms  and  soles.  Syphilitic  onychia  may  be 
present,  and  the  lips  and  angles  of  the  mouth  often  show  fissures  that 
are  of  real  diagnostic  Avorth.  Other  sjnnptoms  are  ulcerations  of  the 
skin  and  mucous  surfaces,  falling  of  the  hair,  and  a  moderate  glandular 
enlargement. 

Enlargement  of  the  spleen  is  a  frequent  characteristic  symptom,  and, 
according  to  White  and  Martin,^  of  greatest  importance  "  when  noticed 

'  With  prenatal  syphilis  we  are  not  concerned. 

*    Vererbunx)  der  Syphilis,  Vienna,  1870, 

'  O&nito-urinai-y  and  Venereal  Diseases,  oth  ed.,  1902. 


SYPHILIS.  393 

early — the  first  three  months  after  birtli — since  at  this  period  enlarge- 
ment of  the  spleen  due  to  rachitis  can  hardly  come  into  question." 

Swelling  of  the  liver  may  also  be  present,  but  is  of  little  diagnostic 
import.  Syphilitic  infants  occasionally  manifest  a  hemorrhagic  tendency. 
At  birth  bleeding  from  the  umbilicus  may  occur;  later,  into  the  sub- 
cutaneous tissue  and  from  the  mucous  membranes  (gastro-intestinal, 
vaginal,  nasal,  etc.).  Hecker^  considers  an  examination  of  the  umbilical 
cord  important  for  the  early  recognition  of  syphilis  in  the  offspring  of 
syphilitic  parents ;  if  the  microscope  shows  characteristic  changes,  time 
may  be  gained  for  treatment ;  "  these  changes  range  from  a  decided 
endarteritis  or  periarteritis  or  phlebitis  to  a  simple  round-celled  infiltra- 
tion of  the  blood-vessel  walls  or  the  surrounding  tissue."  As  pointed 
out  by  Osier,  these  cases  must  not  be  confounded  with  Winckel's  disease. 

Among  nervous  symptoms,  restlessness,  sleeplessness,  and  a  harsh, 
shrill  cry  which  may  be  almost  constant  for  days  together  and  due  most 
probably  to  darting  pains,  are  the  chief.  Anemia  and  other  evidences 
of  syphilitic  cachexia  soon  supervene. 

(8)  Late  Symptoms. — The  symptoms  of  syphilis  hereditaria  tarda 
may  be  arranged  in  groups  (Fournier)  : 

(1)  Those  Indicated  by  the  Greneral  Appearance. — There  is  a  retarded 
general  development,  as  shown  by  the  small  stature,  undeveloped  muscles, 
the  graceful  form,  and  infantile  appearance  at  ages  varying  from  four  to 
twelve  or  more  years.  The  skin  has  an  earthen  tint,  and  the  hair  may 
be  scanty  and  late  in  its  appearance  on  the  face  and  genitals. 

(2)  Skin-cicatrices. — Cutaneous  scars,  particularly  if  multiple  and 
extending  over  a  circumscribed  area,  are  important  diagnostic  signs. 
Their  form  is  usually  round  or  serpiginous,  and  their  chief  location  the 
mouth,  nose,  soft  palate,  and  lumbo-gluteal  regions. 

(3)  Lesions  of  the  Skeleton. — The  natiform  skull,  "  with  a  transverse 
enlargement,  lateral  bulgings,  and  the  flattening  in  the  middle,"  is 
almost  pathognomonic.  Asymmetric  and  hydrocephalic  skulls  are  also 
to  be  considered,  in  many  cases,  as  signs  of  hereditary  syphilis,  as  is  a 
sunken  and  deformed  nose.  The  thickened,  "sabre-shaped"  tibia,  due 
to  gummatous  periostitis,  is  capital  evidence  of  the  disease,  while  the 
chicken-breasted  thorax  is  significant. 

(4)  The  testicles  show  an  arrest  in  development  (infantile  testicles). 
This  is  a  sclerotic  atrophy. 

(5)  Hutchinson's  triad,  under  which  title  come  (rt)  the  Hutchinson 
teeth ;  (h)  ear-conditions ;   (c)  affections  of  the  eye. 

(a)  The  Hutchinson  Teeth. — The  teeth  may  be  late  in  appearing,  and 
the  dental  arch  may  be  malformed,  the  teeth  presenting  various  irregu- 
larities in  form  and  condition  (dental  dystrophy). 

The  incisors,  especially  the  superior  median  of  the  second  dentition, 
are  notched,  and  show  a  thinness  of  the  free  edge,  an  atrophy  of  the 
summit,  and  crescent-shaped  erosions.  Fournier  ^  calls  attention  to  the 
absence  of  one,  two,  or  more  teeth  in  a  great  number  of  cases. 

(6)  Ear-conditions. — Otorrhea,  secondary  to  naso-pharyngeal  catarrh, 
has  already  been  mentioned,  and,  in  addition,  at  or  about  the  time  of 
puberty  an  incurable  form  of  deafness  may  develop  speedily,  without 
the  presence  of  pathologic  lesions  to  explain  the  same. 

^  Jahr.  f.  Kinderh.,  Bd.  li,  Heft  3. 

^  Gas.  hebdom.  de  med.  et  de  chir.,  January  18,  1900. 


394  ANHfAL   PARASITIC  DISEASES. 

(c)  Affections  of  the  Eye. — These  are  interstitial  keratitis  and  iritis, 
affecting  both  eyes  successively. 


Visceral  Syphilis. 

Syphilis  of  the  Brain  and  Cord. — Pathology. — The  most  characteristic 
and  not  intVe^ueut  lesions  are  :  (1)  Diffuse  Gummatous  Meningitis. — This 
occurs  most  often  in  the  pia,  extending  to  either  the  dura  or  brain-sub- 
stance. It  is  seen  as  patches  of  round-cell  infiltration  with  sclerosis  of 
the  blood-vessels.     In  the  cord  the  same  changes  are  found. 

(2)  Crunimata. — Their  usual  situation  is  in  the  membranes,  more  often 
the  dura,  extending  to  the  brain  secondarily.  Rarely  the  brain-substance 
only  is  affected.  Their  size  varies  from  that  of  a  millet-seed  to  that  of  an 
egg,  and  they  present  irregular  contours.  They  are  single  or  multiple  and 
are  usually  situated  either  in  the  cerebral  hemispheres  or  on  the  pons,  and 
rather  superficially,  connecting  directly  or  indirectly  "with  the  dura  or  pia 
mater.  In  gummata  of  average  size  a  cut-section  shows  caseation  in 
spots  -which  are  connected  and  surrounded  by  firm,  translucent,  gray  or 
reddish-gray,  fibrous  tissue ;  and  the  more  irregular  surfaces  and  the 
irregular  caseation  serve  as  important  distinctions  from  tuberculous  tumors. 
When,  as  is  usual,  the  gummata  touch  the  membranes,  meningitis — sub- 
acute or  chronic,  with  much  thickening — is  combined.  Gummatous 
growths  may  attack  the  cord.     They  seldom  attain  to  a  large  size. 

(3)  Endarteritis. — This  important  lesion  of  syphilis  may  result  in 
aneurism,  hemorrhage,  or  narrowing  and  obliteration  of  the  lumen  of  the 
blood-vessels.  As  a  consequence  of  the  latter,  areas  of  softening  and 
secondary  degeneration  occur,  varying  in  size  with  the  distribution  of 
the  affected  vessel.  Thrombosis  in  cerebral  arteries  may  be  found. 
Similar  vascular  lesions  occur  in  the  cord. 

Etiology. — Cerebral  syphilis  is  usually  a  late  (tertiary)  manifestation, 
appearing  on  the  average  three  or  four  years  after  infection,  but  it  may 
appear  much  sooner.  After  twenty  years  it  is  rare.  Taylor^  has  pointed 
out  that  syphilis  of  the  nervous  system  is  likely  to  appear  in  persons  of  a 
neurotic  or  neurasthenic  constitution,  particularly  in  those  cases  where 
the  treatment  required  for  the  secondary  period  of  the  disease  has  been 
neglected  or  insufficiently  carried  out. 

Symptomatology. — ImbeciJitif  and  idiocy  may  be  due  to  inherited 
syphilis,  but  they  are  probably  too  often  attributed  to  this  cause.  The 
other  features  simulate  those  of  the  acquired  form. 

The  symptoms  of  the  acquired  form  are  with  few  exceptions  referable 
to  three  affections:   (a)  epilepsy,  {h)  brain-tumor,  and  (e)  paralysis. 

(rt)  Epilepsy  coming  on  after  the  thirty-fifth  year,  not  dependent  upon 
alcohol  nor  uremia  (p.  1205),  is  usually  due  to  the  ravages  of  syphilis,  and 
a  careful  search  for  traces  of  scars  and  of  the  entire  body  surface  for 
bone-lesions,  etc.,  should  be  instituted.  Convulsions  of  the  epileptic  type 
have  also  occurred  during  or  just  before  the  advent  of  secondary  symp- 
toms. The  appearance  of  the  disease  may  be  preceded  by  psychic  dis- 
turbance, headache,  dizziness,  and  loss  of  memory.  Hysteric  manifesta- 
tions may  also  be  presented,  being  probably  provoked  by  the  specific 
lesions.  On  the  other  hand,  a  protracted  torpor  which  may  last  for  a  few 
1 R.  W.  Taylor,  Venereal  Diseases. 


SYPHILIS  OF  THE  LIVER.  39.0 

days  or  as  many  weeks  may  develop.  While  in  tliis  stuporous  condition 
the  patient  may  wander  aimlessly  about.  In  one  of  my  own  cases  periods 
of  marked  mental  excitement,  that  persisted  for  three  or  four  days,  alter- 
nated with  periods  of  almost  complete  insensibility  of  about  equal  dunition. 

{b)  Brain-tumor. — The  symptoms  pointing  to  brain-tumor  will  be 
discussed  under  this  head  in  the  section  on  Nervous  Diseases.  ^J'he 
syphilitic  nature  of  the  cerebral  growth  cannot  be  determined  with  cer- 
tainty except  in  the  presence  of  a  clear  history  of  syphilis — congenital 
or  acquired — and  the  characteristic  symptoms  or  traces  of  the  primary, 
secondary,  or  tertiary  lesions. 

It  must  be  remembered  that  the  secondaries  are  either  sometimes 
absent  or  go  unnoticed,  and  if  the  patient  has  had  a  primary  sore,  the 
presence  of  the  characteristic  symptoms  of  brain-tumor  (headache,  optic 
neuritis,  convulsions,  etc.)  make  the  existence  of  specific  nerve-lesions 
highly  probable.  The  chancre  may  also  be  overlooked  or  denied,  and  it 
is  in  such  instances  as  the  latter  that  the  occurrence  of  convulsions  in 
persons  over  thirty  should  excite  suspicion. 

((?)  Paralysis. — This  may  take  the  form  of  hemiplegia,  due  usually  to 
cerebral  thrombosis  if  of  sudden  advent  (p.  1170),  or  if  of  gradual  devel- 
opment to  gumma  (p.  1185),  or  of  general  paralysis  (dementia  ijaralyticd). 
The  relation  that  these  affections  bear  to  syphilis  will  be  indicated  in  its 
appropriate  place  in  this  work  in  the  description  of  Nervous  Diseases. 
The  fact  may  here  be  pointed  out  that  syphilis  may  induce  precisely  the 
same  changes  met  with  in  general  paralysis  of  the  insane  (p.  1198). 

The  cranial  nerves,  especially  the  third,  fourth,  and  sixth,  are  liable 
to  be  involved  in  syphilitic  basal  meningitis  (p.  1121). 

The  history  of  syphilitic  infection,  together  with  symptoms  of  spinal 
tumor  (p.  1156),  points  to  gumma  of  the  cord.  Syphilitic  myelitis  usually 
develops  in  five  years  after  the  infection,  and  may  pursue  an  acute  or 
subacute  course,  though  oftener  it  takes  the  form  of  chronic  myelitis 
(pp.  1134  and  1137).  The  latter  attacks  by  preference  the  lumbo-dorsal 
section  of  the  cord — a  fact  corroborated  by  the  character  of  the  symptoms, 
and  in  most  cases  is  not  a  true  inflammation,  but  is  a  softening  due  to 
thrombosis  in  some  of  the  spinal  arteries.  A  type  described  by  Erb,  and 
known  as  Erb's  syphilitic  spinal  paralysis,  presents  rather  characteristic 
symptoms.  These  consist  of  slowly  increasing  weakness  and  stiffness  of 
the  lower  limbs,  with  increased  reflexes  and  sometimes  par^esthesia  of  legs, 
back,  and  anal  region.  There  is  also  some  inco-ordination,  and  Romberg's 
symptoms  may  be  present.  The  gait  is  of  the  ataxic  paraplegic  type 
i(p.  1152),  and  incontinence  of  urine  and  faeces  is  usually  present.  Sensory 
paralysis  is  absent.  A  peculiar  feature  is  that  at  rest  the  rigidity  of  the 
limbs  is  not  marked,  but  becomes  so  when  attempts  to  walk  are  made. 
The  lesion  is  probably  a  thrombosis  of  the  vessels  supplying  the  posterior 
columns  and  pyramidal  tracts. 

G-eneral  Diagnosis. — The  onset  in  nervous  syphilis  may  be  acute  or 
subacute,  and  the  symptom-complex  embraces  a  multiplicity  of  phenom- 
ena, there  being  an  especially  erratic  distribution  of  the  ocular  and  other 
attending  palsies  and  early  marked  impairment  of  the  mind,  all  occurring, 
as  a  rule,  in  early  adult  life.  The  symptoms,  while  they  may  simulate 
any  of  the  various  system  and  general  diseases  of  the  nervous  system,  are 
apt  to  present  some  atypical  feature,  and  their  development  is  frequently 
preceded  by  violent  headache  and  somnolence.     They  are  also  frequently 


396  ANIMAL  PARASITIC  DISEASES. 

more  or  less  transient  and  shiftinir.  Examination  of  the  cerebrospinal  fluid 
for  pleocvtosis  and  increase  in  globulin,  as  Avell  as  the  Wassermann  test 
in  both  blood  and  fluid,  is  of  service  in  doubtful  cases  (pp.  1149  and  1201). 
Proi/nosis. — In  acute  cerebral  syphilis,  with  stupor,  this  is  bad.  In 
other  forms  complete  recovery  may  occur,  but  it  is  well  to  remember  tliat 
where  actual  destruction  of  nerve-cells  and  fibers  has  taken  place  that 
removal  of  the  lesion  will  not  restore  them,  therefore  it  should  always  be 
guarded  as  to  how  much  restoration  of  function  will  occur. 

Syphilis   of  the  Liver. 

In  my  experience  the  liver.  Avith  comparative  frequency,  bears  the 
stress  of  visceral  syphilis.  Syphilis  of  the  liver  occurs  more  frequently 
in  men  than  in  women,  and,  according  toPeiser,^  appears  most  frequently 
in  from  five  to  fifteen  years  after  date  of  infection. 

Pathology. — The  lesions  may  be  thus  classified  :  (a)  Diffuse  Syph- 
ilitic Hepatitis. — This  is  met  with  chiefly  in  congenital  cases.  Though 
its  occurrence  in  adult  life  has  been  questioned  by  some,  I  have  seen  an 
instance  in  an  adult  Avho  died  of  cerebral  hemorrhage.  The  liver  is  uni- 
formly enlarged,  firm,  and  resists  the  cutting-knife.  Its  color  is  grayish- 
yellow.  The  microscope  shows  a  marked  increase  in  the  connective  tissue 
and  a  cell-infiltration  throughout.  From  intense,  focal  cellular  infiltra- 
tion miliary  gummata  may  result ;  these  undergo  contraction,  diminish- 
ing somewhat  the  size  and  altering  the  shape  of  the  organ. 

(5)  Gummata. — These  may  be  seen  in  congenital  cases  (chiefly  the 
miliary  gummata).  As  seen  in  the  adult,  hepatic  gummata  are  dissem- 
inated nodules,  with  the  usual  central,  cheesy  mass  surrounded  by  a  zone 
of  grayish  fibrous  tissue  and  varying  in  size  from  a  hazlenut  to  an  apple. 
They  form  separate  tumors,  whose  favorite  seats  are  the  convex  surface 
of  the  organ,  especially  near  to  the  suspensory  ligament,  and  in  the 
region  of  the  portal  vessels.  They  are  usually  tertiary  lesions,  and 
appear  a  number  of  ^^ears  (two,  three,  or  four)  after  infection.  These  so- 
called  syphilomata  in  the  advanced  stage  contract,  and  the  liver  will  be 
found  smaller  than  the  normal.  Deep  furrows  due  to  contracting  fibrous 
bands  traverse  the  organ  in  diff"erent  directions  and  divide  it  into  lobes 
of  various  dimensions.  Gummata  frequently  undergo  fibroid  change,  but 
more  rarely  they  soften  and  licjuefy  (Wilks).  On  the  other  hand,  before 
contraction  occurs  the  liver  is  increased  in  size  and  the  gummata  form 
protuberances  on  its  surface. 

(e)  Gummatous  Arteritis. — Briefly,  this  may  aff"ect  both  the  portal 
vein  and  hepatic  artery,  though  syphilitic  endarteritis  is  situated  chiefly 
in  the  smaller  branches  of  the  latter. 

(c?)  Perihepatitis. — Here  Glisson's  capsule  is  thickened,  owing  to  aug- 
mentation of  its  connective-tissue  elements.  From  the  latter  there  dip 
into  the  hepatic  tissue  cicatricial  bands,  particularly  along  the  portal 
canals,  which  may  change  somewhat  the  shape  of  the  organ.  Section  shows 
admirably  the  pale  scar-like  tissue  {vide  Diseases  of  the  Liver). 

Clinical   History. — The   aff'ection    may  exist  without   symptoms. 
In  the  congenital  form,  however,  we  have  signs  of  hepatic  enlargement, 
with  icterus,  the  spleen   being  likewise  large  and  firm,  as  a  rule.       The 
history  and  associated  lesions  are  necessary  to  a  certain  diagnosis. 
1  Die  Leber  syphilis  brochure,  Leipsic,  1886. 


SYPHILIS  OF  THE  ALIMENTARY  TRACT.  397 

In  the  adult  syphilis  of  the  liver  does  not  usually  attract  attention 
until  the  gummata  interfere  with  the  portal  circulation.  As  they  un- 
dergo contraction  they  ten<l  to  occlude  soirie  of  tlie  portal  brandies,  or 
they  may,  on  account  of  their  situation,  exert  pressure  upon  the  vena 
porta  itself.  In  either  event  the  evidences  (ascites  and  splenic  enlarge- 
ment) of  portal  obstruction  will  develop  as  in  alcoholic  cirrhosis.  The 
gastro-intestinal  symptoms  common  to  the  latter  disorder  are  also  pres- 
ent, and  obstructive  jaundice  may  supervene,  though  it  is,  compara- 
tively speaking,  rare.  Pain,  usually  localized  to  some  particular  spot 
over  the  right  hypochondrium,  is  sometimes  complained  of,  and  may  be 
quite  severe,  while  pressure  over  the  painful  area  elicits  great  tenderness. 

Physical  Examination. — In  the  early  stage,  while  the  organ  is  en- 
larged, flattened,  irregular  protuberances  may  be  detected  by  the  pal- 
pating fingers.  These  nodules,  or  large,  round  masses,  invade  especially 
the  left  lobe  as  compared  with  the  right.  At  a  more  advanced  period 
ascites  may  interfere  Avith  palpation,  and  in  such  cases  an  aspiration  of 
the  fluid  will  enable  one  to  feel  the  syphilomata.  Finally,  in  the  stage 
of  contraction  the  results  of  palpation  are  obviously  negative. 

There  is  a  group  of  cases  in  which  the  clinical  picture  is  that  of 
advanced  amyloid  disease  of  the  viscera.  The  liver  and  spleen  are  en- 
larged, the  urine  is  increased  in  amount  and  contains  albumin  and  tube- 
casts,  and  finally  dropsy  supervenes. 

Diagnosis. — This  rests  upon  the  etiology,  the  presence  of  scars  on 
the  skin-surface,  bone-lesions  (irregularities  of  the  tibial  surfaces),  or 
other  evidences  of  the  ravages  of  the  disease,  and  upon  moderately  good 
general  health.  The  most  important  local  symptoms  are  the  hemispheric 
prominences  on  the  surface  of  the  liver  and  the  localized  pain.  The 
diagnosis  between  syphilitic  disease  of  the  liver  and  eclmiococcus-cysts  is 
sometimes  extremely  difiicult.  R.  Lennhoff"  has  noted  in  a  number  of 
cases  of  echinococcus-cyst  that  on  deep  inspiration  a  furrow  forms  above 
the  tumor,  between  it  and  the  edge  of  the  ribs. 

The  clinical  findings  resemble  those  of  cancer  of  the  organ.  I  have 
contrasted  the  main  dissimilar  points  in  the  subjoined  table  : 

Syphilis  of  the  Liver.  Cancer. 

History  of  heredity  or  of  infection.  Of  heredity  or  of  primary  growth. 

Occurs  congenitally,  or,  if  acquired,  at  any  Never  congenital.    Usually  occurs  after  the 

age.  age  of  forty. 

Often   accompanied   by   symptoms  of  ter-  Often   preceded    by   the    primary  growth 

tiary  syphilis — alopecia,  rupia,  etc.  pylorus,  uterus,  mammary  gland. 

Jaundice  and  ascites  are  common,  especially  Jaundice  and   ascites  are    rare.     Marked 

the  latter.     No  cachexia.  cachexia. 

The   margin   is   markedly   irregular,   and  Often  the  margin  reveals  the  presence  of 

neither  nodular  nor  umbilicated.  umbilicated  nodules. 

Recovery  may  follow,  or  the  affection  may  Always   fatal.     Duration   usually   from    a 

last  for  years.  few  months  to  a  year. 

The  course  and  the  results  of  antisyphilitic  treatment  are  of  value 
for  diagnosis.  The  course  is  slow  and  often  interrupted,  while  appro- 
priate treatment  may  lead  to  recovery,  as  in  three  of  my  cases. 

Syphilis  of  the  Alimentary  Tract. 

The  lesions  in  the  mouth  have  been  for  the  most  part  considered. 
In  the  tongue  gummata  often  develop.     A  decidedly  fissured  appearance 


398  ASIMAL  PARASITIC  DISEASES. 

of  the  organ  and  whitish  scar-like  patches  upon  the  surftice  may  be  ob- 
served in  syphilis,  but  have  no  essential  connection  with  that  disease. 
Perforation  of  the  palate,  due  to  tertiary  lesions,  is  not  rare.  Gummata 
vilso  appear  on  the  posterior  Avail  of  the  pharynx  and  lead  to  ulceration, 
which  may  cause  fatal  hemorrhage  by  erosion  of  adjacent  large  blood- 
vessels (internal  carotid,  etc.).  The  walls  of  the  esophagus  may  also  be 
invaded,  resulting  usually  in  stenosis. 

The  sfomach-walls  may  be  infiltrated  and,  rarely,  ulcerated.  Einhorn, 
Fournier,  and  others  have  met  gastric  ulcer  in  syphilis  ;  it  was  cured  by 
the  specific  treatment.  Syphilitic  tumor  of  the  stomach  may  rarely 
occur ;  the  symptoms  are  those  of  malignant  growth,  resembling  cancer, 
but  curable.  Syphilitic  ulcers  may  appear  in  the  intestines.  The  condi- 
tion may  lead  to  perforation  and  peritonitis ;  more  often  to  stenosis. 

Gummatous  infiltration  of  the  rectum  is  a  somewhat  frequent,  severe, 
and  clinically  important  affection.  It  is  much  more  common  in  women 
than  in  men,  taking  place  in  the  "  submucosa  above  the  internal  sphinc- 
ter." It  has  frequently  caused  a  fiital  result  in  persons  who  failed  to 
show  post-mortem  specific  lesions  in  other  viscera,  and  hence  it  is  to  be 
classed  as  one  of  the  ravages.  The  result  of  the  gummatous  infiltration 
is  the  production  of  a  funnel-shaped  stenosis  of  the  rectum  which 
narrows  from  below  upward.  Above  the  stenosis,  and  directly  depend- 
ent upon  it,  there  is  dilatation  of  the  rectum  and  the  descending  colon. 
Here  may  also  be  found  ulcers — some  specific,  and  others  the  result  of 
mechanical  pressure  exerted  by  the  fecal  accumulations. 

Symptoms. — The  clinical  features  are  for  the  most  part  those  of  a 
gradually  induced  stenosis  of  the  rectum.  At  first  there  may  be  hem- 
orrhages, suggesting  internal  hemorrhoids.  The  action  of  the  bowels  is 
irregular,  and  is  followed  shortly  by  a  tendency  to  dysenteric  diarrhea, 
with  pains,  tenesmus,  and  scanty  stools  containing  mucus  and  pus. 
Prolapse  of  the  rectal  mucosa  may  occur,  and,  owing  to  the  presence  of 
small  hemorrhoids,  the  true  nature  of  the  case  may  be  overlooked. 
The  disease  is  most  distressing,  and  leads  slowly  and  gradually  to  ex- 
treme emaciation  and  asthenia.  Death  may  be  due  to  the  latter  or  to 
some  complication  (perforative  peritonitis,  etc.). 

Diagnosis. — This  may  be  aided  by  a  clear  history  of  associated 
syphilitic  symptoms  or  of  specific  lesions,  including  amyloid  degenera- 
tion. In  tubercular  ulcer  other  undoubted  evidences  of  tuberculosis  are 
found.  Carcinoma  is  usually  situated  higher  up  the  rectum  than  gumma 
and  more  often  forms  firm  adhesions  to  surrounding  parts.  Final  diag- 
nosis would  depend  on  microscopic  examination  of  an  excised  portion. 

Syphilis  op  the  Lungs. 

While  undoubted  cases  occur,  syphilis  of  the  lungs  is  rare  indeed. 

Pathology. — The  cases  are  pathologically  divisible  into  three  forms  : 
(a)  Gummy  tumors ;  (h)  Interstitial  pneumonia ;  (c)  Fetal  pneumonia. 

(a)  Gummy  Tumors. — These  appear  as  yellowish-white  scattered 
nodules,  varying  in  size  from  a  cherry-pit  to  a  hen's  egg.  Their  centers 
are  dry  and  caseous-looking,  and  their  peripheral  zones  fibrous.  They 
are  relatively  thicker  set  near  to  the  root  of  the  lungs.  Cicatricial 
bands  mav  be  seen  connecting  not  only  the  separate  nodules,  but  stretch- 


SYPHILIS  OF  THE  SPLEEN.  399 

ing  outward  to  the  thickened  pleura.  Such  growths  may  undergo  ulcer- 
ation, thus  forming  a  cavity  that  rarely  attains  to  large  meaHureifjents ; 
or,  on  the  other  hand,  in  favorable  cases  tlie  fibroid  changes  and  cicatri- 
zation may  lead  to  recovery.  A  primary  lesion  is  atrophy  of  the  a]v<'olar 
walls,  with  hyaline  degeneration  of  the  capillaries  (Councilman).  Jironcho- 
pneuraonia  (syphilitic  ?)  may  be  associated. 

(b)  Interstitial  Pneumonia. — This  is  a  fibrous  infiltration,  showing  a 
predilection  for  the  right  lung.  Its  chief  seat  is  the  root  of  the  lung, 
whence  it  extends  along  the  bronchi  and  vessels,  and  usually  involves  a 
part  of  one  or  more  lobes.  Occasionally  its  starting-point  is  the  pleura, 
from  which  the  process  advances  along  lines  corresponding  to  the  inter- 
lobular tissue.  Bronchiectasis  may  be  noticed.  Gummata  may  also  be 
associated,  or  may  have  been  present  and  been  practically  obliterated 
during  the  process  of  cicatrization. 

(c)  Fetal  Pneumonia  (  Virchow's  White  Hepatization). — This  is  pecu- 
liar to  the  new-born,  in  which  miliary  gummata  first  occur,  followed  by 
hepatization  of  large  zones  or  an  entire  lung.  The  chief  changes  are 
an  infiltration  of  the  alveolar  walls,  while  the  air-cells  are  filled  with 
epithelium ;  on  section  the  tissue  presents  a  grayish-white  appearance. 

Symptoms. — From  what  has  just  been  stated  it  is  clear  that  a 
certain  limited  number  of  cases  present  symptoms  and  signs  that  simu- 
late ordinary  ulcerative  phthisis,  but  do  not  show  bacilli  in  the  sputum. 
There  is  another  group  of  cases  in  which  the  picture  presented  to  view  is 
almost  identical  with  that  of  fibroid  induration,  though  usually  giving  a 
distinctly  syphilitic  history.  I  am  not  prepared  to  say  that  there  is 
an  acute  syphilitic  broncho-pneumonia  analogous  to  acute  pneumonic 
phthisis,  though  I  fail  to  see  any  reason  why  this  may  not  occur. 

Diagnosis. — If  a  suspected  case  is  treated  early,  the  result  may 
serve  to  corroborate  the  diagnosis,  which  is  at  first  far  from  being  final. 

Bronchiectasis,  dependent  upon  syphilitic  peribronchitis  or  intersti- 
tial pneumonia,  cannot  be  discriminated  from  other  forms  of  that  disease 
except  there  be  a  clear  history  of  infection,  and  unless  associated  scars 
or  active  syphilitic  lesions  coexist.  Pulmonary  tuberculosis  cannot  be 
distinguished  from  pulmonary  syphilis  without  a  careful  microscopic  ex- 
amination of  the  sputum.  Moreover,  it  must  not  be  forgotten  that  these 
affections  are  often  combined.  The  suspicion  of  syphilis  should  always 
attach  to  lesions  beginning  in  the  lower  parts  of  the  lung,  and  slowly 
progressing  without  the  production  of  fever  (Taylor). 


Syphilis  of  the  Spleen. 

Pathologically,  syphilis  of  the  spleen  is  to  be  classed  with  the  general 
adenopathy  of  the  disease.  According  to  the  statistics  of  S^e  (relating 
to  hereditary  syphilis)  and  of  Avanzini  and  Schuchter  (relating  to  ac- 
quired syphilis),  in  about  25  per  cent,  of  the  cases  of  secondary  syphilis 
hypertrophy  of  the  spleen  may  be  noted.  This  augmentation  begins 
from  two  to  four  weeks  after  the  appearance  of  the  chancre,  and  gradu- 
ally increases,  persisting  throughout  the  secondary  period ;  it  is  not, 
however,  observed  during  tertiary  stage.  It  is  often  accompanied  by 
localized  pain — syphilitic  pleurodynia  (Besnier).      Gummata  are  rare. 


400  ANIMAL  PARASITIC  DISEASES. 

Syphilis  of  the  Cibciilatory  System. 

The  Heart. — The  pathologic  divisions  are — (a)  Gumnidta,  which  attack 
chietly  the  walls  of  the  left  ventricle.     They  are  usually  encysted. 

(b)  A  Fibro-sclerotic  Myocarditis. — The  process  begins  in  the  peri- 
vascular tissue  and  proceeds  from  the  vessel  walls  outward  (Mracek). 
It  is  diffuse,  as  a  rule,  and  leads  to  narrowing  of  the  lumina  of  the  cor- 
onary arteries  and  their  branches  or  to  aneurysmal  bulgings,  but  the 
pathologic  effects  of  these  lesions  are  seldom  detected  clinically.  Sudden 
death  may  occur. 

(c)  Syphilitic  Endocarditis. — The  changes  are  of  the  fibro-sclerotic 
variety,  and  not  of  the  acute  verrucose  ty))e.  The  symptoms  to  which 
the  lesion  gives  rise  are  depicted  under  Organic  Valvular  Disease. 

Syphilis  of  the  Arteries. 

Two  forms  are  recognized  :  (a)  Obliterating  Endarteritis. — Here  the 
syphilitic  product  consists  chiefly  of  proliferated  subendothelial  tissue, 
which  encroaches  more  and  more  upon  the  lumen  of  the  vessel — a  fact 
to  which  the  disease  owes  its  name.  This  so-called  "Heubner's  degen- 
eration "  is  not  peculiar  to  syphilis,  but,  as  Osier  says,  "if,  however, 
there  are  gummata  in  other  parts,  or  if  there  be  gummatous  periarter- 
itis in  adjacent  vessels,  the  process  may  be  regarded  as  syphilitic. 

(h)  Gummatous  Periarteritis. — The  arteries  most  frequently  involved 
are  those  at  the  base  of  the  brain.  Charcot  describes  a  condition  which 
he  calls '•  syphilitic  periarteritis,"  where  the  tunics  of  the  arteries  are  in- 
filtrated Avith  tumors  or  nodosities  whicli  the  microscope  showed  were  the 
result  of  an  acute  arteritis  producing  infiltration  of  connective-tissue  cells 
into  the  tunica  media. 

Syphilis  of  the  arteries  has  an  important  etiologic  bearing  upon 
atheroma  and  aneurysm  {vide  Diseases  of  the  Arteries). 

Syphilis  of  the  Kidneys. 

Renal  syphilis  belongs  chiefly  to  the  tertiary  stage,  though  it  may 
appear  in  the  secondary. 

Pathology. — (a)  Amyloid  degeneration  is  a  common  renal  lesion. 
(5)  Chronic  interstitial  nephritis, 
(e)  Gumma. 
Symptoms. — Except    in   the  case  of  amyloid  degeneration  the  con- 
ditions are  impossible  of  correct  diagnosis.     Wagner  describes  a  special 
form  which  he  calls  acute  syphilitic  glomerulo-nephritis.      Clinically,  it 
is  characterized  chiefly  by  hematuria,  and  ends  rapidly  with  uremia. 

Syphilis  of  the   Joints. 

The  following  division  of  the  affection  is  made  by  Hutchinson: 

(1)  Synovitis  appears  during  the  secondary  stage,  but  soon  clears 
away  under  appropriate  treatment,  leaving  no  traces  behind. 

(2)  Perisynovial  gummata. 

(8)  Arthritis,  due  to  osseous  nodes  or  gummata  in  the  neighborhood 
of  the  joints. 


SYPHILIS  OF  THE   TESTICLES.  401 

(4)  True  Qlironic  Syvmntia. — This  is  the  most  corarnou  form  of"  syph- 
ilitic arthritis. 

(5)  ^yi^ldUtiG  cliondro-artlivitis  (Virchow). 

The  last  four  forms  belong  to  the  tertiary  lesions. 

Symptoms. — It  is  to  be  borne  in  mind  that  a  joint-affection  that  does 
not  yield  to  specific  treatment  is  not  necessarily  non-syphilitic. 

Perisynovial  gumma  attacks  frequently  the  tissues  around  the  knee- 
joint  ;  it  is  very  chronic  in  its  course  and  is  more  common  in  women. 

Arthritis  due  to  osseous  nodes  has  a  special  diagnostic  feature  in  the 
severe  nocturnal  pains.  The  fourth  form  of  syphilitic  arthritis  (true 
chronic)  is  the  most  common  among  the  types  due  to  acquired  syphilis, 
while  the  symmetric  synovitis  of  the  knees  occurring  about  puberty  is 
perhaps  peculiar  to  the  congenital  cases. 

Syphilis  op  the  Testicles. 

The  lesions  are  of  two  forms :  (a)  Gummata. — These  produce  hard, 
usually  nodular,  swellings,  either  single  or  multiple,  and  of  moderate  size, 
that  occupy  the  substance  of  the  testicle  and  sometimes  the  epididymis. 

(6)  Interstitial  Orchitis. — This  is  a  fibro-sclerotic  change  that  leads  to 
slow,  gradual  atrophy.  Though  bilateral,  it  is  usually  more  marked  on 
one  side  than  the  other.  Mpididymitis  occasionally  develops  as  a  late 
secondary  lesion.  It  is  usually  unilateral,  painless,  and  quickly  disap- 
pears under  treatment.     In  the  tertiary  stage  gummata  may  develop. 

Diagnosis. — In  gummatous  orchitis  the  swelling  of  the  testicle  is 
painless,  smooth,  globular,  dense,  and  heavy,  with  no  tendency  to  in- 
volvement or  ulceration  of  the  overlying  skin. 

In  tuberculous  disease  the  history  and  associated  lesions  diflFer  from 
those  of  syphilitic  orchitis,  and  the  head  of  the  epididymis  is  generally 
affected.  Atrophied  testicles  may  be  due  to  congenital  syphilis.  In 
such  instances  typical  scars,  eye-affections,  and  the  characteristic  physiog- 
nomy are  usually  to  be  noted.  Hydrocele  may  owe  its  origin  to  the 
same  cause.  Atrophy  of  the  testes  may  lead  to  impotency  and  sterility. 
Such  instances  are  not  to  be  mistaken  for  the  results  of  metastasis  mmumps. 

General  Diagnosis  of  Syphilis. — Perhaps  sufficient  has  been 
said  regarding  the  importance  of  obtaining  a  correct  statement  with 
reference  to  the  primary  infection.  On  failure  to  find  evidence  of  a 
genital  chancre,  an  examination  for  extragenital  primary  sores  must  be 
instituted,  even  among  children.  The  treponema  pallidum  may  be 
obtained  from  the  serum  of  the  tonsil  in  from  80  to  90  per  cent,  of 
patients  suffering  from  secondary  untreated  syphilis  (Campbell).^ 

The  striking  characteristics  of  the  cutaneous  manifestations  of  sec- 
ondary syphilis  are,  first,  symmetrical  distribution  ;  second,  polymorphous 
character ;  third,  non-inflammatory  nature,  and  fourth,  raw-ham  or  dark 
red  color.  In  this  connection  two  facts  need  to  be  emphasized,  first,  that 
a  syphilitic  eruption,  either  macular  or  papular,  never  causes  trouble- 
some itching ;  and  second,  that  a  patient  with  a  syphilitic  eruption  may 
experience  itching  due  to  another  cause — namely,  eczema  or  scabies. 

Inherited  syphilis  may  be  diagnosticated  on  the  appearance  in  a  child 
under   five    months    of  snuffles    and    the    characteristic  skin-eruptions. 

*  Jour.  Amer.  Med.  Assoc,  May  14,  1910. 
26 


402  AyiMAL  PARASITIC  DISEASES. 

Si/phtlis  JiereJitfiria  tarda  may  be  recognized  either  from  a  retrospective 
vieAv  or  from  the  })resem.'e  of  active  lesions  and  symptoms. 

Tcrtiarif  manifestations  of  acquired  syphilis  embrace  these  points: 
L  The  consideration  of  the  fact  that  obscure  cases  in  general  and  atyp- 
ical symptom-groups  are  often  due  to  the  syphilitic  taint.  2.  Direct 
information  or  proof,  as  the  result  of  careful  inquiry,  to  show  that  the 
primary  and  secondary  stages  (either  one  or  other,  or  both)  have  trans- 
pired. 3.  Tlie  evidence  ]iresented  by  the  patient  and  to  bo  obtained  by 
the  careful  objective  examination  of  the  eyes  (for  iritic  adhesions,  etc.), 
throat  and  skin  (for  scars),  bones  (for  necrosis  and  nodes),  and  the 
testes.  4.  Certain  symptoms  are  significant,  such  as  nocturnal  pains, 
paralysis  of  the  single  cranial  nerves,  double  deafness  without  otorrhea, 
etc.      5.   The  therapeutic  test  may  aid  in  doubtful  cases. 

The  presence  of  scars  constitutes  a  most  important  factor  in  making 
a  retrospective  diagnosis.  Recent  scars  are  pigmented,  and  exhibit  a 
slow,  progressive  clearing  up,  until,  from  four  to  eight  years  after  infection, 
they  are  wholly  decolorized,  pearly  Avhite  in  color,  and  smooth.  On  the 
other  hand,  as  pointed  out  by  Hyde,  eczemato-varicose  scars  remain 
stationary.  These  scars  are  apt  to  be  found  on  the  scalp  and  on  the  an- 
terior surfaces  of  the  legs.  They  may  be  single  or  multiple,  and  may 
exhibit  certain  defined  shapes  (semilunar,  dumb-bell,  etc.). 

Justus's  blood-test  for  syphilis,  which  consists  in  a  sharp,  transient 
reduction  of  the  hemoglobin  after  the  administration  by  inunction  or 
hypodermic  injections  of  mercury,  is  not  pathognomonic,  but  an  aid  in 
diagnosis.  It  occurs  in  conditions  other  than  syphilis  (Christian  and 
Foerster).^  Both  inherited  and  acquired  syphilis  can  now  be  recognized 
by  the  serum  reactions  of  Wassermann  and  Klausner — in  from  90  to  95 
per  cent.,  according  to  Butler.-  Obviously,  the  Wassermann  reaction  is 
of  the  greatest  necessity  and  diagnostic  importance  in  cases  in  which 
syphilis  is  not  recognizable  by  the  ordinary  methods  of  examination — 
e.g.,  cerebral  or  spinal  syphilis,  syphilis  of  bones  and  the  internal  organs. 
The  reaction  being  a  systemic  one,  it  follows  that  it  is  indicative  only 
of  the  presence  of  active  syphilis.  On  tlie  other  hand,  a  negative  Was- 
sermann reaction  does  not  imply  that  the  treponemal  are  absent  in  lesions 
of  a  fibrous  character,  but  may  mean  their  temporary  disappearance  from 
the  lymphatic  and  vascular  structures.  It  is  clear  that  treatment  should 
not  be  discontinued  simply  because  the  Wassermann  reaction  is  negative.^ 
Schmidt  recommends  that  in  syphilis  of  tlie  nervous  system,  the  AVasser- 
mann  reaction  should  be  done  with  the  cerebrospinal  fluid  as  well  as 
with  the  blood-serum.  The  Weil  test*  is  more  sensitive  than  the  Wasser- 
mann in  the  later,  untreated  stage  of  the  disease.  The  cholesterin  reac- 
tion is  valuable  as  a  control  to  the  Wassermann  (Matlack  ^).  Robinson 
contends  that  the  Xoguchi  luetin  reaction  (intradermic  injection  of  killed 
cultures  of  treponema  p)allidum)  is  specific  for  tertiary  syphilis. 

1  Univ.  Med.  Mag.,  Nov.,  1805. 

2  Jour.  Amcr.  Med.  ^-l.s.soc,  Sept.  5,  1908. 

'  Was.sermann'.s  reaQtion  is  quite  complicated,  and  fur  the  details  ol'  tlie  method  itself, 
the  reader  must  cfnisiilt  special  works  on  diagnosis. 

*  This  test  is  ba.sed  u|)on  the  finding  that  the  blood  of  .sy](liilitic  jiatients  is  more  re- 
sistant to  the  hemolytic  action  of  weak  solutions  of  cobra  venom  than  is  the  blood  in  other 
diseases,  with  the  po.ssible  exception  of  carcinoma  (ride  N.  V.  Med.  Jour.,  Jan.  0,  1912, 
p.  23). 

5  MoiUhly  Cyclope.diu  and  Med.  Bull.,  I'hila.,  .July,  1012. 


SYPHILIS.  403 

General  Differential  Diagnosis. — Numerous  affections  and  conditions — 
local  and  general — are  liable  to  be  confounded  with  syphilis.  Mere 
allusion  to  some  of  these  common  errors  of  diagnosis  can  be  made  here, 
while  others  must  be  omitted  altogether: 

(a)  The  primary  sore  of  the  lip  has  been  mistaken  repeatedly  for 
cancer.  The  history  and  symptoms  of  syphilis,  together  with  the  tlicr- 
apeutic  test,  must  clear  up  the  doubt. 

{V)  Certain  shin- eruptions  (lichen,  psoriasis,  papular  eczema,  measles, 
etc.)  may  be  mistaken  for  the  eruption  of  secondary  syphilis.  J.  V.  Shoe- 
maker ^  details  the  differential  diagnosis  in  a  recent  article,  which  the 
reader  who  desires  full  information  may  consult. 

(c)  Care  must  be  exercised  lest  the  specific  eruptive  fevers,  especially 
the  pustular  stage  of  small-pox,  be  mistaken  for  secondary  syphilis. 

{d)  The  syphilitic  arthritis  which  may  develop  at  che  onset  of  the 
second  stage  must  be  discriminated  from  rheumatic  arthritis — an  easy 
task  if  only  the  attention  be  drawn  to  the  primary  lesion  and  the  charac- 
teristic secondaries  in  cases  of  the  former  disease. 

{e)  Syphilis  in  the  tertiary  stage  may  simulate  chronic  gout  or  rheu- 
matism^ and  unless  there  is  definite  evidence  of  syphilis  on  the  one  hand, 
or  typical  rheumatic  symptoms  and  history  on  the  other,  the  diagnosis 
may  remain  indefinitely  uncertain.      The  therapeutic  test  may  aid. 

(/)  Periosteal  nodes,  like  those  occurring  in  syphilis,  may  follow 
vaccination,  small-pox,  typhus  and  typhoid  fevers.  Here  the  history 
and  associated  phenomena  furnish  reliable  data  for  discrimination. 

{g)  Carcinoma  of  the  tonsil  has  often  been  diagnosed,  and  the  tonsils 
have  been  excised  when  really  the  seat  of  a  syphilitic  lesion. 

(A)  Janeway  ^  asserts  that  chronic  syphilitic  fever  and  tuberculosis 
are  not  rarely  confounded. 

Treatment. — (a)  Prophylaxis.- — To  prevent  the  transmission  of 
hereditary  syphilis  infected  persons  should  not  marry  within  four  years 
after  the  appearance  of  the  primary  sore.  "  Marriage  should  also  be 
prevented  when  the  patients  have  not  been  subjected  to  a  thorough  and 
prolonged  treatment  "  (Porter).  If  at  the  end  of  the  third  year  the 
patient  presents  a  mucous  patch,  he  must  wait  one  year  longer. 

A  healthy  mother  may  safely  be  allowed  to  nurse  her  syphilitic  child 
owing  to  her  acquired  immunity  (Colle's  law).  Should  she  be  unable  to 
suckle  the  child  its  prospect  of  survival  is  greatly  diminished.  Wet- 
nurses  should  not  be  employed  for  syphilitic  children,  but  may  be  for 
non-syphilitic,  even  when  the  mother  is  affected.  If  syphilis  appear  in 
the  mother  during  pregnancy,  antiluetic  treatment  should  be  begun  and 
persisted  in  even  after  apparent  recovery.  After  the  birth  of  the  child 
treatment  should  be  continued,  if  the  child  be  nursed  by  the  mother,  with 
a  view  to  medicating  the  milk. 

As  has  already  been  stated,  the  most  frequent  mode  of  infection  is 
irregular  and  illicit  sexual  congress,  and  it  follows  that  absolute  moral 
purity  would  go  further  toward  the  prevention  of  this  widespread  malady 
than  any  sanitary  code  or  legal  restrictions.  Physicians  cannot  too 
strongly  advocate  continence.  Should  prostitution  be  regulated  and 
controlled  by  the  state  ?  Experience  has  shown  that  but  a  slight  con- 
trol is  exercised  over  the  spread  of  syphilis  in  countries  where  system- 

1  Medical  JBulletin,  November,  1893. 

-  American  Journal  of  the  2Iedical  Sciences,  September,  1898. 


404  ANIMAL  PARASITIC  DISEASES. 

atic  regulation  of  prostitution  is  attempted  by  the  state.  I  am  of  opinion 
that  the  state  should  maintain  some  form  of  sanitary  regulation  and  con- 
trol, but,  unfortunately,  to  render  this  eflScieut  demands  that  prostitutes 
shall  be  officially  registered.  Such  a  sanitary  supervision  should  consist 
in  the  examination  of  every  prostitute  at  least  twice  a  week,  including 
a  microscopic  examination  of  the  uterine  and  vaginal  secretions,  and  the 
sending  of  every  diseased  prostitute  to  a  hospital  with  a  special  depart- 
ment for  such  cases. ^  Palmer  suggests  that  the  female  offender  is  usually 
not  aware  of  the  existence  of  a  primary  sore,  while  the  male  is ;  hence 
the  latter  should  undergo  inspection  also.  Inspection  of  prostitutes, 
however,  unless  rigid  and  careful,  is  absolutely  valueless.  Chancres  are 
often  concealed  from  view  in  the  vagina  or  upon  the  lateral  aspect  of  the 
OS  uteri.  The  maintenance  of  legal  brothels,  however,  is  not  here  rec- 
ommended, either  from  a  moral  or  hygienic  standpoint.  Experiments 
have  shown  that  the  application  of  calomel  ointment  within  an  hour  of 
inoculation  is  preventive  of  infection  in  man  (Metchnikoff"  and  Roux). 

{b)  Medicinal  Treatment  of  Hereditary  Syphilis. — For  syphilis  of  the 
new-born,  mercury  by  inunction  or  in  the  form  of  calomel  (gr.  -^-^ — 
0.064.  t.  i.  d.)orgray  powder  (gr.  i — 0.0324,  t.  i.  d.),  is  to  be  employed. 
If  these  babies  must  be  hand-fed  the  issue  is  almost  unexceptionally  bad. 

When  the  first  symptoms  appear  at  the  second  or  third  month  the 
above  method  of  treatment  is  generally  successful.  Among  the  poorer 
classes  no  objection  is  made  to  mercurial  inunctions,  and  these  are  often 
preferable.  The  ointment  may  be  rubbed  into  the  armpits,  thighs,  or 
sides  of  the  abdomen,  which  should  be  covered  with  a  flannel  roller. 
The  parts  must  be  kept  clean  ;  and  the  mouth  washed  after  nursing  with  a  3 
per  cent,  solution  of  boric  acid.  Shaw  prefers  to  treat  infantile  syphilis 
by  inunctions,  because  of  the  digestive  disturbances  usually  following 
the  internal  administration  of  mercury  to  children.  iSi/philis  heredita- 
ria  tarda  is  best  treated  by  the  use  of  potassium  or  sodium  iodid.  To 
the  iodid  may  be  added  mercuric  chlorid  in  suitable  doses,  though  the 
latter  may  sometimes  disagree  (Roberts).  In  addition  to  the  specific 
therapy,  tonic  measures  are  usualh'  indicated. 

(f)  Treatment  of  Acquired  Syphilis. — There  is  a  specific  plan  of  treat- 
ment which  should  be  commenced  as  soon  as  the  appearance  of  the  sec- 
ondaries has  set  the  diagnosis  of  the  given  case  at  rest.  This  is  the  use 
of  mercury,  and  rarely  of  potassium  iodid  also.  •  The  instances  in  which 
the  latter  alone  is  to  be  administered  are  rare.  Fournier's  "chronic  in- 
termittent treatment"'  of  syphilis — which  consists  in  continuous  medica- 
tion for  two  or  three  years  with  mercury  and  iodin  alternately — is 
warmly  advocated  by  some  syphilographers ;  but  the  continuous  mode 
is,  in  the  opinion  of  most  specialists,  of  greater  advantage  to  the  patient. 
Unless  mercury  disagree  or  the  patient  is  exceedingly  susceptible  to  its 
physiologic  effects,  I  use  it  persistently  during  the  secondaries,  and  later 
at  intervals  until  the  end  of  two  years.  It  is  a  protracted  course,  and  a 
protracted  course  only,  of  the  specific  treatment  that  suffices  if  we  would 
obviate  the  dread  ravages  that  otherwise  are  so  apt  to  appear.  I  usually 
employ  the  pi'otiodid  (gr.  i— l — 0.008-0.021,  three  times  a  day),  and 
later  the  biniodid  (gr.  -^-^ — 0.0021-0.0027,  three  times  a  day).  We 
should  begin  by  giving  one  pill  three  times  daily,  and  increasing  one  pill 
each   day  until    the  premonitory    symptoms   of   ptyalism    appear  (ten- 


SYPIIILIS.  405 

dernesa  when  the  teeth  arc  knocked  together,  and  ropy  saliva) ;  then 
the  pills  should  be  reduced  J  or  ^,  depending  upon  the  number 
taken.  By  this  procedure  the  physician  is  able  to  ascertain  for  each 
case  the  largest  dose  of  mercury  that  can  be  given  without  harm. 
Hutchinson  recommends  the  gray  powder  given  in  pill-form,  com- 
bined with  Dover's  powder  (aa  gr.  j-0.0648),  this  pill  to  be  taken  from 
four  to  six  times  daily.  A  well-known  mixture,  prescribo<l  in  dispen- 
saries, contains  mercuric  chlorid  and  potassium  iodid  in  combination. 

Inunctions  of  mercurial  ointment  (.^ss — 2.0,  night  and  morning)  pro- 
duce excellent  results,  and  it  is  advisable  in  cases  in  which  the  syphilids 
yield  unsatisfactorily  to  internal  dosage  to  suspend  the  latter  at  intervals 
of  six  or  eight  weeks  and  give  a  course  of  twenty  inunctions.  White 
advances  the  view  that  in  the  later  stages,  with  the  involvement  of  the 
deeper  tissues,  the  combined  use  of  inunctions  over  the  affected  region 
with  potassium  iodid  internally  often  seems  to  have  distinct  advantages  as 
compared  with  the  administration  of  the  "  mixed  treatment "  by  the  mouth. 
It  is  necessary  to  omit  the  inunction  once  in  seven  or  eight  days  for  one 
day,  and  to  take  a  warm  bath  to  aid  in.  the  elimination  of  the  mercury. 

TJie  hypodermic  use  of  mercury  in  syphilis  is  to  be  adopted  only  when 
very  prompt  action  of  this  agent  is  desired.  Several  preparations  are 
used,  and  whether  these  are  soluble  or  insoluble  is  a  matter  of  little  mo- 
ment. The  bichlorid  takes  first  place,  the  dose  being  gr.  \  (0.0162),  in 
15  to  20  drops  of  water,  twice  a  week.  Calomel  probably  holds  sec- 
ond place  (dose,  gr.  j — 0.0648 — in  15  drops  of  glycerin,  twice  a  Aveek). 
Among  other  preparations  employed  are  the  albuminate  of  mercury  and 
gray  oil.  All  injections  must  be  made  deeply  into  the  muscles.  The 
subcutaneous  injection  of  sterilized  serum  for  the  blood  of  lambs  and 
calves  has  been  successfully  practised  by  Tommasoli. 

The  method  of  fumigation  has  gained  favor  in  the  treatment  of 
syphilis,  particularly  in  institutions  on  the  Continent.  Lane  recom- 
mends that  calomel  (siss — 6.0)  be  put  in  a  china  bowl  about  half 
filled  with  water ;  a  spirit  lamp  is  placed  under  this,  and  the  patient, 
"  sitting  above  it  wrapped  in  a  cloak,  has  a  deposit  of  mercury  settle  all 
over  his  body  as  the  calomel  is  sublimed."  He  should  remain  wrapped 
in  the  cloak  for  one  hour,  take  a  fumigation  once  daily,  and  remain  in- 
doors.    From  six  weeks  to  three  months  are  necessary  to  effect  a  cure. 

It  is  almost  universally  agreed  that  the  new  preparation,  "606," 
offers  incredible  possibilities  in  the  treatment  of  syphilis,  and  yet  the  im- 
mense majority  of  writers  are  of  the  opinion  that  it  should  not  be  used  in 
every  instance  of  the  disease.  The  classes  of  cases  in  which  its  employ- 
ment Avould  appear  to  be  entirely  justifiable  are — [a)  recent  cases,  in  which 
mercury  or  iodides  have  not  been  used ;  [b)  those  in  Avhich  mercury  and 
iodides  have  failed ;  {c)  where  the  Wassermann  reaction  confirms  the 
diagnosis  in  suspicious  cases,  and  also  where  it  discloses  hidden  syphilis. 
The  question  of  its  permanency  of  curative  action  has  not,  as  yet,  been 
definitely  settled.  The  effects  of  the  remedy  must  vary  with  the  stage 
of  the  disease,  the  size  of  the  dose,  and  its  methods  of  administration. 

The  mode  of  introduction  into  the  organism  is  important,  and  Fordyce 
states  that  the  order  of  effectiveness  is  as  follows : 

"  1.  Intravenous  injection  of  a  very  dilute  alkaline  solution. 

"2.  Intramuscular  injection  of  an  alkaline  solution. 


406  AyI^fAL  parasitic  diseases. 

"  3.  Acid  solution  (raonochlorliydrate  or  dichlorhyih'ate). 

"4.  Neutral  emulsion  (intramuscular  or  subcutaneous)." 

The  method  of  injecting  the  drug  in  neutral  suspension  or  emulsion 
subcutaneously  gives  less  permanent  results  than  by  the  other  methods, 
although  it  produces  the  least  amount  of  pain.  The  tcchnic  for  2,  or 
intramuscular  injection  of  an  alkaline  solution,  is  as  follows:  Take  a 
graduated  cylinder  with  ground-glass  stopper,  add  "■  606  "  salt ;  imme- 
diately add  15  c.c.  hot  water,  shake  vigorously  until  every  particle  of 
the  salt  is  dissolved;  then  add  2  c.c.  normal  sodium  hydrate  (NaOH) 
solution  ;  a  precipitate  occurs.  Then  continue  to  add  sodium  hydrate 
solution  in  very  small  quantity,  shaking  vigorously  after  each  addition, 
until  the  solution  begins  to  clear  :  then  drop  by  drop,  until  we  have  a 
clear  solution.  This  should  be  neutral  or  slightly  alkaline ;  if  the 
cylinder  does  not  contain  20  c.c.  of  solution,  sterile  water  is  added  up  to 
that  amount.  Then  10  c.c.  of  this  solution  is  injected  deep  into  the 
buttocks  on  either  side,  always  taking  care  to  cleanse  the  parts  with 
soap,  water,   and  iodin. 

The  intravenous  method  gives  the  most  satisfiictory  results  and  the 
preparation  of  the  solution  employed  follows  :  "  Into  a  graduate  holding 
250  c.c.  drop  10-20  c.c.  of  sterilized  Avater.  Add  the  required  dose  of 
'606,'  and  mix  thoroughly  until  there  is  a  clear  solution;  add  sterile 
water  or,  better,  normal  salt  solution  to  the  100  c.c.  mark  ;  then  add  pro 
0.1  of  '606.'  0.7  of  normal  sodium  hydroxid  solution,  and  mix  thor- 
oughly until  the  precipitate  is  thoroughly  redissolved.  If  after  thorough 
mixture  the  solution  is  not  clear,  add  a  few  drops  of  the  sodium  hydroxid 
solution  to  produce  this,  and  then  add  sufficient  normal  salt  solution  to 
make  200-250  c.c.  The  fluids  used  are  all  to  be  warm.  The  alkaline 
mixture  is  then  ready  for  injection.  The  Cassel  syringe  and  apparatus 
supplied  for  this  purpose  are  preferable,  for  by  their  use  the  dangers  of 
introducing  air  are  reduced,  if  the  operator  continues  cautious  and  follows 
the  directions  given  in  the  original  paper  of  Schreiber."  ^ 

The  dose  to  be  administered  varies,  according  to  difterent  clinicians, 
from  0.3  to  0.7  gramme  subcutaneously  or  intragluteally,  while  0.3  to  0.5 
gramme  is  used  intravenously.  In  cases  in  which  the  combined  intra- 
venous and  subcutaneous  or  intragluteal  methods  are  employed,  as  much 
as  0.9  sriiiiime  should  be  used.  McDonao;h  has  found  that  three  to  seven 
injections  are  necessary  to  cure  most  cases  of  syphilis. 

The  remedy  is  contraindicated  in  organic  valvular  aftections  of  the 
heart,  advanced  arteriosclerosis,  locomotor  ataxia,  non-luetic  retinal  and 
optic  lesions,  chronic  Bright's  disease,  the  acute  infections  (including 
bronchitis),  pulmonary  disease  (except  tuberculosis),  and  advanced  dis- 
eases of  the  brain  and  cord. 

The  teeth  should  be  cleaned  thrice  daily.  Hygiene  plays  no  mean 
role  in  the  successful  management  of  syphilis.  The  diet  must  be  liberal, 
though  green  vegetables  and  fruits  are  not  to  be  taken.  Alcohol  and 
tobacco  are  the  two  great  enemies  of  the  luetic. 

Auxiliai'u  measures,  when  other  lesions  are  associated,  are  important. 
At  present,  atoxyl  and  sodium  cacodylate  as  remedies  promise  much. 
If  syphilis  occur  in  a  tul)erculous  .'ubject,  it  is  of  great  value  to  add  the 
potassium  iodid  to  the  mercurial,  and,  if  active  tuberculous  lesions  are 
present,  cod-liver  oil  and  creasote  as  well.  Anemia  and  debility  call  for 
^  Schreiber,  M'O.nchen.  med.   Woclientschr.,  1910,  No.  39. 


8PIRILL0SIS.  407 

iron  and  a  tonic  plan  of  treatment  generally.  Attention  should  be  given 
to  the  stomach,  bowels,  kidneys,  and  other  organs.  At  all  times  it  should 
be  borne  in  mind  that  the  patient,  as  well  as  the  disease,  is  to  be  treated. 

In  toomen  the  iodids  should  be  suspended  during  menstruation  if 
the  flow  of  blood  is  excessive,  but  not  the  mercury.  Says  Mauriac  : 
"  During  pregnancy  specific  treatment  is  well  tolerated,  and  often  re- 
quires to  be  pushed  to  a  point  a  little  short  of  intoxication  for  the  good 
of  both  the  mother  and  the  child,  close  watch  being  kept  upon  the  kid- 
neys, suspending  treatment  at  th,e  first  sign  of  albumin." 

id)  Treatment  of  Tertiary  Syphilis. — For  most  tertiary  manifestations, 
including  visceral  syphilis,  we  have  a  therapeutic  specific  in  potassium 
iodid.  This  should  be  used  alone,  the  inunctions  of  mercury  being 
added  if  the  iodid  fails  to  produce  the  desired  result.  I  give  the  potas- 
sium iodid  in  a  saturated  solution,  one  minim  being  equal  to  \  grain  of 
the  salt.  I  use  gr.  x  (0.648)  t.  i.  d.  at  the  first  dose,  and  increase  the 
latter  1  grain  (0.0648)  each  day  until  the  manifestations  for  which  it  has 
been  prescribed  disappear  or  iodism  is  induced.  It  is  best  given  in  milk. 
In  cases  showing  cerebral  symptoms  it  is  to  be  cautiously  used,  and  it  is 
then  my  custom  to  combine  the  iodid  with  potassium  bromid. 

In  hepatic  syphilis  the  mercurials  are  u.sually  combined  with  iodids 
from  the  start,  and  particularly  calomel  if  there   be  ascites  or  jaundice. 

In  nervous  syphilis,  especially  in  the  graver  forms,  I  begin  with  large 
doses  (gr.  xx — 1.296,  three  times  a  day),  and  augment  as  above  indi- 
cated. The  limit  of  doses  depends  upon  the  efiect  produced.  I  have 
often  found  sodium  iodid  to  agree  better  with  the  stomach  than  the 
potassium  salt.  Mercury  should  be  administered  preferably  by  inunction 
in  combination  with  the  internal  use  of  the  iodids  in  all  forms  of  nervous 
syphilis.  Among  unpleasant  effects  are  coryza,  conjunctivitis  with 
edema  of  the  eyelids,  salivation,  and  certain  skin-eruptions  (erythema, 
urticaria,  etc.).  In  this  form  of  syphilis  the  specific  treatment  is  made 
more  effective  by  attention  to  hygienic  measures — fresh  air,  appropriate 
diet,  and  rest. 


SPIRILLOSIS. 

(Febris  Recurrens;  Relapsing  Fever.) 

Definition. — An  acute  infectious  disease  caused  by  the  spirillum  of 
Obermeier,  and  characterized  by  febrile  periods  which  usually  last  six 
days,  and  are  separated  by  a  febrile  period  of  the  same  duration. 
Manson  suggested  the  term  spirillosis  for  this  disease,  since  ''  relapsing 
fever"  covers  "a  number  of  infections,  spread  probably  by  a  corres- 
ponding number  of  previously  unsuspected  ticks  or  other  blood-suckers." 

Historic  Note. — The  first  accurate  account  of  this  affection  was 
published  in  1739,  though  it  is  known  to  have  prevailed  in  Europe  and 
Ireland  prior  to  that  period.  During  the  next  century  numerous  epi- 
demic outbreaks,  more  or  less  extensive,  occurred,  and  in  1844  the  dis- 
ease made  its  first  appearance  in  America  at  the  Philadelphia  Hospital, 
being  brought  by  immigrants  from  Ireland.  Subsequently  small  groups 
of  cases  occurred,  and  were  reported  by  Flint  and  others,  and  in  1869 


408  ANIMAL  PARASITIC  DISEASES. 

it  prevailed  considerably  in  Philadelphia  (Avhere  it  was  studied  especially 
by  E.  Rhoads  and  William  Pepper)  and  in  other  large  cities  of  the  coun- 
try.    This  -was  the  last  appearance  of  the  disease  in  the  United  States. 

Pathology. — The  solid  organs  of  the  body  present  no  characteristic 
anatomic  changes,  though  when  death  occurs  during  the  febrile  period 
the  various  viscera  (heart,  liver,  kidneys)  are  the  seat  of  cloud}' swelling, 
and  sometimes  of  hemorrhagic  infarct  and  extravasation.  The  spleen 
shows  the  most  constant  alterations,  being  enlarged,  but  in  size  it  ex- 
hibits a  great  variability.  Infarction  is  frequent,  and  the  lymphoid  ele- 
ment of  the  bone-marrow  often  shoAvs  hyperplasia. 

Ktiology. — Bacteriology. — In  1873,  Obermeier  discovered  in  the 
blood  of  patients  suffering  from  relapsiiig  fever  a  special  organism,  the 

spirillum  Ohermeieri,  until  recently 
classed  with  the  bacteria,  but  now 
placed  by  Schaudinn  and  others  with 
the  flagellate  genus  trypanosomata. 
It  is  a  delicate  filamentous  organism 
of  spiral  form  and  much  elongated,  its 
length  equalling  four  to  six  times  the 
diameter  of  a  red  blood-corpuscle 
(Fig.  30).  Examined  under  the 
microscope  during  a  pyretic  period,  it 
is  seen  to  exhibit  active  motion 
among  the  blood-cells,  this  motion 
being  spiral  and  following  the  long 
axis  of  the  organism.  It  is  aerobic, 
and  may  best  be  demonstrated  in  dry 
—'  blood  by  staining  with  Wright's  stain. 

Fig.  30.— Bacillus  of  relapsing  fever  (from       T+  i^  annarpnt  \w  thp  blond  nnlv  diivino- 
human  blood) ;  X  1000  (Gimther).  ^^  ^^  appaienr  Jii  tue  rjiooa  oiu>  uuxing 

the  paroxysms,  and  Dr.  Van  Dyke 
Carter's  careful  studies  have  shown  that  by  inoculation  of  the  blood  con- 
taining spirillar  organisms  the  disease  may  be  conveyed  to  new  or  old 
subjects.  Shortly  before  the  crisis  the  spirilla  disappear  from  the  blood, 
and  are,  as  a  rule,  absent  during  the  whole  of  the  succeeding  apyrexial 
period.  After  death  they  are  found  in  all  the  organs,  but  they  have  not 
been  cultivated  successfully  on  artificial  media. 

Predisposing  Causes. — ^-^ge. — The  complaint  is  most  common  in  young 
adults  between  fifteen  and  twenty-five  years. 

Sex. — A  larger  ])roportion  of  males  than  females  is  affected. 

Famine  and  antihygienic  surroundings  are  potent  predisposing  causes. 

Mode  of  Infection. — Tiotin's  studies  indicate  tliat  the  medium  of  trans- 
mission may  be  through  suctorial  insects  (as  bedbug.s).  Mackie '  ob.served 
an  epidemic  of  relapsing  fever  in  which  the  pediculus  corporis  played  a 
part  in  the  transmission  of  the  disease.  A  well-marked  percentage  of  the 
lice  taken  from  the  infected  Avard  contained  multiplying  spirilla.  During 
epidemics  nurses  and  physicians  are  frequent  sufferers,  and  there  is  some 
evidence  tliat  tlie  di.^case  may  be  conveyed  by  fomites. 

Clinical  History. — The  incubation  period  ranges  in  its  duration  from 
four  to  ten  days,  though  sometimes  it  is  even  briefer ;  and  in  this  stage 
certain  symptoms  (malaise,  fugitive  pains)  may  appear. 

The  invasion  is  abrupt,  often  occurring  on  awakening  in  the  morning, 

^British  Medical  Journal,  Dec.  14,  1907. 


srmiLLOSis.  409 

and  commonly  the  attack  is  ushered  in  with  a  nev era  rigor,  thouf^h  there 
may  be  only  a  repeated  slight  shivering.  ^J^he  chief  acconif)aiiying  symp- 
toms are  frontal  headache,  vertigo,  severe  pains  in  the  loins  and  limbs, 
and  marked  prostration.  The  tem'perature  rises  soon,  and  often  rapidly, 
reaching  105°-106°  F.  (41.1°  C.)  on  the  first  or  second  day.  'i'he  nkin 
is  dry  and  pungent,  and  presents  very  soon  either  a  "characteristic  dirty- 
yellow  color  "  or  a  distinctly  bronzed  appearance.  The  cheeks  are  flushed, 
the  eyes  sunken,  and  profuse  perspiration  often  takes  place,  in  consequence 
of  which  sudamina  are  frequently  observed.  Other  forms  of  eruption 
have  been  described,  but  none  that  are  either  constant  or  characteristic. 
In  certain  epidemics  herpes  /a5m^2'.>?  has  been  noticed.  At  first  the  tongue 
is  moist  and  coated  with  a  yellowish-white  fur,  and  later  it  may  become 
brown,  dry,  and  fissured,  with  sordes  on  the  teeth.  Ulcerative  stomatitis 
has  been  observed  occasionally,  and  catarrhal  pharyngitis  and  mild  ton- 
sillitis may  be  evidenced  by  pain  on  swallowing.  Among  the  earlier 
symptoms  are  excessive  thirst,  anorexia,  nausea,  and  vomiting.  The 
vomitus  may  be  yellowish-green,  green,  or  even  black  in  color,  and  con- 
sists partly  of  bile  (rarely,  also,  blood)  and  gastric  secretions.  Constipation 
often  precedes  invasion,  and  is  apt  to  continue  throughout  the  attack. 

The  pulse  rises  rapidly  with  the  temperature,  though  the  normal 
ratio  between  the  two  is  not  maintained.  The  pulse  is  full  and  strong, 
and  its  beats  number  from  100  to  140  or  more  per  minute ;  but  in  serious 
cases  it  becomes  weak,  irregular,  or  even  intermittent,  while  at  the  same 
time  the  heart-sounds  grow  more  and  more  indistinct.  Hemic  murmurs 
may  be  audible.  The  nervous  manifestations  are  not  of  a  grave  character, 
but  the  headache  persists,  is  severe  throughout,  and  the  patient  is  restive 
and  sleepless.  Delirium  is  not  common,  excepting  only  in  rare  cases 
toward  the  crisis,  and  the  intellect  remains  clear,  as  a  rule.  The  urine 
presents  the  ordinary  febrile  characteristics,  and  may  contain  albumin 
and  casts.  It  also  contains  bile-pigment  when  jaundice  is  present.  The 
respirations  are  accelerated,  and   urgent  dyspnea  may  precede  the  crisis. 

The  physical  signs  during  the  febrile  paroxysms  are  few.  The  epi- 
gastric region  and  the  nerve-trunks  are  tender  to  the  touch,  while  the 
skin-surface  and  certain  muscles  are  often  hyperesthetic.  Palpation 
detects  a  variable  degree  of  enlargement  of  the  spleen  and  liver,  and 
the  signs  of  bronchitis,  of  lobular  pneumonia,  and  of  hypostatic  con- 
gestion of  the  lungs  may  be  present.  The  symptoms  above  detailed 
persist  with  slight  daily  fluctuations  of  temperature  until  the  crisis. 

The  Crisis. — This  occurs  from  the  fifth  to  the  seventh  day,  and  rarely 
as  late  as  the  tenth.  It  is  sometimes  heralded  by  a  critical  rise  of 
temperature,  the  mercury  touching  108°  F.  (42.2°  C),  but  evidenced 
chiefly  by  a  rapid  fall  of  temperature  (within  twelve  hours)  to  or  below 
the  normal,  with  profuse  sweating.  Coincidently,  all  other  symptoms 
disappear  with  marvellous  rapidity.  The  critical  sweat  may  be  replaced 
by  diarrhea,  intestinal  hemorrhage,  metrorrhagia  or  epistaxis,  and  after 
the  lapse  of  a  day  or  two  the  patient  expresses  himself  as  being  well. 

During  the  intervals  between  the  paroxysms  the  skin  may  exhibit  a 
faintly  jaundiced  tint;  there  may  be  trivial  evening  exacerbations  of 
temperature,  particularly  if  complications  be  present  and  outlast  the 
fever  stage ;  and  the  spleen  is  evidently  enlarged.  There  may  be, 
rarely,  but  a  single  paroxysm.  As  a  rule,  at  the  expiration  of  the  second 
week,  a  recurrence  of  all   the  active  symptoms  of  the  primary  attack 


410 


AXLVAL  PARASTTIC  DISEASES. 


occurs,  including  the  rigor  and  fever.  Quite  fre((uently  a  third  pyrexial 
stage  takes  place,  aiid  rarely  a  fourth  or  even  fifth. 

The  duration  of  tlie  first  relapse  is  briefer  than  the  primary  pyretic 
stage,  and  if  there  be  subsequent  relapses,  each  succeeding  one  is  sepa- 
rated from  its  predecessor  by  the  usual  apyrexial  period,  but  is  briefer 
and  lighter.  Hence,  should  a  fourth  or  a  fifth  febrile  period  occur,  it 
is,  as  a  rule,  ((uite  rudimentary.  The  relative  duration  and  severity  of 
the  different  febrile  periods,  and  their  manner  of  recurrence,  are  best 
appreciated  by  a  glance  at  the  temperature-chart  (vide  Fig.  31). 

Complications. — These  are  not  frequent.  At  the  head  of  the  list 
stands  lobar  j)nea)uonia,  and  next  comes  hroncho-pneumonia,  which  is 
always  secondary.     Rupture  of  the  spleen  may  occur.      Other  complica- 


10  11  12  13  14  15  16  17  18  19  20 


Firat  intermi»3ion.  First  relapne.     Second  intermiMion. 

Fig.  31.— Temperature-curve  of  relapsing  fever. 


tions  are  septico-pyemic  processes,  hemorrhagic  nephritis,  hematuria, 
iritis,  irido-choroiditis,  parotitis,  laryngitis,  entero-colitis,  and  neuritis. 
In  pregnant  women  abortion  may  take  place.  Epistaxis  has  been  noted, 
and  may  prove  dangerous.  As  the  result  of  the  very  high  temperature 
and  toxemia,  the  heart  may  become  suddenly  paralyzed. 

Clinical  Varieties. — The  difference  in  the  general  course  of  cases 
in  different  epidemics,  and  even  in  the  same  one,  is,  for  the  most  part, 
the  direct  result  of  the  varying;  degrees  of  intensity  of  the  infection. 
Thus  very  ligJit  or  even  rudimentary  cases  occur  in  which  the  whole 
course  may  be  made  up  of  one  or  two  brief  febrile  periods,  and  their 
resemblance  to  ordinary  intermittents  may  be  close.  The  so-called 
'"'■  bilious  typhoid,''  which  is  a  form  of  relapsing  fever,  occupies  the  other 
extremity,  being  of  malignant  type.  The  symptoms  are  greatly  intensified ; 
but  more  often,  perhaps,  the  condition  early  merges  into  a  typhoid  state, 
to  Avhich  are  added  certain  grave  features  and  complications  (marked 
icterus,  hematemesis  and  hemorrhages  from  other  outlets  of  the  body, 
uremia,  sudden  collapse,  etc.).  Septic  and  pyemic  processes,  including 
infarctions,  are  common  accompaniments,  and  the  outcome  is  frequently 
unfavorable.  Novy  and  Knapp  believe  the  African  form,  or  tick  fever, 
to  be  due  to  the  spirillum  duttoni. 


SPIRILLOSIS.  411 

Diagnosis. — The  prevalence  of  an  epidemic  in  wliich  tlie  cases  pre- 
sent similar  symptoms;  the  sudden  onset;  the  course  and  intensity  of 
the  fever  with  its  concoinitants  ;  the  termination  by  crisis  on  or  about 
the  seventh  day  ;  and  the  peculiar  manner  of  repetition  of  the  fever- 
attacks  after  an  afebrile  period  of  e(|ual  duration, — are  points  that  dis- 
tinguish relapsing  fever  from  other  aifections  which  simulate  it  more  or 
less  closely.  Additional  symptoms  that  are  of  special  value  for  diag- 
nosis are — enlargement  of  the  spleen  and  liver,  a  negative  character  of 
the  nervous  and  a  prominence  of  the  gastric  phenomena,  and  jaundice. 
To  be  able  to  state  that  relapsing  fever  is  positively  present  the  spiro- 
cheta  Ohermeieri  must  be  found  in  the  blood,  and  this  is  particularly 
true  in  the  earlier  cases  of  an  epidemic,  before  they  have  passed 
through  their  typical  relapses.  To  demonstrate  the  presence  of  this 
parasite  in  the  blood  during  the  fever-stage  is  not  a  difficult  task.  A 
drop  of  blood  obtained  from  the  finger-tip  is  to  be  examined  microscopi- 
cally without  previous  dilution.  On  account  of  their  size  and  motility 
the  spirilla  can  be  readily  detected,  and  usually  the  attention  of  the  ex- 
aminer is  first  arrested  by  the  peculiar  joggling  movements  of  the  red 
blood-corpuscles.  Then  the  real  disturbing  agents  appear  as  slender 
spirals  with  a  snake-like  motion.  Their  identity  may  be  confirmed  by 
staining  with  anilin  colors,  and,  in  exceptional  cases,  by  injecting  them 
into  the  blood  of  the  monkey,  in  whom  they  produce  the  disease. 

Differential  Diagnosis. —  Typhus  fever  may  be  mistaken  for  relapsing 
fever,  since  both  have  the  same  predisposing  causes,  both  prevail  epi- 
demically, both  are  characterized  by  an  abrupt  onset,  with  or  without 
prodromes,  and  by  a  continued  type  of  fever.  In  relapsing  fever,  how- 
ever, the  eyes  are  clear  but  hollowed,  the  cheeks  are  flushed,  and  there 
is  a  dirty-yellow  tint  of  skin ;  in  typhus  the  eyes  are  injected,  the  pupils 
contracted,  the  face  wears  a  stupid,  inanimate  expression,  and  the  charac- 
teristic maculopetechial  eruption.  In  relapsing  fever,  delirium  and 
stupor  are  rare,  the  period  of  fever  briefer,  while  the  blood  shows  the 
presence  of  the  spirillum.  In  typhus  relapses  are  the  exception.  Yellow 
fever  resembles  relapsing  fever  in  its  general  course,  but  in  the  former 
the  stage  of  remission  is  both  briefer  and  more  incomplete.  Yellow  fever 
presents  a  stage  of  collapse  with  black  vomit,  and  jaundice  is  more 
intense.  The  spirilla  may  be  detected  in  the  blood,  and  there  is  marked 
splenic  enlargement  in  relapsing  fever. 

Pel  and  Ebstein  have  described  a  febrile  condition  which  sometimes 
occurs  in  pseudoleukemia  and  simulates  that  of  relapsing  fever ;  but  it 
may  be  distinguished  by  the  absence  of  the  spirilla  from  the  blood,  the 
general  enlargement  of  the  lymphatic  glands,  liver,  and  spleen,  and  the 
fact  that  the  pyrexial  periods  do  not  tend  to  grow  shorter. 

Prognosis. — The  prognosis  of  relapsing  fever  is  good,  but  of  "  bil- 
ious typhoid  "  it  is  bad  indeed.  Apart  from  the  type,  we  must  consider, 
in  this  as  in  all  other  acute  infectious  disease,  the  number,  character, 
and  frequency  of  occurrence  of  the  various  complications.  As  stated, 
these  are  few,  infrequent,  and  mostly  benign.  Among  those  signalizing 
danger  are  severe  hemorrhages  (epistaxis,  metrorrhagia,  hematemesis, 
etc.),  premature  labor,  signs  of  uremia  and  syncope,  marked  jaundice 
and  excessive  vomiting,  and  urgent  diarrhea.  Perhaps  the  most  fre- 
quent causes  of  death  are  pneumonia  and  acute  hemorrhagic  nephritis. 


412  ANIMAL  PARASITIC  DISEASES. 

Individual  circumstances  render  the  prognosis  more  grave — as  the  Avant 
of  good  nursing,  privation,  a  previously  enfeebled  system,  and  old  age. 

The  duration  depends  upon  the  number  of  paroxysms,  since  the 
latter  areof  definite  length.  In  most  cases  there  is  but  one  relapse,  and 
in  this  event  the  disease  hists  from  eighteen  to  twenty  days. 

Treatment. — Thorough  disinfection  and  isolation  must  be  carried 
out  in  rekipsing  fever.  The  general  management,  inehuling  the  time 
and  use  of  stimulants,  must  be  based  on  the  same  principles  as  are 
employed  in  typhoid  fever.  The  fever,  as  -well  as  the  nervous  and  other 
symptoms,  is  to  be  opposed  by  the  cold  or  gradually  cooled  bath, 
employed  as  indicated  in  the  article  on  the  treatment  of  the  latter  dis- 
ease. Cold  spongings,  with  the  ice-cap  or  the  cold  pack,  may  be  substi- 
tuted for  the  baths  in  special  cases.  Internal  antipyretics  may 
be  reserved  for  use  in  cases  in  which  the  temperature  is  very 
high  and  the  above-mentioned  means  are  impracticable.  Small 
doses  of  phenacetin  (gr.  ij  to  v — 0.1296  to  0.3240)  or  acetanilid 
(gr.  ij  to  iij — 0.1296  to  0.1944)  are  to  be  adminij^tered,  at  the  same 
time  guarding  the  heart,  and  the  signs  of  collapse  must  be  promptly 
met  by  the  free  use  of  stimulants  (strychnin,  alcoholics,  ammonium, 
etc.).  Vomiting  often  induces  marked  debility,  and  calls  for  the  use  of 
ice  or  iced  champagne  and  small  doses  of  cocain,  morphin,  or  dilute 
hydrocyanic  acid,  preceded  by  a  mercurial  laxative.  Counter-irritation 
over  the  epigastrium  is  also  useful.  For  the  intense  muscular  pain, 
restlessness,  and  sleeplessness  nothing  is  so  good  as  morphin  given  sub- 
cutaneously,  and  Dover's  powder  may  be  employed  if  the  pain  be  of 
moderate  severity.  During  the  intermissions  the  patient  should  be 
kept  indoors  for  ten  days  or  more,  lest  exposure  or  sudden  exertion 
predispose  him  to  a  relapse.  Solid  food  may  now  be  gradually  resumed, 
and  tonics  judiciously  given.  H.  Lowenthal '  treated  131  cases  with 
antispirochetic  serum  (obtained  from  a  horse  that  had  been  treated  with 
blood  containing  the  spirochet?e)  with  but  1  death.  Ardin-Delteil,  Negre, 
and  Reynaud  feel  sure  that  a  specific  remedy  for  relapsing  fever  has  been 
discovered  in  salvarsan,  which  should  be  employed  in  massive  doses 
(0.6  gm.-gr.  x).  The  treatment  of  relapses  differs  in  no  way  from  that 
of  the  first  febrile  period. 

1  Deutsche  med.  Woch.,  October  27  and  November  3^  1898. 


.        PART  III. 

CONSTITUTIONAL   DISEASES. 


DIABETES. 

{Diabetes  MelUtus.) 


Definition. — A  nutritional  affection,  attended  by  an  abnormal 
amount  of  sugar  in  the  blood,  and  characterized  clinically  by  persistent 
glycosuria,  by  polyuria,  and  by  a  progressive  loss  of  flesh  and  strength. 

Pathogenesis. — This  is  still  undetermined.  Post-mortem  lesions  of 
different  organs  and  structures  of  the  body  have  been  met  with  in  dia- 
betes— a  fact  that  has  given  rise  to  a  variety  of  views. 

(1)  That  it  is  dependent  upon  organic  disease  of  the  pancreas,  espe- 
cially granular  atrophy,  or  upon  marked  functional  disturbance  of  this 
organ.  It  has  been  shown  experimentally  that  extirpation  of  the  pan- 
creas is  followed  by  diabetes,  and  that  if  one-half  the  gland  remains 
glycosuria  does  not  result. 

It  may  safely  be  assumed  that  total  loss  of  function  always,  and  par- 
tial loss  sometimes,  leads  to  diabetes.  Lepine  and  Martz  have  been  able 
to  produce  a  glycolytic  ferment  by  treating  the  pancreas  after  their  own 
special  method,  which  need  not  be  detailed  here.  It  is  probable  that  the 
pancreas,  and  particularly  the  cells  forming  the  islands  of  Langerhans, 
furnishes  an  internal  secretion  containing  a  glycolytic  ferment.  This 
ferment  is  identical  with  that  which  is  contained  in  the  blood,  and  in  the 
presence  of  which  glycogen  is  assimilated.  Croftan  ^  has  placed  the 
origin  of  the  blood-ferment  in  the  leukocytes,  and  believes  it,  wjth  the 
pancreatic  ferment,  to  be  identical  with  trypsin. 

(2)  The  suprarenal  glands  have  assumed  a  role  of  much  importance 
since  the  valuable  researches  of  Herter.^  He  found  that  a  solution  of 
adrenalin  chlorid  injected  into  dogs  or  painted  on  their  pancreas,  caused 
marked  glycosuria.  Other  reducing  substances  acted  in  a  similar  man- 
ner. On  the  other  hand,  excision  of  the  left  suprarenal  gland  with 
ligation  of  the  blood-vessels  of  the  right  gland,  caused  a  reduction  in  the 
percentage  of  sugar  in  the  blood.  He  concludes  that  "  the  suprarenal 
glands  make  a  secretion  which  is  capable  of  stimulating  the  pancreas  in 
such  a  way  as  to  call  forth  an  increased  conversion  of  hepatic  glycogen 
into  sugar."       And  further  "  it  seems  that  this  disturbance  in  metab- 

1  Amer.  Jour.  Med.  ScL,  April,  1902.  ^  Medical  News,  October  25,  1902. 

413 


^1^  COySTITUTIOXAL  DISEASES. 

olism  (glycosuria)  is  in  some  way  dependont  on   interference  with   the 
oxidative  activities  of  the  cells  of  tiie  pancreatic  gland." 

(3)  If  the  glycogenic  function  of  the  liver  be  interfered  Avith 
materially,  diabetes  follows.  This  may  result  from  organic  hepatic 
disease  or  a  faulty  nervous  system.  Puncture  of  the  floor  of  the  fourth 
ventricle  will  also  cause  glycosuria,  and  section  of  the  pneumogastric 
nerve  is  followed  by  paralysis  of  the  hepatic  vessels,  disappearance  of 
glycogen  from  the  liver,  and  saccharinuria. 

(4)  The  so-called  aJimentary  (/It/cvsuria  has  frecjuently  been  induced 
experimentally  by  Miura  and  others.  It  results  from  the  ingestion  of 
more  carbohydrates  and  peptone  than  can  be  stored  in  the  liver  as  gly- 
cogen, so  that  some  of  the  latter  finds  its  way  into  the  hepatic  vessels 
"with  resultino;  irlycosuria. 

(5)  The  administration  of  phloridzin  produces  glycosuria  both  in 
animals  and  man.  There  are  two  views  as  to  the  cause  of  phloridzin 
diabetes :  (a)  that  the  kidneys,  owing  to  the  action  of  the  phloridzin  on 
the  renal  epithelium,  eliminate  the  sugar  from  the  organism ;  {b)  that 
an  excessive  formation  of  glucose  occurs  (generally  held). 

(G)  Tlie  Mierohie  Theory. — Ernst  and  others  have  observed  all 
the  forms  of  fungi,  but  as  yet  no  etiologic  relationship  has  been 
shown. 

(7)  Another  view  regarding  diabetes  is  that  the  carbohydrates  of  the^ 
food  are  converted  into  fat  by  the  protoplasmic  action  of  cells  in  the 
intestinal  villi,  and  enter  the  system  in  the  same  way  as  do  fats  taken  as 
such.  The  surplus  carbohydrates  that  escape  the  action  of  the  cells  of 
the  villi  are  transmuted  into  glycogen  in  the  liver.  The  glycogen  stored 
in  the  liver  obviously  forms  fat  also,  since  this  organ  has  some  fat-form- 
ing function,  and  there  are  thus  two  barriers  preventing  the  carbohydrate 
matter  from  entering  into  the  blood,  and  if  either  is  deranged,  hypergly- 
cemia with  consequent  glycosuria  results. 

The  influence  of  the  nervous  system  is  undoubted,  and  Pavy  ^  claims 
that  the  disease  is  essentially  a  neurosis  affecting  a  particular  part  of  the 
vaso-motor  system.  In  light  cases  the  carbohydrates  are  not  warehoused 
in  the  liver  and  muscles,  and  the  excess  of  glycogen  not  burned  up  in 
the  tissues,  so  that  from  the  storage  reservoirs  (liver  and  muscles)  the 
blood  is  supplied  with  an  excess  of  grape  sugar.  In  severe  cases  the 
carbohydrate  moiety  of  the  proteids  of  the  food  or  tissues  furnishes  the 
sugar  excreted  in  the  urine  (Stengel). 

Pathology. — The  pancreas  in  more  than  one-half  the  instances 
shows  morbid  changes.  Opie's^  researches,  since  confirmed  by  other 
observers,  indicate  that  the  important  lesions  are  those  afi'ecting  the 
islands  of  Langerhans.  These  peculiar  structures  appear  to  have  a 
different  function  from  that  possessed  by  the  other  pancreatic  cells,  and  are 
probably  the  source  of  the  internal  secretion  of  the  pancreas.  In 
chronic  interstitial  pancreatitis  of  the  interlobular  type,  the  islands  of 
Langerhans  are  aifected  only  late,  and  glycosuria  is  rare.  The  changes 
following  occlusion  of  the  pancreatic  duct  by  calculus,  growths,  etc.,  are 
of  this  variety.  In  the  interacinar  type  the  cells  forming  the  islands 
1  Lancet,  May  3,  1906.  '  Jour,  of  Exper.  Med.,  V.,  No.  4,  1901. 


DIABETES.  Alb 

of  Langerhans  are  affected  early,  hyaline  degeneration  of  the  capillaries 
may  be  seen,  and  there  is  frequent  and  early  glycosuria.  In  Ilerter's  ^ 
experiments  the  injection  of  fatal  doses  of  adrenalin  was  followed  by 
granular  degeneration  of  the  islands  of  Langerhans. 

Acute  necrosis  of  pancreas,  primary  cancer,  and  diffuse  cancer  may 
cause  glycosuria,  but  rarely.  The  liver  is  often  enlarged  and  fatty,  par- 
ticularly the  zones  corresponding  to  the  distribution  of  the  hepatic 
artery.  According  to  French  writers,  there  is  a  diabetic  cirrhosis  of 
the  organ  {cirrhose  pigmentaire),  the  pigment  being  derived  from  de- 
stroyed blood-cells.  Mici-oscopically ,  the  liver-cells  are  found  to  be 
enlarged,  nucleated,  and  globular  in  outline.  Rindfleisch  holds  that 
these  changes  are  most  striking  in  the  peripheral  portion  of  the  lobule. 

The  Kidneys. — A  well-marked  chronic  interstitial  nephritis,  with 
fatty  degeneration,  is  often  present.  The  tubal  epithelium  and  the  ves- 
sels of  the  Malpighian  bodies  may  show  a  hyaline  change.  More  com- 
monly the  appearances  are  those  of  an  ordinary  catarrhal  nephritis. 

Nervous  System. — In  rare  instances  organic  disease  of  the  medulla 
(tumors,  sclerosis,  etc.)  is  found.  Changes  in  the  posterior  columns  of 
the  cord  have  been  noted,  and  a  peripheral  neuritis,  simple  or  multiple, 
is  commonly  seen.  The  so-called  diabetic  tabes  is  generally  supposed  to 
be  due  to  multiple  neuritis.  Extreme  hyperemia  and  edema  of  the  men- 
inges was  found  in  all  of  8  cases  of  diabetic  coma  (Ilanssen). 

The  Lungs. — The  commonest  lesions  in  the  lungs  are  gangrene  fol- 
lowing pneumonia  and  the  so-called  diabetic  phthisis.  Fatty  emboli  are 
found  in  the  pulmonary  vessels. 

The  Heart. — Arterio-sclerosis  with  cardiac  hypertrophy  is  often  met 
with,  but  does  not  constitute  a  peculiar  lesion. 

The  Skin. — Cutaneous  pigmentation  (diabetic  bronze  of  the  French), 
more  or  less  uniform,  has  been  reported  in  9  cases  (Hanot  and  Chauf- 
fard).     It  is  associated  with  hypertrophic  cirrhosis  of  the  liver. 

The  Stomach. — Dilatation  and,  according  to  Jacobson,  marked  catar- 
rhal changes  are  common  in  the  early  stage. 

The  Blood. — The  normal  proportion  of  sugar  in  the  blood  (0.15  per 
cent.)  is  increased,  though  there  is  no  immediate  connection  between  the 
percentage  of  sugar  in  the  blood  and  the  urine  in  diabetes.  Both  in  ex- 
perimental and  pathologic  diabetes  hyperglycemia  may  be  marked,  with 
moderate  or  slight  glycosuria,  and  Lepine  has  shown  that  diuretics  di- 
minish hyperglycemia  by  increasing  the  glycosuria.  The  blood-plasma 
contains  much  fat.  It  is  probable  that  the  albuminoid  matters  in  the 
blood  may  produce  glucose.  Glycogen  probably  exists  in  the  blood- 
corpuscles,  and  not  in  the  plasma,  "where  it  would  be  destroyed  by  the 
diastasic  ferment"  (Dastre),  and  it  is  a  normal  element  of  the  blood, 
apparently  belonging  to  the  leukocytes  (Huppert  and  Czerny).  The 
alkalinity  of  the  blood  is  diminished,  probably  owing  to  the  presence  of 
oxybutyric  acid.      The  corpuscles  show  no  special  alterations. 

General  Ktiology. — (a)  Heredity  is  generally  believed  to  exert  a 
predisposing  influence,  since  cases  are  observed  to  succeed  one  another 
in  the  same  family,     {h)  Season  also  exerts  an  influence,  diabetes  appear- 
ing more  frequently  in  the  months  of  March,  April,  July,  and  Novem- 
^  Medical  News,  May  10,  1902. 


416  CONSTITUTIONAL  DISEASES. 

ber  (Davis),  (c)  The  male  sex  suffers  much  more  frequently  than  the 
female.  Wegeli,  however,  found  in  107  cases  that  chiklren  of  both  sexes 
were  affected  in  an  ecjual  proportion,  (d)  Age. — Most  cases  occur  between 
thirty-five  and  sixty  years  of  age.  Infantile  diabetes  is  rare,  and  occurs 
most  freijuently  about  the  age  of  five,  though  it  has  been  met  with  under 
one  year,  (c)  The  Hebrew  race  is  especially  susceptible.  The  colored 
race  rarely  suffers,  although  of  a  series  of  77  cases  8,  or  10.3  per  cent., 
were  in  negroes  (Futcher).  (/)  The  better  classes  of  society  furnish 
most  instances,  and  particularly  that  large  element  composed  of  neurotic 
subjects.  (//)  A  nervous  shock  or  strain  or  prolonged  mental  anxiety 
acts  as  a  predisposing  cause,  (/i)  Occupation. — The  urine  of  607  indi- 
viduals engaged  in  manual  labor  that  re(j[uired  great  muscular  and  respi- 
ratory activity  showed  no  sugar  in  any  case ;  while  the  urine  of  100  in- 
dividuals engaged  in  intellectual  work  of  a  more  or  less  fiitiguing  charac- 
ter, but  always  intense  and  sedentary,  showed  sugar  in  10  of  the  cases 
(Worms).  («')  Obesity  predisposes,  somewhat,  particularly  to  the  lipogenic 
form.  (/)  Certain  chronic  diseases — e.  g.  syphilis,  malaria,  gout — pre- 
dispose. {Ti)  Pregnancy  has  a  slight  though  decisive  influence.  (?)  It 
sometimes  follows  acute  infectious  diseases,  (m)  Locality. — Diabetes  mel- 
litus  is,  comparatively  speaking,  rare  in  America,  although  Hare's  statis- 
tics indicate  that  diabetes  is  becoming  more  prevalent.  In  certain  other 
countries  (Normandy,  India,  France)  diabetics  appear  to  be  constantly 
increasing  in  number,  the  mortality  in  Paris  having  more  than  doubled 
from  1883  to  1892,  inclusive.  The  disease  is  much  more  frequent  in 
cities  than  in  rural  districts.  Contagion. — Among  770  cases.  Senator 
saw  9  instances  of  man  and  wife  suffering  from  the  disease.  In  a  series 
of  5,000  cases  1.8  per  cent,  of  conjugal  diabetes  occurred  (Schram). 

Special  Etiology. — Under  this  head  may  be  arranged  the  following 
groups  of  cases :  (1)  Diabetes  due  to  "pouncreatic  disease.  (2)  Cases  oc- 
casioned by  hepatic  disease  {organic  and  functional).  (3)  Those  com- 
paratively rare  instances  caused  by  disease  of  the  brain  (tumors,  sclerosis, 
or  irritative  lesions  of  the  diabetic  center)  and  sjnnal  cord.  (4)  Diabetes 
following  traumatism,  and  especially  injuries  to  the  head.  Not  infre- 
quently it  occurs  after  injuries  to  other  parts  of  the  body,  such  as  the 
spine,  sacral  region,  abdomen,  etc.  In  212  cases  of  traumatism  of  the 
head  Higgins  and  Ogden  found  20  cases  of  glycosuria,  though  only  a 
small  proportion  of  the  cases  (2)  exhibited  a  permanent  glycosuria. 
Ebstein,^  after  an  exhaustive  study  of  6  of  his  own  cases  and  of  44 
gathered  from  literature,  concludes  that  there  can  be  no  question  of  the 
direct  causal  relation  of  traumatic  neurosis  and  diabetes. 

Clinical  History. — For  the  sake  of  accuracy  and  convenience  of 
description,  the  cases  will  be  divided  into  the  acute  and  chronic  forms. 

1.  Acute  Diabetes  Mellitus. — The  instances  are  few  and  the  course  is, 
as  a  rule,  ratber  subacute  than  acute,  manifesting  a  predilection  for  the 
young  and  middle-aged.  The  onset  is  more  abrupt  than  in  the  chronic 
form,  but  the  characteristic  features  do  not  differ  from  those  of  the  lat- 
ter. Many  of  the  cases  due  to  pancreatic  disease  are  of  this,  class. 
Exceptionally,   acute  diabetes  occurs  in  the  aged. 

2.  Chronic  Diabetes. — The  symptoms  are  evolved  slowly  and  gradu- 

'  Deutsche  Arch.  f.  klin.  Med.,  Ajjril,  1895. 


nr A  BETES.  417 

ally,  as  a  rule,  and  prominent  among  prodromal  conditions  is  dyspepsia 
or  chronic  gastric  catari'h.  We  may  note  certain  nervous  disorders,  such 
as  headache,  mental  irritability,  moroseness,  and  insomnia,  with  or  with- 
out gastro-intestinal  symptoms.  I^he  patient  may  suffer  merely  from 
general  debility  and  malaise,  and  either  frequent  micturition,  polyuria, 
or  unnatural  thirst  is  apt  to  be  noticed.  Rarely,  diabetes  has  an  abrupt 
onset,  as  after  an  injury,  a  sudden  nervous  shock,  or  a  chill.  With  the 
development  of  the  affection  the  polyuria  and  thirst  become  marked,  the 
appetite  keen,  and  glycosuria  appears.  In  spite  of  the  enormous  quan- 
tities of  food  taken,  progressive  emaciation  and  debility  attend. 

Leading  Symptoms  and  Complications  in  Detail. — (1)  The  Urinary 
Symptoms. — The  daily  amount  of  urine  varies  from  four  or  five  pints  to 
as  many  gallons.  In  mild  cases  and  in  intercurrent  febrile  attacks  it  may 
be  slightly,  if  at  all,  increased  in  quantity.  The  twenty-four-hour  speci- 
men should  be  examined  at  once,  lest  yeast-cells  develop  and  cause  the 
sugar  to  disappear.  Its  color  is  pale  and  its  specific  gravity  ranges  from 
1020  to  1050,  rarely  being  as  low  as  1015 ;  it  has  an  acid  reaction,  a 
sweetish,  aromatic  odor,  and  a  distinctly  sweetish  taste.  Sugar  is  present, 
the  amount  varying  from  |-  to  1  to  2  per  cent,  in  mild  cases,  to  5  or  even 
10  per  cent,  in  severe  attacks.  The  amount  eliminated  in  the  twenty-four 
hours  varies  from  five  ounces  to  a  pound  or  more. 

Other  forms  of  sugar  than  glucose  (inosite  and  levulose)  may  be  con- 
tained in  the  urine,  and  glycogen  has  rarely  been  found.  The  urine  may 
also  contain  fermentation-products  (acetone,  diacetic  acid,  beta-oxybutyric 
acid).  Acetone  strikes  a  Burgundy-red  color  on  the  addition  of  the 
chlorid  of  iron.  Hirschfeld's  studies  upon  the  excretion  of  acetone  in 
diabetics  show  that  in  severe  forms  an  increased  amount  is  excreted, 
while  other  writers  regard  it  as  being  benign.  Diacetic  acid  is  probably 
of  graver  significance  than  acetone,  whilst  the  presence  of  /?-oxy butyric 
acid  is  a  danger-signal  of  diabetic  coma  {vide  infra). 

The  urea  is  increased,  Kaufman  finding  it  in  the  blood  of  diabetic 
dogs  to  be  doubled.  Uric  acid  is  either  normal  in  quantity  or  increased, 
but  a  large  amount  of  ammonium  is  present,  indicating  an  increase  of  or- 
ganic acids.  The  phosphates  may  also  be  present  in  greatly  increased 
proportion  (Ralfe),  and  in  such  cases  the  glycosuria  may  be  more  or  less 
intermittent.  This  has  been  described  as  a  special  variety — phosphatic 
diabetes.     Lipuria  may  be  present  and  creatinin  is  increased. 

Slight  albuminuria,  often  with  an  intermittent  tendency,  is  common 
even  in  the  early  stages,  and  is  not  of  grave  significance.  Well-marked 
nephritis  with  its  characteristic  phenomena  may  develop,  though  usually 
in  advanced  diabetes;  and  if  albuminuria  be  marked,  the  amount  of 
sugar  excreted  may  be  considerably  diminished.  The  development  of 
chronic  interstitial  nephritis,  however,  is  not  a  favorable  complication, 
as  some  have  supposed.  Arteriosclerosis  may  be  observed,  and  pyelo- 
nephritis (rarely)  and  cystitis  (not  rarely)  may  appear  as  complications. 
A  marked  reduction  in  the  percentage  of  dexti'ose  may  accompany  the 
development  of  intercurrent  febrile  aflfections.  As  the  result  of  fermen- 
tative processes  in  the  bladder  gases  may  form  [pneumaturia). 

(2)  Digestive  Symptoms. — Although  a  general  feature,  thirst  may  be 
discussed  under  this    head.      This    symptom   may  be    most  distressing, 

27 


118  CONSTITUTIONAL  DISEASES. 

necessitating  the  drinking  of  large  quantities  of  Avater  at  frequent  inter- 
vals both  by  night  and  by  day.  The  amount  of  water  taken  stands  in 
direct  relation  to  the  amount  eliminated.  Notwithstanding  the  fact  that 
the  increased  amount  of  water  is  needed  to  dissolve  the  sugar,  cases  of 
confirmed  diabetes  are  met  with  in  which  thirst  is  not  marked.  Cases  are 
also  encountered  in  which  the  amount  of  urine  is  large  and  the  percent- 
age of  sugar  excreted  very  low.  The  cause  of  the  unusual  thirst  is 
probably  an  increased  systemic  demand  for  liquids. 

The  appetite  is  abnormally  large  and  sometimes  almost  insatiable 
(bulimia),  and  there  may  be  an  intense  craving  for  carbohydrates.  I 
have,  however,  met  with  instances  of  diabetes  in  which  the  appetite  was 
not  inordinate.  Considering  the  quantity  of  food  consumed,  the  digestion 
is  often  surprisingly  good,  but  the  association  of  dyspepsia  and  diabetes 
is  by  no  means  an  uncommon  one.  The  stomach  may  be  found  enor- 
mously dilated  at  times,  yet  functionating  normally.  There  is  consti- 
pation, though  brief  intervening  attacks  of  diarrhea  may  occur. 

The  tongue  is  generally  dry,  large,  often  presenting  a  rough  and 
fissured  surface,  and  it  may  either  be  coated  or  red  and  glazed.  The 
gums  sometimes  swell,  and  may  ooze  blood.  The  saliva  is  scanty  and 
its  reaction  persistently  acid,  while  the  salivary  secretion  may  show 
sugar  on  testing.  The  teeth  decay,  and  aphthous  stomatitis  or  thrush 
may  attack  the  oral  cavity. 

The  liver  is  frequently  somewhat  enlarged,  though  the  biliary  secre- 
tion usually  is  not  disturbed;  jaundice  may,  however,  arise  as  a  com- 
plication. Marie  has  given  a  description  of  pigmentary  "  hypertrophic 
cirrhosis  with  diabetes  mellitus,"  of  which  only  9  undoubted  cases  have 
been  published.  It  appears  late  in  adult  life,  and,  in  addition  to  the 
symptoms  of  diabetes  mellitus,  slight  ascites,  considerable  hypertrophy 
of  the  liver  and  spleen,  with  brown  or  even  gray-black  cutaneous  pig- 
mentation, are  among  the  chief  features  noted.  There  is  no  true  icterus 
as  a  rule,  but  the  urine  is  highly  colored  and  contains  bile-pigments. 
Bernoulli  ^  reports  41  cases  of  so-called  bronze  diabetes. 

(3)  Cutaneous  Manifestations. — Diabetic  urine,  on  account  of  the 
sugar  it  contains,  has  irritant  properties,  and  often  produces  in  the 
female  pruritus  vulvce,  a  troublesome  symptom  and  one  that  should 
excite  suspicion  of  this  disease.  In  the  male,  balanitis  often  occurs, 
due  to  the  eifect  of  the  decomposing  urine,  and  from  the  same  cause 
the  genitals  and  adjacent  cutaneous  surfaces  may  be  the  seat  of  eczema, 
particularly  in  women.  General  pruritus,  due  to  irritation  of  sensory 
nerves  by  the  glycemia,  may  be  observed.  The  skin  is  usually  harsh 
and  dry,  though  rarely  copious  perspiration  may  be  observed,  and 
particularly  if  phthisis  be  a  complication.  The  hair  often  falls  off,  and 
in  one  of  my  cases  onychia  with  shedding  of  the  nails  occurred.  Among 
the  commonest  of  the  early  cutaneous  symptoms  are  furuncles  and  boils. 
Later  large  carbuncles  often  appear.  Gangrene  (especially  of  the  feet) 
due  to  arteriosclerosis  is  not  infrequent,  and  edema,  arising  independently 
of  nephritis,  is  not  uncommon.  Morris  has  reported  21  cases  of  xanthoma 
diabeticorum. 

(4)  Nervous  Symptoms. — Diabetic  coma  is  the  most  important  symp- 

^  Correspondenz-Blatl  fur  Schweker  Aerzte,  Basel,  July  1,  1910. 


DIABETES.  4  ] '.) 

torn,  marking  a  fatal  termination  in  more  than  half  the  cases.  It  is  of 
most  frequent  occurrence  in  instances  showing  rapid  wasting  and  in  the 
young,  and  is  heralded  by  a  fruity  odor  in  the  exhaled  breath  and  in 
the  urine.  The  polyuria  and  glycosuria  lessen,  while  acetoniiria  increases 
as  a  rule.  The  tolerance  for  the  carbohydrates  is  increased  (Hirschfield). 
The  cases  may  be  brought  under  six  heads : 

Group  1.  To  this  belong  abortive  forms  that  terminate  in  quick  re- 
covery. This  process  may  be  repeated  several  times  at  intervals,  and 
at  last  a  fatal  coma  may  supervene. 

Group  2.  Perhaps  the  largest  group,  in  which  the  diabetic  coma  fol- 
lows some  form  of  exhausting  exercise.  It  may  end  fatally  in  a  few 
hours  or,  though  less  frequently,  in  three  or  four  days. 

Group  3.  -This  is  a  comparatively  small  class,  and  is  characterized 
by  collapse  of  the  circulation  (small,  rapid,  feeble  pulse,  cyanosis,  etc.), 
leading  to  coma.  It  is  induced  either  by  over-exercise  or  by  intoxica- 
tion. I  have  seen  2  typical  instances,  but  feel  that  it  may  be  ques- 
tioned whether  most  of  these  cases  should  be  classed  as  diabetic  coma. 

Group  4.  Without  previous  dyspnea  or  distress  there  appear  such 
symptoms  as  headache  and  signs  of  intoxication,  and  these  are  followed 
quickly  by  deep  and  fatal  coma  (Frerichs). 

Group  5.  Here  diabetic  coma  is  preluded  by  symptoms  of  some 
localized  disorder,  such  as  gastro-enteritis,  pharyngitis,  pneumonia, 
gangrene,  or  carbuncle.  The  attack  sets  in  with  headache,  delirium, 
distress,  and  dyspnea  both  inspiratory  and  expiratory.  Cyanosis  may 
develop  early,  and,  if  so,  cardiac  failure  precedes  the  coma.  The  dura- 
tion is  from  one  to  five  days.  This  group,  which  was  first  described  by 
Frerichs,  may  have  a  different  onset,  and  I  have  seen  two  fatal  cases,  one 
attended  by  carbuncle,  the  other  with  gastric  symptoms. 

Group  6.  Hirschfeld  has  recently  described  a  class  of  cases  in  which 
we  find,  in  old  persons,  a  moderate  glycosuria  and  coma  supervening 
under  the  influence  of  gangrene  or  carbuncle. 

The  causes  of  diabetic  coma  are  still  obscure.  Hirschfeld  points  to 
insufficient  nutrition  from  an  exclusive  meat  diet  as  a  factor.  Kussmaul 
believed  diabetic  coma  to  be  due  to  acetone.  Kulz,  Stadelman,  and 
others  have  more  recently  found  /3-oxybutyric  acid  in  the  urine,  and  this 
is  now  generally  held  to  be  the  immediate  excitant  of  diabetic  coma 
(which  is  an  acid-intoxication).  This  acid  results  from  an  increased  de- 
struction of  the  proteids.  Lastly,  coma  must  sometimes  be  of  uremic 
origin,  and  Herrick  ^  emphasizes  the  fact  that  casts  are  very  common. 
Cases  that  follow  suppuration  and  gangrene  may  be  septic  in  nature. 

Peripheral  neuritis  is  common.  The  most  frequent  form  is 
diabetic  tabes,  indicated  by  an  absence  of  the  knee-jerks,  darting 
pains,  paresis  of  the  extensors  of  the  foot,  and  by  the  steppage  gait. 
Other  symptoms  may  be  numbness,  tingling,  and  certain  trophic 
disturbances — shedding  of  the  nails  and  perforating  ulcer  of  the 
foot.  R.  T.  Williamson  found  the  knee-jerk  absent  in  25  of  50  cases 
recorded;  and  in  18  of  21  cases  of  diabetic  coma.  Schupfer^  attrib- 
uted absence  of  patellar  reflex  to  toxic  efiects  in  most  cases.     Neuralo-ia 

^  Jour.  Ame)'.  Med.  Assoc,  January  26,  1901. 
*  Soe.  Lancisiana  Roma,  January  24,  1898. 


420  CONSTITUTIOyAL   DISEASES. 

may  be  a  troublesome  symptom,  particularly  when  it  is  of  the  sym- 
metrical sciatio  type,  and  it  points  to  neuritis.  The  same  is  true 
of  paraplegia,  a  condition  that  may  be  met.  Herpes  zoster  may  be 
observed. 

Psi/chopathia  {e.  g.  irritability  of  temper,  hypochondriasis)  may 
sometimes  be  present,   and  temporary  hemiplegia  has  been  noted. 

(5)  Special-sense  Symptoms. — Not  infrequently  cataract  develops, 
leading  to  blindness.  Its  cause  is  not  clear.  Transient  ptosis  and 
strabismus  are  seen,  and  among  other  ocular  conditions  are  optic- 
nerve  atrophy,  iritis,  retinitis  (often  due  to  associated  nephritis),  and 
hemorrhage.  Amaurosis  is  rarely  observed.  Among  the  aural  symp- 
toms I  would  mention  otalgia,  otitis  media,   and  mastoid  disease. 

(6)  Muscular  Symptoms. — In  diabetics  there  is  a  tendency  to  cramps, 
especially  in  the  calf  of  the  leg,  that  appears  during  the  night  and  on 
waking  in  the  morning.  Unschuld  found  it  present  in  33  out  of  109 
cases.  Another  variety  of  cramps  that  may  appear  at  any  hour  of  the 
day  may  occur  with  the  so-called  "gastric  crisis."  In  tliese  attacks 
colicky  pain  in  the  epigastrium  with  vomiting  and  fever  attend. 

(7)  Respiratory  System. — Serious  pulmonary  complications  may 
appear  in  the  advanced  stages.  The  most  frequent  is  pulmonary  tuber- 
culosis, which  has  the  customary  termination,  and  does  not  differ  from 
the  usual  form  of  the  disease.  A  second,  quite  frequent  complication  is 
gangrene  (circumscribed  or  general).  The  peculiar  offensive  odor  of  the  ex- 
pectoration may  be  wanting  here.  A  serious  form  of  pneumonia  (lobar 
or  lobular)  sometimes  occurs,  and  may  terminate  in  gangrene. 

(8)  Circulatory  System. — The  pulse  may  be  of  natural  frequency 
and  tension.  In  other  cases  it  is  somewhat  slow,  and  the  tension  may 
be  inci'eased  :  this  is  often  due  to  an  associated  arterio-sclerosis.  The 
heart  is  sometimes  quite  weak.  The  rate  of  the  pulse,  therefore,  varies 
greatly  :  it  may  be  slow  (brachycardia),  not  exceeding  40  or  50  beats 
per  minute,  or  it  may  be  accelerated.  Dyspnea,  a  tendency  to  syncope, 
and  gastric  disturbance  may  be  seen  in  combination.  Symptomatic  ane-: 
mia  is  present,  and,  in  most  cases,  a  relative  lymphocytosis. 

(9)  Sexual  Symptoms. — Impotence  may  be  an  early  symptom;  it  is 
often  of  great  diagnostic  significance.  Diabetes  may  be  acquired  during 
pregnancy  :  per  contra,  the  diabetic  may  conceive,  though  rarely,  and 
bear  a  healthy  child ;  but  death  of  the  foetus  occurs  in  about  one-half 
of  the  cases.  Premature  delivery  occurs  in  many  cases  (26  per  cent.). 
After  delivery  the  condition  is  generally  aggravated. 

(10)  Constitutional  Symptoms. — Usually  there  is  a  constantly  increas- 
ing loss  of  flesh  and  strength.  In  the  mildest  types,  however,  good 
bodily  nutrition  and  a  fair  degree  of  strengtli  may  be  maintained. 
When  emaciation  is  progressive  the  polyuria  is  apt  to  be  proportional. 
The  temjjerature  is  at  first  normal,  later  usually  subnormal,  though  in- 
tercurrent febrile  attacks,  due  to  complications,  are  often  witnessed. 

Clinical  Varieties. — {a)  Infantile  Diabetes. — Heredity,  traumatism, 
and  convalescence  from  severe  acute  infectious  disease  are  the  chief 
causes.  The  type  is  severer  and  the  course  shorter  than  in  adults. 
A  comparatively  mild  chronic  form,  however,  is  rarely  met  in  chil- 
dren. 


DIABETES.  421 

(6)  Pancreatic  Diabetes. — This  is  a  ^rave  variety,  and  may  present 
evidences  of  pancreatic  involvement.  Tliere  may  he  epigastric  pain  ; 
the  fats  are  poorly  assimilated  ;  and  the  physical  signs  may  rarely  point 
to  pancreatic  growth.  Fitz  noted  that  out  of  1G6  cases  treated  in  the 
Massachusetts  General  Hosj)ital  fatty  stools  were  not  recorded  in  any 
instance.     Marked  polyuria  and  great  thirst  may  he  absent. 

{c)  Alimentary  or  Lipogenic  Glycosuria. — This  is  caused  by  dietetic 
errors,  and  especially  by  excesses  in  eating  and  drinking,  combined 
with  physical  inactivity.  Block  experimented  on  50  patients,  and  found 
that  the  amount  of  grape-sugar  that  could  be  given  before  glycosuria 
appeared  differed  widely  in  diff'erent  diseases.  Frequently  the  smallest 
quantity  was  required  in  nervous  diseases,  and  particularly  in  cerebral 
affections  and  hysteria.  This  form  of  the  disease  is  often  a  temporary 
affair.     The  percentage  of  sugar  in  the  urine  is  usually  small. 

Prognosis. — In  acute  diabetes  the  duration  varies  from  a  few  days 
to  eight  or  ten  weeks,  while  in  chronic  diabetes  the  course  ranges  from 
one  or  two  to  five  or  even  ten  years.  When  the  disease  commences  in 
the  declining  period  of  life,  the  course  is  longer  still.  The  severe  forms 
are  generally  fetal,  and  occur,  as  a  rule,  at  an  early  period  of  life  and  in 
persons  with  an  hereditary  taint.  The  mild  types  and  those  that  occur 
later  in  life  off'er  a  more  hopeful  prognosis,  and  in  certain  cases  the 
v^^ithdrawal  of  all  carbohydrates  from  the  diet  will  cause  the  sugar  to 
disappear  from  the  urine.  Of  the  special  varieties,  alimentary  glyco- 
suria is  altogether  favorable  in  its  course,  traumatic  diabetes  somewhat 
less  so,  while  the  prognosis  of  i\ie  pancreatic  form  is  quite  unfavorable. 

Stout  persons  bear  saccharine  diabetes  better  than  lean.  Diabetes  in 
gouty  subjects  often  pursues  a  favorable  course.  Pre-existing  aflfectious 
may  render  the  prospect  gloomy,  and  certain  complications  indicate 
grave  danger  (coma,  phthisis,  gangrene,  pneumonia,  cardiac  weakness, 
nephritis).  Of  108  such  cases,  64  per  cent,  terminated  fatally  (Wegeli), 
and  between  the  ages  of  four  and  five  years  20  out  of  29  cases  perished. 
The  appearance  of  /9-oxybutyric  and  diacetic  acids  in  the  urine  is  of 
serious  omen.      Cases  showing  heredity  give  an  increased  mortality-rate. 

Diagnosis. — Diabetes  is  distinguishable  by  means  of  (1)  its  causal 
influences  and  its  pathologic  antecedents  and  relations  ;  (2)  its  gradual 
onset,  by  certain  suspicious  symptoms  {e.  g.,  debility,  impotence,  symmet- 
rical sciataca,  cataract,  furunculosis) ;  (3)  the  persistent  presence  of  gly- 
cosuria, polyuria,  and,  later,  acetonuria  and  albuminuria ;  (4)  the  inordi- 
nate thirst  and  appetite ;  (5)  cutaneous  boils,  carbuncles,  gangrene, 
pruritus  vulvae,  balanitis  ;  (6)  neuritis  (especially  double  sciatica),  diabetic 
tabes,  and  coma;  (7)  muscular  cramps;  (8)  special  complications;  and 
(9)  the  long  course  with  slowly  progressive  asthenia  and  wasting. 

In  suspicious  cases,  even  before  the  discovery  of  sugar  in  the  urine, 
grape-sugar  may  be  administered  for  diagnostic  purposes.  If  glycosuria 
result,  the  cases  are  to  be  treated  just  as  in  pure  diabetes.  Transient 
glycosuria,  however,  is  not  the  genuine  aff'ection.  Grape-sugar  must  be 
eliminated  for  weeks,  months,  or  years  (von  Noorden). 

Blood-test. — Williamson's  blood-test,  depending  upon  the  power  of 
diabetic  blood  to  change  a  warm  alkaline  solution  of  methylene-blue  to 
a  dingy  yellow  color,  has  decided  value.     It  occurs  constantly. 


422  CONSTITUTIONAL  DISEASES. 

Treatment. — 1.  A  properly  regulated  diet  is  of  the  first  importance. 
Such  food-articles  as  coutaiu  starch  or  sugar  (houey,  sugar,  ordinary 
flour  or  bread,  biscuits,  rusks,  toast,  arrow-root,  oatmeal,  cracked  wheat, 
potatoes,  tapioca,  sago,  peas,  beans,  turnips,  carrots,  parsnips,  asparagus, 
artichokes,  squashes,  beets,  corn,  rice,  hominy,  the  stalks  and  white 
parts  of  cabbage,  lettuce,  broccoli,  figs,  gra))es,  prunes,  ajjples,  pears, 
bananas,  jams,  syrups,  sweet  pickles,  chocolate,  cocoa,  liquors,  and 
sweet  Avines)  are  either  to  be  prohibited  or  restricted  to  definite  quanti- 
ties, as  will  be  pointed  out  below.  Among  articles  to  be  forbidden  arc 
also  the  livers  of  animals,  mollusks  (oysters,  etc.),  and  the  inside  meat 
of  crabs  and  lobsters.  The  chief  diet  must  be  nitrogenous,  ;uid  my  own 
plan  is  to  first  note  the  effect  of  a  rigid  dietary  as  follows  : 

(a)  Animal  food  :  Fresh  meats,  poultry,  game,  bacon,  ham,  fish  of 
all  kinds,  including  crabs  and  lobsters  (except  the  inside  meat  of  the 
latter).  Fatty  substances  in  large  quantities  (.sviij — 256.0 — daily),  with 
a  view  to  restricting  nitrogenous  destruction,  are  highly  commended  by 
Klemperer.  The  free  use  of  butter  is  urged,  while  eggs,  cream-clieese, 
curds,  and  buttermilk  are  also  allowed. 

[h)  Vegetahha :  Sour-kraut,  lettuce,  sorrel,  mushrooms,  water-cresses, 
spinach,  chicory,  celery,  cucumbers,  mustard-cress,  and  pickles  of  vari- 
ous sorts  (except  sweet).  Soya  bean,  in  which  the  starch  and  fermentable 
carbohydrates  are  removed,  or  carton,  which  contains  35  per  cent,  of 
vegetable  protein,  is  recommended  by  Von  Noorden  and  Lampe. 

{c)  Bread :  The  crust  of  a  French  roll,  first  recommended  by  Flint. 
Ebstein  has  recently  very  highly  recommended  aleuronat  bread  ;  it  con- 
tains a  large  proportion  of  vegetable  albumins.  The  so-called  No.  1 
gluten  biscuit^  is  the  only  form  of  gluten  bread  made  in  this  country 
that  does  not  contain  nearly  as  much  starch  as  the  white  flours  (Tyson). 
Mosse  and  SaAvyer^  find  that  |^otatoes,  steamed  with  their  skins  on  to  re^ 
tain  the  potash  salts,  are  often  well  borne  in  diabetic  glycosuria. 

{<£)  Fruits :  Lemons,  oranges,  and  nuts  (except  chestnuts). 

(e)  Beverages  :  Milk  enough  for  cooking  purposes ;  tea  and  coffee, 
sweetened  with  glycerin  or  saccharin  ;  alkaline  mineral  waters  (Sara- 
toga-Vichy, Seltzer-water),  simple  water  with  some  brandy,  and  acidu- 
lated drinks  ;  Bass's  ale,  in  which  all  the  sugar  is  converted  into  carbonic 
acid  and  alcohol,  and  certain  acid  wines  (claret,  Rhine). 

This  strict  diet  usually  causes  the  sugar  to  diminish  greatly  in  amount, 
and  in  many  cases  to  disappear  entirely.  If  the  patient  keeps  well- 
nourished  and  strong,  carbohydrates  should  not  be  added,  since  there  is 
no  toleration  for  tlie  latter.  On  the  other  hand,  Pilosohof  ^  found  that 
a  small  amount  of  carbohydrate  (two  apples)  added  to  the  albumino- 
fatty  diet  caused  a  diminution  of  sugar  and  acetone.  In  advanced  cases 
with  acidosis  a  carbohydrate  diet  is  indicated;  it  consists  of  protein, 
gm.  60,  carbohydrates,  gm.  300.  One  or  other  of  the  pure  starches,  as 
potato,  rice,  and  oatmeal,  are  used  for  the  purpose.  Again,  inulin  and 
levulose  are  recommended,  and  possess  the  advantage  of  passing  directly 
into  the  blood  unchanged ;  this  form  of  carbohydrate  is  epecially  indicated 
in  cases  in  which  pancreatic  disease  is  coexistent.  An  exclusive  oatmeal 
diet   for   a  few   days,  to   be   alternated   with   a  diet    consisting   of  flesh 

'  This  is  made  l)v  the  Battle  Creek  Sanitarium  Co.,  of  Battle  Creek,  Mich. 
■'Bril.  M.d.  Jour.,  March  .5,  1904. 
'  Roasiky  Vrulcli,  November  25,  1906. 


DIABETES.  423 

greens,  butter,  cheese,  and  the  like  lias  been  advocated.  l*aii  ;irid  others 
believe  that  the  starch  of  the  oatmeal  has  a  specific  action  in  this  disease. 
The  glycosuria  and  polyuria  must  not  he  relieved  at  the  expense  of  the 
general  strength  of  the  patient.  Yon  Noorden  claims  that  a  non-carbo- 
hydrate diet  improves  tissue-metabolism,  and  recommends  a  rigid  albu- 
minoid diet  at  intervals  of  a  few  months.  S.  Solis  Cohen  recommends 
levulose  as  a  form  of  sugar  that  can  be  assimilated  without  augmenting 
the  excretion  of  glucose.  Lactose  has  been  found  to  give  similar  results. 
As  a  substitute  for  the  latter  agents  a  small  amount  of  ordinary  bread 
(which  contains  55  per  cent,  of  starch)  or  potatoes  may  be  allowed. 
Strauss  has  given  inulin  (§iij  ss — 100.0  per  day)  mixed  with  the  food, 
and  has  found  it  to  be  well  tolerated,  the  patients  increasing  in  weight. 
The  effects  upon  the  general  condition  of  the  patient  (body-weight),  as 
well  as  upon  the  glycosuria  (ascertained  by  a  daily  quantitative  estima- 
tion of  the  sugar  in  the  urine),  are  to  be  carefully  noted,  and  the  propor- 
tion of  carbohydrates  may  be  increased  gradually  until  the  limit  of  the 
system's  ability  to  assim.ilate  them  is  found.  A  more  generous  dietaiy  is 
allowable  only  after  the  sugar  has  been  absent  from  the  urine  for  a  couple 
of  months,  and  then  it  is  to  be  adopted  in  a  gradual  manner.  A  skimmed- 
milk  diet  has  been  recommended  by  Donkin,  Tyson,  and  others.  Disque 
and  others  recommend  vegetable  days,  one  or  two  a  week,  in  the  treat- 
ment of  diabetes. 

2.  Next  to  an  appropriate  diet  stand  certain  directions  as  to  proper 
hygienic  living  :  {a)  AH  forms  of  mental  excitement  and  worry  must  be 
avoided ;  (h)  moderate  and  regular  physical  exercise  aids  metabolism,  and 
is  thus  directly  useful ;  massage  may  be  substituted  for  active  exercise 
when  the  latter  is  prohibited  on  account  of  weakness ;  (e)  the  diabetic 
requires  a  temperate  and  equable  climate;  (c?)  a  daily  tepid  bath  if  the 
patient  be  feeble,  and  a  cold  bath  if  he  be  strong,  are  to  be  commended ; 
{e)  flannels  should  be  worn  next  to  the  skin  all  the  year  round ;  (/)  the 
living  and  sleeping  apartments  must  be  thoroughly  ventilated  ;  [g)  the 
teeth  must  receive  careful' attention  in  order  to  prevent  caries. 

3.  The  medicinal  measures  play  a  subsidiary  part  in  diabetic  thera- 
peutics and  opium  is  our  best  antiglycosuric  drug.  It  is  not  necessary 
to  employ  it  in  all  cases,  but  it  may  be  tried  if  the  dietetic  and  hygienic 
treatment  fails  to  eflfect  a  cure.  Opium  seems  not  only  to  exert  an 
influence  over  the  polyuria  and  the  excretion  of  sugar,  but  it  almost 
invariably  lessens  the  intense  thirst  and  conduces  to  refreshing  sleep. 
The  drug  is  well  tolerated  by  diabetics.  The  commencing  dose  may  be 
gr.  j  (0.0648)  three  times  daily,  and  later  increased  to  gr.  v  (0.324)  or 
even  to  gr.  x  (0.648)  three  times  daily.  If  morphin  be  employed,  we 
may  begin  with  gr.  \  (0.0162)  and  increase  the  dose  to  gr.  j  (0.0648)  or 
more  three  times  daily.  Pavy  warmly  advocates  the  use  of  codein  (gr. 
^iij — 0.0324-0.1944,  three  times  a  day).  My  own  best  results  have 
been  obtained  from  the  use  of  the  latter  remedy  in  the  form  of  the  sul- 
phate, in  ascending  doses,  commencing  with  gr.  ^  (0.0162),  three  times 
a  day,  and  augmenting  the  dose  by  gr.  ^  (0.0162)  every  second 
day  until  gr.  ij — 0.129  (rarely  more)  are  taken  thrice  daily.  Codein 
possesses  the  advantage  of  being  less  constipating  and  less  likely  to  dis- 
turb the  digestive  function  than  either  opium  or  morphin.  In  patients 
of  a  full  habit  the  alkaline  waters  exercise  a  valuable  influence — Bethesda, 


424  CONSTITUTIOyAL  DISEASES. 

Carlsbad,  and  A^icliy  of  France  have  long  had  a  reputation.  For  the 
foreign  water  our  native  alkaline  uaters  may  be  substituted,  especially 
the  Saratoga- Vichy.  While  these  are  valuable  adjuncts,  they  are  Avith- 
out  the  curative  eft'ect  that  is  claimed  for  them  by  certain  authorities. 

Among  other  therapeutic  agents  that  have  been  employed  are  the  fol- 
lowing:  the  solution  of  the  bromid  of  arsenic,  IlliiJ-v  (0.199-0.338), 
three  times  a  day,  after  meals — in  some  cases  a  usciul  adjuvant  to  the 
treatment  above  outlined;  potassium  bromid,  gr.  xx  (1.290),  three  times 
a  day,  approximating  in  efficacy  the  latter  remedy.  Fowler's  solution, 
in  ascending  doses  until  mild  toxic  eft'ects  appear  and  then  gradually  re- 
duced, is  preferable  to  the  opium  in  non-n.ervous  cases  ;  antipyrin  (gr.  x — 
0.648),  three  times  a  day;  sodium  salicylate,  gr.  xv  (0.972),  and  aspirin, 
gr.  V  (0.324),  three  times  daily,  lessen  the  formation  of  sugar;  and 
strychnin,  gr.  -^^j  (0.0021),  three  times  daily,  is  an  almost  invariably 
useful  remed3\  Rudisch*  observed  that  methylbromid.  or  sulphate,  of 
atropin  in  increasing  dosage  renders  diabetics  tolerant  of  larger  quantities 
of  carbohydrates.  Horowitz  recouiniends  the  Bulgarian  bacillus,  which 
liberates  free  lactic  acid  in  the  alimentary  tract,  the  latter  interfering 
with  the  rapidity  of  the  starch  digestion. 

The  treatment  of  diabetes  by  fresh  pancreas  or  by  dry  or  glycerin 
extracts  has  been  generally  unsuccessful.  Fit/,,  however,  mentions  a 
case  in  Avhich  remarkable  improvement  followed  the  exhibition  of  raw 
calf-pancreas.  These  preparations  have  been  employed  to  supply'  the 
ferment  (internal  secretion)  essential  to  the  assimilation  of  sugar.  R. 
Lupine  has  obtained  from  the  fresh  pancreas,  from  saliva,  and  from  the 
diastase  of  malt  a  glycolitic  ferment  by  a  method  which,  he  tells  us,  still 
requires  to  be  perfected.  This  agent  he  has  used  in  4  cases  of  diabetes 
with  a  fair  degree  of  success.  Williams  tried  grafting  sheep's  pancreas 
in  diabetics  in  2  cases,  but  the  results  Avere  unsatisfactory. 

Thyroid  extract,  in  small  doses,  was  followed  by  immediate  improve- 
ment in  2  of  my  cases;  it  is  indicated  in  alimentary  glycosuria. 

4.  Symptomatic  Treatment. — Most  symptoms  demanding  therapeutic 
interference  the  competent  physican  is  prepared  to  meet  by  following 
general  rules.  Balint-  gives  a  sugar  solution  in  diabetic  acidosis — 100 
to  150  gm.  of  sugar  by  proctoclysis  daily,  with  favorable  effect.  The 
sugar  is  absorbed  into  the  general  circulation  at  once  instead  of  being 
obliged  to  go  by  Avay  of  the  ])ortal  system.  The  management  of  diabetic 
coma,  however,  will  be  briefly  discussed.  Klemperer  urges  the  use  of 
fatty  substances  in  large  quantities  as  the  best  means  of  restricting  nitrog- 
enous destruction,  and  thus  preventing  the  condition  to  Avhich  diabetics 
so  frequently  succumb.  When  a  disgust  develops  for  fats  a  substitution- 
method  of  treatment  consists  in  administering  alcohol  (liss — 48.0 — per 
day).  Alcohol  in  small  quantity  checks  Avaste  (Hirschfeld).  When  indi- 
cations of  coma  arise,  carbohydrates  should  also  be  added  to  the  diet. 
Foster  states  that  an  oatmeal  diet  is  the  best  method  of  treating  acidosis. 

The  coma  is  almost  certainly  due  to  intoxication  Avith  beta-oxybutyric 
acid,  and  treatment  Avith  alkalies  has  given  the  best  results.  When  an 
attack  threatens,  sodium  bicarbonate,  or,  preferably,  sodium  citrate, 
should  be  given  in  large  doses  (siij — 96.0  daily)  until  the  urine  becomes 

1  Medicnl  Record,  1909,  xxvi.,  109.3. 

^Berliner  klinisrhe  Wochenschrijt,  Aug.  21,  1911. 


DIABETES  INSIPIDUS.  425 

alkaline.  In  the  attack,  the  intravenous  injection  of"  the  same  remedy  is 
to  be  used  freely.  Normal  salt  solution  by  hypodermoelysis  may  be  tried. 
Oxygen  should  be  inhaled,  and  strychnin,  digitalis,  or  ether  may  be  given 
hypodermically.  Prolonged  tepid  baths  with  occasional  douching  have 
seemed  to  produce  beneficial  results,  and  are  worthy  of  a  trial.  Elimina- 
tion from  the  bowels  is  to  be  increased.  The  a;-rays  projected  over  the 
hepatic  region  have  caused  decrease  in  glycosuria. 


DIABETES  INSIPIDUS. 

Definition. — A  chronic  nervous  aflfection,  characterized  by  constant 
thirst  and  an  excessive  flow  of  urine,  which  is  free  froru  sugar  and  of 
low  specific  gravity. 

Pathology. — No  characteristic  lesions  have  been  noted,  though  some 
degree  of  enlargement  of  the  kidneys,  together  with  sacculation,  due  to 
pressure  backward  upon  the  renal  structure  by  the  enormous  quantities 
of  urine  in  the  bladder  and  ureters,  has  been  observed.  The  ureters  and 
pelves  of  the  kidneys  may  be  dilated,  and  the  bladder,  owing  to  constant 
over-distention,  may  be  hypertrophied.  The  nervous  lesions  are  not 
peculiar  to  simple  polyuria.  Most  important,  perhaps,  are  the  tubercu- 
lous and  other  tumors  about  the  floor  of  the  fourth  venti'icle. 

Ktiology. — (a)  Diabetes  insipidus  is  often  induced  by  nervous  influ- 
ences— shock,  fright,  etc.  In  many  cases  it  follows  injuries  to  the  head, 
but  also,  more  rarely,  to  injuries  of  other  parts  of  the  body.  Tubercu- 
lous and  other  lesions  in  the  vicinity  of  the  floor  of  the  fourth  ventricle 
may  produce  polyuria.  It  has  also  been  caused  by  paralysis  of  the  sixth 
nerve,  with  or  without  meningitis.  Frank  holds  that  overactivity  of  the 
pituitary  gland  may  be  a  cause,  {b)  It  may  occur  during  convalescence 
from  acute  infectious  diseases.  I  have  seen  two  instances  after  influenza 
in  young  subjects,  (c)  Intemperance,  especially  the  consumption  of  in- 
ordinate quantities  of  malt  liquors,  proves  a  cause.  In  several  of  my 
own  cases  the  amount  of  urine  passed  was  out  of  all  proportion  to  the 
quantity  of  fluid  ingested,  (d)  Heredity. — Weil  found  in  four  genera- 
tions of  a  certain  family,  consisting  of-  91  members,  that  23  exhibited 
continuous  polyuria — all,  however,  remaining  in  good  health,  (e)  Age. — 
The  disease  is  relatively  more  frequent  in  childhood  and  early  adoles- 
cence  than  is  diabetes  mellitus.  Of  70  cases  collected,  22  were  under 
ten  yea,rs  of  age,  and  13  between  ten  and  twenty  (Roberts).  Diabetes 
insipidus  may  be  congenital.  (/)  Most  cases  occur  in  males  as  compared 
with  females,  {g)  Diabetes  insipidus  may  be,  though  rarely,  a  sequel  of 
diabetes  mellitus  occasioned  by  traumatism  to  the  head. 

Nature  of  the  Affection. — We  are  totally  ignorant  of  its  true  nature, 
though  the  facts  discovered  by  Bernard,  that  either  a  puncture  at  a  cer- 
tain spot  in  the  floor  of  the  fourth  ventricle  or  section  of  the  vagus  causes 
polyuria,  go  to  show  that  it  is  of  nervous  origin.  It  is  true  that  the 
disease  may  come  on  in  persons  apparently  in  robust  health  without 
discernible  causative  agencies.  In  many  instances,  such  as  organic 
aff"ections  of  the  brain  or  abdominal  tumors,  the  condition  is  purely 
symptomatic,  and  these  are  probably  not  to  be  classed  as  cases  of  gen- 


426  CONSTITUTIONAL  DISEASES. 

nine  diabetes  insipidus,  which  is  a  vaso-motor  neurosis,  usually  of  cen- 
tral, though  sometimes  of  reflex,  origin. 

Clinical  Symptoms. — The  onset  is  graduah  as  a  rule,  but  when  it 
follows  a  fright  or  traumatism  it  may  develop  quickly.  There  are  two 
main  symptoms — the  passage  of  an  enormous  (juantity  of  limpid  urine, 
and  the  constant  thirst.  The  daily  amount  of  urine  varies  from  20  to 
60  pints  (10-30  liters) ;  it  is  transparent,  and  the  specific  gravity  is  low 
(1001  to  1005).  While  the  percentage  of  solids  is  lessened,  the  total 
is  usually  about  normal,  and  may  even  be  increased.  Albumin  and 
8U(far  are  rare,  but  in  a  few  cases  inosite  has  been  detected.  The  act 
of  micturition  is  of  very  frequent  occurrence,  and  the  (quantity  of  urine 
passed  at  each  sitting  surprisingly  large.  The  persistent  thirst  necessi- 
tates frequent  drinking,  but  the  voracious  appetite  seen  in  diabetes  mel- 
litus  does  not  mark  this  disease,  in  which  the  appetite  is  only  slightly 
increased.  As  a  result  of  the  polyuria  the  skin  and  mucous  membrane)= 
are  abnormally  dry,  as  in  genuine  diabetes.  But,  unlike  the  latter 
affection,  a  fair  degree  of  bodily  nutrition  is  maintained  as  a  rule 
The  saliva  and  other  digestive  secretions  are  scanty,  and  this,  together 
with  the  good  appetite,  is  a  fact  which  explains  the  disturbances  of 
digestion  sometimes  met  with.  The  tolerance  of  the  system  to  alcohol 
is  often  phenomenal.  Associated  nervous  phenomena  are  frequently 
observed,  such  as  neurasthenic  symptoms,  insomnia,  and  chorea. 

Prognosis. — The  majority  of  instances  proceed  to  recovery  sooner 
or  later,  while  others  pursue  an  almost  endless  course — forty  or  even 
fifty  years  in  duration — and  the  patient  meanwhile  retains  his  general 
good  health.  There  is  a  small  group  of  grave  cases  that  are  due  to 
organic  diseases  either  of  the  brain  or  abdominal  organs  (tuberculosis). 
Death  may  also  be  occasioned  by  some  intercurrent  affection. 

Diagnosis. — The  clinical  recognition  of  diabetes  insipidus  rests 
upon — (a)  the  enormous  amount  of  urine  passed  ;  (6)  its  low  specific 
gravity  ;  and  (c)  the  absence  of  sugar  and  albumin. 

Differential  Diagnosis. — Among  affections  that  must  be  differentiated 
are  diabetes  mellitus,  which  has  a  single  point  of  resemblance — namely, 
the  polyuria ;  hysteric  polyuria,  which  is  transient  and  accompanied  by 
other  hysterical  manifestations  ;  and  chronic  interstitial  nephritis,  which 
generally  distinguishes  itself  by  the  presence  of  albumin  and  hyaline 
casts  in  tlie  urine,  arterio-sclerosis,  and  cardiac  hypertrophy. 

Treatment. — The  amount  of  drinking-water  is  to  be  moderated  in 
a  gradual,  cautious  manner,  and  the  patient  should  be  warned  not  to 
exceed  his  actual  necessities.  I  find  also  that  methodic  physical  exer- 
cise and  a  diet  poor  in  salt  and  albumin  reduces  the  diuresis.  Galvanisn^ 
has  its  advocates. 

Of  medicines,  nervines,  especially  valerian  and  its  preparations,  are 
useful  in  the  idiopathic  variety  of  the  complaint,  and  may  be  given 
in  the  form  of  the  ammoniated  elixir  (.^j-ij — 4.0-8.0)  three  or  four 
times  daily.  The  valerianate  of  zinc,  quinin,  and  iron  may  be  variously 
combined,  according  to  the  indications  presented  by  special  cases.  Ergot 
and  gallic  acid  have  long  enjoyed  a  high  reputation  in  this  disease.  The 
commencing  doses  should  be  moderate,  and  then  be  increased  until  full 
physiological  doses  are  employed,  this  method  often  bringing  about  ad- 


ARTHRITIS  DEFORMANS.  427 

mirable  results.  Antipyrin,  acetanilid,  the  broraids,  and  arsenic  have 
been  extensively  employed  and  lauded  by  different  writers  in  the  treat- 
ment of  this  affection.  My  own  best  results  have  been  attained  by  the 
use  of  ergot.  The  potassium  iodide  is  much  vaunted.  Next  to  this 
agent  the  bromids  and  acetanilid,  given  alternately  at  intervals  of  a 
couple  of  weeks,  have  been  found  to  be  most  useful.  In  one  case,  Iferrick 
obtained  excellent  results  from  lumbar  puncture.  If  a  primary  disease, 
e.  g.,  syphilis,  exists,  it  must  be  met  on  intelligent  general  therapeutic 
principles. 


ARTHRITIS  DEFORMANS. 

(Rheumatoid  Arthritis;  Rheumatic  Gout.) 

Definition. — A  chronic  disease,  characterized  by  progressive  changes 
in  the  arthritic  structures  (cartilages,  synovial  membranes,  etc.)  and  by 
osseous  periarticular  formations,  producing  great  deformity.  The  aff'ec- 
tion  may  rarely  be  acute  in  its  course. 

Pathology. — Among  early  gross  changes  there  may  be  an  eff"usion 
into  the  affected  joints,  but  this  disappears  later.  The  cartilages  are  ab- 
sorbed, the  process  beginning  centrally,  where  there  are  both  the  maxi- 
mum amount  of  friction  between  the  opposed  cartilaginous  surfaces  and 
the  minimum  blood-supply.  Disappearance  of  the  cartilages  is  natur- 
ally followed  by  contact  of  the  ends  of  the  bones,  the  latter  becoming 
polished  and  resembling  ivory  as  the  result  (eburnated).  The  friction 
between  the  bony  extremities  may  lead  to  absorption  of  the  latter. 

At  the  periphery,  where  pressure  is  slight  or  even  absent,  the  carti- 
lages become  greatly  thickened  in  consequence  of  persistent  irritation, 
and  later  become  ossified,  forming  osteophytes  which  overlie  the  articular 
surfaces.  These  may  lock  the  joints.  Bony  nodules  may  also  be  formed 
from  the  periosteum  of  the  bony  shafts. 

Almost  simultaneously  the  synovial  membranes  become  inflamed,  a 
proliferation  of  their  cells  taking  place,  and  this  exudate  may  undergo 
organization  and  rarely  ossification.  Later  the  capsule  and  the  liga- 
ments are  thickened,  causing  a  restriction  of  movement  of  the  aff"ected 
joints  and  producing  pseudo-ankylosis.  Less  frequently  they  soften 
and  weaken  to  such  an  extent  that  often  partial,  and  sometimes  com- 
plete, dislocation  of  the  joints  ensues ;  but  displacement  of  the  ends  of 
the  bones,  amounting  even  to  complete  luxation,  may  also  be  due  to 
absorption.  This  is  often  observed  in  the  head  of  the  femur,  producing 
the  so-called  morbus  aoxoe  senilis.  Muscular  wasting  occurs  and  may  be 
profound.     Neuritis  has  been  noted. 

The  Msto-pathologic  changes  consist  in  cell-proliferation,  with  fibril- 
lation and  softening  of  the  matrix  of  the  cartilages,  followed  by  absorp- 
tion due  to  pressure.  At  the  margin,  however,  proliferation  of  the  cell? 
leads  to  massive  nodulation. 

Ktiology. — The  nature  of  the  disease  is  still  dubious,  though  the  old 
view,  that  it  is  closely  connected  with  rheumatism  on  the  one  hand  or 
gout  on  the  other,  should  be  abandoned.  J.  K.  Mitchell  long  since  main- 
tained that  rheumatoid  arthritis  is  of  neurotrophic  origin,  being  espe- 


428  CONSTITUTIONAL   DISEASES. 

cially  dependent  upon  affections  of  the  spinal  coid,  and  -witliout  stopping 
to  adduce  all  of  the  facts  that  tend  to  siipjiort  this  theory,  the  following 
deserve  mention  :  (1)  Diseases  of  the  cord  (locomotor  ataxia,  etc.)  are 
known  to  cause  arthritic  conditions  ;  (2)  The  character  of  certain  causal 
factors,  such  as  nervous  shocks,  griefs,  etc.  ;  (3)  The  symmetry  of  the 
joint-deformities ;  (4)  The  time  of  occurrence  ;  and  (5)  Noticeable 
trophic  disturbances  that  are  fre(juently  associated.  Falli^  autopsied 
4  cases,  2  of  which  were  typical,  and  in  the  latter  lesions  were  found  in 
the  anterior  horns  of  the  spinal  cord,  atrophic  in  the  first  case,  but 
degenerative  as  well  as  atrophic  in  the  second.  According  to  Falli,  not 
all  cases  of  arthritis  deformans  are  to  be  interpreted  as  instances  of 
nervous  disease.  The  microhic  theory  of  the  disease  claims  a  small  but 
increasing  number  of  supporters. 

Bacteriology. — Dor  claims  to  have  succeeded  in  finding  a  definite 
organism.  He  also  claims  to  have  reproduced  the  disease  by  injecting 
cultures  directly  into  the  blood  of  rabbits,  and  considers  the  germ  an 
"attenuated  culture  "  of  the  staphylococcus  pyogenes  mireus.  v.  Dun- 
gern  and  Schneider  isolated  after  death  from  the  mucus  of  the  gall- 
bladder, and  also  from  the  exudate  in  the  joints,  small  diplococci  that  did 
not  resemble  the  organisms  previously  described  by  Blaxall  and  Schiiller. 
Injections  of  the  cultures  into  the  knee-joint  of  rabbits  resulted  in  the 
production  of  lesions  similar  to  those  observed  in  the  patient. 

Predisposing  Causes. — (a)  Nervous  shocks,  mental  worry,  and  deep 
grief,  {b)  Females  are  more  frequently  victims  than  are  males,  the  pro- 
portion, according  to  the  statistics  of  Garrod,  being  about  one  to  five  in 
favor  of  the  former  sex.  To  account  in  part  for  its  greater  frequency 
in  women  is  the  fact  that  sterility  and  certain  ovarian  and  uterine  com- 
plaints seem  to  exert  a  strong  etiologic  influence,  (c)  Age  exerts  a  de- 
cided influence.  It  is  most  frequently  contracted  in  the  third  decade  of 
life,  though  it  has  been  noted  as  late  as  the  end  of  the  fifth.  It  occurs 
also  in  children,  though  rarely.  Out  of  307  cases  treated  in  the  Devon- 
shire Hospital  during  1892,  only  2  per  cent,  manifested  the  disease  be- 
fore the  age  of  ten.  {d)  Heredity  has  been  traced  in  some  instances, 
and  in  many  a,  family  tendency  to  joint-affection,  (e)  Though  it  occurs 
in  all  classes  of  society,  the  poor  or  those  exposed  especially  to  debili- 
tating influences  are  more  liable  than  the  rich.  (/)  Infectious  diseases 
may  have  an  influence,  (g)  Ewart^  recognizes  some  mixed  conditions 
in  which  rheumatoid  arthritis  may  supervene  on  the  gouty  diathesis. 

(1)  Symptoms  of  the  Chronic  Form. — At  first  one  joint,  usually 
of  the  hand,  is  slowly  involved  ;  soon  the  corresponding  joint  on  the 
opposite  side  is  attacked.  These  may  recover  apparently,  but  are  soon 
reinvaded  and  grow  progressively  worse.  The  affected  joints  slowly  en- 
large, and  are  moderately  painful,  particularly  on  movement.  Pain, 
however,  may  either  be  slight  or  even  absent,  or  severe,  if  the  synovial 
membrane  be  involved.  There  is  neither  redness  nor  tenderness,  as  a 
rule,  but  on  palpation  an  effusion,  variable  in  extent,  is  generally  detecta- 
ble. The  cou7\^e  during  the  early  stage  is  often  marked  by  periods  of 
improvement,  alternating  with  exacerbations  in  the  local  symptoms,  and 

^11  PolicUmco,  Dec,  1894. 

^  InterTiatimal  Medical  Magazine,  April,  1899. 


Fig.  32.— Hand  of  M.  R.,  aged  fifty  years,  showing  characteristic  deformity,  including  ulnar  deflec- 
tion of  fingers,  in  advanced  arthritis  deformans. 


ARTHRITIS  DEFORMANS.  429 

especially  in  the  swelling  and  pain.  While,  as  intimated,  one  or  two 
joints  only  are  affected  at  the  start,  gradually  those  of  the  feet,  arms, 
legs,  and  trunk  are  invaded  symmetrically,  until,  in  the  worst  cases, 
every  joint  is  deformed. 

The  most  characteristic  symptom  is  the  deformity,  which  manifests 
itself  earliest  in  the  hands.  The  fingers  are  generally  pointed  toward 
the  ulna,  rarely  toward  the  radius,  and  the  presence  of  the  osteophytes 
and  the  immensely  thickened  capsular  ligaments,  together  with  the  re- 
tracted muscles,  all  tend  to  alter  entirely  the  shape  of  the  joints.  The 
fingers,  for  example,  are  flexed  and  extended  upon  the  hand,  and  some- 
times overlie  one  another.  With  the  progress  of  the  deformity  a  partial, 
and  less  often  a  complete,  luxation  of  the  joints  occurs  (see  Fig.  32). 
The  joints  may  become  finally  either  quite  fixed,  owing  to  the  presence 
of  the  periarticular  osteophytes,  or  a  limited  degree  of  movement  may 
remain. 

Palpation  and  auscultation  of  the  involved  joints  reveal  crepitation 
during  movement.  Strangely  enough,  the  thumb  remains  intact,  com- 
pensating for  the  loss  of  the  functional  movement  of  the  fingers  to  a 
remarkable  extent.  In  addition,  the  hand  is  sometimes  less  afiected 
than  the  rest  of  the  joints — a  fact  which  enables  the  patient  to  per- 
form a  great  variety  of  delicate  movements,  or  even  to  engage  in  use- 
ful and  surprisingly  skilful  handicraft.  The  adjacent  muscles  be- 
come wasted  and  are  the  seat  of  contractures,  causing  flexion  of  the 
limbs,  especially  of  the  thigh  upon  the  abdomen  and  the  leg  upon  the 
thigh.  Other  trophic  changes,  such  as  paresthesia  and  pigmentation  or 
glossy  areas  of  the  skin,  may  be  observed.  In  3  of  my  cases  onychia 
was  present.  In  extreme  instances  the  decubitus  is  lateral  and  the 
patient  utterly  helpless. 

The  course  of  the  disease  throughout  the  more  advanced  stages  is 
exceedingly  variable.  Its  advance  may  be  arrested  and  the  general 
health  remain  unimpaired,  and  this  may  take  place  after  implication  of 
but  a  few  joints,  so  that  the  entire  aff'ection  may  be  confined  to  a  com- 
paratively small  part  of  the  body,  either  in  the  upper  or  lower  extrem- 
ities. In  progressive  cases  more  or  less  gastro-intestinal  disorder  arises  ; 
the  symptoms  of  indigestion  with  subacidity  appear,  the  appetite  is  im- 
paired, and  anemia  develops.  The  patient's  suff"erings  make  him  irritable. 
Hypochondriasis  may  be  a  concomitant.  In  established  cases  the  pulse 
is  persistently  rapid  and  the  skin  inclined  to  perspiration. 

Clinical  Varieties. — (1)  Of  the  chronic  form  there  are  certain 
sub  varieties.  The  disease  may  be  limited  to  a  single  joint  {inonartic- 
ular),  this  form  most  commonly  aff"ecting  the  hip-joint,  when  it  is  known 
as  morbus  coxoe  senilis.  It  is  seen  generally  in  old  men,  and  often  fol- 
lows an  injury.  Its  features — pathologic  and  clinical — including  the 
muscular  wasting,  are  the  same  in  kind  as  those  of  the  polyarticular 
variety.  Monarticular  arthritis  deformans  may  also  be  confined  to 
the  shoulder-joint  or  the  knee,  and,  as  in  the  preceding  form,  men 
who  have  passed  the  middle  period  of  life  are  mainly  affected. 

A  special  variety,  which  is  generally  not  monarticular,  involves  only 
the  vertebrae  {spondylitis  deformans).  With  this  may  be  combined  disease 
of  one  or  more  of  the  neighboring  large  joints,  forming  the  spondylose 
rhizom^lique  of  Marie,  or  the  condition  may  be  confined  to  the  cervical 
spine,  as  in  a  recent  case  of  my  own,  thus  preventing  flexion  of  the  head. 


430  CONSTITUTIONAL  DISEASES. 

A  fair  degree  of  rotation  usually  remains,  but  it  sometimes  happens  that 
the  entire  spinal  column  is  involved  and  lield  in  a  perfectly  rigid  position. 

Still  another  form  in  which  the  distal  joints  of  the  fingers  become 
knobbed  (Hcbcnhn's  nodes)  demands  separate  description.  Heberden's 
nodosities  occur  chiefly  in  -women  between  the  thirtieth  and  fortieth  years. 
According  to  Ileberden.  who  first  described  them,  the  nodes  have  no 
intimate  association  with  gout,  and  this  view  coincides  with  my  obser- 
vations. At  first  the  affected  joints  become  swollen,  tender,  slicihtJy  red, 
and  puinful,  and  then  seemingly  undergo  great  improvement.  The  con- 
dition however,  is  progressive,  advancement  occurring  in  the  form  of 
fresh  exacerbations,  which  are  only  rarely  traceable  to  errors  in  diet,  and 
are  separated  by  periods  of  remission.  The  morbid  process  is  the  same  as 
in  rheumatoid  arthritis,  and  the  destructive  changes  in  the  joints  pro- 
ceed until  distinct  hard  nodules  are  formed.  These  are  usually  most 
marked  at  the  sides  of  the  extensor  surfaces  of  the  second  phalanges. 
The  disease  does  not  spread  to  any  of  the  larger  joints,  and,  although 
incurable,  it  is  free  from  danger  to  life. 

(2)  The  Acute  Form. — This  is  comparatively  rare,  and  occurs  com- 
monly between  the  ages  of  twenty  and  thirty.  It  occurs  in  children, 
and  is  more  common  in  women  than  in  men.  Among  its  common  ante- 
cedents in  women  are  pregnancy,  delivery,  excessive  lactation,  and  the 
menopause.  Multiple  arthritis,  affecting  both  the  large  and  small  joints, 
sets  in  acutely,  and  there  are  pain  and  either  a  slight  redness  or  a  con- 
siderable swelling,  due  chiefly  to  an  efi'usion  which  is  intra-  rather  than 
periarticular.  There  are  only  a  slight  tendency  to  migration  from  joint 
to  joint,  and  a  slight  febrile  disturbance. 

Still  described  a  form  of  chronic  joint-disease  in  children  which  he 
thinks  presents  differences  sufiiciently  marked  to  suggest  a  distinct 
clinical  and  pathologic  entity,  and  differing  from  the  rheumatoid  arth- 
ritis of  adults.  It  is  defined  as  a  progressive  enlargement  of  the  joints 
associated  with  general  enlargement  of  the  glands  and  enlargement  of 
the  spleen.  He  has  studied  22  cases,  19  of  which  came  under  his  per- 
sonal observation.  It  occurs  before  the  second  dentition.  Stiffness, 
general  thickening  of  the  tissues  around  the  joints  without  redness  or 
tenderness,  except  in  very  acute  cases,  with  limitation  of  movement  and 
more  or  less  rigid  flexion  of  the  joints,  characterize  the  arthritic  dis- 
turbance. The  most  distinct  feature  of  the  disease  is  the  enlargement 
of  the  lymphatic  glands,  those  in  relation  to  the  involved  joint  being 
primarily  affected.  The  glandular  swelling  is  general  and  constant,  and 
with  the  enlargement  of  the  spken,  points  toward  an  infectious  origin. 
Cardiac  complications  are  absent.      The  course  of  the  disease  is  slow. 

Differential  Diagpaosis. — The  diagnosis  between  the  chronic  form 
of  the  disease  and  chronic  rheumatism  is  often  extremely  difficult.  In 
the  latter,  however,  a  few  of  the  larger  joints  only  are  involved,  while 
there  is  an  absence  of  the  peculiar  deformity  and  marked  fixity  of  the 
articulations.  On  the  other  hand,  cardiac  complications  are  absent  in 
chronic  rheumatoid  arthritis,  and  the  course  is  progressive.  A  mon- 
articular arthritis  which  differs  in  its  morbid  process  from  rheumatoid 
artliritis  sometimes  affects  the  shoulder-joint.  It  is  not  uncommon,  and 
is  ■'  characterized  by  pain,  thickening  of  the  capsule  and  of  the  liga- 
ments, wasting  of  the  shoulder-girdle  muscles,  and  sometimes  by  neuritis  " 


ARTHRITIS  DEFORMANS.  431 

(Osier).  I  have  met  with  5  instances  of  this  sort,  in  all  of  which  pain 
was  intense  and  the  course  subacute.     All  ended  in  recovery. 

The  frequency  of  the  occurrence  of  intercurrent  acute  polyarthritis  in 
arthritis  deformans  causes  the  danger  of  mistakiiiir  this  for  acute  rheu- 
matism.^ Acute  rheumatoid  arthritis  is  to  be  discriminated  by  tlie  special 
etiologic  factors,  the  less  severe  pain,  the  less  marked  rodncss,  the  slight 
tendency  to  migration  from  joint  to  joint,  the  sligliter  febrile  disturbance, 
and  by  the  practical  freedom  from  cardiac  complications.  Gout  will  be 
distinguished  in  the  description  of  that  disease. 

Prognosis. — Though  incurable,  rheumatoid  arthritis  is  not  immedi- 
ately dangerous  to  life  ;  in  some  cases  improvement,  and  in  a  smaller  pro- 
portion arrested  progress  of  the  disease,  may  be  expected. 

Treatment. — This  especially  involves  measures  that  are  directed 
toward  the  improvement  of  bodily  nutrition — a  generous  dietary,  sys- 
tematic warm  bathing,  and  an  abundance  of  fresh  air,  with  properly 
regulated  physical  exercise.  Tonics  may  be  necessary  to  invigorate  the 
economy,  and  iron  to  overcome  the  anemia.  The  prolonged  use  of  cod- 
liver  oil  has  given  me  excellent  results.  Of  special  agents,  the  most 
satisfactory  in  their  effects  if  administered  early  are  iodin  and  arsenic. 
The  former  may  be  administered  in  the  form  of  a  saturated  solution  of 
sodium  iodid,  of  which  10  to  15  drops  may  be  given  in  milk  one  hour 
after  food.  Sheffer  advocates  sodium  silicate  well  diluted  (dose  1.5  to  3 
grams  daily).  The  silicates  are  useful  in  overcoming  defective  metabo- 
lism. The  prolonged  use  of  extract  of  thyroid  in  small  doses  (gr.  ss  to  j — 
0.0324  to  0.0648),  with  occasional  intermissions,  is  favored  where  in- 
sufficiency of  thyroid  secretion  is  suspected.  Schliller  and  Hirschberg^ 
have  had  favorable  results  in  the  treatment  of  this  disease  by  limiting 
the  amount  of  lime  in  the  diet.  The  patient  may  be  sent  to  a  warm 
climate  in  winter  and  to  a  cooler  one,  preferably  a  mountain-resort,  in 
summer.  These  patients  also  do  well  at  certain  mineral  springs,  such  as 
the  Sulphur  Springs  of  Virginia,  the  hot  springs  of  Arkansas  or  Toplitz, 
at  Baden  in  Switzerland,  and  the  warm  sodium  chlorid  baths  in  Wiesbaden. 
Hot  mineral  spas  should  only  be  resorted  to  in  the  early  period  of  the 
affection.  Striimpell  has  seen  excellent  results  follow^  the  employment 
of  hot  sand-baths,  which  can  be  used  at  home.  Stewart  advocates  the 
Tallerman  method  of  treatment — i.  e.,  of  superheated  dry  air.  Immobile 
contractures  may  be  broken  up  under  anesthesia  and  tendons  lengthened 
by  tendoplasty,  followed  by  plaster-of-Paris  dressing  until  pain  and  irri- 
tation have  subsided  (Ochsner).  Pain  may  also  be  relieved  by  aspirin 
or  tincture  gelsemium. 

Eliminative  Treatment. — Guaiacol  carbonate  may  be  given  in  doses 
of  from  5  to  15  grains  (0.3-1.0  gm.)  daily  and  increased.  This  com- 
bines with  the  toxins,  and  is  eliminated  as  guaiacol  sulphate  (Bannatyne). 

The  local  means  are  of  value.  If  the  joints  be  inflamed,  cold  com- 
presses, covered  with  oiled  silk,  to  which  some  narcotic  agent  may  be 
added,  will  afford  relief.  This  should  be  followed  by  thorough  and  sys- 
tematic massage,  which  is  our  best  measure  for  the  reduction  of  the 
swelling  (by  promoting  absorption)  and  for  lessening  joint-rigidity,  and 
restoring  the  atrophied  muscles.  Swedish  movements  are  useful  in  main- 
taining mobility  and  mechanical  or  electric  vibration  may  prove  helpful. 
Bier's  hyperemia  may  be  used  where  the  affected  joints  are  few. 

^  Thos..  McCrae :  Jour.  Amer.  Med.  Assoc,  Jan.  6,  1904,  p.  164. 
2  Berlin.  Mm.  WocL,  1911,  xlviii.,  2056. 


432  CONSTITUTIOSAL   DISEA.SES. 

GOUT. 

[Podagra.) 

Definition. — A  form  of  perverted  nutrition  due  to  an  auto-infection, 
accompanied  by  the  formation  of  a  variable  (usually  increased)  amount 
of  uric  acid,  and  characterized  clinically  by  attacks  of  acute  arthritis, 
witli  or  without  uratic  deposits  in  and  around  the  joints. 

Nature  of  the  Affection. — The  numerous  theories  that  prevail  at  pres- 
ent in  regard  to  the  disease  are  irreconcilable,  but  it  seems  certain  that 
there  is  {a)  an  excessive  absorption  of  nutritive  substances,  both  solid 
and  liquid :  {h)  a  disordered  metabolism  growing  out  of  the  effects  of 
imperfect  physical  development,  combined  with  too' little  muscular  exer- 
cise ;  {c)  a  defective  elimination  of  waste-products,  although  in  some 
cases  a  normal  elimination  of  waste-products  exists. 

There  are  a  number  of  uric-acid  theories,  some  of  which  may  be 
briefly  mentioned  :  1.  Garrod  contends  that  an  acute  attack  of  gout  is 
invariably  produced  by  an  excess  of  uric  acid  in  the  blood,  due  to  increased 
formation  and  greatly  decreased  elimination  :  also,  that  inflammation  is 
caused  by  the  deposition  in  the  joints  of  sodium  urate.  2.  Haig  holds 
that  there  is  a  diminished  alkalinity  of  the  blood,  and  that  the  latter 
cannot  therefore  hold  the  uric  acid  in  solution,  and  not  an  excessive  pro- 
duction of  uric  acid.  3.  Ebstein  thinks  it  probable  that  there  exist  an  ex- 
cessive production  and  accumulation  in  the  blood  of  uric  acid.  The  sur- 
charged blood  excites  local  inflammation,  followed  by  necrosis,  and  uric 
acid  deposits.  4.  Sir  William  Roberts  believes  that  acute  attacks  of  gout 
are  dependent  upon  the  precipitation  of  the  crystalline  biurate  of  sodium  ; 
that  the  urate  is  transformed  into  the  less  soluble  biurate  in  the  blood. 
5.  V.  Noorden  concludes  that  the  essential  process  is  a  tissue-necrosis 
attributable  to  the  presence  of  a  hypothetic  ferment,  and  that  the  uric 
acid,  which  is  without  etiologic  efiect,  is  deposited  at  the  necrotic  focus. 
Hall  ^  affirms  that  as  an  etiologic  entity,  uric  acid  must  be  definitely  dis- 
carded. 6.  Klemperer^  has  shown  as  the  result  of  observations  made  in 
cases  of  gout,  that  as  long  as  the  function  of  tlie  kidneys  is  not  materially 
interfered  with  the  presence  of  considerable  amounts  of  uric  acid  in  the 
blood  must  be  attributed  to  increased  formation.  But  the  presence  of 
an  equivalent  of  uric  acid  in  the  blood  in  certain  aftections  other  than 
gout  {e.  g.,  leukemia")  shows  that  this  factor  is  not  the  sole  cause  of  gout. 
7.  Morhorst  states  that  in  any  alkaline  liquid  the  basic  substances  com- 
bine with  uric  acid,  if  this  be  present,  to  form  a  urate.  Those  uratic 
precipitations  are  met  in  non-vascular  tissues  only,  the  alkalinity  of 
which  is  less  than  that  of  the  blood,  and  that  they  are  the  essential 
cause  of  the  symptoms.  8.  Kolisch  maintains  that  when  the  kidneys 
are  healthy  the  alloxuric  bodies  are,  in  great  part,  excreted  as  uric  acid  ; 
but  when  they  are  diseased  the  xanthin  bases  are  increased  at  the  expense 
of  the  uric  acid.  Chittenden  and  others,  however,  hold  that  the  xanthin 
bases  are  practically  free  from  toxic  effects.  9.  Luff  thinks  that  uric 
acid  is  formed  in  the  kidneya  from  a  combination  of  urea  and  glycocin, 
an  increased  amount  of  the  latter  substance  being  formed  in  the  liver.    10. 

1  The  Practitioner,  1906,  Ixxvi.,  p.  361. 

'^Deutsche  medicinische  Wochenachrift,  189-5,  No.  40,  p.  653. 


OOUT.  433 

Duckworth  insists  that  gout  is  essentially  of  nervous  origin.  Tiio  view 
that  failure  of  the  renal  function  precedes  the  developniont  of  gouty 
manifestations,  and  the  older  view,  that  an  increased  proportion  of  uric 
acid  is  found  in  the  blood,  are  widely  accepted. 

Pathology. — The  post-mortem  history  of  gout  is  concerned  princi- 
pally with  the  arthritic  changes,  including  the  deposits  of  the  urate  of 
sodium  in  the  cartilages,  the  ligaments,  and  the  synovial  membranes. 
These  are  fluid  in  their  earliest  state  and  contain  numerous  small  crys- 
talline masses;  they  soon  inspissate  and  later  become  hard  and  dry 
(tophi).  The  latter  excite  secondary  inflammatory  changes  that  may 
lead  to  fibrous  overgrowths,  distortion,  and  fixation  of  the  joints.  Gouty 
tophi  may  be  absorbed  or  they  may  finally  be  discharged  through  the 
skin  in  consequence  of  an  ulcerative  process.  The  chalky  concretions 
have  been  found  also  in  the  cartilages  of  the  ears,  less  frequently  of  the 
nose,  eyelids,  and  larynx.  They  have  also  been  described  in  the  peri- 
osteum and  along  the  tendons  of  the  palms  of  the  hands,  where  they 
produce  a  characteristic  form  of  contraction  of  one  or  more  fingers  (Du- 
puytren's  contraction).  Charcot  has  found  them  in  the  penis.  If  death 
occur  in  the  acute  attack,  hyperemia  and  swelling  of  the  capsule,  liga- 
ments, and  synovial  membrane  are  found,  together  with  an  inflammatory 
exudation  into  the  joint. 

The  kidneys  are  usually  involved,  the  changes  being  similar  in  char- 
acter to  those  observed  in  the  joints,  and  innumerable  areas  of  necrosis, 
followed  by  uratic  deposits,  are  seen  throughout  the  organs,  though 
chiefly  in  the  papillae.  Osier  says  that  "  the  presence  of  these  uratic 
concretions  at  the  apices  of  the  pyramids  is  not  a  positive  indication  of 
gout."  N.  S.  Davis,  Jr.,  points  out  that  the  kidneys  are  afi'ected  in  spots, 
with  intermissions  in  the  degenerative  changes,  which  are  microscopical 
in  size,  until  finally  large  areas  are  involved.  Granular  contracted  kid- 
ney (chronic  interstitial  nephritis),  with  or  without  arteriosclerosis,  is 
sometimes  caused  by  the  gouty  condition  {vide  Interstitial  Nephritis). 

The  heart  and  blood-vessels  always  present  changes.  Gout  induces 
arterio-sclerosis,  and  the  latter  in  turn  causes  cardiac  hypertrophy, 
particularly  of  the  left  ventricle.  In  chronic  cases  fatty  degeneration 
of  the  heart-muscle  sometimes  occurs,  and  chronic  valvulitis,  with  de- 
posits of  urate  of  sodium  in  the  valves,  has  been  noted.  Chronic  bronchi- 
tis, asthma,  and  emphysema  are  among  the  more  common  changes 
connected  with  the  respiratory  tract,  acute  conditions  being  rare. 

Ktiology. — The  following  are  the  principal  contributing  causes  : 

(a)  Heredity. — Garrod's  dictum,  "that  more  than  one-half  of  all 
gouty  subjects  can  distinctly  trace  their  ailment  to  an  hereditary  taint," 
is  doubtless  correct,  heredity  from  the  grandparents,  which  is  of  not  in- 
frequent occurrence,  being  included  in  this  estimate.  If  the  better 
class  of  society  alone  be  considered,  the  percentage  will  probably  be 
still  larger.  It  must  not  be  forgotten,  however,  that  patients  out  of 
pride  represent  other  articular  affections  as  gout.  (5)  Age. — Primary 
attacks  are  most  frequent  in  middle  life.  They  are  rare  before  puberty, 
though  exceptionally  seen  even  in  suckling  infants  ;  but  after  the  age  of 
puberty  they  become  more  frequent.  After  the  fiftieth  year  they  de- 
crease rapidly  in  frequency,  and  are  very  rare  in  quite  advanced  life. 
The  cases  that  develop  quite  early  in  life  often  show  a  striking  heredi- 
28 


434  CONSTITUTIOyAL  DISEASES. 

tary  taint,  (c)  Sex. — The  arthritic  form  is  less  frequent  in  women  than 
in  men,  while  the  former  are  disposed  to  the  irregular  type  of  chronic 
gout  quite  as  strongly  as  the  latter,  {d)  Diet. — Over-indulgence  in  the 
pleasures  of  the  table,  together  with  defective  muscular  exercise,  consti- 
tutes a  potent  factor,  and  this  even  in  persons  wlio  are  endowed  with 
e.xceptional  powers  of  digestion.  (<')  AIcohoL  and  particularly  the  fer- 
mented liquors,  are  among  the  chief  favoring  influences.  The  fact  ex- 
plains the  relatively  greater  frequency  of  gout  in  certain  countries  (e.  ^7. 
England  and  Germany),  in  which  the  heavier  beers  and  ales  are  freely 
used,  than  in  America,  where  lighter  fermented  drinks  are  more  popular. 
The  cases,  however,  are  on  the  increase  in  this  country.  (  f )  Social  State. 
— Most  cases  occur  among  the  upper  class  of  society,  but  there  is  also  a 
well-defined  form  of  "  poor-man's  gout  "  due  to  an  excessive  use  of  malt 
beverages,  (i^)  Lead. — Workers  in  lead  furnish  numerous  typical  ex- 
amples of  gout.  Garrod  found  that  in  30  per  cent,  of  the  hospital 
cases  the  patients  had  been  painters  or  workers  in  lead.  He  also  showed 
that  the  administration  of  lead  salts  to  gouty  persons  almost  invariably 
determined  a  gouty  paroxysm.  Whether  lead  produces  gout  by  arrest- 
ing the  excretory  processes,  and  by  thus  inducing  a  fibroid  change  in  the 
kidney  and  liver,  as  is  held  by  Oliver  of  New  Castle,  is  not  definitely 
settled.  Poore  points  out  that  gout  produced  by  lead  or  chronic  kidney 
trouble  is  constantly  associated  with  anemia  and  emaciation,  and  forms 
a  distinct  clinical  entity.  We  may  presume  the  existence  of  a  primary 
renal  gout.  (A)  Cornillon  and  others  detail  cases  in  which  injuries  were 
followed  by  the  first  appearance  of  the  disease. 

Clinical  History. — 1.  Acute  Gout. — The  earliest  manifestations  of 
the  disease  are  apt  to  take  the  form  of  a  more  or  less  typical  attack  of 
acute  arthritic  gout.  The  latter  is  usually  preceded  by  certain  prodromal 
symptoms,  which  vary  in  diflferent  cases,  but  are  almost  constantly  simi- 
lar for  the  paroxysms  of  individual  cases.  The  patient  may  complain 
either  of  slight  muscular  cramps  and  articular  pains,  or  of  dyspeptic  dis- 
order, or  of  an  asthmatic  seizure  ;  or  he  may  exhibit  mental  disturbance 
— irritability  of  disposition,  broken,  restless  sleep,  and  depression  of 
spirits.  In  a  small  percentage  of  instances,  just  prior  to  the  attack  the 
patient  feels  better  than  ordinarily.  It  has  been  observed  that  imme- 
diately before  and  also  during  the  early  part  of  a  paroxysm  the  daily 
amount  of  uric  and  phosphoric  acids  found  in  the  urine  is  diminished; 
hut  Klemperer  has  shown  that  no  relation  exists  between  the  amount  of 
uric  acid  present  in  the  urine  and  the  character  of  the  disease. 

The  attach  generally  develops  in  the  very  early  morning  hours.  The 
patient  awakens  sufi'ering  from  pains  in  the  metatarso-phalangeal  joint 
of  the  great  toe,  that  soon  become  excruciating,  while  the  joint  feele 
as  if  it  were  tightly  compressed  in  a  vise.  The  local  signs  of  inflamma- 
tion— heat,  redness,  swelling,  and  excessive  sensitiveness — quickly  super- 
vene. The  skin  pits  on  pressure  and  becomes  shiny.  The  hody-tem- 
perature  rises  to  102°  or  103°  F.  (39.4°  C),  and  the  patient  manifests 
intense  irritability. 

At  the  end  of  an  hour  or  two  the  suff'erings  abate,  the  fever  often 
declines,  with  free  perspiration,  and  the  patient  may  be  able  to  pursue 
his  avocation.  During  the  next  day  some  degree  of  enlargement  and 
inflammatory  edema  remains,  and  on  the  following  night  the  symptoms 
are  usually  repeated  in  all  their  violence.     The  condition  usually  pro- 


a  OUT.  435 

grasses  in  this  manner  from  four  to  seven  or  eight  days,  though  after  a 
few  days  the  intensity  of  the  paroxysms  is  apt  to  lessen.  After  the 
attack  the  swelling  subsides  and  there  is  a  slight  desquamation  of  the 
skin,  which  resumes  its  normal  color,  and  the  general  health  is  often 
unusually  good.  These  so-called  fits  of  gout  usually  recur  from  time  in 
time,  the  duration  of  the  intervals  depending  largely  upon  the  patient's 
habits  or  routine  of  life.  On  the  whole,  the  first  interval  is  apt  to  be 
the  longest,  while  later  the  intermissions  may  not  exceed  two  or  three 
months.  With  subsequent  attacks  the  affection  is  apt  to  spread  to  other 
articulations.      There  is  no  tendency  to  suppuration. 

2.  Retrocedent  Gout. — This  term  implies  the  sudden  transmission  of 
the  arthritic  process  to  some  internal  organ.  During  a  paroxysm  the 
joint-inflammation  may  quickly  disappear  with  an  equally  sudden  de- 
velopment of  intense  pain  in  the  region  of  the  stomach,  vomiting,  diar- 
rhea, faintness,  and  a  rapid,  feeble  pulse.  Suppressive  gout  may  attack 
the  heart  and  produce  precordial  pain,  dyspnea,  cardiac  palpitation,  and 
much  anxiety  of  mind.  It  may  also  excite  pericarditis  with  a  fatal 
result.  Transmission  to  the  head,  with  the  development  of  intense  cere- 
bral symptoms  (maniacal  excitement,  coma,  and  apoplexy),  also  occurs. 
Nervous  phenomena,  however,  are  more  commonly  due  to  uremic  poison. 

3.  Symptoms  of  Chronic  Gout. — Chronic  gout  follows  the  acute  variety. 
The  transition  is  gradual,  the  intervals  between  attacks  shorter,  while 
the  attacks  themselves  grow  milder  and  longer.  At  last  the  local  in- 
flammation does  not  appear.  The  condition  extends  to  other  joints : 
first,  to  the  corresponding  joint  on  the  opposite  side,  then  to  the  other 
toes  and  the  ankles.  Later,  the  fingers  and  wrists  may  be  invaded,  but 
almost  never  the  largest  joints.  With  the  progress  of  the  aff'ection  the 
chalk  deposits  slowly  increase  until  the  characteristic  deformity  is  pro- 
duced. The  skin  covering  the  tophi  may  ulcerate,  exposing  the  chalk- 
stones,  an  unmistakable  picture.  When  the  fingers  are  aff"ected  we  note 
a  deflection  at  the  second  or  third  joint,  constituting  a  peculiar  habitus. 

Among  important  associated  conditions  are  chronic  gastric  catarrh, 
arterio-sclerosis,  cardiac  hypertrophy  with  considerable  functional  dis- 
turbance of  the  heart,  and  "contracted  kidney,"  forming  a  much  com- 
plicated yet  easily  recognized  clinical  picture.  If  in  cases  of  this  soi  t 
the  urine  of  a  gouty  person  is  carefully  examined,  and  is  found  to  con- 
tain a  small  percentage  of  albumin  and  tube-casts,  the  whole  train  of 
events  becomes  easy  of  interpretation.  The  cases  may  be  divided  into 
two  classes:  (a)  those  in  which  the  complexion  is  florid  and  the  general 
health  vigorous ;  (b)  those  with  pale,  sallow  facies,  emaciation,  and  en- 
feeblement.  These  groups  are  chiefly  dependent  upon  the  differences  in 
the  etiologic  factors.    Gouty  subjects  often  manifest  unusual  mental  vigor. 

The  course  of  chronic  gout  is  liable  to  be  interrupted  by  acute  exacer- 
bations with  fever,  during  which  dangerous  complications  may  arise — 
e.  g.  uremia,  pericarditis,  pleurisy,  pneumonia. 

4.  Irregular  Gout. — Says  Sir  Dyce  Duckworth :  "  Gout  manifesting 
itself  anywhere  but  in  a  joint  is  to  be  considered  irregular  or  incom- 
plete." Such  cases  are  confined  chiefly  to  persons  of  gouty  heritage, 
though  I  feel  confident  that  the  diathesis  may  be  also  acquired.  But 
though  the  etiologic  factors  that  produce  lithemia  also  in  time  produce 


436  coNsriTuriONAL  diseases. 

gout,  these  two  couditions  should  be  discriminated;  for,  while  in  both 
we  usually  note  an  excess  of  uric  acid  in  the  blood,  in  litheniia  there 
are  no  tophi  present,  and  hence  no  necrotic  foci  in  the  joints  or  else- 
where. Irregular  gout,  then,  rarely  occurs  in  persons  who  have  had 
previous  typical  attacks,  but  should  any  of  the  conditions  described 
below  be  associated,  or  should  they  alternate,  with  acute  gout,  they  may 
be  properly  ascril)ed  to  the  latter.  On  the  other  hand,  Avhen  these  con- 
ditions occur  in  persons  who  are  free  from  hereditary  taint,  and  who  are 
not  addicted  to  the  intemperate  use  of  alcoholic  beverages,  or  excessive 
indulgence  in  the  jileasures  of  the  table,  and  are  not  possessed  of  luxury- 
:ind  rest-loving  temj)crament,  tiie  diagnosis  of  irregular  gout  is  to  be 
made  with  extreme  caution.  It  is  justifiable  to  apply  a  therapeutic  test 
Avhen  other  means  of  diagnosis  fail. 

The  features  of  irregular  gout  are  exceedingly  diversified  ;  the  follow- 
ing are  the  more  important: 

(a)  Joint-  and  31uscle-pains. — The  muscular  pains  may  be  anywhere, 
and  ''Hying"  in  nature,  but  the  muscles  of  the  back  of  the  neck,  the 
lumbar  region,  the  abductors  of  the  thigh,  and  the  gastrocnemii  are 
especially  liable  (Tyson).  These  pains  are  most  severe  in  the  early 
morning  hours  and  subside  as  the  day  grows.  Articular  pains  attended 
with  some  degree  of  swelling  and  deformity  of  the  joints  (the  latter,  how- 
ever, not  due  to  uratic  deposits)  may  be  of  gouty  origin  ;  and,  according 
to  Paget  and  Garrod,  Heberden's  nodosities  (previously  described  under 
Rheumatoid  Arthritis)  may  present  vesicular  eminences  due  to  gout. 

(h)  G astro-intestinal  Disturhances. — The  symptoms  referable  to  the 
intestines  are  identical  with  those  presented  by  lithemia.  In  one  of  my 
cases  intestinal  colic  followed  by  diarrhea  put  in  an  appearance  at  long 
intervals.      Tonsillitis,  pliaryngitis.  and  parotitis  may  be  manifestations. 

{<•)  Cardio-V((ScnIar  jSi/vq/toms. — Just  as  in  pure  litliemia,  so  in  atypi- 
cal gout,  the  increased  amount  of  uric  acid  usually  present  in  the  blood, 
by  increasing  the  blood-tension,  excites  arterio-sclerosis  and  chronic  in- 
terstitial nephritis — aff"ections  w'hich  are  fully  described  in  appropriate 
sections  of  this  work.     Occasionally  pericarditis  is  a  manifestation. 

{d)  Nervous  Manifestation^. — The  different  varieties  of  headache, 
including  migraine,  are  common.  Sciatica  and  other  forms  of  neuralgia, 
tingling,  itching,  burning  sensations,  and  even  pain  in  the  palms  of  the 
hands  and  soles  of  the  feet,  are  of  frequent  occurrence.  Hot  and  itch- 
ing eyeballs  are,  according  to  Hutchinson,  among  frequent  manifesta- 
tions ;  apoplexy  may  arise,  secondary  to  atheroma  induced  by  gout ; 
and  rarely  meningitis  (basilar)  is  among  the  gouty  morbid  states.  The 
latter  also  include  certain  psychopathia — insomnia,  irritability  of  temper, 
and  melancholia.     The  possibility  of  gouty  neuritis  is  to  be  remembered. 

(e)  Urinary  Symptoms. — The  urine  is  highly  colored,  of  high  specific 
gravity,  often  scanty,  and  the  standing  specimen  deposits  lithic  acid. 
This  is  not  peculiar  to  gout,  however.  In  many  cases  uric  acid  is  in 
excess  only  at  intervals,  giving  rise  to  so-called  uric-acid  showers,  while 
at  other  times  it  is  diminished  in  quantity.  Futcher'  reports  an  investi- 
'>-ation  of  the  excretion  of  uric  acid  and  phosphoric  acid  in  a  number  of 
gout  cases,  and  concludes  that  there  is  a  close  parallel  relationship  be- 
tween the  two.  He  believes  that  both  ai-e  products  of  nuclein  disinte- 
gration. Gouty  persons  are  liable  to  gravel:  I  agree  Avith  Tyson,  how- 
'  The  PractUioner,  August,  1903,  p.  181. 


GOUT.  437 

ever,  in  thinking  that  the  two  conditions  moi-c  frequently  alternate  than 
eoexist.  Intermittent  <^]yeosuria  is  also  common  in  gouty  subjects,  amX 
may  lead  to  true  diabetes  mellitus ;  this  glycosuria  may  alternate  with 
uric-acid  showers.  With  these  affections — intermittent  glycosuria  and 
gout — obesity  is  not  uncommonly  associated.  Oxaluria  has  been  noted. 
Grandmaison  believes  the  association  of  albuminuria  with  gout  to  be  a 
frequent  one,  and  that  the  early  albuminuria  is  often  intermittent. 
Zuelzer^  has  observed  an  increased  eliniiniition  of  uric  acid  in  gouty 
subjects  after  the  use  of  atophan,  and  Weintraud  has  shoAvn  that  ui'ic 
acid  injected  intravenously  into  gouty  subjects  is  retained  for  a  long  time 
unless  atophan  be  given — a  diagnostic  sign.  Among  grave  necondary 
affections  chronic  interstitial  nephritis,  with  its  characteristic  features 
(slight  albuminuria  and  later  casts),  very  commonly  develops,  sooner  or 
later,  and  cystitis  (with  gouty  hemorrhage  into  the  bladder),  urethritis, 
prostatitis,  and  orchitis  all  may  be  dependent  upon  gout. 

(/)  Pulmonary  Disturbances. — Chronic  bronchitis,  to  which  asthma 
and  emphysema  may  be  secondary,  is  often  due  to  podagra. 

{g)  Cutaneous  Eruptions. — Eczema  is  frequently  associated  with  the 
gouty  diathesis,  and  I  have  often  observed  eczematous  eruptions  alternat- 
ing with  the  symptoms  of  bronchitis  or  gastric  catarrh. 

(A)  Ocular  Disorders. — The  chief  eye-symptoms  are  conjunctivitis 
and  keratitis  (with  tophi  in  the  cornea  and  eyelids),  iritis,  hemorrhagic 
retinitis,  and  glaucoma.  Gouty  involvement  of  the  ear  (external  canal 
and  the  auricle  particularly)  occurs  oftenest  late  in  life,  though  hereditary 
gout  may  rarely  cause  ear  symptoms  shortly  after  birth. 

Differential  Diagnosis. — The  distinction  between  typical  acute 
gout  and  acute  articular  rheumatisyn  is  a  simple  matter.  But  when,  as 
is  rarely  the  case,  the  former  manifests  itself  as  a  polyarthritis,  the  dis- 
crimination may  be  difficult.  W.  H.  Thompson  has  pointed  out  that  in 
gouty  polyarthritis,  Avhen  the  knees,  elbows,  and  phalangeal  finger-joints 
are  affected,  the  points  of  greatest  tenderness  on  transverse  pressure  are 
over  the  condyles.  On  the  other  hand,  in  acute  rheumatism  the  points 
of  maximum  tenderness  correspond  with  the  tendons  anterior  and  pos- 
terior to  the  joints.  Moreover,  gout  distinguishes  itself  by  its  previous 
history  (heredity,  alcoholism,  gluttony),  by  the  tophi,  Avhich  may  be  first 
detected  in  the  ears  or  conjunctivge,  by  the  development  of  contracted 
kidneys,  and  the  less  marked  fever.  After  repeated  attacks  deformities 
of  the  joints  ensue.  In  a  doubtful  case  the  blood-serum  may  respond  to 
Garrod's  uric-acid  test,  as  follows :  Add  5  to  6  minims  (0.399)  of  acetic 
acid  to  2  di'ams  (8.0)  of  blood-serum  in  a  Avatch-glass ;  then  place  a  linen 
thread  in  the  solution,  and  after  twelve  to  twenty-four  hours  this  will  be 
encrusted  with  crystals  of  uric  acid.  The  same  result  is  obtained  in 
leukemia  and  pneumonia, — affections  from  which  gout  is  easily  distin- 
guishable. 

.  Chronic  rheumatism  is  distinguished  from  gout  by  the  fact  that  the 
latter  disease  involves  chiefly  the  small,  and  chronic  rheumatism  chiefly 
the  large,  joints.  Moreover,  chronic  interstitial  nephritis  and  arterio- 
sclerosis, with  their  varied  and  often  serious  consequences,  are  frequently 
attendant  upon  gout,  but  not  upon  chronic  rheumatism. 

To  differentiate  chronic  gout  and  rheumatoid  artliritis  may  be  difiicult, 
but  the  following  table  will  indicate  the  main  points  of  difference : 
1  Berlin.  kUn.  Woch.,  1911,  xlvii.,  2101. 


4o8  CONSTITUTIONAL   DISEASES. 

Gorx.  Arthritis  Deformans. 

Frequently  hereditary.  Not  so. 

Causes  are  chiefly  dietetic.  Causes  chiefly  nervous. 

Aftects  males  and  the  better  classes  most  Affects  females   and  lower  classes  most 

frequently.  frequently. 

Begins    in  the    big  toe   and   extends   to  Begins  in  the  fingers,  which  point  to  the 

other  toes;  it  is  unilateral.  ulnar    side;    develops    in    symmetric 

order. 

Attacks  are  periodic.  More  steadily  progressive. 

Deformity  due  to  tophaceous  deposits.  Deformity   due    to    exostosis   and   anky- 
losis, and  more  marked. 

Uric  acid  in  excels  in  the  l)io()d.  Not  so. 

Complications     (nephritis,    arterio-sclero-  Very  rare. 

sis). 

Treatment. — \^)  Prophylaxis. — In  order  to  prevent  the  develop- 
ment of  gout,  especially  in  persons  who  have  inherited  or  acquired  a 
strong  predisposition  to  the  disease,  temperate  and  even  rigid  habits  of 
living  should  be  adopted.  Alcohol,  particularly  the  heavier  wines  (Madeira, 
port,  sherry,  champagne,  etc.)  and  heavier  malt  liquors,  must  be  eschewed, 
and  the  patient  must  eat  sparingly  of  concentrated  meat  (particularly 
red  meat).  A  residence  in  the  country  with  active  out-of-door  exercise 
is  of  paramount  importance,  but  straining  efforts,  both  mental  and  phys- 
ical, are  to  be  avoided.  The  climate  should  be  temperate  and  mode- 
rately dry.  The  sleeping  apartments  should  be  capacious,  Avell  venti- 
lated, and  free  from  draught,  and  the  action  of  the  skin  is  to  be  favored 
by  cleanliness,  and  if  the  patient  be  strong  by  a  cold  bath  in  the  morn- 
ing with  friction.  For  the  robust,  Turkish  baths  at  intervals  of  two  or 
three  weeks  constitute  an  excellent  measure.  In  debilitated  patients  w'arm 
baths  on  retiring  are  preferable,  and  the  chilling  of  the  skin-surface  is  to 
be  carefully  gua  ded  against.      The  patient  should  wear  flannels. 

(2)  Active  Treatment. — (a)  Dietetic. — ''  There  is  no  diet  for  gout,  but 
there  is  a  diet  for  the  patient  "  (H.  C.  Wood).  The  amount  of  food  must 
be  lessened  as  a  rule,  and  taken  at  regular  intervals.  On  the  other  hand, 
spare  gouty  subjects  are  met  with,  and  in  such  I  have  found  a  generous 
diet,  including  fat-producing  foods,  of  great  service.  During  an  attack 
we  should  attempt  to  overcome  the  perverted  metabolism  of  the  liver  and 
gaetro-intestinal  tract,  and  to  minimize  the  production  of  the  purin 
bodies.  Broadly  speaking,  the  dietary  should  be  constituted  as  follows : 
succulent  vegetables  (cabbage,  salads,  string-beans)  ;  fruits  (except  bana- 
nas, tomatoes,  and  strawberries) ;  farinacea,  as  rice,  hominy,  and  the  like 
(oatmeal  to  be  avoided) ;  weats  should  be  restricted ;  beef  and  mutton  in 
moderation  may  be  allowed  except  in  well-marked  cases  of  gout ;  oysters 
and  fish  (except  those  that  contain  too  much  protein,  salmon,  smoked 
herring,  canned  sardines,  mackerel,  halibut,  salt  codfish,  flounder),  and 
fowl,  particularly  the  white  meat  of  chicken,  are  permissible ;  fats  in 
the  form  of  good  butter  may  be  taken  freely — from  2^  to  3  J  ounces  (70.0 
—100.0)  per  diem,  according  to  Ebstein  ;  milk  is  entirely  unobjectionable, 
and  should  be  used  in  large  quantities.  If  whole  milk  does  not  agree,  it 
may  be  mixed  with  an  equal  part  of  Vichy.  According  to  Kolisch,  eggs 
are  not  objectionable,  as  the  nucleins  contained  do  not  form  alloxins. 
Stale  breads  may  be  used./  Occasionally  patients  do  best  on  albuminoids, 
while,  on  the  other  hand,  with  about  equal  frequency  they  improve  on  a 
vegetable  diet ;  but  a  mixed  diet  is  best  adapted  to  the  vast  majority  of  the 


GOUT.  439 

cases.  Among  articles  to  be  avoided  are  pastry,  tea  and  coffee,  hot  bread  and 
cakes,  sweet  puddings,  cheese,  dried  meats,  and  all  highly  seasoned  dishes. 

Beverages. — Alcohol  is  ordinarily  to  be  interdicted.  Rarely  it  becomes 
necessary  to  administer  it,  particularly  in  cases  of  suppressed  gout,  and 
when  needed,  whiskey  is  to  be  preferred.  Champagne,  Tokay,  Port,  and 
malted  liquors  are  injurious  in  their  effects,  but  clarets,  Rhine,  and 
Moselle  Avines  can  be  often  taken  without  unfavornble  results. 

Mineral  waters.,  particularly  the  alkaline,  are  highly  advantageous, 
and  sometimes  are  even  curative.  Their  value,  like  that  of  the  warm 
baths  and  systematic  exercise,  is  dependent  upon  their  power  to  increase 
renal  elimination.  Whether  they  promote  solubility  of  the  uric  acid  in 
the  blood  is  questionable ;  moreover,  according  to  the  observations  of 
Klemperer,  this  is  not  a  rational  indication.  The  carbonate  and  citrate 
of  lithium  are  efficient  diuretics,  but  have  no  other  claim  to  virtue  in 
this  disease.  Among  natural  waters  of  special  value  abroad  are  Vichy, 
Carlsbad,  Homburg,  Ems,  Kissingen,  Aix,  Buxton,  and  Bath,  and  in 
this  country  Saratoga  and  Bedford.  These  waters  are  to  be  taken  in 
large  quantities  and  when  the  stomach  is  empty.  It  is  highly  probable 
that  the  environment,  rigid  system  of  hygiene,  including  exercise  and 
an  appropriately  modified  dietary,  play  the  principal  role  in  producing 
the  favorable  results  obtained  at  these  noted  springs. 

(h)  Medicinal  Treatment. — During  an  acute  attack  the  pain,  if  excru- 
ciating, is  to  be  relieved  by  a  hypodermic  injection  of  morphin,  which  is  to  be 
followed  by  a  purgative  dose  of  some  mercurial.  Colchicum  is  the  specific 
remedy,  and  must  be  administered,  in  the  form  either  of  the  wine  or  the  tinc- 
ture, in  doses  of  ITLxx-xxx  (1.333-1.999)  every  four  hours.  It  alleviates  the 
inflammation  and  promptly  relieves  the  pain,  but  its  effects  during  the  attack 
should  be  carefully  noted.  The  salicylates  may  also  be  given  to  relieve  pain. 
After  the  paroxysm  it  should  be  continued,  though  in  small  doses,  combined 
with  the  citrate  or  bicarbonate  of  potassium  or  lithium.  Gudzent  reports 
success  with  radium  emanations  (by  inhalation  in  a  closed  room)  two 
hours  daily ;  this  agent  causes  the  disappearance  of  uric  acid  from  the 
blood.  The  limb  should  be  raised  and  the  affected  joint  or  joints  wrapped 
in  flannel  or  cotton-wool.  Warm  alkaline  solutions  or  hot  fomentations 
often  afford  relief  in  the  worst  cases,  and  anodynes  may  be  tried  locally. 
The  diet  should  consist  chiefly  of  milk,  animal  broths,  and  egg-w^hite  during 
the  attack,  later  rice,  eggs,  fish,  and  other  light  forms  of  meat  may  be 
added,  the  more  liberal  dietary  previously  indicated  being  slowly  resumed. 

In  the  intervals  between  the  acute  attacks  the  prophylactic  and 
dietetic  measures  previously  mentioned  are  to  be  resorted  to,  in  order 
that  recurring  paroxysms  may  be  prevented,  and  in  addition  the  alkaline 
diuretics  and  saline  laxatives,  together  with  warm  bathing,  will  be  found 
of  value.     Hepatic  stimulants  yield  good  results. 

In  chronic  and  irregular  forms  of  gout  medicines  are  of  subsidiary 
importance,  and  are  in  no  wise  comparable  in  their  beneficial  efiects  to 
the  previous  recommendations.  Piperazin  has  been  warmly  advocated 
in  all  forms  of  gout  for  its  supposed  efiect  as  a  solvent  of  uric  acid,  and 
clinicians  are  almost  unanimous  in  reporting  its  favorable  results.  Its 
beneficial  efi"eots  are  probably  due  to  its  diuretic  action.  The  dose  is 
gr.  v-x  (0.324-0.648)  thrice  daily,  freely  diluted  with  water.  The  late 
Sir  William  Roberts  recommended  potassium  bicarbonate  (oSS — 2.0.  in  a 
tumbler  of  water  at  bedtime)  to  stem  the  nightly  acid  tide.    Some  authors 


440  CONSTITUTIONAL  DISEASES. 

highly  recommeiul  the  salicyhites  for  acute  attacks  of  gout,  both  })ri- 
mary  and  intercurrent,  in  the  course  of  the  chronic  form.  In  ray  own 
experience  thoy  have  been  less  effective  in  this  disease  than  colchicum. 
Benzoic  acid  and  colchicin  have  a  double  action  in  that  they  stimulate 
the  he})atic  circulation  and  also  "  bind  the  glycocol,  thus  ])reventing  it 
from  precipitating  the  uric  acid  in  theorganism.  "  ^  0.  von  Noorden  and 
.L.  Schliep-  have  shown  that  there  is  a  certain  tolerance  for  nucleins  in 
gout ;  and  in  every  case  its  exact  degree  should  be  determined  by 
allowing  a  definite  number  of  grams  of  meat  per  diem  and  extracting  the 
uric  acid,  the  diet  being  restricted  accordingly.  Luff"  has  demonstrated 
by  exjterimentation  the  negative  value  of  the  alkalies  and  salicylates  in 
the  treatment  of  gout.  If  nephritis  or  a  failure  of  compensation  be  present, 
even  the  former  remedies  should  be  administered  Avith  extreme  caution. 

For  chronic  gout  potassium  has  been  much  used,  though  with  slight 
advantage  to  the  patient,  I  think.  Fenner  lauds  a  sterilized  solution  of 
thyminic  acid  (gr.  ij — 0.13)  by  intramuscular  injection,  in  subacute  and 
chronic  forms  of  podagra.  A  small  dose  (gr.  iv — 0.26,  daily)  after  meals 
for  three  months  and  then  every  alternate  week,  tends  to  avert  the  onset 
of  acute  symptoms.  The  bitter  tonics,  combined  with  a  vegetable  salt 
of  iron,  as  well  as  change  of  climate,  should  be  resorted  to  in  the  anemic, 
debilitated  class  of  gouty  patients. 


LITHEMIA. 

Definition. — A  condition  due  to  a  disturbed  cellular  metabolism. 
It  is  characterized  chemically  by  an  excess  of  uric  acid  in  the  blood,  ana 
clinically  by  various  digestive,  circulatory,  genito-urinary,  and  nervous 
phenomena.  My  purpose  in  describing  lithemia  is  that  the  common 
error  may  be  avoided  of  attributing  its  symptoms  to  other  causes. 

Pathogenesis  and  i^tiology. — Lithemia  is  comparatively  a  latent 
condition.  There  is  an  excess  of  uric  acid,  which  may  be  for  a  time 
eliminated  through  the  natural  channels  (kidneys,  lungs,  skin,  etc.)  with- 
out the  occurrence  of  symptoms.  On  the  other  hand,  when,  as  the  result 
of  too  little  exercise,  impaired  elimination,  luxurious  living,  the  use  of 
sweet  wines,  uric  acid  is  allowed  to  collect  in  diff"erent  parts  of  the  organ- 
ism, marked  disturbances — nervous,  gastro-hepatic,  etc. — follow.  DaCosta 
defines  lithemia  as  a  condition  in  which  "  the  income  of  nutriment 
is  in  excess  of  the  output  of  waste."  C.  G.  Stockton  holds  that  lithemia 
is  a  gastro-intestinal  auto-intoxication.  Among  agencies  that  predispose 
are  alcoholism,  heredity,  climate  (temperate  or  cold  climates  favor  dimin- 
ished action  of  the  skin),  and  the  male  sex. 

Sj^mptoms. — The  nervous,  circulatory,  respiratory,  integumentary, 
and  genito-urinary  symptoms  are  practically  the  same  as  those  described 
under  Irregular  Gout ;  but  I  would  here  emphasize  the  broad  clinical 
fact  that  the  urethral  and  genital  mucous  membranes  often  become 
inflamed  on  slight  provocation,  producing  urethritis,  cystitis,  orchitis, 
epididymitis,  vaginitis,  endometritis.    These  conditions  resist  treatment. 

Gastro-intestinal    Symptoms. — The    appetite    is    variable,    sometimes 

voracious,  and  at  other  times  it  is  impaired  or  perverted.     The  tongue 

is  coated,  and  a  metallic  taste  is  often  complained  of,  while  various  forms 

of  indigestion  attend.     There  may  be  a  delay  in  the  conversion  of  the 

1  H.  Kionka,  /^e»^sc/^  med.  Woch.,  .July  20,  1905.       ^  Berlin.  kUn.  Wool,.,  October  9.  1905. 


LITHEMIA.  441 

albuminoids,  causing  pyroHin^  r/astric  oppression,  fulness ,  and  HonK.tiines 
nausea  and  vomiting  soon  after  food.  These  symptoms,  together  with 
onarked  flatulence,  are  manifested  at  a  hiter  period  after  meals  if  there 
be  failure  in  the  digestion  of  the  carbohydrates.  ^The  bowels  work 
irregularly,  and  there  may  be  diarrhea  attended  by  colicky  pain,  with 
frothy  and  ill-smelling  discharges.  Hemorrhoids  are  usual,  and  melena 
may  occur  independently  of  the  hemorrhoids.  The  liver  is  soinewliat 
enlarged  and  often  tender.  A  few  prominent  cardio-vascular  symptoms 
should  be  mentioned,  such  as  palpitation,  particularly  after  eating,  or 
lying  abed.  Increased  arterial  tension  may  develop  early,  and  is  due 
probably  to  the  action  of  toxins  in  the  blood  upon  the  vaso-motor  nerves, 
exciting  universal  contraction  of  the  arteries.  This  condition  often  leads 
to  arterio-sclerosis  and  sooner  or  later  the  well-known  clinical  group — 
chronic  gout,  arterio-sclerosis,  and  granular  kidney — will  be  presented. 

Treatment. — (1)  Prophylaxis. — The  patient  should  be  taught  the 
lesson  of  thorough  mastication,  and  robust,  plethoric  persons  should  ex- 
ercise with  method  in  the  open  air,  with  a  view  to  consuming  the  fats  in 
the  body.  For  this  purpose  cycling,  horseback-riding,  rowing,  and  walk- 
ing are  all  excellent.  Nervous  persons,  however,  demand  rest  (Gray). 
The  constant  use  of  lithia-water,  more  particularly  in  the  spring  of  the 
year,  is  warmly  advocated  by  Wilcox. 

(2)  Diet. — As  in  gout,  so  in  the  preliminary  stages  of  lithemia,  no  sin- 
gle dietary  suits  all  cases,  though  I  agree  with  those  who  contend  that  a 
diet  consisting  chiefly  of  albuminoids  is  proper  in  most  cases.  The 
lighter  forms  of  albuminous  articles  of  diet  are  to  be  preferred,  and,  if 
well  borne,  fruits  and  green  vegetables  may  be  added.  Assuming  that 
certain  cases  are  dependent  upon  an  auto-intoxication  from  the  gastro- 
intestinal tract,  the  object  should  be  to  limit  fermentation  by  the  use  of 
a  nitrogenous  diet ;  and  I  have  found  large  amounts  of  water  very  bene- 
ficial in  such  instances.  There  are  cases  in  which  the  gastric  digestion 
is  feeble,  and  in  such  the  carbohydrates  are  better  borne  than  the  albu- 
minoids. Cream  and  good  butter  are  the  only  forms  of  fat  to  be  allowed. 
Alcohol  should  be  interdicted. 

(3)  Medicinal  Treatment. — If  the  patient  be  robust,  it  is  well  to  begin 
with  a  saline  laxative,  such  as  Carlsbad  Spriidel  salt  (3J-ij — 4.0-8.0), 
moderately  diluted  and  taken  before  breakfast.  If  necessary,  the  hepatic 
function  may  be  stimulated  still  further  by  a  mild  mercurial  or  by  podo- 
phyllin.  On  the  other  hand,  the  neurasthenic,  delicate  sufi"erer  must  use 
a  milder  form  of  laxative,  such  as  Rochelle  salt  in  the  same  dose,  or 
sodium  phosphate  in  the  morning,  or  a  rhubarb  pill  at  night.  This  class 
of  lithemics  also  requires  nerve-sedatives  (sodium  bromid,  etc),  and 
diuretics  to  aid  in  the  excretion  of  uric  acid.  If  it  be  true,  as  some 
claim,  that  the  sodium  phosphate  is  for  the  greater  part  excreted  by  the 
urine,  and  that  it  holds  in  solution  more  uric  acid  than  any  other  salt, 
it  is  one  of  the  foremost  remedies  in  the  treatment  of  the  affection.  Per- 
sonally, I  have  found  it  to  be  a  most  useful  agent.  To  reduce  acidemia 
and  to  stimulate  gently  hepatic  activity  the  salts  of  lithium,  highly  di- 
luted, may  also  be  tried.  To  aid  in  the  digestion  of  the  albuminoids 
hydrochloric  acid  may  be  needful,  and  if  the  appetite  be  impaired  it  may 
be  combined  with  a  simple  bitter  or  with  nux  vomica  (TTLx-xv — 0.666- 
0.999)  thrice  daily. 


442  CONSTITUTIONAL  DISEASES. 

RACHITIS. 

{Rickets.) 

Definition. — A  constitutional  disorder  of  childhood,  exhibiting 
developmental  anomalies,  chiefly  in  the  bones  and  cartilages,  causing 
deformities. 

Pathology. — A  mere  summary  of  the  anatomic  characters  can  be 
given  here.  There  is  a  derangement  of  the  nutritive  processes  which 
retards  and  otherwise  modifies  the  growth  of  the  bony  skeleton,  particu- 
larly of  the  skull,  the  ends  of  the  ribs  and  of  tlie  long  bones.  The 
latter  soften  or  remain  unduly  flexible  as  the  result  either  of  the  absorp- 
tion of  ossified  structures  or  of  the  greatly  diminished  deposition  of  lime- 
salts.  Longitudinal  section  of  the  lono;  bones  shows  the  seat  of  the  chief 
changes  to  be  at  the  junction  of  the  epiphysis  with  the  shaft.  In  health 
yre  note  at  this  point  two  thin  layers,  an  outer  (next  to  the  epiphyseal 
cartilage)  proliferative  zone,  and  an  inner  layer  (of  ossification).  In 
rachitis  both  zones,  though  more  particularly  the  proliferative,  are 
greatly  thickened,  much  softened,  and  their  margins  irregularly  notched. 
The  periosteum  is  thickened  and  easily  separable  from  the  shaft. 

A  microscopic  examination  shows  an  increased  rate  of  proliferation 
of  the  cartilage-cells  with  a  scanty,  fibroid  matrix,  while  the  ossific  layer 
presents  disseminated  and  imperfectly  calcified  areas.  Similarly,  the 
osteoblastic  layer  of  the  periosteum  is  thickened,  and  remains  spongoid. 
It  is  highly  probable  that  absorption  of  true  bone-tissue  rarely  occurs, 
and  that  the  most  characteristic  pathogenic  change  is  a  lack  of  develop- 
ment of  the  normal  structures.  The  morbid  changes  may  arise  from  the 
presence  of  hyperemia  of  the  cartilage,  marrow,  and  periosteum — a  process 
that  interferes  with  the  deposition  of  lime  salts. 

The  cranial  bones  present  areas  of  the  so-called  craniotabes,  and 
yield  to  the  pressing  finger  in  consequence  of  delayed  ossification. 
This  may  lead  to  a  disappearance  of  the  cranium  in  certain  areas, 
causing  depressions,  while  flattened  protuberances  may  develop  over  the 
arterio-lateral  regions.  When  cases  terminate  in  recovery  the  bones 
become  hard  and  ossify,  although  the  deformities  persist.  The  chemist 
has  shown  us  that  rachitic  bones  may  contain  less  than  half  the  normal 
percentage  of  lime-salts.  The  liver  and  spleen  are  moderately  enlarged, 
and  rarely  the  mesenteric  glands  are  increased  in  size. 

Ktiology. — (1)  Rachitis  may  occur  in  the  netv-bor?i.  Schwartz  states 
that  among  500  new-born  children  in  A^ienna,  75.8  per  cent,  show  dis- 
tinct signs  of  rachitis.  Doubtless  this  estimate  is  too  high,  and  entirely 
at  variance  Avith  the  experience  of  clinicians  in  general ;  but  I  believe 
that  congenital  rickets  is  by  no  means  a  rare  condition.  Many  of  the 
cases  are  still-born,  and  those  that  outlive  childhood  become  peculiarly 
dwarfed  {micromania).  (2)  Heredity. — The  instances  in  which  rachitis  de- 
velops at  an  early  period  of  life,  due  to  ante-partum  causes,  are  not  rare,  but 
it  must  not  be  forgotten  that  it  is  extremely  hard  to  estimate  the  influence 
of  heredity  where  both  parent  and  child  are  exposed  to  similar  unfavor- 
able hygienic  and  dietetic  conditions.  Ill-health,  malnutrition,  close  con- 
finement, lactation,  and  syphilis  may  all  act  as  predisposing  factors  dur- 
ing pregnancy.      Setting  aside  syphilis,  and  perhaps  phthisis,  the  state  of 


RACHITIS.  443 

the  health  of  the  father  has  little  if  any  effect  in  the  causation  of  rachitis 
in  his  offspring.  (3)  Gednrdpldcal  JJlMrilmtion. — The  disease  is  more 
common  by  far  in  large  cities  tha,n  in  rural  districts,  an<l  in  Eui-opean 
countries — Russia,  Germany,  Great  Britain,  and  lt;i,ly  rjiore  especially — 
the  disease  prevails  more  extensively  than  in  America.  It  is  rare  in 
tropical  countries  and  during  the  hot  season  in  temperate  climates.  (4) 
Race. — The  colored  race  furnishes  a  preponderance  of  rachitic  subjects. 
The  reason  for  this  may  be  a  racial  need  of  warmth  that  is  not  supplied 
by  the  temperature  of  more  northerly  latitudes,  tlieir  native  habitat  being 
in  a  more  southerly  climate.  The  Italian  race  also  suff'crs  inordinately. 
("))  Station. — It  is  especially  among  the  ranks  of  the  poor  children,  whose 
environment  is  highly  unfavorable,  in  large  cities  that  rachitis  is  seen. 
Joukownski,  from  personal  observations  in  over  3000  poor  children  in 
St.  Petersburg  examined  for  rachitis,  found  that  from  the  working- 
classes  come  the  greatest  number  of  cases.  Like  scurvy,  rickets  may  be 
found  in  the  families  of  the  wealthy  under  perfect  hygienic  conditions 
(Osier).  The  quarters  of  the  cities  in  which  the  poorer  classes  live  are 
densely  crowded,  the  dwellings  are  insufficiently  ventilated,  and  there  is 
a  great  lack  of  sunlight.  (6)  Diet. — The  disease  is  dependent  largely 
upon  unsuitable  or  insufficient  food ;  and  among  hand-fed  children,  espe- 
cially if  the  milk  is  sterilized,  the  disease  is  much  more  common  than 
among  those  at  the  breast.  It  also  occurs  in  breast-fed  infants  when 
the  mother's  milk  is  poor  in  quality  as  the  result  of  previous  ill-health 
or  too  long-continued  lactation.  The  view  was  at  one  time  widely  held 
that  rickets  was  produced  by  a  farinaceous  diet,  and  that  the  active 
agent  was  lactic  acid,  produced  by  the  fermentative  processes  set  up  by 
the  starch.  Granting  that  the  lactic  acid  forms  a  soluble  salt  by  union 
with  the  lime  of  the  bone,  thus  removing  it  from  the  system,  this  does 
not  explain  the  productive  lesions  described  under  Pathology.  Accord- 
ing to  another  view,  which  is  supported  by  experimental  proof,  rachitis 
is  apt  to  develop  when  the  amount  of  both  proteids  and  fats  is  low. 
Certain  forms  of  diet  predispose  to  rickets,  principally  for  the  reason 
that  they  do  not  supply  certain  necessary  articles  in  adequate  proportion. 
(7)  Age. — Of  903  cases,  more  than  75  per  cent,  occurred  before  the  end 
of  the  second  year,  but  of  these  only  99  commenced  during  the  first 
half-year  (Bruennische,  Von  Rittershain,  Ritsche).  It  may  occur  as 
late  as  the  tenth  year.  (8)  Sex  is  without  effect.  (9)  Syphilis. — Divers 
views  are  entertained  regarding  the  r6le  played  by  syphilis  as  a  cause  of 
this  disease.  It  cannot  be  denied  that  syphilis  brings  about  a  marked 
impairment  of  nutrition,  so  that  the  disease  may  engender  a  predis- 
position to  rickets. 

(10)  Findlay^  attributes  rickets  to  lack  of  exercise  and  confinement. 

Bacteriology. — Mircoli  contends  that  it  is  produced  by  the  action  of 
ordinary  pyogenic  organisms  upon  the  osseous  and  nervous  systems. 

Symptoms. — The  onset  is  slow.,  and  the  symptoms  of  gastro-intes- 
tinal  catarrh,  with  their  usual  eff'ect  upon  the  general  nutrition,  may  pre- 
cede or  accompany  the  true  rachitis  symptoms.  At  the  beginning  the 
infant  is  restless,  irritable,  and  sleeps  poorly,  and  slight  fever  is  present 
in  some  cases.  About  the  head  and  neck  the  child  perspires  freely,  espe- 
cially when  asleep,  wetting  his  pillow  while  the  rest  of  the  bed  is  dry. 
It  is  also  annoyed  by  the  bed-clothes,  which  it  continually  throws  off", 
^  Boston  Medical  Journal,  July  4,  1908. 


444  CONSTITUTIONAL  DISEASES. 

lying  exposed  even  in  a  cool  temj)eraturo.  Among  the  earlier  symptowa 
is  a  tenderness  both  over  the  bony  surfaces  and  the  soft  parts,  so  that  the 
patient  wishes  to  keep  still  and  dreads  to  be  handled.  The  child  is 
languid  and  disinclined  to  move  his  limbs  or  to  walk  or  jjlay,  even  if  he 
have  done  so  previously. 

The  symptoms  are  progressive  in  their  development,  rachitis  being 
ordinarily  a  chronic  disease,  so  that  after  many  months  more  pronounced 
features,  including  various  bone-deformities,  appear.  Owing  to  the  im- 
pairment of  nutrition  of  the  muscles  the  use  of  the  limbs  may  become 
impossible,  and  these  cases  have  been  spoken  of  by  writers  as  ."rachitic 
paralysis;"  tliis,  however,  is  a  misnomer.  Cases  have  been  reported  by 
Berg  and  others  that  resembled  spastic  paralysis,  pseudo-hypertrophic 
paralysis.  Urinary  phenomena  are  neither  constant  nor  characteristic. 
Secondary  anemia  of  mild  grade  supervenes,' the  hemoglobin  often  being 
comparatively  low,  and  there  may  lie  a  leukocytosis. 

The  first  rachitic  osteal  changes  are  presented  by  the  cranial  bones, 
the  ribs,  the  radius,  and  the  ulna.  The  cranium  appears  enlarged,  though 
this  enlargement  is  more  apparent  than  real,  being  due  to  the  diminished 
size  of  the  facial  bones.  The  sutures  remain  open,  the  fontanels  are 
large,  and  their  closure  is  delayed,  sometimes  until  the  fifth  or  even  the 
eighth  year.  Craniotahes  is  most  frequently  seen  in  infimts  under  one 
year  of  age.  This  soft,  thin  condition  of  the  bones  is  due  to  pressure 
both  from  within  and  Avithout ;  it  occurs  on  the  surfaces  on  which  the 
head  of  the  child  rests  while  lying.  To  detect  the  presence  of  cranio- 
tahes light  pressure  wath  the  fingers  is  to  be  .made  in  a  direction  away 
from  the  sutures.  It  is  to  be  recollected  that  craniotahes  is  often  a 
syphilitic  manifestation.  Per  cotitra,  increased  hardness  of  certain  bones 
may  be  observed  (cranio-sclerosis).  A  rachitic  head  generally  ap- 
proaches a  square  in  outline,  or  it  may  present  marked  angularities, 
with  an  increase  in  the  antero-posterior  diameter  and  a  flattened  top. 
Hyperostosis  may  cause  prominence  of  the  parietal  and  frontal  emi- 
nences, giving  the  forehead  a  square,  broad  outline.  A  short,  round  head 
(brachycephaly)  may  rarely  be  met  (Bonnifay).  The  veins  of  the  scalp 
are  enlarged,  and  the  hairy  growth  is  usually  scanty,  being  often  re- 
moved from  the  back  of  the  head  by  rubbing.  Drs.  Whitney  and  Fisher 
first  called  attention  to  the  fact  that  the  ear  placed  over  the  anterior 
fontanel  often  detects  a  systolic  murmur.  A  considerable  patency  of 
the  anterior  fontanel  both  in  health  and  disease  allows  of  detection  of 
this  murmur,  however,  and  hence  its  diagnostic  value  is  slight.  A  prom- 
inent feature  of  the  disease  is  delayed  teething,  the  teeth  that  appear 
being  deficient  in  enamel,  ill-shaped,  although  not  prone  to  decay. 

The  ribs  early  become  beaded.  Anteriorly,  where  they  join  the 
costal  cartilages,  swellings  occur,  causing  the  "rachitic  rosary."  This  is 
composed  of  nodules  corresponding  with  the  costo-chondral  articulationSr 
and  these  can  generally  be  seen  and  always  felt  under  the  skin.  They 
rarely  outlast  the  fourth  or  fifth  year.  The  ribs  present  two  short  curves 
— one  at  the  junction  of  the  dorsal  and  lateral  parts  of  the  thorax,  and 
the  other  in  front,  where  they  turn  sharply  inward  toward  the  sternum. 
This  deformity  is  the  result  of  the  atmospheric  pressure  upon  the  softened 
bones,  a  shallow  groove  usually  being  produced  in  the  line  of  the  costo- 
chondral  articulations  or  obliquely  from  the  second  or  third  rib  downward 


Fig.  33.— Outward  curvature  of  tibia  and  fibula  (Willard). 


RACHITIS.  445 

and  outward.  These  changes  lessen  the  transverse  diameter  of  the  thorax 
in  front  and  interfere  with  the  lung-expansion  in  the  antero-lateral  por- 
tions of  the  chest.  They  also  produce  bulging  of  the  sternum,  resulting 
in  the  so-called  pigeon  or  chicken  breast.  On  both  sides,  from  a  point 
corresponding  to  the  anterior  end  of  the  eighth  or  ninth  rib,  there  passes 
outward  toward  the  axilla  a  furrow  (Harrison's  groove)  which  is  caused  by 
an  eversion  of  the  lower  part  of  the  thorax,  and  is  heightened  by  atmo- 
spheric pressure,  particularly  during  inspiration.  This  thoracic  deformity 
is  not  peculiar  to  rickets,  but  is  met  with  in  all  cases  in  which  there  is 
moderate  obstruction  to  the  ingress  of  air  into  the  lungs. 

Among  the  first  indications  of  rickets  is  an  enlargement  of  the  lower 
end  (junction  of  the  shaft  and  epiphysis)  of  the  radius.  The  radius  and 
ulna  are  sometimes  twisted  and  deflected  outward,  owing  to  the  fact  that 
some  of  the  body-weight  is  supported  by  the  hands  when  sitting  or  crawl- 
ing. The  clavicle  may  be  thickened  and  curved  near  either  end,  and 
occasionally  the  scapulae  may  be  enlarged,  but  deformities  of  the  upper  ex- 
tremities are  rare  as  compared  with  those  of  the  lower.  Occasionally  the 
vertebrae  and  intervening  cartilages  soften,  with  a  resulting  spinal  curva- 
ture, usually  antero-posterior. 

Pelvic  deformities  are  not  uncommon,  and  are  of  no  little  importance 
in  female  children  as  bearing  upon  the  questions  of  marriage  and  subse- 
quent labor.  The  femora  may  be  curved,  often  forward  and  more  rarely  out- 
ward ;  swelling  of  the  lower  end  of  the  tibia  is,  however,  the  first  change  to 
be  observed  in  the  lower  extremities.  In  some  well-advanced  cases  the 
heads  of  the  bones  forming  the  knee-joints  are  also  enlarged,  and  outward 
curvature  of  the  femora  and  tibia  is  common,  especially  under  the  age  of  one 
year  (see  Fig.  33).  After  the  child  begins  to  walk  a  forward  bowing  of 
these  bones,  due  to  the  weight  of  the  body  and  to  muscular  action,  occurs. 
Knock -knee  is  sometimes  observed.  Those  who  have  suffered  from 
rickets  in  infancy  usually  fall  short  of  the  average  stature  on  reaching 
adolescence,  giving  rise  to  disproportion  between  head  and  height. 

These  skeletal  changes  sustain  a  causal  relation  to  many,  and  some 
serious,  affections,  chiefly  nervous.  Thus,  craniotabes  is  supposed  to  in- 
duce laryngismus  stridulus,  though  this  condition  may  also  arise  in  the 
rachitic  without  cranial  softening.  Rickets  also  predisposes  to  tetany, 
which  affects  most  commonly  the  upper  extremities.  Convulsions  are 
prone  to  occur  in  this  disease.  The  reflex  nervous  excitability  is  unques- 
tionably exaggerated  in  rickets,  and  another  cause  for  the  eclampsia  often 
met  with  is  the  associated  gastro-intestinal  catarrh.  The  abdomen  be- 
comes greatly  enlarged,  chiefly  by  flatulence,  though  to  a  less  extent  also 
by  the  swelling  of  the  liver  and  spleen  (passive  congestion).  Wm. 
Ewart^  has  recently  called  attention  to  the  importance  of  abdominal 
atony  and  distention  in  rickets ;  it  interferes  with  circulation  and  respi- 
ration. Chest-complications  due  primarily  to  interference  with  the 
cardio-pulmonary  circulation,  and  the  respiration,  are  common.  Among 
these  are  atelectasis,  bronchial  catarrh,  broncho-pneumonia,  and  emphy- 
sema. Anemia,  when  present,  may  be  accounted  for  by  some  complication. 
G reen-stick  fracture  of  the  bones  often  occurs  in  the  rachitic  subject. 

Diagnosis. — Says  Holt :  "  The  most  important  early  symptoms 
for  diagnosis  are  sweating  of  the  head,  craniotabes,  great  restlessness 
at  night,  delayed  dentition,  and  enlarged  fontanel.  All  these,  taken 
^Brit.  Med.  Jour.,  Oct.  13,  1906. 


446  CONSTITUTIONAL  DISEASES. 

separately,  may  mean  something  else,  but  collectively  they  can  mean 
nothing  but  rickets."  At  a  later  period  the  beading  of  the  ribs  and 
other  characteristic  deformities  are  usually  present. 

Prognosis. — The  evolution  of  rickets  is  a  long  process  ;  hence 
most  patients  become  weak,  anemic,  and  emaciated.  The  so-called  "  fat 
rickets"'  is  not  rare.  Innately,  the  disease  tends  to  spontaneous  cure, 
which  is  attained  from  the  end  of  the  second  to  the  fifth  year ;  but  its 
course  may  be  abridged  to  a  few  months  by  appropriate  treatment. 
When  death  occurs,  it  is  usually  occasioned  by  one  or  other  of  the  com- 
plications before  mentioned  (laryngismus  stridulus,  pneumonia). 

Treatment. — Prophylaxis. — Simple  means  directed  to  the  ante- 
partum causal  Victors  in  the  mother  may  be  preventive  of  rickets. 
l*rophylaxis  also  embraces  appropriate  feeding  and  other  agencies  that 
tend  to  maintain  the  normal  nutrition  of  infants. 

Hygienic  Management. — Proper  feeding  is  an  important  factor,  and 
if  the  child  cannot  be  satisfactorily  nursed  by  its  mother  and  if  it  is 
under  the  age  of  six  months,  a  wet-nurse  should  be  procured.  Should 
this  not  be  practicable,  it  must  be  hand-fed,  and  the  best  artificial  food 
is  cows'  milk,  if  properly  prepared.  It  is  diluted  to  suit  the  age,  and 
I  have  found  that  barley-water,  when  made  in  the  manner  recom- 
mended by  J.  Lewis  Smith,  may  be  added  to  milk,  replacing  the  water 
most  advantageously.  A  heaping  teaspoonful  of  barley-flour  is  poured 
into  25  teaspoonsful  (siij — 96.0)  of  water,  and  when  the  mixture  is 
lukewarm  10  or  15  drops  of  diastase  (Forbes)  are  added  to  it,  the  gruel 
in  a  few  minutes  becoming  much  thinner  from  the  digestion  of  the  starch. 
The  physician  must  regulate  with  much  precision  the  frequency  of  the 
feeding,  and  the  amount  of  food  taken  according  to  the  age  of  the  child. 
The  stools  are  also  to  be  inspected.  If  they  are  green  or  if  curds  appear, 
either  digestion  is  imperfect  or  the  child  is  being  over-fed.  Older  children 
may  be  given  the  lighter  meats,  freely,  green  vegetables,  and  fruits, 
but  these  must  be  carefully  selected. 

Other  hygienic  details  are  of  little  less  importance  than  a  proper  diet. 
The  decubitus  of  the  child  must  be  changed  frequently,  so  as  to  prevent 
bony  deformities ;  moreover,  the  rickety  child  should  not  be  allowed  to 
walk,  and  to  prevent  his  doing  so  splints  extending  beyond  the  feet  have 
been  recommended.  A  tepid  bath,  warm  clothing,  and  a  prolonged  daily 
stay  in  the  open  air  are  measures  that  should  not  be  neglected. 

Of  medicines,  those  that  rank  highest  are  phosphorus,  the  hypophos- 
phites,  iron,  and  cod-liver  oil.  The  officinal  oleum  phosphoratum  (gr.  y^^ 
— 0.0021)  is  used  by  Jacobi.  Phosphorus  is  highly  spoken  of  by  many 
writers.  It  may  be  given  either  pure(gr.  YTo^'^T'ffTr — 0.0003  to  0.0006) 
or  preferably  in  the  form  of  an  emulsion  with  sweet  oil  or  cod-liver  oil : 

^.  Phosphori,  gr.  ^  (0.00648) ; 

Oleiolivse,  5ij(64.0); 

M.  et  ft.  emulsio. 
Sig.  3j  three  times  a  day,  after  meals,'  for  a  child  under  the  age 
of  one  year. 

Kissel  states  there  is  no  evidence  in  favor  of  the  use  of  phosphorus 
in  rickets.     Baginsky,  Leray,  Weiss,  and  others  have  found  from  its 


SCORBUTUS.  447 

extensive  employment  that  it  is  of  doubtful  value  in  the  majority  of 
cases.  Kassowitz,  Swetchen,  and  others,  however,  observed  cases  with 
cure,  hence  the  remedy  deserves  a  trial. 

When  it  is  desired  to  administer  cod-liver  oil  and  it  is  not  tolonitod  by 
the  stomach,  it  may  be  rubbed  gently  into  the  skin  of  the  thighs  and 
trunk.  Arsenic  in  small  doses  has  proved  to  be  a  capital  remedy  in 
selected  cases ;  and  iron,  particularly  in  combination  with  arsenic,  is  in- 
dicated if  anemia  be  pronounced.  Klotz  recommends  pituitary  extract, 
supplementing  it  with  calcium  carbonate  to  supply  material  for  bone  growths 

The  numerous  complications  to  which  rachitic  subjects  are  liable  pre- 
sent special  indications  which  are  to  be  jpaet  by  the  same  measures  as 
when  they  arise  under  other  circumstances.  The  condition  of  the  diges- 
tive organs  must  be  kept  constantly  in  mind ;  and  no  remedy,  however 
promising,  that  is  designed  to  assist  the  general  condition  should  be  con- 
tinued if  it  tends  to  aggravate  the  digestive  disturbance.  Ewart  advises 
massage  for  the  abdominal  atony  and  also  the  use  of  an  elastic  belt 
which  gives  support  to  the  abdominal  parietes  and  improves  circulation 
and  respiration.  The  treatment  of  the  rachitic  deformities  belongs  to  the 
domain  of  the  orthopedic  surgeon  and  should  be  undertaken  early. 


SCORBUTUS. 

[Scurvy.) 

Definition. — A  constitutional  disorder,  dependent  upon  dietetic 
errors,  and  characterized  by  anemia,  excessive  weakness,  spongy  gums, 
a  tendency  to  muco-cutaneous  hemorrhages,  and  a  brawny  induration 
affecting  chiefly  the  muscles  of  the  calves  and  the  flexor  muscles  of  the 
thighs.      Scorbutus  and  rickets,  distinct  aff'ections,  often  coexist. 

Pathology. — We  know  nothing  concerning  the  pathogenesis  of 
scurvy.  Evidences  of  profound  anemia  are  found  upon  microscopic  ex- 
amination of  the  blood,  which  is  thin  and  dark,  but  there  is  no  leukocy- 
tosis. The  skin  may  show  spots  of  subcutaneous  hemorrhage  (ecchy- 
moses),  but  the  most  characteristic  hemorrhage  is  that  under  the  periosteum 
of  the  femora.  Bleedings  into  the  articulations  and  muscles  may  also  at 
times  be  noted,  and  occasionally  the  serous  membranes  are  the  seat  of 
hemorrhages,  as  well  as  the  internal  organs.  Submucous  hemorrhages 
are  extremely  common.  The  intestinal  mucosa  may  also  present  ulcers. 
The  gums  are  swollen,  spongy,  dark  in  color,  and  sometimes  ulcerated, 
and  the  teeth  may  be  loose  or  missing.  The  epiphyses,  particularly  of 
the  lower  end  of  the  femora,  may  be  congested,  and  even  detached.  The 
spleen  is  soft  and  swollen.  The  heart,  liver,  and  kidneys  sometimes 
show  fatty  and  often  parenchymatous  degeneration. 

il^tiology. — Incidence. — In  former  times  scurvy  was  very  prevalent 
among  sailors  at  sea  and  soldiers  in  the  fiield,  and  epidemics  were  com- 
mon. Doubtless,  however,  it  has  declined  in  importance  as  a  disease 
incident  both  to  sea-life  and  to  armies ;  but,  as  pointed  out  by  Wise, 
it  would  seem  that  changing  physiologic  and  economic  conditions 
may  cause  it  to  be  dreaded  on  the  land  as  it  has  hitherto  been  on 
the  sea.  Osier  states  that  the  disease  is  not  infrequent  among  Hun- 
garians, Bohemians,  and  Italian  miners  in  Pennsylvania.  It  is  rarely 
epidemic    at    the    present    day.       F.    A.  McGrew  records  an  epidemic 


448  CONSTITUTIONAL  DISEASES. 

(with  a  total  of  42  cases)  in  Chicago,  in  1894.  Endemic  appearances 
ut"  scurvy  are  still  common,  particularly  in  portions  of  Russia  (lloftman) 
and  elsewhere  also,  sweeping  through  prisons,  barracks,  almshouses,  and 
other  institutions  of  like  kind.  "While  the  majority  of  cases  met  with 
are  sporadic,  the  above  facts  point  to  the  infectious  character  of  scurvy. 
Russell  contends  that  adult  scurvy  is  caused  by  lime  starvation. 

Bacteriology. — Testi  and  Beri  have  isolated  a  micro-organism  which 
has  been  cultivated  and  inoculated  into  guiiica-])igs  and  rabbits,  pro- 
ducing in  the  latter  pathologic  lesions  and  symptoms  simulating  closely 
those  of  scurvy.  The  microbe  is  perfectly  round  and  is  a  diplococcus. 
These  experiments  require  con^rmation. 

Predisposing  Causes. — The  chief  factor  is  an  unsuitable  dietary  long 
continued.  The  absence  of  the  organic  (potassium)  salts  present  in 
fresh  vegetables  disturbs  normal  histogenesis.  Albertoni  has  recently 
shown  tiiat  in  scurvy  of  a  protracted  course  free  hydrochloric  acid 
is  absent  from  the  gastric  juice,  and  that  the  total  acidity  is  much 
reduced,  but  this  is  so  neither  in  every  case  nor  at  all  stages  of  the 
disease.  ITe  found  no  deficiency  of  chlorids  in  the  body.  Peptoniza- 
tion is  feeble.     It  may  be  a  true  toxemia. 

Debilitating  influences,  as  unhygienic  surroundings,  excessive  mus- 
cular exercise,  humidity,  and  cold,  often  play  no  mean  role  in  causing 
scurvy.  Mental  anxiety  and  depression  seem  to  have  etiologic  signifi- 
cancCc  The  old  are  very  susceptible,  and  all  ages  are  liable  to  the  dis- 
ease. Sex  has  no  special  influence  upon  scorbutus.  Starvation  does  not 
predispose  to  the  disease. 

Symptoms. — Scurvy  has  a  slow  onset.  The  earliest  symptoms  are 
generally  a  swelling  around  the  eyes,  over  which  the  skin  has  the  color 
of  a  bruise,  and  a  pale  face,  which  looks  bloated  and  wears  an  apathetic 
expression.  There  is  noticeable  almost  from  the  start  a  gradually  in- 
creasing debility,  emaciation,  an  inability  to  perform  mental  or  physical 
labor,  and  despondency.  The  patient  experiences  arthritic  and  muscular 
rheumatoid  pains  and  dyspnea  on  slight  exertion. 

With  rare  exceptions  the  gums  swell,  sometimes  enormously,  and  be- 
come spongy,  bleeding  most  readily.  They  may  become  ulcerated,  and 
may  be,  though  rarely,  fungoid  in  appearance.  The  teeth  often  become 
loose,  and  in  rare  cases  drop  out.  The  breath  emits  an  oifensive  odor, 
that  is  sometimes  due  to  necrosis  of  the  jaw.  The  tongue  swells,  though 
it  is  usually  clean  and  often  pale.  In  the  mouth  may  be  observed  sub- 
mucous hemorrhages  in  many  cases.  There  is  loss  of  appetite,  but  the 
digestion  is  usually  good  ;  there  may,  however,  be  constipation  or  diar- 
rhea, more  frequently  the  former.  Scorbutic  dysentery  has  been  de- 
scribed by  certain  Avriters.  The  ski7i  is  dry  and  of  a  muddy  color, 
blended  occasionally  Avith  a  greenish  or  greenish-yellow  tinge.  At  the 
end  of  a  week  or  ten  days  peteehice  and  ecchymoses  appear  upon  the  legs, 
arranging  themselves  about  the  hair-follicles.  These  may  also  come  out 
later  on  the  trunk  and  upper  extremities.  Submucous  hemorrhages  may 
give  rise  to  circumscribed  swellings,  and  subperiosteal  hemorrhages  may 
occur  and  engender  node-like  protuberances.  There  may  be  frequently 
noticed  a  peculiar  brawny  induration,  due  to  extensive  hemorrhagic  infil- 
tration of  the  muscles  and  subcutaneous  tissues,  most  marked  in  the  hams 
and  calves.     The  condition  is  not  without  considerable  pain,  particularly 


SCORBUTUS.  449 

if  the  parts  be  touched,  and  in  severe  cases  bulhc  and  vibices  may  be  seen, 
as  in  a  recent  case  of  my  oAvn.  Hemorrhages  from  tlie  mucous  eliannels 
of  the  body  occur,  and  epistaxis  is  frequent.  In  bad  cases  hematuria, 
also  melena  and  rarely  hematemesis,  may  be  observed.  Blood  may  be 
eflfused  into  the  serous  membranes,  accompanied  sometimes  by  inflamma- 
tory changes  in  the  latter ;  also  into  the  lungs,  which  are  rarely  the  seat 
of  secondary  pneumonia.  Pulmonary  infarction  occurs,  but  is  a  rare 
event.  Hemoptysis  may  be  a  symptom  of  the  lung-complications  or  may 
occur  as  an  independent  phenomenon. 

The  heart  may  present  symptoms,  such  as  palpitations,  feeble  impulse, 
arrhythmia,  and  sometimes  a  basic  blood-murmur,  but  these  are  without 
diagnostic  importance.  The  pulse  is  soft,  small,  and  on  exertion  much 
accelerated.  The  temperature  is  sometimes  subnormal,  and  the  presence 
of  fever  is  a  certain  indication  of  the  existence  of  some  complication. 

The  nervous  symptoms,  aside  from  the  profound  mental  depression,  are 
not  prominent.  Insomnia  may  be  a  distressing  symptom.  Delirium  (late) 
is  sometimes  witnessed.  Meningeal  hemorrhage  may  supervene.  Both 
night-blindness  and  day-blindness  are  among  the  rarer  and  extraordinary 
ocular  features. 

The  urinary  symptoms  vary  in  different  cases.  Albuminuria  is 
common.  The  specific  gravity  of  the  urine  is  increased,  the  color  high, 
and  solid  constituents  diminished,  except  the  phosphates,  which  are 
abundant.  Albertoni  found  the  proportion  of  chlorids  less  than  the 
normal,  while  other  investigators  claim  that  the  percentage  is  high. 
Nephritis  may  occur  as  a  complication.  The  bones  in  long-standing 
cases  may  be  congested  and  sometimes  necrotic,  and  the  epiphyses 
may  separate  from  the  shafts.  In  one  of  my  cases  an  old  cicatrix 
reopened. 

Diagnosis. — This  rests  upon  the  following  points :  the  history,  the 
peculiar  facies,  the  spongy  and  swollen  gums,  the  gingival  and  deep- 
seated  cutaneous  hemorrhages,  the  progressive  loss  of  strength  and 
energy,  great  mental  depression,  and  the  speedy  recovery  after  an  appro- 
priate regimen.  Scurvy  will  be  distinguished  from  purpura  under  the 
description  of  the  latter  disease. 

Prognosis. — Unless  far  advanced,  the  prognosis  generally  becomes 
good  upon  the  institution  of  correct  dietetic  principles.  If  the  disease 
have  made  extensive  inroads,  the  danger  to  life  is  considerable.  The 
gravity  of  the  internal  symptoms  (particularly  pulmonary)  is  far  greater 
than  of  the  external,  and,  indeed,  the  presence  of  the  latter  is  a  favor- 
able omen.  Certain  complications  augur  a  serious  termination,  such  as 
pneumonia,  hemorrhagic  infarctions  of  the  lung,  pleurisy  with  bloody 
effusion,  dysentery,  acute  nephritis,  etc. 

Treatment. — Prophylaxis. —  By  carrying  out  the  known  means 
of  prevention  the  disease  has  been  diminished  more  than  90  per  cent, 
among  mariners  and  soldiers.  This  change  has  been  brought  about  by 
the  enforcement  of  governmental  regulations  which  demand  that  an  ade- 
quate supply  of  antiscorbutic  articles  of  food  must  be  provided  for  military 
campaigns  and  for  long  sea-voyages.  Fresh  fruits  and  vegetables  can 
be  readily  transported  in  hermetically  sealed  jars  or  cans. 

Treatment  of  the  Attack. — The  chief  indication  is  to  be  met  by 
the  use  of  fruits  and  fresh  vegetables.  Of  the  former,  two  or  three 
29 


450  CONSTITUTIONAL  DISEASES. 

lemons  daily  or  oranges  and  other  fruits  suffice  to  "work  a  surprising  de- 
gree of  imprDvement  in  a  short  space  of  time.  Baumaim  and  Howard's 
experiments  show  that  the  loss  of  various  food  constituents  through  the 
feces  is  lessened  when  fruit  juices  are  added  to  the  diet.  Antiscorbutic 
vegetables  (potatoes,  water-cresses,  raw  cabbage,  lettuce,  saiir-kraut)  in 
liberal  (juantity  should  also  be  given.  Meats,  eggs,  milk,  and  farinaceous 
dishes  are  not  to  be  prohibited,  since  the  patients  require  all  forms  of 
food  ;  but  if  the  digestive  power  be  feeble  it  is  advisable  to  begin  with  the 
juice  of  oranges  or  lemons,  conjoined  with  meat-juice,  egg-white,  milk, 
and  light  farinaceous  articles,  adding  the  stronger  forms  of  animal  food 
and  fresh  vegetal)les  when  improvement  is  noted.  We  may  assist  the 
digestive  function  by  the  use  of  simple  bitters,  strychnin,  and  hydro- 
chloric acid ;  hematinics  are  sometimes  indicated. 

Special  symptoms  may  call  for  appropriate  measures.  Constipation 
requires  simply  an  enema.  On  the  other  hand,  diarrlica  presents  an  in- 
dication for  intestinal  antiseptic  and  astringent  remedies.  The  oral  con- 
dition varies,  hence  the  measures  to  relieve  it  vary  also ;  but  if  ulcers  be 
present,  the  solution  of  potassium  chlorate  is  best.  For  swelling  of  the 
gums  the  application  by  means  of  a  cotton  swab  of  tannic  acid  (2  per 
cent.)  or  a  solution  of  silver  nitrate  (2-5  per  cent.)  is  serviceable.  A 
combination  of  boric  and  carbolic  acids  in  a  solution  of  suitable  strength 
may  be  used  as  a  mouth-wash.  If  copious  hemorrhages  occur,  hemostatics 
are  eminently  useful.  The  various  complications  must  be  met  by  the 
usual  measures,  according  to  their  nature. 

Inpa-Ntile  Scorbutus. 

{Bui-low's  Disease.) 

Definition. — A  constitutional  disease,  characterized  by  the  same 
symptoms  as  scurvy  in  adults,  except  that  in  many  instances  undoubted 
evidences  of  rachitis  are  associated. 

Pathology. — The  bones  are  thickened  and  excessively  sensitive, 
owing  to  a  marked  subperiosteal  hemorrhage,  with  more  or  less  macera- 
tion, and  want  of  firmness  between  the  epiphysis  and  shaft.  The  muscles 
may  be  the  seat  of  effusion.     The  lesions  of  I'ickets  are  often  associated. 

The  nature  of  the  affection  is  unsettled.  Originally  looked  upon  by 
most  observers  as  acute  rickets,  it  was  subsequently  described  by  Cheadle 
(from  the  clinical  side)  and  Barlow  (from  the  anatomo-pathologic  side)  as 
infantile  scurvy.  On  the  other  hand,  Ashby  of  Manchester,  Fiirst  and 
other  German  writers,  are  inclined  to  the  view  that  the  affection  should 
be  considered  a  hemorrhagic  form  of  rachitis.  The  belief  that  rickets 
predisposes  to  scurvy,  but  that  the  two  diseases  have  not  the  same  patho- 
genesis, is  probably  the  correct  one. 

Htiology. — Scurvy  is  largely  confined  to  hand-fed  infants.,  especially 
those  reared  upon  the  numerous  infant-foods  which  have  been  foisted  upon 
the  market,  including  condensed  milk,  etc.  Louis  Starr,  Jacobi,  and 
others  have  shown  that  it  sometimes  follows  the  prolonged  use  of  steril- 
ized milk,  although  the  etiologic  importance  of  the  latter  food  has  been 
over-emphasized.  Concetti^  concludes  that  infantile  scurvy  is  caused 
by  alimentary  intoxication.  An  investigation  by  a  committee  of  the 
American  Pediatric    Society^  showed  that  of   379    cases  the    majority 

^Archiv  J.  Kinderheilk,  April  17,  1909.  '^Medical  Record,  July  2,  1898. 


INFANTILE  SCORBUTUS.  451 

occurred  between  the  ages  of  7  and  14  months,  inclusive,  and  tliat  the 
disease  has  a  greater  tendency  to  occur  among  tlie  rich  or  well-to-do. 
"  The  farther  a  food  is  removed  in  character  from  the  natural  food  of  a 
child,  the  more  likely  its  use  is  to  be  followed  by  the  development  of 
scurvy." 

Sj^mptoms. — The  skin  presents  the  muddy  color  peculiar  to  the  dis- 
ease in  adults.  The  patient  may  be  well  nourished,  but  more  often  there 
is  a  tendency  to  wasting,  and  other  symptoms  of  impaired  nutrition  appear, 
particularly  irritability  and  disinclination  to  exertion.  'J'he  more  cha- 
racteristic features  appear  after  one  or  two  months,  and  the  child  cries 
when  handled,  especially  on  touching  the  lower  limbs.  About  the  same 
time  there  is  an  irregularly  cylindrical  swelling  of  one  of  the  thighs,  due 
to  subperiosteal  effusion.  Soon  the  other  limb  is  similarly  involved, 
though  not  always  to  a  like  degree.  At  first  the  legs  are  flexed,  but  later 
they  become  straightened  and  slightly  everted  on  account  of  the  progres- 
sive hemorrhage  or  separation  of  the  epiphyses.  The  bones  in  other  por- 
tions of  the  body  may  be  involved  secondarily  in  more  or  less  rapid  suc- 
cession, but  the  swellings  are  less  marked  than  in  the  lower  limbs.  Later, 
if  teeth  be  present,  the  gums  may  swell  and  become  spongy.  Ecchymoses 
in  the  form  of  petechise  appear  upon  the  skin-surface,  and  particularly 
about  the  eyes.  Barlow  describes  a  remarkable  ocular  phenomenon  : 
"  There  develops  a  rather  sudden  swelling  of  one  eyebrow,  with  puflBness 
and  very  slight  staining  of  the  upper  lid.  Within  a  day  or  two  the  other 
lid  presents  similar  appearances,  though  often  of  less  severity.  The 
ocular  conjuntivge  may  show  a  little  ecchymosis  or  may  be  quite  free. 
Hemorrhages  from  the  mucous  surfaces  may  finally  put  in  an  appear- 
a.nce. 

Diagn^OSiS. — To  distinguish  rickets  from  infantile  scurvy  Barlow's 
brief  though  clear  aggregation  of  the  characteristics  of  the  latter  disease 
may  be  quoted:  "(1)  Predominance  of  lower-limb  afiiection,  in  which 
there  is  immobility  going  on  to  pseudo-paralysis ;  excessive  tenderness ; 
general  swelling  of  the  lower  limbs ;  skin  shiny  and  tense,  but  seldom 
pitting,  and  not  characterized  by  undue  local  heat ;  on  subsidence  reveal- 
ing a  deep  thickening  of  the  shafts,  also  liability  to  fracture  near  the 
epiphysis.  (2)  Swelling  of  the  gums  about  erupted  teeth  only,  varying 
from  definite  sponginess  to  a  minute,  transient  ecchymosis." 

In  incipient  and  anomalous  cases  there  is  danger  of  diagnosticating 
rheumatism  when  scurvy  is  really  the  condition  present  (Grifiith). 

Prognosis. — Favorable,  even  in  well-established  instances,  if 
brought  under  the  proper  regimen. 

Treatment. — An  antiscorbutic  dietary — mother's  milk  or  fresh 
cows'  milk,  meat-juice,  and  orange-  or  lemon-juice — successfully  meets 
the  main  indication.  If  there  be  systemic  exhaustion — a  condition  that 
is  not  infrequent — gentle  stimulation  with  brandy  (highly  diluted)  and 
an  abundance  of  fresh  air  are  pre-eminent  among  the  measures  to  be 
employed.  Iron,  arsenic,  and  cod-liver  oil  may  be  needful  to  complete 
the  cure,  but  usually  the  simple  means  already  mentioned  will  prove 
effective.  The  limbs,  especially  the  lower,  may  claim  attention.  Local 
treatment,  however,  is  rarely  necessary,  except  there  be  separation  of 
the  epiphyses,  when  suitable  splints  are  to  be  applied. 


452  CONSTITUTIONAL  DISEASES. 

PURPURA. 

Two  main  groups  are  to  be  distiniruished :  (1)  Secondary  purpura, 
which  occurs  from  a  great  variety  of  causes  and  in  numerous  att'octions, 
in  which  its  clinical  significance  has  been  pointed  out  in  appropriate  sec- 
tions of  this  work.  It  seems  pertinent,  however,  to  enumerate  the  chief 
among  the  diseases  and  conditions  under  which  it  may  arise,  as  follows : 
(a)  scurvy;  (b)  acute  infectious  diseases  (typhus  fever,  ulcerative  endo- 
carditis, cerebrospinal  meningitis,  variola,  measles,  septicemia  and  scarla- 
tina, and  typhoid  rarely  :  (r)  hemophilia;  (d)  numerous  chronic  affections, 
as  nephritis,  leukemia,  pernicious  anemia,  jaundice,  Ilodgkin's  disease, 
tuberculosis,  syphilis,  chronic  alcoholism,  and  heart  disease ;  (<■)  malig- 
nant sarcomata  :  (/")  nervous  affections,  as  locomotor  ataxia,  acute  and 
transverse  myelitis,  and  hysteria  ;  (//)  mechanical  causes,  straining  efforts, 
paroxysms  of  whooping-cough,  and  violent  convulsions;  (A)  certain 
drugs  may  produce  a  petechial  eruption — the  iodids,  (juinin,  copaiba, 
belladonna,  ergot,  mercury,  chloral,  antipyrin,  and  turpentine  ;  (i)  snake- 
poisons  produce  rapid  and  extensive  hemorrhagic  extravasation  (S.  Weir 
Mitchell)  ;  (_/)  senile  purpura  (Bateman),  situated  chiefly  on  backs  of 
the  hands  and  along  the  forearms. 

(2)  Primary  or  idiopathic  purpura  forms  the  second  group.  It  is  di- 
visible into  (a)  simple  purpura  [purpura  simplex) ;  (b)  arthritic  purpura, 
of  which  two  varieties  may  be  recognized  :  (1)  peh'osis  rheumatica,  and 
(2)  Henoch's  purpura ;  {c)  hemorrhagic  purpura  {j)urpura  hcemor- 
rhagica). 

(rt)  Simple  Purpura. — The  cause  is  unknown.  Among  predisposing 
influences,  however,  is  age,  the  condition  being  most  common  in  children 
about  the  time  of  puberty.  It  may  be  a  sequel  of  the  acute,  infectious 
diseases,  and  in  not  a  few  cases  develops  in  seemingly  healthy  subjects. 

Symptoms. — This  is  the  mildest  variety  of  primary  purpura.  The 
hemorrhages  into  the  skin  take  the  form  of  petechi?e,  vibices,  or  ecchy- 
moses.  The  first  are  extravasations  of  blood  in  the  form  of  minute 
points,  that  appear,  as  a  rule,  in  the  hair-follicles,  and,  unlike  the  ery- 
themas, do  not  disappear  upon  pressure.  The  vibices  receive  their  name 
from  the  fact  that  the  hemorrhages  occur  as  streaks,  while  the  ecchymoses 
are  larger,  but  similar  in  nature  and  behavior  to  the  petechias.  They 
may  exceed  in  size  that  of  a  split  pea,  and  their  hue  ranges  from  a  deep 
red  to  a  bluish  tint.  As  they  fade  away  they  assume  at  first  a  yellow- 
ish-brown, then  a  yellow  color,  and  finally  disappear.  The  eruption 
appears  in  a  series  of  crops,  and  its  seat  of  election,  often  favored  by  the 
erect  posture,  is  the  legs  (orthostatic  purpura).  Bloody  serum  may  be 
effused  into  ])ullae  or  large  blebs.  Shepherd  and  others  have  reported 
cases  in  which  the  purpuric  eruption  ended  in  gangrene,  though  in 
Shepherds  case  the  gangrene  was  due  to  the  use  of  sodium  salicylate. 

(b)  Arthritic  Purpura. — (1)  Pcliosis  Itheumatica  [Schdnlein  s  Disease). 
— The  cause  of  this  remarkable  disease  is  unknown.  Formerly  many 
writers  inclined  to  the  view  that  it  is  of  rheumatic  origin,  and  since  en- 
docarditis and  pericarditis  are  occasionally  observed  in  association  with 
peliosis  rheumatica,  considerable  coloring  is  given  to  this  belief.  On  the 
other  hand,  the  fact  that  the  cardiac  complications  are  rare  in  arthritic 
purpura  shows  that  not  all  cases  of  the  latter  disease  are  genuinely  rheu- 


PURPURA.  453 

matic.  It  occurs  chiefly  in  males  from  the  twentieth  to  the  thirtieth 
year  of  age,  Among  the  prodromata  are  angina,  slight  articul;i.r  pains, 
headache,  loss  of  appetite,  and  fever  ranging  from  100"^  to  102''  F. 
(•37.7°-38.8°  C).  The  affection  is  especially  characterized,  however,  by 
jjoly  arthritis^  the  joints  being  swollen,  painful,  and  very  tender;  also  by 
purpura,  associated  or  not  with  urticarial  wheals  or  erythema  exudativum ; 
and  by  subcutaneous  edema.  The  purpuric  erujAmi  is  the  only  symp- 
tom that  has  pathognomonic  significance,  and  in  this  affection  it  shows  a 
strong  preference,  as  regards  distribution,  for  the  affected  joints  and  the 
legs.  The  eruption,  as  already  intimated,  does  not  display  constant  cha- 
racteristics. It  may  not  differ  from  that  of  simple  purpura,  and  the  rash 
consists  of  petechise,  ecchymoses,  streaks,  and  rarely  of  bullae  (pemphi- 
goid purpura) ;  or  it  may  be  made  up  of  wheals  of  urticaria,  attended 
with  intense  itching  ;  and,  finally,  it  may  be  identical  with  erythema 
nodosum.     These  forms  of  eruptions  may  be  variously  combined. 

Hemorrhages  from  the  mucous  surfaces  rarely  occur,  though  epistaxis 
is  the  most  common.  The  extent  of  the  edema  varies  greatly,  in  rare  cases 
being  quite  extensive  and  overshadowing  all  other  symptoms  (febrile  pur- 
puric edema).  Albuminuria  may  be  noted,  and  accompanying  the  pur- 
puric eruption  there  will  be  a  mild  febrile  movement.  Convalescence  is 
usually  protracted. 

The  diagnosis  is  made  from  the  presence  of  three  characteristic  symp- 
toms— polyarthritis,  a  purpuric  rash,  and  edema.  The  combination  of 
purpura  and  urticaria  is  one  of  the  chief  distinguishing  features.  It  is 
not  always  possible  to  eliminate  rheumatism,  but  the  non-rheumatic  cha- 
racter of  some  of  the  cases  may  be  clearly  shown  by  the  therapeutic  test, 
as  happened  in  one  of  my  own  patients. 

Prognosis. — This  type  of  the  disease  is  generally  benign,  death  being 
very  rare.  Complications,  however,  may  prove  serious,  especially  the 
cardiac.  The  throat-condition  may  outlast  the  attack,  and  terminate  in 
gangrene  of  the  uvula  or  tonsils. 

(2)  Henoch's  Purpura — Henoch  and  Couty  have  described  a  form  of 
rheumatic  purpura  occurring  chiefly  in  children,  and  characterized  by 
painful  and  sometimes  swollen  joints ;  by  a  purpuric  eruption,  plus  ery- 
thema multiforme ;  by  vomiting,  diarrhea,  and  intestinal  pain  ;  by  local- 
ized edema  of  the  skin  ;  and  by  hemorrhages  from  the  mucous  membranes 
and  sometimes  into  the  kidneys. 

The  diagnosis  is  difficult  in  proportion  to  the  scanty  development  of 
the  purpuric  symptoms,  some  of  which  are  often  wanting.  Intussuscep- 
tion usually  occurs  earlier — in  babes. 

The  prognosis  is  favorable,  though  complications  of  more  or  less  seri- 
ous import  may  arise.  One  of  Osier's  cases  proved  fatal  with  the  symp- 
toms of  acute  hemorrhagic  Bright's  disease. 

(3)  Factitious  Purpura. — Bruce  and  Galloway  ^  report  a  case  in  which 
any  irritation  of  the  skin,  such  as  might  be  caused  by  drawing  the  blunt 
end  of  a  pencil  over  it,  produced  a  white  line,  which  presently  became 
pink  and  then  intensely  purpuric.  In  this  way  letters,  figures,  and  the 
like  could  be  shown  as  hemorrhagic  outlines. 

{e)  Purpura  Hsemorrhagica  [Morbus    Werlhofii). — This  is  the  severest 
form  of  purpura,  and  its  apparent  etiologic  connection  with  certain  infec- 
tious diseases,  particularly  rheumatism,  malaria,  etc.,  is  interesting,  but 
'  British  Jour,  of  Dermatology,  Jan.,  1898. 


454  CONSTITUTIOyAL   DISEASES. 

not  Avell  understood.  The  disease  is  perhaps  most  ^ommon  in  young 
females,  particularly  if  they  have  fallen  into  general  ill  health  ;  but  all 
persons  are  liable,  and  post-mcrtem  anatomo-patliologic  pictures  of  the 
disease  leave  little  room  for  doubt  that  it  is  an  infectious  ctimplaint.  The 
hemorrhages  are  probably  ilue  to  an  endotheliolvsin  ])roduced  by  the  action 
of  bacteria  (^streptococci,  staphylococci,  ]uieumococci,  etc.)  under  certain 
circumstances  not  perfectly  known.  Duke^  believes  that  purpura  hemor- 
rhagica is  caused  by  an  agent  which  reduces  the  platelets  of  the  blood  to 
a  sufficient  degree. 

Si/>npto))is. — Prodromal  si/mptoms,  (malaise,  headache,  depression, 
anorexia)  may  appear,  and  last  one  or  two  days.  The  invasion  is  moder- 
ately abrupt,  with  fever,  and  soon  cutaneous  ecchymoses  appear  upon 
the  skin,  quickly  increasing  in  size  and  numbers.  Slight  hemorrhages 
from  the  mucous  membranes  into  the  internal  organs  occur.  Epistaxis 
generally  comes  first ;  it  tends  to  persist  and  to  recur,  and  the  same  pecu- 
liarities pertain  to  bleedings  from  other  points.  Prostration  now  becomes 
rather  marked,  the  patient  complaining  of  pains  in  the  limbs,  loins,  abdo- 
men, and  chest,  and  the  latter  often  presage  a  fresh  hemorrhage.  There 
is  moderate  fever,  as  a  rule,  the  temperature  during  the  height  of  the 
attack  ranging  from  101°  to  103°  F.  (38.3°-39.4°  C),  or  it  may  reach 
104°  to  105°  F.  (40.5°  C),  though  rarely.  Thepulse  is  accelerated  (120 
to  130  per  minute),  but  full  and  regular,  though  in  the  worst  cases  it 
becomes  small  and  very  rapid.  The  mind  is  usually  clear.  The  face 
may  be  pale  and  anxious.     Hematuria  followed  by  nephritis  may  occur. 

There  is  secondary  anemia,  var^'ing  in  intensity  with  the  extent  of 
the  hemorrhage.  It  is  more  pronounced,  owing  to  a  greater  loss  of  blood, 
in  this  form  than  in  the  preceding  varieties  of  purpura.  Occasionally  the 
red  count  falls  very  low,  while  there  is  often  a  slight  increase  in  the 
number  of  leukocytes,  although  the  different  varieties  are  present  in  nor- 
mal proportions.  "  In  stained  specimens  of  purpuric  blood  the  number 
of  blood-platelets  is  found  greatly  diminished  in  severe  cases"  (Pratt). 
The  course  is  run  in  from  seven  to  ten  days  in  mild  cases,  while  the 
severer  attacks  pursue  a  longer  course.  The  malignant  form  [purpura 
fulminans)  has,  however,  a  speedily  fatal  termination. 

The  diaf/nosis  of  purpura  hnemorrhagica  rarely  presents  any  difficulty. 
Scurvy  may  simulate  it  in  some  particulars,  but  is  distinguished  by  its 
chief  etiologic  factor — a  diet  deficient  in  fresh  vegetables  and  fruits — by 
the  spongy,  swollen  condition  of  the  gums,  the  loosened  teeth,  and 
brawny  induration  of  the  limbs.  Moreover,  in  purpura  hsemorrhagica 
the  hair-follicles  do  not  occupy  the  centers  of  the  ecchymotic  spots,  and 
the  hemorrhages  from  the  mucous  membranes  are  more  copious  than  in 
scurvy.  Malignant  types  of  the  eruptive  fevers  distinguish  themselves 
by  the  history  of  the  prevailing  epidemic,  by  the  characteristic  prodromes 
and  invasion,  and  by  the  high  temperature,  although  variola  purpura 
often  pursues  an  afebrile  course.  A  blood  examination,  which  should 
always  be  made  in  purpura,  will  exclude  leukemia. 

Prognosis. — Grave,  except  in  mild  cases.  In  the  malignant  type  death 
may  come  before  hemorrhages  from  the  mucosa  appear.  Certain  compli- 
cations may  prove  fatal — cerebral  hemorrhage,  inundation  of  the  lungs 
with  blood,  Bright's  disease,  and  shock  from  rapid,  profuse  bleedings. 
Death  may  also  be  the  result  of  exhaustion  due  to  protracted  bleedings. 

^  Archives  of  Internal  Med.,  Nov.  15,  1912. 


HEMOPHILIA.  455 

Chronic  Purpura. — Two  forms  have  been  described — one  in  which  the 
stage  of  convalescence  of  the  acute  form  is  interrupted  by  recurrences 
of  the  characteristic  manifestations,  the  other  in  whicli  tlie  symptoms 
are  continuous,  lasting  over  months  or  years. 

Treatment. — (a)  The  management  of  secondary  purpura  is  em- 
braced, in  other  portions  of  this  volume,  in  connection  with  the  treatment 
of  the  diseases  and  conditions  which  it  accompanies. 

ih)  Simple  purpura  demands  arsenic,  first  in  moderate  doses,  and  then 
increased  until  slight  toxic  effects  are  noticeable.  Legroux  speaks  in 
warm  terms  of  the  iron  compounds,  and  especially  of  iron  perchlorid  in 
doses  of  3SS-J  (2.0-4.0)  daily,  and  if  the  child  is  somewhat  anemic,  the 
inhalation  of  oxygen  will  promote  hematosis.  The  disease  also  requires 
fresh  air  in  abundance  and  a  generous  diet. 

(c)  In  peliosis  rheumatica,  in  addition  to  the  measures  recommended 
in  purpura  simplex,  the  salicylates  should  be  tried. 

(c?)  Purpura  Hcemorrhagica. — In  all  kinds  of  purpura  the  patient 
should  be  confined  to  bed.  An  abundance  of  nourishment,  by  support- 
ing the  patient's  power,  is  of  the  greatest  service.  Internally,  ergot, 
turpentine,  tincture  of  the  chlorid  of  iron,  acetate  of  lead,  and  dilute 
sulphuric  acid  enjoy  the  widest  reputation.  Calcium  chlorid,  suggested 
by  Wright,  should  be  tried,  as  should  also  adrenalin  chloride.  A  2  per 
cent,  solution  of  gelatin  in  normal  salt  solution  given  subcutaneously  is  a 
remedy  of  great  value.  The  following  combination,  recommended  by 
Hardaway,  I  have  found  useful : 

Vi/j.  Fluidext.  ergotse, 

Tr.  ferri  chlorid.,  da  f.lij  (64.0).— M. 

Sig.  Three  to  ten  drops  in  water,  t.  i.  d. 


HEMOPHILIA. 

[Bleeder's  Disease.) 


Definition. — An  hereditary  aflFection,  transmitted  by  females  who 
are  themselves  not  aifected  (Nasse's  law).  It  is  characterized  by  fre- 
quent uncontrollable  hemorrhages  that  are  either  spontaneous  or  due  to 
slight  traumatism. 

Pathology. — The  constitutional  changes  on  which  the  disease  de- 
pends are  to  be  found  in  the  blood-vessels  rather  than  in  the  blood  itself 
(Henry) ;  microscopic  changes  have  been  found  in  the  arterioles,  the 
middle  muscular  tunic  being  either  absent  or  much  atrophied.  Vaso- 
motor influences  also  play  an  important  part  in  causing  an  attack.  The 
blood  presents  slight  changes,  although  Addis  holds  that  the  cause  of 
hemophilia  is  an  inherited  peculiarity  in  the  constitution  of  the  pro- 
thrombin whereby  its  activation  into  thrombin  is  retarded.  Synovitis 
with  hemorrhages  into  the  joints  may^  sometimes  be  observed. 

il^iology. — Hemophilia  is  more  distinctly  hereditary  than  any  other 
known  disease,  but  Nasse's  law  is  not  of  such  universal  application  as 
is  supposed.  R.  Kolster  found  that  of  50  hemophilic  families.  18  cases 
followed  this  law,  16  others  with  some  exceptions  to  its  provisions,  and 
12  without  any  regard  to  it.     The  law  embraces  the  following  points: 


456  CONSTITUTIONAL   DISEASES. 

The  daughter  (not  herself  affected)  of  a  bleeder  transmits  the  tendency 
to  her  sons,  who  become  bleeders :  her  daughters  do  not  suft'er,  but  in 
turn  transmit  the  disease  to  their  sons.  Females,  hoyrever.  may  be 
bleeders,  and,  according  to  Virchow.  one  ■woman  is  affected  to  every 
seven  men.     The  disease  has  been  traced  for  centuries  in  a  few  families. 

It  is  observed  in  all  classes  of  society,  and  is  most  frecjuent  in  families 
whose  members  are  large,  vigorous,  and  have  delicate  complexions,  the 
complaint  usually  manifesting  itself  before  the  end  of  the  second  year  of 
life,  thougli  exceptionally  as  late  as  ])uberty.  An  accjuired  hemorrhagic 
diathesis  is  seen  occasionally  in  connection  with  certain  acute  infections 
and  more  commonly  in  the  graver  anemias  (leukemia,  pernicious  anemia). 
Weil  refers  the  hereditary  form  to  the  presence  in  the  blood  of  anticoagu- 
lants, and  the  sporadic  to  the  absence  of  substances  essential  to  coagulation. 

Symptoms. — The  occurrence  of  profuse  and  persistent  bleedings 
that  are  either  spontaneous  or  the  result  of  slight  injury  characterizes 
hemophilia.  The  character  of  the  injuries  that  lead  to  dangerous  bleed- 
ings is  often  exceedingly  trivial;  thus  a  slight  scratch,  cut,  blow,  the  ex- 
traction of  a  tooth,  and  other  minor  surgical  operations  {e.  g.  circumcis- 
ion) may  be  followed  by  severe  hemorrhage. 

If  we  include  spontaneous  hemorrhages,  bleedings  take  place  most 
frequently  from  the  nose.  Legg  has  made  three  clinical  groups,  based 
on  the  intensity  of  the  symptoms,  as  follows  :  (1)  Seen  most  frequently 
in  men,  and  characterized  by  external  and  internal  bleedings  of  all  kinds 
and  by  joint-affections  :  (2)  most  frequent  in  women,  and  distinguished 
by  spontaneous  hemorrhages  from  mucous  membranes  only  ;  and  (3)  cha- 
racterized simply  by  eecliymoses. 

The  capillaries  ooze  blood — a  process  that  may  vary  in  duration 
from  a  few  hours  to  as  many  weeks.  A  fatal  result  may  occur  in  a  few 
hours,  while,  on  the  other  hand,  recovery  may  follow  a  slow  oozing  of 
blood  that  has  continued  for  many  days.  In  the  latter  instances  profound 
anemia  follows,  the  blood,  however,  being  rapidly  replaced.  Extensive 
blood-extravasations  (hematomata)  usually  follow  contusions.  Petechite, 
when  they  occur,  are  apt  to  be  spontaneous.  The  coagulation  time  of  the 
blood  is  delayed,  due  to  insufficient  formation  of  the  fibrin  ferment  factors 
(Morowitz  and  Lossen).  Fussell,  in  2  cases,  found  the  leukocytes  in- 
creased (24,000  and  15,000  per  c.mm.),  while  the  red  cells  Avere  moder- 
ately diminished. 

Arthritic  symptoms  are  common,  the  larger  joints,  and  especially  the 
knees,  being  most  frequently  affected  and  showing  swelling  that  is  due 
chiefly  to  hemorrhages  into  the  joints.  In  other  instances  febrile  syno- 
vitis may  be  present,  resembling  rheumatism.  The  joint-symptoms  may 
either  announce  an  approaching  hemorrhage  or  pain  alone  may  be  ex- 
perienced. The  attacks  are  liable  to  recur,  especially  in  cold,  damp 
weather,  and  may  result  in  stiffened,  deformed  joints  (Musser). 

Diagnosis. — When  persistent  capillary  oozing  occurs  in  a  person 
with  a  clear,  hereditarv  disposition  the  diagnosis  is  clear.  Without  an 
inherited  tendency  we  cannot  be  certain  of  the  diagnosis  unless  pro- 
tracted hemorrhages  from  insufficient  causes  are  repeatedly  manifested. 
The  presence  of  joint-involvement  is  very  helpful. 

Differential  Diagnosis. — Peliosis  rheumatica  is  an  affection  which,  as 
Osier  remarks,  touches  hemophilia  very  closely,  particularly  in  the  re- 
lation of  the  joint-swelling.     It  is  true  that  the  former  may  also   show 


HPJMOPinLIA.  457 

itself  in  several  members  of  a  family,  but  the  presence  in  this  affection 
of  more  or  less  edema,  and  often  of  wheals  of  urticaria,  accompanied  by 
intense  itching,  aids  greatly  in  its  elimination. 

Prognosis. — In  undeveloped  forms  the  outlook  is  not  particularly 
grave,  since  in  these  the  tendency  may  either  lessen  or  become  alto- 
gether arrested  after  childhood.  In  the  majority  of  well-marked  cases 
the  children  do  not  survive  this  period.  On  the  other  hand,  those  who 
live  to  become  full-grown  show  a  diminished,  and  in  a  small  class  of 
cases  an  absolute,  disappearance  of  the  tendency.  The  first  hemor- 
rhage rarely  proves  fatal.  Boys  suff'er  from  a  more  serious  form  than 
girls.  Moreover,  menstruation,  though  sometimes  very  copious,  does 
not  to  any  great  extent  endanger  the  life  of  a  hemophilic  woman.  Of 
130  cases  of  pregnancy  and  labor,  the  death  of  the  mother  occurred  in 
only  3,  and  abortion  in  16  cases  (Kolster). 

Treatment. — The  physician  can  do  most  in  the  direction  of  pro- 
phylaxis. All  surgical  operations  that  are  not  absolutely  necessary 
must  be  avoided  ;  neither  should  the  teeth  be  erupted  nor  the  operation 
of  circumcision  be  permitted.  Leeches  are  not  permissible.  Females 
who  belong  to  bleeder  families,  as  well  as  males  who  have  had  hemo- 
philia,  should  not  marry. 

During  the  attack  absolute  rest — mental  and  bodily — must  be  en- 
joined, and  light  compr,ession,  and  if  this  fail  strong  pressure  or  styp- 
tics, should  be  tried.  In  epistaxis  ice,  tannin,  and  turpentine  should 
be  tried  before  using  nasal  plugs ;  and  if  the  latter  prove  indispensable, 
the  lightest  only  should  be  employed.  J.  Greig  Smith  regards  lint 
saturated  with  spirit  of  turpentine  as  the  best  local  application  in  epis- 
taxis. Adrenalin  chloride  and  gelatin  in  5  per  cent,  solution  are  of 
great  value  locally.  Schloessmann  suggests  the  systematic  use  locally  of 
tissue  extract,  e.  g.,  fresh  goitre  tissue.  Blood-serum  may  also  be  applied 
to  the  bleeding  part.  Internal  medicines  are  of  secondary  importance, 
but  opium  is  unquestionably  of  value,  since  it  tends  to  favor  repose.  The 
remedies  that  have  been  given  are  various.  Delafield,  Fiirth,  and  others 
have  used  successfully  the  fluidextract  of  hydrastis  canadensis,  the  dose 
being  from  20  to  40  drops  daily  ;  among  other  hemostatics,  gallic  acid, 
turpentine,  and  iron  perchlorid  produce  the  best  results.  The  dose  of  the 
latter  should  be  3ss  (2.0)  every  two  hours,  with  a  purge  of  sulphate  of 
soda  (Legg).  The  use  of  calcium  salts  has  produced  good  results  in  some 
cases  and  merits  a  trial,  as  does  adrenalin  chloride.  The  subcutaneous 
injection  of  the  gelatin  solution  already  mentioned  has  undoubted  value. 
Gelatin  seems  also  to  have  hemostatic  power  when  given  by  mouth  or 
rectum.  The  most  successful  method  (first  advocated  by  Weil)  is  fresh 
normal  blood,  either  from  the  horse,  or  rabbit,  or  human  blood  (Lappe), 
The  dose  of  the  fresh  serum  if  given  subcutaneously  is  20  to  40  c.c.  The 
coagulability  of  the  blood  is  greatly  increased  thereby.  Sahli  advises 
repeated  injections  of  fresh  human  seram  and  repeated  small  bleedings 
to  stimulate  the  physiological  reactive  thrombokinase  formation.  Knead- 
ing the  tissues  immediately  surrounding  the  bleeding-point  liberates 
thrombokinase  and  thus  tends  to  arrest  hemorrhage.  Thyroid  extract 
and  inhalations  of  oxygen  have  also  been  advocated.  During  convales- 
cence, arsenic,  iron,  the  bitter  tonics,  and  a  liberal  dietary  will  aid  full 
recovery. 


468  CONSTITUTIOy.lL  DISEASES. 


HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

(a)  Epidemic  Hemoglobinuria  ( lI'mcA-f/'s  D/srase). — Hi  is  aftection, 
which  is  septic  in  nature,  is  occasionally  met  -with  in  lying-in  hospitals, 
and  occurs  in  children  from  one  to  ten  days  after  hirth.  The  infants 
refuse  the  hrcast  and  show  hematogenous  (?)  icterus ;  gastro-enteric 
catarrh  is  an  attendant  of  the  disease.  The  stools  are  meconic;  the 
urine  is  scanty,  dark  colored  (from  methemoglobin),  often  albuminous, 
and  may  contain  casts.  Hemorrhages  occur  into  organs  other  than  the 
kidney  and  into  the  mucous  membranes,  there  also  being  mild  fever, 
rapid  emaciaticm,  and  often  mild  convulsions.  It  is  a  very  fatal  dis- 
ease. Bacteriologic  experiments  have  shown  that  the  disease  may  be 
produced  by  the  growth  of  the  colon  bacillus  in  the  buccal  epithelium 
of  infants.  Kilham  and  Mercelis*  report  an  epidemic  of  10  cases  oc- 
curring in  the  New  York  Infirmary;  complete  bacteriologic  studies 
were  made  in  all,  and  the  organism  discovered  suggested  the  diplo- 
coccus  of  pneumonia  or  the  pneumococcus  group.  There  is,  however, 
great  confusion  in  regard  to  the  possible  specific  micro-organism  of 
this  disease. 

(b)  Acute  Fatty  Degeneration  of  the  New-born  {Buhrs  Disease). — 
This  disease  may  be  similar  to  Winckel's  in  nature.  It  was  first  de- 
scribed by  Hecker  and  Buhl  as  an  infectious  disease  of  the  new-born, 
characterized  by  cyanosis,  jaundice,  and  copious  visceral  hemorrhages. 
The  chief  pathologic  change  is  an  acute  fatty  degeneration  of  the  inter- 
nal organs. 

(c)  Syphilis  Haemorrhagica  Neonatorum. — Either  at  birth  or  soon 
thereafter  bleedings  take  place  into  the  skin  (ecchymoses)  and  from 
the  mucous  surfaces  and  the  navel.  Jaundice  may  be  associated.  The 
viscera  are  found  upon  post-mortem  examination  to  be  the  seat  of  syphi- 
litic lesions. 

{d)  Morbus  Maculosus  Neonatorum. — Hemorrhage  from  the  gastro- 
intestinal mucosa  of  the  new-born  (melsena  neonatorum)  occurs,  and 
may  be  due  to  intracranial  lesions  during  birth ;  it  may  also  take  place 
independently  of  the  latter.  Preuschen  has  collected  the  reports 
of  37  cases,  in  5  of  which  the  brain  was  examined,  and  all  of  these 
showed  cerebral  hemorrhages.  The  latter  may  occur  in  spontaneous 
births  and  give  rise  to  melaena  neonatorum.  Gartner  believes  the  dis- 
ease to  be  an  infectious  one,  and  claims  that  in  2  cases  he  was  able  to 
identify  a  bacillus  for  which  the  navel  is  believed  to  be  the  entrance- 
point.  The  blood  may  also  come  from  the  mouth,  nose,  navel,  etc. 
Townsend  found  morbus  maculosus  neonatorum  in  45  cases  in  6700 
deliveries,  and  in  most  of  these  instances  the  bleeding  was  general.  The 
hemorrhage  usually  sets  in  during  the  first  week,  rarely  later,  and  the  du- 
ration of  the  disease  is  between  one  and  seven  days,  the  mortality  being 
a  little  over  50  per  cent.  Vomiting  of  the  blood  which  the  child  has 
drawn  from  the  breast  must  not  be  confounded  with  true  melena.  The 
treatment  is  by  gallic  acid  and  ergotin,  the  latter  hypodermically.  Gela- 
tin subcutaneously  has  apparently  saved  life.^  Stimulants  may  also  be 
required,  and  warmth  to  the  extremities  if  the  peripheral  circulation  be 
sluggish. 

'  Archives  of  Pediatrics,  March,  1899. 
*  Miinch.  med.  Wochen.]  Sept.  2,  1902. 


PART   IV. 

DISEASES  OF  THE   BLOOD  AND  THE 
DUCTLESS  GLANDS. 


ANEMIA. 

Definition. — A  pathologic  condition,  characterized  either  by  a 
diminution  in  the  quantity  of  blood  or  by  a  deficiency  in  one  or  more 
of  its  constituents.  Anemias  may  be  subdivided  into — I.  Primary  or 
Essential  (chlorotic  and  pernicious)  ;  II.  Secondary  (symptomatic) ;  III. 
Leukemia  (myeloid  and  lymphoid). 

Pathology. — Anemia,  in  its  different  forms,  is  characteristic  of  dis- 
eases of  the  blood  or  of  the  blood-making  organs.  It  may  be  manifest, 
on  examination,  as  a  diminution  of  the  total  quantity  or  body  of  the 
blood  {oligemia) ;  of  the  number  of  red  corpuscles  {oligocythemia) ;  of 
the  hemoglobin  (oligochromemia) ;  and  of  other  constituents,  as  fluid 
{anJiydremia).  The  diminution  of  hemoglobin  gives  rise  to  the  most 
obvious  sign  of  anemia  or  impoverished  blood — namely,  the  pallor  of  the 
cutaneous  surface — but  it  is  important  to  point  out  here  that  the  quan- 
tity of  hemoglobin  in  the  blood  is  not  necessarily  proportionate  to  the 
number  of  red  corpuscles.  Thus  the  percentage  of  hemoglobin  con- 
tained by  the  red  corpuscles  may  vary  in  disease,  so  that  a  reduction  in 
its  amount  does  not  necessarily  involve  a  corresponding  decrease  in  the 
number  of  red  corpuscles.  Conversely,  a  diminution  in  the  number  of 
the  latter  may  not  be  accompanied  by  a  proportionate  diminution  in  the 
amount  of  hemoglobin,  the  corpuscular  richness  in  coloring-matter  being 
quite  normal.  As  a  matter  of  fact  it  frequently  happens  that  oligo- 
chromemia is  associated  with  a  certain  degree  of  oligocythemia,  and 
vice  versa,  though  where  they  coexist  the  degrees  of  reduction  may 
neither  be  relatively  nor  proportionately  equal. 

Anemia  can  be  positively  ascertained  only  by  an  adequate  examina- 
tion of  the  blood.  It  may  be  inferred  from  the  presence  of  pallor, 
languor,  dyspnea,  palpitation,  etc.  ;  but  it  should  be  borne  in  mind  that 
not  every  pale  person  has  anemia,  since  pallor  of  the  face  may  be  hered- 
itary, and,  at  the  same  time,  perfectly  consistent  with  good  health,  a 
normal  number  of  corpuscles,  and  a  normal  percentage  of  hemoglobin. 
Conversely,  a  person  with  marked  vascularity  of  the  face,  and  a  rosy 
complexion  even,  may  have  anemia. 

The  anemias  embrace  those  conditions,  also,  in  which  there  are 
changes  in  the  shape  of  the  red  corpuscles  {poikilocytosis),  and  in  their 
size  {micro-,  macro-,  or  megalocytosis). 

459 


460     DISEASES  OF  THE  BLOOD  AXD   THE  DUCTLESS  GLANDS. 


I.  THE   PRIMARY    OR  ESSENTIAL.   ANEMIAS. 

Primary  anemias  constitute  those  forms  in  which,  so  far  as  our  pres- 
ent knowledge  of  their  etiology  and  pathology  goes,  no  other  tissues  or 
organs  than  the  blood  and  the  blood-making  organs  are  either  at  fault 
or  are  directly  aifected.  Future  investigations  of  the  life-history  of  the 
blood  may  reveal  the  exact  causation  of  what  are  now  regarded  as  pri- 
mary or  essential  anemias,  and  thus  permit  of  a  clearer  discrimination 
and  a  more  accurate  classification. 

CHLOROSIS. 

[Green  Sickness.) 

Definition. — A  blood-disease,  occurring  chiefly  in  adolescent  fe- 
males, dependent  upon  defective  hemogenesis,  and  characterized  princi- 
pally by  a  deficiency  of  hemoglobin  in  the  red  corpuscles.  Chlorosis 
is  steadily  diminishing  in  frequency  of  occurrence. 

Pathology. — It  is  so  seldom  that  death  occurs  in  cases  of  chlorosis 
that  nntnpsies  of  this  disease  have  not  been  frequent  enough  to  determine 
definitely  the  nature  of  the  findings.  There  is  no  loss  of  fat  in  the 
body,  but  signs  of  physical  degeneration  and  disorders  of  development 
are  quite  common,  hypoplasia  of  the  vascular  system  and  of  the  genital 
organs  seeming  to  be  the  most  prominent.  Incurable  cases  of  chlorosis 
are  nearly  always  characterized  by  anomalies  of  the  blood-vessels  and 
genitalia  (Rokitansky).  Virchow  has  also  shown  that  congenital  arrest 
of  development  of  the  aorta  and  larger  arteries,  as  indicated  by  their 
small  size,  their  soft  and  elastic  walls,  is  quite  constant  in  chlorotics. 
The  uterus  (especially)  and  adnexa  manifest  the  hypoplasia,  and  yellow- 
ish spots  and  streaks  of  fatty  degeneration  are  sometimes  seen  in  the 
intima  of  the  arteries.  The  cardiac  muscle  is  softened,  the  whole  heart 
is  dilated,  and  the  left  ventricle  is  usually  somewhat  hypertrophied. 

etiology. — Chlorosis  occurs  most  frequently  in  girls  at  or  near 
puberty,  and  also  may  appear  between  that  period  and  twenty  or 
twenty-five  years  of  age.  It  usually  happens  that  the  condition  dates 
from  a  scanty  menstruation,  beginning  late  in  the  "  teens,"  but  it  should 
be  recollected  that  amenorrhea  is  not,  as  formerly  supposed,  a  cause, 
being  rather  an  efi"ect  of  the  underlying  blood-disorder.  Blondes  are 
oftener  aff'ected  than  brunettes.      In  males  the  disease  is  rare. 

The  influence  of  heredity  in  the  causation  of  chlorosis  is  undoubted 
in  those  cases  described  by  Virchow,  in  which  congenital  hypoplasia  of  the 
blood-vessels  and  genitalia  is  found  to  exist.  Other  cases  also  bear  the 
stamp  of  heredity,  in  that  their  mothers  have  been,  and  their  sisters 
are,  chlorotic.  A  faviily  tuberculous  taint  may  predispose  to  chlorosis 
(Jolly) ;  it  is  probable,  hoAvever,  that  constitutional  predisposition  im- 
plies merely  delicacy  of  organization.  Such  unhygienic  conditions  as  bad 
air,  dimly  lighted  rooms,  a  lack  of  nutritious  food  and  out-door  exercise, 
a  sedentary  occupation,  excessive  tea-  and  coffee-drinking  ;  bodily  fatigue, 
as  from  stair-climbing  and  standing  in  constrained  positions  without  in- 
tervals of  rest — all  these  predispose  to  the  disease.  And  yet  girls  living 
amid  the  most  luxurious  and  favorable  surroundings  have  had  chlorosis. 
Sir  Andrew  Clarke  believed  that  copremia — the  absorption  of  the  toxic 


CHLOROSIS.  461 

ptomains  and  leukoraains  from  the  colon  in  constipation — is  often  the 
cause  of  chlorosis,  though  physiologic  chemists  fail  to  find  in  the  urine 
the  evidences  of  intestinal  putrefaction.  Sometimes  a  previously  existing 
simple  constitutional  anemia  appears  to  he  an  underlying  cause.  I  helievc 
that  occult  gastro-intestinal  bleeding  due  to  gastric  or  diioik.'nal  ulcer  mwy 
be  a  cause  of  chlorosis. 

Sudden  emotional  excitement  and  prolonged  mental  overexertion 
operate  as  causative  agencies.  Shock  from  bad  news,  such  as  loss  of 
relatives,  homesickness,  disappointment  in  love,  rankling  grievances, 
and  perhaps  ungratified  sexual  desires,  may  contribute  to  the  "neuro- 
pathic" origin  of  chlorosis.  A  change  of  climate  seems  to  operate  as  a 
cause,  and  is  manifested  especially  in  the  case  of  girls  emigrating  from 
rural  Ireland  to  enter  domestic  service  here  (Townsend).  A  late  cldoroHU 
has  also  been  described,  but  its  existence  must  be  rare. 

Symptoms. — A  brief  outline  of  the  moi'e  frequent  and  prominent 
general  manifestations  of  chlorosis — or  "  green  sickness  " — may  be  nar- 
rated at  the  outset.  The  gradual  onset  is  usually  marked  by  languor, 
indisposition  to  either  physical  or  mental  exertion,  motor  weakness,  irri- 
tability or  inertia  of  mind,  and  a  more  or  less  constant  fatigue.  Palpi- 
tation of  the  heart  and  dyspnea  on  slight  exertion  are  much  complained 
of  in  most  cases ;  headaehe  is  also  an  early  symptom,  and  may  be  accom- 
panied by  vertigo  in  some  cases  ;  and  dyspepsia  and  constipation  occur  in. 
65  per  cent,  of  cases  (Townsend).  Probably  in  one-half  of  all  case? 
cessation  of,  or  scanty  and  irregular,  menses  may  form  the  burden  of 
complaint.     A  slight  fever  is  present  in  many  instances. 

Gastro-intestinal  Symptoms. — The  appetite  is  either  poor  or  perverted 
and  a  capricious  desire  for  such  innutritions  substances  as  chalk,  slate- 
pencils,  and  even  bits  of  earth  (pica),  or  for  sour,  highly  spiced,  and 
unwholesome  articles  of  food  (malacia),  is  not  uncommon.  An  abnor- 
mal cravino;  for  alkalies  has  been  ascribed  to  an  overacid  stomach.  Morn- 
ing  vomiting  or  regurgitation  of  food  and  eructations  occur,  in  some  cases 
pain  after  eating  may  be  noticed,  and  dilatation  of  the  stomach  and 
high  position  of  the  diaphragm  are  found  in  many  instances.  The  gas- 
tric contents  show  a  hyperacidity  in  most  cases.  The  tongue  is  pale, 
flabby,  often  dry,  and  the  edges  show  indentations. 

Constipation  is  usually  present,  though  sometimes  diarrhea,  lasting 
for  a  day  or  two,  may  alternate,  as  after  the  ingestion  of  some  unwhole- 
some article  that  has  been  eaten  to  satisfy  the  perverted  appetite. 

General  Appearance. — The  subcutaneous  fat  is  not  only  well  re- 
tained, but  in  many  cases  is  even  increased,  and  the  rotundity  of  the 
body  and  members  preserved.  The  peculiar  greenish-yellow  tint  of 
the  complexion  is,  however,  the  most  striking  manifestation  to  the  eye. 
It  differs  thus  from  the  muddy  pallor  of  cancerous  anemia,  from  the 
lemon-yellow  tint  of  pernicious  anemia,  from  the  saffron  hue  of  jaundice, 
and  from  the  blanched  pallor  after  severe  hemorrhages.  The  sclerce 
are  often  pearly-  or  bluish-white  ("cerulean  hue"),  and,  though  this  is 
considered  by  many  the  earliest  positive  indication  of  anemia,  when  the 
skin-tint  is  not  characteristic,  yet,  according  to  ToAvnsend's  analysis  of  87 
cases  of  chlorosis,  it  is  not  the  most  constant.  The  nails  showed  pallor 
in  95  per  cent,  of  the  cases ;  the  cheeks,  tongue,  and  lips  were  paled  in 
89,  84,  and  76  per  cent,  respectively,  while  the  sclerge  were  pale  in  but 


462    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

64  per  cent.  On  exertion  the  cheeks  and  lips  may  become  quite  ruddy 
in  cases  of  moderate  anemia  (chlorosis  rubra). 

Circulatory  symptoms  are  breathlessness,  palpitation,  and  the  tendency 
to  vertigo  and  syncope  complained  of  in  the  majority  of  cases;  other 
circulatory  disturbances  may  occur.  The  skiti  and  the  extremities  are 
frequently  cold,  owing  to  sluggish  heart-action.  The  pulse  is  usually 
full  and  easily  compressible,  and,  owing  to  its  excitability,  it  may  be 
accelerated  for  the  time  being  by  various  external  influences  (see  Fig. 
84).  Visible  undulating  pulsations  of  the  carotid  vessels  are  frequent, 
and  a  pulsation  at  the  base  of  the  heart  and  in  the  peripheral  veins  is 
also  observed  at  times.  Physical  examination  shows  the  heart  to  be 
slightly  dilated.  Systolic  murmurs,  soft  and  "whiffing"  in  character, 
are  heard  at  the  base,  though  in  severe  cases  they  may  be  heard  at  the 
apex  of  the  heart  also.  Si/stolic  Moiving  rtiurmurs  of  hemic  origin  are 
not  infrequently  heard  over  the  carotid  arteries.  More  common  and 
characteristic,  however,  is  the  venous  hum  or  bruit  de  diable — the  soft 
continuous  murmur  heard  over  the  larL;e  cervical  veins.  Thrombosis  of 
the  larger  veins  or  of  a  cranial  sinus  may  occur,  and  is  always  ominous. 

Of  the  nervous  manifestations  that  are  often  present,  neuralgias  of 
the  head,  mental  depression,  hyperesthesia  of  the  skin,  particularly  of 
the  abdomen,  gastralgic  attacks,  and  hysteria,  are  most  frequently  met 
with.    Tinnitus  aurium  and  anemic  amaurosis  have  been  known  to  occur. 

Edema  of  the  ankles  is  found  in  perhaps  one-third  of  the  cases.  The 
uriyie  is  generally  pale,  free  in  quantity,  and  its  specific  gravity  is  some- 
what lowered ;  and  according  to  recent  studies  there   is  a  diminished 


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pulse  by  eating,  exertion,  and  excitement. 


excretion  of  urea,  despite  the   abnormal    destruction    of  albuminoids. 
Movable  kidney  is  often  associated. 

Blood- examination. — The  blood  flowing  from  a  punctured  finger-pulp 
or  ear-lobule  is  pale,  though  seldom  thin  or  hydremic,  and  the  paleness 
is  due  to  a  qualitative  rather  than  a  quantitative  change.  There  is 
a  disproportionate  reduction  of  the   hemoglobin  as  compared  with  the 


CHLOROSIS.  4G3 

number  of  the  red  cells.  The  hemoglobin  may  range  from  50  per  cent. 
to  as  low  as  16  or  17  per  cent,  in  severe  cases,  the  average  fjuantity  being 
about  38  or  40  per  cent.  On  the  other  hand,  the  number  of  red  corpus- 
cles is  not  greatly  reduced,  and  may  even  be  normal.  The  moderate 
oligocythemia  and  marked  oUyochromemia  are  almost  distinctive  of 
chlorosis :  these  features,  however,  may  be  closely  simulated  by  the 
chloroanemia  of  syphilis  or  early  tuberculosis.  Morawitz  *  calls  atten- 
tion to  "masked  chlorosis,"  in  which  Seiler  found  that  the  hemoglobin 
percentage  was  only  10  or  15  below  normal.  The  average  number  of 
red  corpuscles  is  from  3,700,000  to  4,100,000  per  cubic  millimeter  of 
blood,  but  the  count  in  very  severe  cases  may  be  as  low  as  1,900,000. 
Approximately,  the  number  of  red  corpuscles  is  from  70  to  85  per  cent, 
of  the  normal,  while  the  leukocytes  are  only  slightly  increased  in  num- 
ber (8000  to  8500  per  c.mm.).  Microscopically,  the  red  cells  are  seen 
to  be  paler  than  normal,  and  somewhat  altered  in  size  and  shape.  Some 
are  distinctively  larger  than  is  usual  (macrocytes),  but  the  majority  are 
slightly  undersized  (microcytes).  Irregularity  in  shape  (poikilocytosis) 
is  seen  in  quite  a  number  of  the  red  cells  in  the  severe  cases,  and  an 
occasional  normoblast  (small  nucleated  red  corpuscle)  may  be  noted. 
There  is  usually  a  relative  lymphocytosis,  especially  in  severe  cases.  The 
eosinophiles  are  occasionally  increased  (Cabot).  There  is  a  marked  in- 
crease in  the  amount  of  blood  plasma  (polyplasmia). 

Diagnosis. — When  the  greenish  pallor  of  the  face  is  marked  this 
can  often  be  correctly  made  at  a  glance.  The  blood-examination  must 
be  made,  however,  to  completely  establish  the  diagnosis,  even  when  dis- 
tinctive symptoms  are  present,  such  as  the  shortness  of  breath,  palpita- 
tion, weakness  and  languor,  faintness,  amenorrhea,  capricious  appetite, 
together  with  a  well-nourished  appearance  of  the  body.  The  bluish- 
white  sclerae  and  pallid  nails  are  confirmatory  when  observed,  and  search 
should  be  made  for  the  physical  signs. 

Differential  Diagnosis. — The  primary  character  of  the  anemia  may  be 
determined  in  doubtful  cases,  or  in  those  in  which  incipient  tuberculosis 
("  chloro-anemia"),  or  syphilis^  or  Bright' s  disease  may  be  suspected,  by 
exclusion.  Here  the  physical  examination  of  the  chest,  the  history, 
and  urinalysis  should  supplement  the  blood-examination.  In  the  chloro- 
anemia of  chronic  phthisis  fever  and  progressive  emaciation  are  also 
observed.  Organic  disease  of  the  heart  may  be  simulated  by  the  breath- 
lessness,  palpitation,  vertigo,  and  edema. 

Prognosis. — This  is  always  favorable,  except  in  those  cases  in 
which  congenital  or  developmental  anomalies  of  the  vascular  system  are 
associated.  The  discontinuance  of  proper  treatment  before  a  substan- 
tial cure  is  eifected  is  often  followed  by  a  relapse,  and  even  after  appar- 
ent cure  one  or  more  recurrences  may  be  witnessed  before  the  age  of 
thirty.  The  average  duration  of  a  case  of  chlorosis  is  from  two  to 
three  months.  In  cases  of  very  severe  type,  in  which  the  dividing-line 
between  this  disease  and  pernicious  anemia  may  not  be  marked  clearly, 
the  prognosis  should  be  made  with  due  reserve. 

Treatment. — While  the  treatment  of  chlorosis  by  the  administra- 
tion of  iron  is  wellnigh  specific,  the  hygienic  measures  are  also  import- 
ant, and  particularly  in  order  that  relapses  may  be  avoided. 

Hygienic. — Pure  air,  wholesome  food,  and  plenty  of  rest  and  sleep, 
1  Miinchener  medizinische  WochenschriJ't,  July  5, 1910. 


464    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 


with  regular  habits,  are  prime  rei|uisites.  Sometimes  a  change  of  occu- 
pation, even  temporary,  where  confinement  may  be  rei)laced  by  an  out- 
door life  and  sunshine,  as  in  the  case  of  store-girls  and  mill-operatives, 
is  of  value  in  bringing  about  a  rapid  improvement.  Patients  in  better 
circumstances  may  be  sent  to  rural  districts,  the  mountains,  or  sea-shore. 
In  cases  marked  by  much  palpitation,  dizziness,  and  dyspnea,  rest  in 
bed  for  a  week  or  so  is  often  imperative  at  the  outset.  As  improvement 
goes  on,  however,  light  and  then  moderate  exercise  may  be  permitted, 
and  the  increasing  appetite  should  be  gratified  by  a  generous,  easily 
assimilable  diet  (milk,  meat,  eggs,  fish,  jiurc^es  of  green  vegetables,  stewed 
fruit).  Fats  and  carbohydrates  should  gcnerlly  be  avoided.  Coffee,  tea, 
and  alcoholics  do  harm.      Hot  baths  have  been  recommended. 

Medicinal. — The  one  remedy,  par  excellence,  on  both  rational  and 
empirical  grounds,  is  a  good  preparation  of  iron.  This  should  be 
given    methodically    and     persistently    until    the    percentage    of   liemo- 


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Fig.  35.— Chart  of  a  ease  of  rhlorosis,  showing  the  improvemont  following  the  administration 
of  iron.  Convalescence  almost  complete;  relapse.  Black,  red  corpuscles;  red,  hemoglobin; 
blue,  white  corpuscles. 

globin  is  90,  and  then  maintained  there  by  continuing  the  adminis- 
tration of  the  iron  for  several  weeks  to  prevent  a  recurrence  (Fig.  35). 
E.xactly  how  the  iron  acts  in  curing  chlorosis  has  not  been  definitely 
proved,  but  its  almost  specific  action  is  indubitable.  Not  all  prepara- 
tions of  iron  are  e(iually  well  borne  by  the  stomach,  however,  and  sev- 
eral changes  may  be  necessary  during  the  course  of  a  given  case.  Prob- 
ably the  best  form  for  general  use  is  the  dried  sulphate,  usually  given 
together  with  potassium  carbonate  in  the  well-known  Eland's  pills — 2 


PROGRESSIVE  PERNICIOUS  ANEMIA.  465 

grains  (0.12&)  of  each  to  the  pill.  Starting  with  one  pill  thrice  daily 
for  a  week  or  ten  days,  the  daily  dosage  is  increased  until  nine  pills  daily 
are  administered  in  the  third  week,  and  continued  for  several  weeks  or 
as  long  as  the  case  may  require.  It  is  very  important,  meanwhile,  that 
the  bowels  should  be  kept  soluble  by  the  use  of  cascara  sagrada,  salines, 
and  the  like.  A  preliminary  course  of  intestinal  antiseptics  for  a  week 
or  80  is  strongly  advised  by  some  authorities,  and  is  worthy  of  recom- 
mendation. Beta-naphtol,  thymol,  guaiacol,  and  salol  are  used  for  this 
purpose.  The  hematinic  effect  of  the  iron  seems  to  be  produced  earlier 
and  better  when  this  plan  is  followed  ;  and  this  fact  seems  to  give  cor- 
roborative evidence  to  Bunge's  theory  of  the  absorption  of  the  iron  in 
chlorosis — in  a  certain  class  of  cases  at  least.  Other  iron  preparations 
of  value  in  this  disease  are  the  citrate,  protoxalate,  lactate,  carbonate, 
the  succinate,  and  the  reduced  iron.  The  albuminates  of  iron,  so  much 
vaunted  for  a  time,  are  practically  worthless.  In  severe  cases  Quincke 
uses  at  first  a  5  per  cent,  solution  of  the  ferric  citrate  bypodermically 
(ttlviiss-Siiss — 0.5-10.0,  daily).  Bitter  tonics  and  dilute  hydrochloric 
acid  are  indicated  in  a  certain  number  of  cases  in  which  indigestion 
is  troublesome.  The  acid  tincture  of  iron  chlorid  is  sometimes  used 
in  such  cases.  Mild  cases  often  yield  to  the  simple  use  of  remedies  for 
the  cure  of  gastro-intestinal  derangement.  Adjuvants  in  the  treatment 
of  chlorosis  that  may  be  of  use  are  arsenic,  manganese,  mercuric  chlorid, 
and  arsenite  of  copper  in  minute  does.  Kottman  thinks  that  rarely  vene- 
section is  required  in  obstinate  cases  to  whip  up  the  torpid  blood-pro- 
ducing apparatus. 

PROGRESSIVE   PERNICIOUS   ANEMIA. 
{Idiopathic  Anemia  ;  Biermier^s  Anemia.) 

Definition. — A  grave  blood-disease  characterized  by  a  great  de- 
struction of  red  corpuscles,  and  a  persistent  tendency  from  a  bad  to 
a  worse  condition.  It  usually  ends  in  death,  and  seldom  exhibits  causal 
lesions  other  than  those  of  the  blood  or  blood-making  organs. 

The  term  "  idiopathic  anemia  "  applied  to  this  disease  by  Addison, 
whose  first  clear  description  of  its  clinical  history  has  become  classical, 
is  applicable  to  a  proportionately  smaller  number  of  cases  to-day  than 
during  his  time.  This  is  owing  to  the  later  discovery  (^post-morteni)  of 
adequate  causes  for  the  pernicious  anemia  that  during  life  could  not 
be  found.  Thus,  while  Biermier's  anemia  is  usually  considered  a  special 
disease-entity,  for  descriptive  purposes  it  will  be  convenient  to  classify 
both  groups  under  the  title  of  progressive  periiicious  anemia  in  order  to 
describe  the  invariable  tendency  of  both.  Under  Diagnosis  {vide  infra\ 
however,  will  be  found  differential  clinical  features. 

Pathology. — The  subcutaneous  fat  is  rarely  diminished,  so  that 
emaciation  is  exceptional.  The  skin  is  pale  and  of  a  lemon-yellow 
tint,  and  most  of  the  tissues  and  organs  are  anemic,  except  the 
muscles,  which  are  often  decidedly  red  in  color.  The  fat  is  usu- 
ally pale  and  yellowish,  and  fatty  degeneration  is  one  of  the  most 
striking  changes  in  this  affection.  The  heart  is  usually  large  and  flabby, 
and  on  section  of  the  ventricular  walls  there  is  a  marked  pallor,  as  well 
as  a  friability,   and  a  fatty  change  shown  by  the  yellow  tint.     Micro- 


466     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

scopically,  the  fibers  or  columns  of  heart-muscle  are  seen  to  be  distinctly 
fatty.  The  heart-cavities  contain  little  light-colored  blood.  Other 
organs  showing  the  fatty  degeneration  (of  the  epithelium)  are  the  liver, 
kidneys,  gastric  and  intestinal  walls,  and  the  intima  of  many  of  the 
smaller  blood-vessels  (in  patches).  This  general  fiitty  change  is  prob- 
ably due  to  the  deficient  oxygenation  of  the  tissues  and  to  the  anemic 
blood-supply. 

Owing  to  the  above  degenerative  change  in  the  vessel-walls,  small 
extravasations  of  blood  are  found  in  different  parts.  Most  frequently 
these  punctiform  hemorrhages  are  seen  in  the  retina  and  on  the  principal 
serous  membranes.  Ecchymoses  are  also  observed  occasionally  on  the 
mucous  membranes  and  on  the  skin.  Moi'e  or  less  general  edema  and 
dropsical  accumulations  in  tlie  serous  cavities  are  not  uncommon.  The 
spleen  and  liver  are  seldom  and  only  slightly  enlarged.  The  lymph- 
glands  are  often  somewhat  swollen  and  intensely  red  in  color,  owing  to 
the  unusual  number  of  red  corpuscles. 

In  a  series  of  8  cases,  Warthin  ^  has  found  changes  in  the  hemolymph 
glands  consisting  of  "  dilatation  of  the  blood-sinuses  and  evidences  of 
increased  hemolysis,  as  shown  by  the  increased  number  of  phagocytes 
containing  disintegrating  red  cells  and  blood  pigment." 

A  marked  and  important  pathologic  feature  of  pernicious  anemia  is 
the  presence  of  abundant  deposits  of  iron-pigment,  especially  in  the 
liver,  but  also  in  the  spleen,  kidneys,  pancreas,  and  other  organs.  The 
fact  that  the  abnormal  quantity  of  iron  in  the  liver  is  peculiarly  distrib- 
uted about  the  periphery  and  middle  zone  of  the  lobules  is  particularly 
noteworthy,  and  quite  characteristic  of  pernicious  anemia.  The  origin 
of  this  iron  is  doubtless  the  enormous  destruction  of  red  corpuscles,  and 
that  the  pigment  in  the  hepatic  lobules  is  ferruginous  may  be  determined 
by  a  micro-chemic  test  with  ammonium  sulphid,  granules  of  black  sul- 
phid  of  iron  being  formed. 

Of  special  interest  are  the  lesions  found  in  the  bone-marrow  on 
account  of  its  hematopoietic  function.  This  is  virtually  hypertrophied, 
and  is  in  many  cases  deep-red  instead  of  yellow,  and  more  like  the 
hemoblastic  marrow  of  childhood  (H.  C.  Wood).  While  formerly  held  to 
be  causative,  this  change  is  now  regarded  as  being  secondary  to  the  severe 
anemia.  Cellular  hyperplasia  may  be  seen  microscopically  in  the 
great  number  of  large  and  small  granular  medullary  cells,  and  also  in 
the  nucleated  red  cells. 

An  atrophied  condition  of  the  gastric  and  duodenal  mucosa  is  noticed 
in  some  cases.  The  sympathetic  ganglion  cells  may  also  show  changes. 
More  constant,  however,  is  the  sclerosis  of  the  posterior  columns  and, 
to  some  extent,  of  the  lateral  columns  of  the  spinal  cord :  this  is 
especially  marked,  according  to  Burr,  in  the  cervical  swelling.  Patveu 
examined  9  cases  ;  in  4  he  found  hyaline  degeneration  of  the  vessels  of 
the  Avhite  substance,  and  in  5  small  hemorrhages.  These  changes  are 
probably  due  to  a  toxic  agent. 

Ktiology. — There  are  three  etiologic  categories  into  which  cases  of 
pernicious  anemia  may  be  grouped :  (1)  those  cases  in  which  no  discov- 
erable cause  for  the  hemolysis  (blood-destruction)  is  ascertained,  either 
during  life  or  after  death — /.  e.  the  idiopathic  variety  of  Addison  ;  (2) 
^  Amt'):  Jour.  Med.  Sciences,  October,  1902. 


PROOBESNIVE  PEENWWUS  ANEMIA.  467 

those  in  which  an  adequate  cause  is  found  post-mortem  only  ;  (3)  those 
that  are  apparently  traceable,  ante  mortem,  to  some  primary  causal  con- 
dition acting  directly  or  indirectly. 

(1)  As  regards  the  obscure  (genuine)  cases  of  idiopathic  anemia,  the 
essential  cause  of  the  symptomatic  condition  is  evidently  an  actively 
increased  hemolysis.  The  blood-generation  (hemogenesis)  may  be  nor- 
mal in  power,  or  there  may  be  a  congenital  or  acquired  underlying 
deficiency  in  hemogenic  power.  Grawitz  and  Stengel  believe  that  the 
hemolysis  originates  in  the  gastro-intestinal  capillaries  and  depends 
upon  poisons  generated  or  absorbed  from  that  tract — an  auto-intoxica- 
tion. Von  Jaksch  holds  that  the  similarity  of  pernicious  anemia 
to  Kala-azar  suggests  a  protozoon  infection.  William  Hunter^  concludes 
that  the  disease  is  of  infectious  (streptococcal)  nature,  dependent  primarily 
upon  caries  of  the  teeth.  Goullard  and  Goodall  ^  hold  that  a  hemolytic 
toxin  (not  necessarily  from  the  intestines)  acts  on  the  bone-marrow. 

(2)  Apparently  causeless  cases  of  a  pernicious  type  of  anemia  may  be 
found  post-mortem  to  have  been  caused  by  [a)  obscure  malignant  dis- 
ease ;  (h)  parasites,  especially  the  Anchylo stoma  duodenalis,  and  rarely 
by  the  Bothriocephalus.  Not  infrequently,  by  a  careful  study  of  the 
anamnesis  of  a  patient,  aided  by  modern  methods  of  examination,  the 
cause  of  pernicious  anemia  may  be  detected  during  life.  It  is  held 
that  atrophy  of  ventricular  and  intestinal  glands  is  an  effect  rather 
than  the  cause,  as  formerly  believed  of  the  anemia  (Grawitz). 

(3)  Exhausting  causes,  operating  directly  or  indirectly,  may  precede 
this  affection,  as  severe  or  prolonged  hemorrhages  or  diarrhea,  fevers, 
mental  shock,  profound  chlorosis,  pregnancy,  and  parturition. 

Predisposing  Causes. — Unfavorable  hygienic  surroundings  and  insuf- 
ficient nourishment,  habitually  kept  up,  may  favor  the  development  of  the 
disease.  Males  are  more  frequently  affected  than  females  after  the  thirty- 
fifth  year  and  it  occurs  mostly  during  middle  life.  Griffith  has  collected 
several  cases  occurring  under  twelve  years  of  age.  The  disease  is  widely 
distributed,  and  it  may  behave  endemically  at  times,  as  in  Switzerland 
and  Leipsic.  Changes  left  in  the  tissues  after  syphilis  may  be  the  patho- 
logic basis,  and  osteosarcoma  may  act  similarly. 

SjmiptoillS. — Idiopathic  pernicious  anemia  develops  so  slowly  and 
insidiously  that  it  is  hardly  ever  possible  to  fix  upon  any  precise  date  as 
the  commencement  of  the  disease.  The  transition  from  health  to  pro- 
gressive pernicious  anemia,  particularly  in  persons  previously  feeble  and 
pale,  is  usually  too  gradual  to  be  demonstrable  ;  though  a  rapid  and 
acute  onset  is  rare,  it  may  occur  in  pregnant  or  puerperal  women. 

Pallor  is  soon  noticed  and  gradually  increases,  or  when  there  has 
been  a  previous  pallor,  this  becomes  more  marked.  Shortness  of  breath 
Zkixdi  palpitation  of  the  heart,  especially  on  exertion,  are  complained  of; 
the  patient  is  also  easily  fatigued,  and  becomes  quite  languid.  Soreness 
of  the  tongue  is  among  the  initial  symptoms  in  many  cases  (Schauman). 
Occasional  nausea  may  come  on  early  in  those  cases  in  which  a  previous 
gastro-intestinal  disturbance  has  been  noted,  and  headache,  vertigo,  tin- 

1  Lancet,  January  27,  1900. 

^Jour.  Path,  and  Bad.,  January,  1905. 


468    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

nitus  aurium,  and  anorexia  ensue  and  grow  progressively  "worse.  Gen- 
eral weakness  increases,  and  occasional  attacks  of  faintness  and  vomit- 
ing supervene.  Meanwhile,  the  skin  takes  on  a  bloodless,  waxy  appear- 
ance, and  soon  the  characteristic  lemon-bellow  tint  appears.  The  mucous 
membranes  are  pale  and  colorless.  Prostration  in  bed  gradn^Wj  becomes 
almost  absolute  as  the  feebleness  and  Habbiness  of  the  tissue  increase. 
3Ialleolar  edema  is  sometimes  noticeable,  and  ecchymoses — mucous  and 
cutaneous — are  seen  in  profound  cases  of  anemia.  Although  the  intellect 
is  not  impaired,  except  that  mental  exertion  becomes  irksome,  the  tone 
and  manner  of  speech  are  feeble.  As  the  debility  becomes  severe  the 
mind  wanders,  and,  to  use  Addison's  words,  the  patient  "  falls  into  a 
prostrate  and  half-torpid  state,  and  at  length  expires." 

Emaciation  is  rare,  the  fat  being  preserved  and  sometimes  increased 
in  quantity.  Pulsation  in  the  large  arteries  is  abnormally  visible,  and 
a  diffuse,  exaggerated  cardiac  impulse  is  felt.  The  pulse  early  in  the 
case  may  be  strong,  and  generally  it  is  rapid  (100-120),  soft,  and  com- 
pressible, and  as  full  and  quick,  often,  as  the  water-hammer  pulse  of 
aortic  regurgitation.  Auscultation  reveals  the  characteristic  hemic  mur- 
murs, best  heard  at  the  base,  and  the  bruit  de  diable  in  the  veins  of  the 
neck.     There  may  be  visible  pulsations  in  the  latter. 

G astro-intestinal  symjitoms  may  be  the  most  prominent  signs  where 
gastritis  polyposa  and  gastritis  atrophica  are  present.  Diarrhea,  dyspep- 
sia, nausea,  and  vomiting  are  then  seen  throughout  the  course;  otherwise, 
constipation,  eructations,  and  simple  anorexia  are  most  common.  Frieden- 
wald  has  analyzed  58  cases  with  reference  to  the  gastro- intestinal  symp- 
toms ;  he  found  anorexia  in  38  cases,  nausea  in  27,  vomiting  in  19,  in- 
digestion in  33,  pyorrhea  in  20,  and  constipation  in  27.  Enteroptosis 
was  present  in  21  cases. 

An  ophthalmoscopic  examination  shows  the  cause  of  the  anemic 
amaurosis,  in  the  profound  cases  of  anemia,  to  be  one  or  more  retinal 
hemorrhages.  The  whites  of  the  eyes  become  pearly,  the  conjunctiviB 
pale.  The  liver  and  spleen  are  rarely  palpable.  The  bones,  and  espe- 
cially the  sternum,  are  sometimes  sensitive  to  pressure. 

Respiratory  Symptoms. — The  breathing  is  accelerated,  and  the 
anemic  dyspnea  may  become  pronounced  and  stertorous,  accompanied 
by  a  sense  of  thoracic  oppression  and  a  "hunger  for  air."  Near  the 
end  pleural  serous  effusions  and  pulmonary  edema  may  appear. 

The  urine  is  of  low  specific  gravity,  and,  on  account  of  its  pigmenta- 
tion with  pathologic  urobilin,  dark  in  color.  The  urobilin  is  detected 
both  by  chemic  and  spectroscopic  examination.  In  the  former  the  addi- 
tion of  a  few  drops  of  an  alcoholic  solution  of  zinc  chloride  to  the  urine 
gives  a  green  fluorescence.  The  presence  of  indican  points  to  intestinal 
putrefaction.  Albumin  and  glucose  are  absent,  but  uric  acid  and  urea 
are  both  increased  in  amount,  the  former  occasionally  and  the  latter 
usually.  Fever  of  a  moderate  degree  is  commonly,  though  not  invaria- 
bly, present,  the  evening  temperature  sometimes  reacliing  102°  F. 
(38.8°  C).     Previous  to  death  the  temperature  may  be  subnormal. 

Nervous  Symptoms. — Paresthesia,  spastic  paralysis  of  the  limbs,  and 
a  loss  of  control  of  the  sphincters  indicate  the  paralytic  tendency  of  those 
cases  in  which  sclerosis  of  the  cord  occurs.  Tabetic  symptoms  are  some- 
times marked. 


PROGRESSIVE  PERNICIOUS  ANEMIA. 


4  GO 


Blood-examination. — The  blood  is  usually  pale,  tliouj^li  sornetirnes  dark 
and  watery,  and  the  oligocythemia  is  distinctive  of  pernicious  anemia. 
The  number  of  red  corpuscles  may  be  reduced  to  less  than  200,000  per 
c.mm.,  and  is  seldom  more  than  1,000,000.  The  percentage  of  hemo- 
globin may  be  approximately  proportionate  to  the  number  of  red  corpus- 
cles in  the  earlier  stages,  hut  as  the  disease  progresses  the  index  rises,  so 
that  the  individual  corpuscles  are  rich  in  hemoglobin.  In  otiier  words, 
although  there  is  a  reduction  in  the  total  amount  of  hemoglobin,  it  is 
usually  not  so  great  as  the  reduction  in  the  number  of  erythrocytes ; 
therefore,  the  color  index  is  nearly  always  relatively  higher  than  that  of 
the  red  globules  (see  Fig.  36),  a  condition  in  marked  contrast  with 
chlorosis.  Macrocytes  (which  cause  the  relatively  higher  percentage  of 
hemoglobin),  microcytes,  poikilocytes,  and  polychromatophilia  are  con 
stantly  present,  and  the  former  abundant.  The  presence  of  nucleated 
red  corpuscles  is  also  a  striking  characteristic  of  pernicious  anemia.  When 
normal  in  size  they  are  known  as  normoblasts ;  Avhen  very  large,  as 
megalohlasts.  In  the  former,  according  to  Bhrlich,  the  eccentrically 
placed  nuclei  stain  deeply ;  in  the  latter  the  large  nuclei  stain  faintly. 
The  former  are  typical  of  those  nucleated  red  globules  found  in  the 
hematopoietic  organ  of  adults ;  the  latter  of  those  found  in  the  blood- 
development  of  embryonic  life.  Megalohlasts  may  be  found  in  non- 
idiopathic  anemias.     There  are  other  forms  of  degeneration  of  the  red 


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Fir    36.— Blood-chart  of  a  case  of  progressive  pernicious  anemia.    Black,  red  corpuscles  ;  red, 
■  hemoglobin. 

cells,  and  Grawitz  regards  the  microcytes  of  importance  as  showing 
erythrocytic  degeneration.  There  is  usually  a  relative  increase  in  the 
small  lymphocytes  at  the  expense  of  the  polynuclear  cells ;  and,  accord- 
ing to  Cabot,  there  was  always  a  marked  leukopena  in  a  series  of  110 
cases.^  Myelocytes  are  almost  constantly  present,  though  usually  in  low 
percentage.  The  average  is  about  2  per  cent.  The  blood-plates  are 
generally  fewer  than  normal.  The  blood-plasma  is  markedly  decreased 
(Adami).  Cabot  ^  found  that  a  blood  examination  made  for  the  first 
time  during  the  period  of  remission  may  resemble  that  in  chlorosis,  and 
in  9  of  14  cases  ring-like  bodies  were  seen  in  the  red  cells.  There  is  a 
decrease  in  rouleaux-forming  power,  due  to  some  change  in  the  corpuscles. 
1  Cabot,  Medical  News,  May  5,  1900.  2  Atner.  Jour.  Med.  Sciences,  Aug.,  1900. 


470    DISEASES  OF  THE  BLOOD   AXD   THE  DUCTLESS  GLANDS. 

Diagnosis  and  Differential  Diagnosis.— The  clinical  cbarac- 
teristics  of  the  atlection,  ]iarticularly  their  steady  iirogression  with  remis- 
sions, are  quite  as  important  as  microscopic  study  of  the  bU)od.  An 
important  blood  feature  of  the  disease  is  a  high  color  index.  The  possi- 
bility of  hidden  carcinoma,  gastric  atrophy,  the  anchylostoma  or  other 
parasite,  and  incipient  tuberculosis  should  be  borne  in  mind  also.  Intes- 
tinal parasites  are  recognized  from  the  microscopic  examination  of  the 
feces  after  a  brisk  purge  when  their  eggs  or  the  parasites  themselves  may 
be  found.  Atrophic  (/at<tritis  may  be  discriminated  by  examining  the 
viscus  and  gastric  juice  by  modern  methods.  The  following  table  will 
permit  the  elimination  of  obscure  gastric  carcinoma  as  a  rule  : 

Pkogressive  Pernicious  Anemia.  Obscure  Gastric  Carcinoma. 

The  blood  shows  characteristic  changes,  Blood  shows  characteristics  of  secondary 
and  tlie  red  corpuscle  count  falls  to  or  anemia,  and   the  count  does  not  fall  to 

below  1,000,000  per  c.min.  1,000,000,  as  a  rule. 

Color  index  relatively  high.  Color  index  low. 

Leukopenia  and  relative  lymphocytosis  There  may  be  leukocytosis  or  a  relative  in- 
common,  crease  in  the  polynuclear  cells. 

Found  earlier  in  life.  Occurs  after  middle  life. 

Gastric  symptoms  not  so  prominent.  Gastric  symptoms  more  suggestive. 

Lemon-tinted  skin  common.  Skin   of    a   pale,   muddy   color,    or    only 

slightly  jaundiced  (saffron-yellow). 

Adipose  tissue  fairly  well  preserved.  Progressive  emaciation. 

Ko  glandular  enlargements  palpable.  Supraclavicular  or  inguinal  glands  may  be 

palpable. 

No  physical  signs  over  stomach.  There  may  be  an  area  of  increased  resist- 

ance over  the  stomach. 

Free  hydrochloric  and  lactic  acids  usually  Examination  of  gastric  contents  shows 
absent.  deficiency   or    absence    of    free    hydro- 

chloric acid  and  presence  of  lactic  acid. 

Some  improvement  may  be  brought  about  Condition  becomes  steadily  worse  until 
— even  cure,  thougli  very  rarely.  death  ends  the  case. 

May  show  retinal  hemorrhages.  Absent. 

From  chlorosis  the  affection  may  be  differentiated  easily  by  the  blood- 
examination.  The  relative  increase  in  hemoglobin,  the  presence  of  gi- 
gantoblasts  and  many  macrocytes,  and  the  severe  oligocythemia  are 
pathognomonic  of  pernicious  anemia,  and  are  in  marked  contrast  to  the 
oligochromemia,  and  slight,  if  any,  reduction  in  the  number  of  red 
globules  of  chlorosis.  Again,  the  progressive  pernicious  character  of 
the  former  and  the  tendency  to  hemorrhage  should  be  remembered,  as 
well  as  the  contrasting  factors  of  age  and  sex  in  the  two  affections. 
Talley^  states  that  anemia  secondary  to  portal  cirrhosis  Avithout  hem- 
orrhage occasionally  resembles  progressive  pernicious  anemia.  Tabes 
dorsalis  m;iy  be  simulated,  but  the  blood  examination  will  show  character- 
istic indications  of  pernicious  anemia. 

Prognosis. — The  disease,  as  a  rule,  terminates  fatally.  The  course 
of  pernicious  anemia  is  usually  slow  and  gradual,  and  may  be  interrupted 
by  improvement  or  apparent  recovery.  Recurrences,  however,  invari- 
ably occur.  Idiopathic  anemia  is  therefore  almost  hopeless,  although  a 
few^  apparently  substantial  recoveries  have  been  reported.  The  duration 
of  the  disease  is  seldom  more  than  a  year,  and  may  not  be  more  than  two 
or  three  months.  The  nucleated  red  corpuscles  usually  become  much 
^Jour.  of  the  Amer.  Med.  Assoc,  October  3,  1908. 


PROGRESSIVE  PERNTCfOUS  ANEMIA. 


All 


more  numerous  shortly  before  death  (Tjillings).  Death  may  be  caused 
either  by  syncope,  cerebral  hemorrhage,  or  by  slow  asthenia. 

Treatment. — Hygienic  measures  must  be  regarded  as  of  signal  im- 
portance, and  rest  in  bed,  togetlier  with  light  nutritious  food  given  at 
short  regular  intervals,  is  indicated  first  of  all.  Klemperer  advises  a 
fatty  diet — one  liter  of  cream  and  200  grams  of  butter  per  diem.  Salt- 
water baths  and  gentle  and  systematic  massage  are  useful  adjuvants. 
Fresh,  open  air  is  advisable  when  it  can  be  taken. 

The  value  of  arsenic  in  this  disease  is,  I  think,  analogous  to  that  of 
iron  in  chlorosis.  The  best  action  of  the  drug  will  be  obtained  ])y  the 
administration  of  gradually  ascending  doses  of  Fowler's  solution.  Begin- 
ning with  four  or  five  drops  of  the  former,  three  times  daily  during  the 
first  week,  and  thereafter  adding  one  drop  to  the  dose  every  day  or  two 
up  to  the  point  of  tolerance,  as  much  as  twenty  or  thirty  drops,  well  diluted, 


100* 
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NOVEMBER 

DECEMBER 

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Fig.  37.— Chart  of  a  case  of  progressive  pernicious  anemia,  showing  the  improvement  following 
the  administration  of  arsenic.    Black,  red  corpuscles  ;  red,  hemoglobin. 

may  be  taken  (see  Fig.  37).  Evidences  of  gastro-intestinal  irritation  should 
be  watched  for,  and  the  arsenic  discontinued  temporarily  should  they  appear. 
Sometimes  it  is  advisable  to  use  the  remedy  hypodermically.  Arsenous 
acid  is  given  in  pill  form,  commencing  with  ^or^Vgr-  (0.0021-0.0032). 
Bramwell  is  of  the  opinion  that  salvarsan  is  a  more  efi"ective  remedy  than 
arsenic  given  by  the  mouth.  Dawes  ^  has  treated  14  cases  of  undoubted 
pernicious  anemia  with  sodium  cacodylate,  administered  hypodermically, 
with  a  remarkable  degree  of  success.  Atoxyl  may  be  used  in  the  same 
manner. 

The  introduction  by  Fraser  of  Edinburgh  of  bone-marrow  in  the 
treatment  of  pernicious  anemia  has  been  followed  by  various  results : 
some  cases  have  been  reported  in  Great  Britain  and  in  the  United  States 
in  which  it  has  seemed  to  do  good,  while  in  others  it  was  found  to  be 
useless.  While  the  glycerin  extract  is  the  preparation  generally  used, 
it  is  not  so  reliable  as  the  raw  red  bone-marrow,  or  that  freshly  prepared 
each  day  by  mixing  with  it  an  equal  quantity  of  glycerin  ;  an  ounce  or 
two  may  be  administered  daily.  A^etlesen  has  used  glycerin — half  an 
ounce  with  the  juice  of  half  a  lemon,  thrice  daily — wit-h  success.  Brieger 
advises  pancreatin  with  a  view  to  reducing  the  antitrypsin  content  of  the 
blood-serum.  Hunter  suggests  the  use  of  antistreptococcus  serum  coupled 
^  Monthly  Cyclopedia  and  Medical  Bulletin,  June,  1911,  p.  321. 


472    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

with  the  antiseptic  care  of  the  mouth  and  gastro-intestinal  antisepsis. 
Iron  is  unnecessary,  as  tliere  are  enormous  quantities  of  it  in  the  liver 
(GuUand). 

Near  the  end  of  the  disease  the  danger  often  greatly  increases,  owing 
to  the  marked  reduction  in  the  quantity  of  the  blood  {oligemia).  This 
may  be  combated  by  the  injection  of  warm  water  or  a  weak  saline  solu- 
tion into  the  colon,  and  also  into  the  subcutaneous  tissue.  Both  the 
former  procedure  and  gastric  lavage  are  of  value  in  ameliorating  the 
gastro-intestinal  disturbance  from  fermentation.  Intestinal  antiseptics 
(salol  and  beta-naphtol)  should  be  given  by  the  mouth.  Grawitz  ^  out- 
lines a  causal  treatment ;  he  eliminates  animal  albumin  from  the  diet,  ad- 
ministering fruit  juices  to  supjdy  the  lack  of  hydrochloric  acid.  A  daily 
lavage  with  a  1  or  2  per  cent,  solution  of  sodium  chlorid  and  a  daily  colon 
irrigation  are  to  be  given.  Bovaird-  reports  favorable  results  from  transfu- 
sion of  blood  in  cases  in  which  the  hemoglobin  falls  below  20  percent.;  it 
offers  the  possibility,  not  only  of  averting  death,  but  for  a  time,  at  least,  of 
initiating  one  of  the  periods  of  (juiescence  so  characteristic  of  the  disease. 

Anthelmintics  must  be  used  in  those  cases  of  pernicious  anemia  in 
which  intestinal  parasites  are  associated.  Morgenroth  and  Reicher^  have 
shown  that  experimental  anemias  in  animals  are  benefited  by  administra- 
tion of  cholesterin,  Avhich  they  have  employed  in  the  treatment  of  pernicious 
anemia  to  prevent  hemolysis.  A  3  per  cent,  solution  of  cholesterin  in  oil 
is  prepared  and  100  grams  of  this  administered  daily.  Dilute  hydrochloric 
acid  and  bitter  tonics  are  serviceable  in  cases  in  which  digestion  is  impaired. 

Recurrences  will  yield  to  the  same  treatment,  if  they  yield  at  all. 

Aplastic  Anemia. — Senator*  has  called  attention  to  a  form  of  pernicious 
anemia  to  which  he  gave  the  terra  aplastic.  A  variety  of  pathologic  changes 
have  been  found.  Blumer  classifies  these  into  three  groups  :  (1)  Cases  in 
which  the  lesions  are  those  of  progressive  pernicious  anemia;  (2)  those  cases 
in  which  the  bone-marrow  shows  primary  aplasia ;  and  (3)  cases  in  which 
there  is  a  hyperplasia  of  the  mononuclear  elements  of  the  bone-marrow. 

The  symptoms  a,nd physical  signs  are  those  of  pernicious  anemia,  but  the 
cases  run  a  more  rapid  course — six  to  nine  months.  The  blood  findings 
are  unlike  those  of  pernicious  anemia,  nucleated  red  blood-cells  being 
absent  and  the  number  of  leukocytes  greatly  diminished.  A  differential 
count  of  the  leukocytes  shows  the  small  mononuclear  forms  to  be  rela- 
tively increased  70  to  90  per  cent.,  while  the  eosinophiles  are  few. 

II.  THE   SECONDARY   ANEMIAS. 

The  secondary  anemias  are  symptomatic  of  abnormal  processes  or  of 
existing  disease,  whether  acute  or  chronic,  and  their  causes  are  numerous 
and  various.  Several  possible  causes  may  exist  in  a  given  case  of  symp- 
tomatic anemia,  and  it  may  be  quite  difficult  to  discover  which  of  these 
is  the  active  factor  in  the  condition.  In  certain  secondary  anemias,  also, 
the  associated  impairment  of  the  blood-making  organs  is  so  evident  that 
the  anemia  may  assume  almost  a  primary  importance. 

The  Blood. — There  is  oligocythemia,  usually  of  a  moderate  degree, 
about  3,000,000  red  corpuscles  per  cubic  millimeter  being  noted,  although 

'  New  York  Medical  Journal,  October  15,  1910,  p.  777. 

*  Medical  Record,  February  11,  1911. 

3  Berlin.  Klin.  Woch.,  Oct."  12,  1908.         *Zeit.J'.  klin.  Med.,  vol.  liv.,  Nos.  1  and  2. 


THE  SECONDARY  ANEMfAS. 


47a 


in  cases  following  hemorrhage  the  reduction  may  be  as  great  for  a  time 
as  in  pernicious  anemia.  There  is  also  a  relative  decrease  in  the  amount 
of  hemoglohin,  and  sometimes  tlie  percentage  may  be  relatively  lower 
even  than  is  compatible  with  the  decrease  of  the  red  corpuscles.  Early 
evidences  of  secondary  anemia  are  alterations  in  the  viscosity  (stickiness) 
of  the  red  cells  and  failure  to  form  rouleaux  and  an  unequal  distribution 
of  the  hemoglobin,  certain  cells  being  overcharged  while  others  are  in- 
adequately supplied.  Next  in  the  process  of  degeneration  of  the  red 
cell  is  irregularity  in  size  and  shape  (microcytes,  macrocytes,  poikilocytes), 
and  third  is  abnormal  staining  reactions  (polychromatophilia,  punctate 
basophilia).  Lastly  there  appears  abnormally  lai'ge  nucleated  red  cells 
(megaloblasts).  Normoblasts  are  also  present  in  severe  cases.  There 
is  a  relative,  and  often  an  absolute,  increase  in  the  number  of  leukocytes. 


70jf 

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Fig.  3a-Blood-chart  of  a  case  of  symptomatic  anemia.    Black,  red  corpuscles ;  red,  hemoglobiu ; 

blue,  white  corpuscles. 

The  most  important  etiologic  groups  of  secondary  anemias  are  as 
follows :  (1)  Hemorrhage. — Hemorrhages  occur  under  a  great  variety  of 
circumstances,  and  if  copious,  result  in  an  acute  secondary  anemia. 
Thus  there  may  be  the  rupture  of  an  aneurysm,  menorrhagia,  post^ 
partum  hemorrhage,  hemoptysis,  gastrorrhagia,  enterorrhagia,  etc.,  all 
of  which  produce  the  same  general  effect  upon  the  system.  Repeated 
small  hemorrhages  may  finally  produce  the  same  result  as  a  single  large 
one,  and  spontaneous  hemorrhages  or  epistaxis,  such  as  occur  in  persons 
of  a  hemorrhagic  diathesis  (hemophilia)  or  in  purpura  and  scurvy,  may 


474    DISEASES  OF  THE  BLOOD  AXD  THE  DUCTLESS  GLANDS. 

cause  profound  secondary  anemia.  Females  are  most  tolerant  of  losses 
of  blood,  but  infants  of  both  sexes  bear  depletion  very  badly.  The  total 
mass  of  blood  may  be  much  diminished  (oligemia),  and  tlie  sudden  loss 
of  a  great  volume  of  blood  may  prove  fatal  in  a  few  moments ;  but 
it  is  often  surprising  how  recovery  can  take  place,  and  often  does,  after 
the  rapid  loss  of  several  pounds  of  blood — e.  g.  in  hemoptysis,  hematem- 
esis,  or  menorrhagia.  Sometimes  the  source  of  bleeding  is  obscure, 
as  in  cases  of  intestinal  parasites,  hepatic  cirrhosis,  or  duodenal  ulcer ; 
or  it  may  be  intentionally  kept  suh  rosa  by  females  having  uterine  dis- 
order or  bleeding  hemorrhoids.  The  ((uick  blanching  of  the  counte- 
nance, the  weakness,  the  coldness  of  the  skin,  faintness,  dimness  of  vision, 
tinnitus  aurium,  sighing  respiration,  and  feeble,  rapid  pulse  are  charac- 
teristic symptoms  of  acute  anemia.  Unconsciousness  and  epileptiform 
cotivulsions  precede  death  in  cases  in  which  the  total  volume  of  blood 
lost  is  sufficiently  large.  When  recovery  takes  place  the  blood-regen- 
eration goes  on  rapidly,  so  that  within  from  one  to  three  weeks  restitu- 
tion is  complete.  The  normal  volume  is  soon  restored — first  by  the 
absorption  of  water,  hydremia  existing  for  several  days  before  the  saline 
and  albuminous  elements  are  renewed.  The  white  corpuscles  are  earlier 
restored  than  the  red,  so  that  there  is  a  temporary  relative  leukocytosis. 
The  hemoglobin  is  restored  still  more  slowly  than  the  red  corpuscles. 

(2)  Inanition. — Anemia  from  inanition  may  be  caused  by  a  food- 
supply  that  is  insufficient  either  in  quantity  or  quality,  or  both  ;  or, 
even  with  abundant  food  of  sufficient  nutritive  qualities  the  digestive 
power  may  be  so  impaired  as  to  cause  defective  assimilation.  Esophageal 
carcinoma  and  chronic  gastritis,  especially  of  the  atrophic  variety,  may 
thus  cause  anemia  from  inanition.  The  reduction  of  the  blood-plasma 
forms  a  feature,  while  the  corpuscles  may  be  aflPected  but  slightly. 

(3)  Excessive  albuminous  discharges,  as  in  chronic  Bright's  disease, 
prolonged  suppuration,  long-continued  lactation,  chronic  dysentery,  etc., 
drain  the  system  so  that  marked  anemia  may  be  produced. 

(4)  Toxic  Agents. — The  poisons  may  either  be  organic  or  inorganic, 
though  toxic  anemias  are  most  common  from  the  absorption  of  lead, 
arsenic,  mercury,  and  phosphorus.  The  poisoning  is  usually  chronic, 
and  affects  principally  the  corpuscles.  Anemia  due  to  the  poisons  of 
acute  or  chronic  infectious  diseases  is  also  frequently  met  with,  and  may 
thus  be  observed  during  and  after  typhoid  fever,  diphtheria,  yellow  fever, 
and  inflammatory  (articular)  rheumatism  among  the  acute  diseases,  and 
during  chronic  malaria,  tuberculosis,  and  syphilis  ("syphilitic  chlo- 
rosis ").  There  is  considerable  destruction  of  the  red  corpuscles  in  some 
of  these  diseases,  either  directly  or  indirectly,  and  the  greater  the  pyrexia 
the  greater  the  action  upon  the  blood  or  blood-making  organs. 

Symptoms. — The  common  indications  of  secondary  anemia  are  the 
pallor  of  the  face  and  mucosae,  muscular  and  mental  weakness,  loss  of 
nerve-function,  neuralgias,  coolness  of  the  skin,  dyspnea  on  exertion, 
cardiac  palpitation,  impaired  appetite  and  digestion,  and  a  weak  pulse. 
The  physical  signs  are  those  of  the  primary  or  essential  anemias. 

Diagnosis. — Here  may  be  advantageously  contrasted  the  distin- 
guishing features  of  symptomatic  and  essential  anemias,  respectively  : 


LEUKEMIA.  475 

Symptomatic  or  Secondary  Anemia.  Idiopathic  or  Essential  Anemia. 

A  symptomatic  blood-condition  secondary  A    primary    disease   of    tiie    blood    and 

to  a  detectable  disease  elsewhere.  blooil-making  organs. 

Occurs  at  any  age.  Occurs    principally   during    adoloscence 

and  early  middle  life. 

Previous   or   associated   history  of  trau-  Previous  history  negative  in  it^  l^earings 

matic     or     spontaneous    hemorrhage,  upon  the  disease, 
chronic  suppuration,  prolonged  lacta- 
tion,  chronic  Bright' s   disease,    carci- 
noma, chronic  lead-poisoning,  chronic 

malaria,  heart,  liver,  or  gastric  trouble.  Distinctive      blood-characteristics,      and 

Blood-changes  not  so  marked  and  more  often    profound    changes,    both    as   to 

variable  ;  steadily  progressive  in  ma-  blood-cells  and  hemoglobin, 

lignant  disease.        _  Marked  reduction  in  both  the  hemoglo- 

Moderate    reduction  in  both,  merely  the  bin  percentage  and  in  the  number  of 

relative  proportion  being  maintained.  red   corpuscles,  but  tlie  proportionate 

ratio  is  lost. 

General  symptoms  and  signs  usually  sub-  General   symptoms  and   signs  also  more 

ordinate  in   manifestation  to  those  of  characteristic   of  the    respective    form 

the  primary  disease  or  lesion.  of  anemia  in  the  case. 

Gravity  of  anemia  depends  on  that  of  the  Gravity     depends     on     type   of    blood- 
primary  disease.  changes    and   progressiveness   of  dis- 
ease. 

Often  responds  to  treatment,  depending  One  variety  (chlorotic)  quite  curable,  the 

on  the  cause  ;  in  a  few  instances,  as  other  (progressive  pernicious)  relaps- 

in  hemorrhage,  it  is  short  in  duration.  ing,  and  finally  fatal. 

The  prognosis  depends  upon  the  cause  of  the  anemia. 

Treatment. — Symptomatic  anemia  is  amenable  to  treatment  accord- 
ing to  the  cause.  The  traumatic  acute  variety  does  well  under  simple 
hygienic  measures  after  the  urgent  indications  have  been  met.  Plenty 
of  pure  air,  wholesome  food,  and  graduated  rest  and  exercise  may  suf- 
fice, and  drugs  not  be  needed.  Cases  in  which  it  is  difficult  or  Avellnigh 
impossible  to  remove  the  cause  of  the  anemia  of  course  do  not  improve 
under  any  treatment,  as  a  rule,  for  obvious  reasons.  Nutritious  aliment, 
iron  in  some  form,  a  judicious  hygienic  regimen  calculated  to  increase 
the  assimilation,  and  stomachic  and  general  tonics  are  required  in  the 
majority  of  cases.  In  severe  forms,  hypodermic  injections  of  iron  and 
arsenic,  in  combination,  act  favorably.  Toxic  substances  must  be  elim- 
inated, their  re-introduction  into  the  body  prevented,  and  the  repair  of 
the  blood  and  tissue  actively  promoted. 

LEUKEMIA. 
(Leukocythemia. ) 

Definition. — A  blood-disease,  usually  chronic,  characterized  by  a 
peculiarly  marked  and  persistent  increase  in  the  number  of  leukocytes, 
associated  with  lesions  occurring  either  respectively  or  unitedly  in  the 
bone-marrow  and  lymphatic  glands. 

Pathology. — Bodily  emaciation  and  pallor  are  pronounced,  and 
edema,  with  dropsical  effusions  in  the  serous  cavities,  is  by  no  means 
uncommon.  The  cardiac  chambers  and  principal  veins  are  distended 
with  large  blood-clots  of  a  greenish-yellow  or,  in  extreme  cases,  yellow- 
ish-white, purulent  appearance.  Subserous  ecchymoses  of  the  pericar- 
dium and  endocardium  are  frequent,  and  the  myocardium  is  often  found 
to  have  undergone  a  moderate  degree  of  fatty  degeneration.     Various 


476     DISEASES   OF  THE  BLOOD   AND   THE  DUCTLESS  GLANDS. 

abnormal  substances  have  been  found  in  leukemic  blood — leucin,  tyrosin, 
acetic,  formic,  and  lactic  acids,  and  certain  albuminous  substances  (deu- 
tero-albumose  and  nucleo-albumin) — resulting;  probably  from  tlie  destruc- 
tion of  blood-corpuscles.  The  alkalinity  of  the  blood  is  diminished. 
The  minute,  octahedral  (Charcot's)  crystals  are  found  most  abundantly 
in  settled  leukemic  blood,  and  have  also  been  detected  in  the  spleen, 
bone-marrow,  and  liver,  as  well  as  in  other  affections. 

Although  the  bone-marrow  or  the  lymph-glands  may  alone  show  the 
pronounced  pathologic  changes  of  leukemia,  it  is  usual  to  find  both  more 
or  less  affected.  It  is  customary  to  speak  of  two  principal  groups  :  (1) 
myeloid  leukemia,  the  more  frequent  variety  ;  and  (2)  hjmplioid  leukemia. 
There  is  nearly  always  some  splenic  enlargement,  and  in  many  cases 
the  enlargement  is  considerable.  Leukemic  spleens  sometimes  weigh  as 
much  as  from  two  to  eighteen  pounds,  and  their  lengths  may  vary  from 
six  to  twelve  inches.  The  enlargement  is  generally  uniform,  and  the 
notches  upon  the  anterior  border  may  be  much  exaggerated.  White 
patches  of  perisplenitis  and  a  thickened  capsule  adhering  to  the  surround- 
ing organs  and  the  abdominal  wall  may  also  be  noticed.  The  consistence 
of  the  spleen  is  firm  and  resistant  to  the  knife,  though  in  the  earlier 
stages  it  may  be  quite  soft  and  pulpy.  The  cut  surface  is  either  of  a 
uniformly  brown  color  or  mottled  by  the  presence  of  grayish-  or  yellow- 
white  circumscribed  lymphoid  tumors,  or  by  deep-red  or  brownish-yellow 
hemorrhagic  infarcts.  The  Malpighian  bodies  may  or  may  not  be  visible. 
The  blood-vessels  at  the  hilum  are  enlarged.  Microscopic  examination 
shows  hyperplasia  of  the  organ.  The  cells  of  the  pulp  sometimes  show 
granular  and  fatty  degeneration,  and  in  advanced  cases  the  trabeculse 
may  be  thickened  by  connective  tissue.  Ewing  believes  that  the  splenic 
enlargement  is  due  to  the  mechanical  sifting  of  the  red  and  white  cells 
from  the  circulation  with  subsequent  inflammatory  changes. 

In  the  majority  of  cases  the  bone-marrow  is  the  primary  seat  of  the 
disease  in  the  myeloid  variety.  The  medullary  substance,  instead  of 
being  fatty,  is  rich  in  lymphoid  and  blood-cells  in  various  stages  of  devel- 
opment, and  is  either  reddish-brown  or  greenish-yellow  in  color.  Neu- 
man  regarded  the  marrow  change  as  an  essential  lesion  of  leukemia,  and 
called  the  former  transfoi-mation  ''  lymph-adenoid  "  and  the  latter  "  pyoid." 
The  pus-like  marrow  and  the  dark  red  may  exist  side  by  side,  although 
the  former  is  more  common. 

A  fine  reticulum  may  be  seen  between  the  cells,  especially  in  the  dark- 
red  variety,  and  small  hemorrhagic  infarcts  may  also  be  noted  occasionally. 
Microscopically,  the  medulla  contains  an  abundance  of  lymphoid  cells  and 
nucleated  red  corpuscles.  Eosinophilic,  mononuclear,  and  polynuclear  leu- 
kocytes are  also  present,  the  first-named  being  quite  numerous,  as  are  also 
certain  rayelo-plaques  and  cells  showing  karyo-kinetic  figures.  The  lymph- 
atic glands  are  more  or  less  enlarged  in  the  myeloid  form  of  leukemia. 

In  the  lymphoid  variety,  especially  when  acute,  an  early  and  marked 
hyperplasia  of  all  the  glands  takes  place,  and  may  form  distinct,  soft,  and 
movable  tumors,  their  color  being  a  reddish-gray. 

The  histologic  examination  shows  an  increase  in  the  cellular  elements. 
A  similar  hyperplasia  occurs  in  those  glandular  tissues  that  are  allied  to 
the  lymphatic  glands,  such  as  the  tonsils,  lymph-follicles,  the  tongue, 
mouth  and  pharynx,  thymus  gland,  the  solitary  and  Peyer's  agminated 
intestinal  glands]^  and  the  Malpighian  bodies  in  the  spleen. 


LEUiamiA.  477 

Proliferation  of  the  bonc-Tnariow  cells,  which  ;ire  carried  to  other 
tissues  and  there  multiply,  is  the  essence  of  the  disease.  Available 
space  for  the  production  of  red  cells  is  encroached  uj)on  by  lymphocytic 
proliferation,  hence  the  anemia. 

The  liver  may  be  greatly  enlarged  ;  indeed,  some  of  the  instances  of 
greatest  enlargement  of  this  organ  have  been  those  due  to  leukemia,  the 
weight  being  as  much  as  fourteen  pounds.  The  enlargement  is  uniform 
and  due  to  a  diffuse  leukemic  infiltration.  The  capillaries  and  inter- 
lobular tissue  are  distended  with  leukocytes,  and  disseminated  whitish 
or  grayish  nodules,  usually  quite  small,  consisting  of  lymphoid  cells 
undergoing  indirect  division  of  their  nuclei,  are  frequently  found. 
Sometimes  these  leukemic  nodules  appear  as  definite  growths,  with  an 
adenoid  reticulum  between  the  cells  (lymph-adenomata). 

Similar  changes  are  observed  in  the  kidneys^  enlargement,  paleness, 
and  diffuse  and  circumscribed  leukemic  infiltration  of  the  capillaries  and 
interlobular  tissue  all  being  noted.  Leukemic  nodules  may  also  be 
found  in  other  parts  of  the  body,  such  as  the  retina,  brain,  serous  mem- 
branes, lungs,  testicles,  and  skin.  Karyokinetic  figures  are  numerous 
in  the  cells  accompanying  these  leukemic  growths. 

Htiology. — The  primary  cause  of  leukemia  is  unknown ;  that  it 
directly  affects  the  blood-forming  organs,  however,  is  most  probable, 
though  with  differences  of  selection  and  co-ordination  and  with  different 
degrees  of  intensity.  The  combination  of  lesions  in  the  spleen,  lymph- 
glands,  and  bone-marrow,  along  with  the  histologic  similarity  of  the 
leukemic  growths  to  the  infectious  granulomata,  and  the  clinical  history 
of  cases  of  acute  leukemia,  would  seem  to  point  strongly  to  the  microhic 
origin  of  the  disease.  Moreover,  various  cocci  and  bacilli  have  been 
found,  but  not  one  of  them  has  been  definitely  proved  to  be  the  specific 
cause  of  the  disease.  Auto-intoxication  by  toxic  albuminoids  from  the 
digestive  tract  is  believed  by  Vehsemeyer,^  who  analyzed  600  cases,  to 
be  the  important  point  of  departure  of  the  disease.  It  is  likely  that  the 
direct  cause  of  the  leukocythemia  is  a  simple  increase  of  the  cytogenic 
function  of  one  or  more  of  the  hematopoietic  organs.  Kottnitz  held  leuko- 
cythemia to  be  a  reactive  condition  following  auto-intoxication  with  pep- 
tones, and  consequently  a  leukolysis,  the  over-action  of  the  hematopoietic 
organs  leading  to  hypertrophy.  Whether  the  reduction  of  the  erythrocytes 
is  due  to  diminished  production  or  to  increased  destruction  is  not  posi- 
tively known,  although  the  former  factor  is  more  probably  operative. 

The  disease  has  often  been  preceded  by  an  injury  or  a  bloiv  in  the 
splenic  region,  but  its  direct  traumatic  origin  is  hypothetic  only.  In- 
testinal ulceration  has  been  a  frequent  feature  prior  to  leukemia,  and 
undoubtedly  affords  a  source  of  possible  infection  from  the  tract. 
Stomatitis  also  may  furnish  a  means  of  entrance  for  the  infectious  agent. 
The  causal  relation  of  pseudo-leukemia  and  true  leukemia  is  uncertain, 
although  a  few  cases  of  the  one  have  been  observed  to  pass  into  the  other. 

In  a  considerable  proportion  of  cases  leukemic  patients  have  had 
malaria  of  some  form.  Syphilis  may  be  associated  with  the  disease,  but 
it  is  not  probable  that  it  acts  in  a  causative  manner. 

Hereditary  influences  undoubtedly  play  a  part ;  a  "  lymphogenous 
diathesis  "  may  thus  be  transmitted,  and  several  generations  may  be 
affected  by  the  disease.  Adverse  hygienic  and  social  conditions  may  also 
1  International  klin.  Rundsch.,  Vienna,  Nov.  25,  1894. 


478    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

predispose  to  leukemia.  It  mav  also  develop  after  pregnancy,  or  more 
commonly  at  the  eUmacteric.  Anxiety,  worry,  and  mental  depression 
have  been  mentioned  as  predisposing  causes,  with  doubtful  justification. 

Leukemia  occurs  most  frequently  in  males  during  tlie  middle  period 
of  life,  and  is  apt  to  attack  young  persons.  It  has  occurred  during  in- 
fancy, and  as  late  also  as  the  seventieth  year,  but  the  average  age  ranges 
from  twenty-five  to  forty-five  years.  Sometimes  the  previous  condition 
was  one  of  apparently  perfect  health. 

Symptoms. — Acute  leukemia,  comparatively  rare,  usually  occurs  in 
an  adolescent  who  may  have  enjoyed  previous  good  health.  Fussel  and 
Taylor  collected  56  cases  from  the  literature.  Ilamman  tabulated  111 
cases,  and  in  several  aftections  of  the  mouth  or  throat  were  observed  at 
the  commencement.  Its  onset  is  sudden,  and  usually  begins  with  prostra- 
tion, hemorrhage  of  the  mucous  membranes,  and  high  fever.  Acute  splenic 
tumor  rapidly  develops  ;  the  lymphatic  glands  may  enlarge :  and  palpita- 
tion, dyspnea,  and  gastro-intestinal  symptoms  of  a  severe  type  appear.  The 
skin  becomes  anemic,  and  edema  of  the  feet  is  common.  The  blood  shows 
a  marked  increase  in  the  number  of  leukocytes,  the  ratio  to  the  red  corpus- 
cles being  1  to  30  or  1  to  50,  instead  of  the  normal  1  to  350  or  1  to  600. 
In  acute  h/mphoid  leukemia  the  lymphocytes  are  very  numerous.  In 
acute  myeloid  leukemia  there  is  an  increase  in  the  blood  of  a  cell  orig- 
inating from  the  myelocytic  cells  of  the  bone-marrow,  representing  the 
ancestor  of  the  myelocytes  and  granular  leukocytes,  which  are  numerous  in 
the  blood  picture.  The  case  grows  progressively  worse;  hematemesis,  cer- 
ebral or  retinal  hemorrhages,  and  petechia  supervene  perhaps,  and  the  clin- 
ical features  may  then  resemble  an  infectious  disease  with  hemorrhagic  and 
purpuric  manifestations.  Early  in  life  the  hemorrhages  are  less  common 
and  the  increase  in  lymphocytes  is  apt  to  concern  the  small  variety  of  cells. 

In  chronic  leukemia  the  onset  is  generally  slow  and  insidious  and  for 
many  months  the  earlier  symptoms  may  not  differ  from  those  of  simple 
anemia.  Languor,  a  deranged  appetite,  dizziness,  noises  in  the  ears, 
faintness,  breathlessness  on  exertion,  and  palpitation  may  all  appear. 
Sometimes,  however,  not  even  these  symptoms  are  present,  common  as 
they  are  to  most  anemic  cases,  and  the  patient  may  first  consult  the 
physician,  because  of  a  swelling  or  distress  in  the  left  side  of  the  abdo- 
men— the  enlarged  spleen.  Early  manifestations  may  be  hemorrhagic 
(epistaxis,  hematemesis,  enterorrhagia),  with  nausea,  vomiting,  and 
diarrhea  ;  or  increasing  pallor  of  the  countenance,  yet  at  times  a  patient 
may  appear  to  be  plethoric  ;  or  troublesome  priapism  may  appear.  As  the 
disease  progresses  the  anemia  becomes  more  marked,  edema  of  the  de- 
pendent portions  of  the  body  may  appear,  and/(?rt'?-,  though  slight  at  first 
(99.5°  F.— 37.5°  C),  may  gradually  rise  to  102°  or  103°  F.  (39.4°  C), 
either  remaining  constant  or  alternating  with  periods  of  apyrexia. 

The  pulse-rate  is  increased  ;  in  quality  it  is  soft  and  compressible, 
though  sometimes  full  in  volume.  The  dyspnea  may  be  aggravated  by 
the  hydrothorax  in  advanced  cases,  or  by  the  upward  displacement  of 
the  diaphragm  owing  to  the  increasing  splenic  and  hepatic  enlargement. 
Epistaxis  may  become  ol)Stinate.  Retinal  hemorrhage  is  common,  and 
there  may  be  aggresxations  of  leukocytes  (leukemic  growths).  Hemorrhages 
from  mucous  membranes  are  common,  and  localized  gangrene  may  occur, 
with  the  symptoms  of  infection.     Hemic  murmurs  are  quite  constant. 

Ulcerative  processes  in  the  bowels  may  give  rise  to  severe  dysenteric 


LEUKEMIA.  479 

diarrhea.  Ascites  is  usually  present  in  advanced  cases  on  account  of 
the  splenic  tumor,  or  owing  to  pressure  upon  the  portal  vein  by  enlarged 
glands.  Jaundice  is  an  occasional  event.  Leukemic  peritonitis  may 
occur  from  the  presence  of  lymphomatous  growths  in  the  membrane. 

Nervous  symptoms^  such  as  headache,  vertigo,  and  syncopal  attacks, 
recur  as  the  anemia  and  prostration  increase  and  the  liability  to  hemor- 
rhage becomes  more  frequent.  Sudden  coma  and  hemiplegia  following 
upon  the  rupture  of  a  cerebral  vessel  (apoplexy)  may  be  the  immediate 
cause  of  death.  Minute  brain-hemorrbages  may  account  for  deafness. 
Priapism  may  be  troublesome.  Peripheral  paralysis  of  several  cranial 
nerves,  due  to  hemorrhages  into  their  sheaths,  has  been  reported. 

Cutaneous  ecchymoses  are  sometimes  observed,  and  sometimes  there 
is  a  troublesome  pruritus.  The  urine  contains  an  excess  of  uric  acid, 
but  albuminuria  does  not  occur,  except  as  a  complication. 

Along  with  the  anemia  and  debility  are  the  signs  of  splenic  and 
lymphatic  involvement,  and  rarely  of  the  bone-marrow.  The  liver  may 
also  become  enlarged. 

Leading  Symptoms  in  Detail. —  The  Spleen. — This  organ  is  generally 
enlarged  in  all  forms  of  leukemia,  but  especially  in  the  spleno-medullary, 
the  most  frequent  form.  It  is  a  prominent  feature,  both  on  account 
of  its  being  the  first  subject  of  complaint,  and  because  of  the  huge 
size  it  frequently  attains.  The  enlargement  is  gradual,  and  there  may 
be  neither  pain  nor  tenderness  over  it.  The  tumor  may  cause  a  visible 
projection  below  the  ribs,  and  in  marked  cases  great  abdominal  disten- 
tion may  be  produced,  pushing  up  the  diaphragm  and  thoracic  organs, 
and  extending  to  the  navel  in  the  median  line  and  to  the  pelvis  below, 
in  which  case  the  cardiac  pulsation  is  seen  at  the  second  or  third  inter- 
space. The  edge  and  notch  or  notches  may  be  felt  easily  in  such  in- 
stances, while  the  surface  is  smooth  and  the  consistence  firm.  A  friction- 
fremitus  is  felt  sometimes  during  respiratory  movement.  The  tumor  may 
vary  in  size,  and  after  severe  hemorrhage  or  diarrhea  it  may  become 
swollen.  Gastric  distress  after  eating  and  obstructive  constipation  are 
usually  complained  of  in  cases  of  great  splenic  enlargement.  Jaundice 
may  also  be  present.  Pulsation  has  been  noted  and  a  systolic  murmur — 
"  splenic  souffle  " — has  been  heard  at  times  over  the  tumor.  The  percus- 
sion-note is  dull  over  the  tumor,  and  areas  of  movable  dulness,  due  to  fluid 
occupying  the  peritoneal  cavity,  are  not  infrequent.  A  wave  of  fluctu- 
ation may  be  detected  over  the  abdomen.      The  liver  is  often  enlarged. 

Lymphatic  Glands. — In  the  splenic-lymphatic  variety,  which  is  less 
common  than  the  splenic-myelogenous,  and  in  the  still  rarer  purely 
lymphatic  leukemia,  the  superficial  lymph-glands  may  be  both  visibly 
and  palpably  enlarged,  though  not  in  bunches  as  in  Hodgkin's  disease. 
They  are  soft,  resilient,  and  movable. 

The  Bones. — Purely  myelogenous  leukemia  is  very  rare,  and  local 
bone-symptoms  are  scarcely  ever  manifested.  There  may  be  some  ten- 
derness on  immediate  percussion  over  the  sternum  or  some  of  the  long 
bones,  and  slight  swelling,  irregularity,  or  deformity  of  the  ribs,  the 
sternum,  or  other  bones  may  result  from  leukemic  hyperplasia. 

The  Blood. — It  is  by  the  blood-examination  alone  that  the  pathog- 
nomonic features  of  leukemia  are  determined.  The  blood  is  paler  than 
normal,  and  sometimes  has  a  brownish-red  or  chocolate  color.  Upon  a 
microscopic  examination  of  the  blood  in  the  myeloid  form  of  the  aff"ection 


480    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 


the  striking  increase  in  the  number  of  leukocytes  is  observed  at  once. 
The  count  shows  usually  from  85.000  to  500,000  white  corpuscles  per 
cubic  millimeter,  and  the  ratio  of  the  white  to  the  red  colls  may  thus 
vary  from  1  to  1 50  down  to  1  to  10  or  1  to  5  in  the  average  case,  instead 
of  the  normal,  1  to  500  (see  Fig.  40).  In  extreme  cases  the  number  of 
leukocytes  may  be  e(|ual  to,  or  even  slightly  greater  than,  tiiat  of  the 
erythrocytes,  :ind  such  an  instance  has  been  recorded  by  Sbrensen,  in 
which  the  proportion  of  Avhites  to  reds  was  3  to  2. 

Stained  specimens  of  the  blood  enable  us  to  recognize  the  variety 
of  leukemia  (Fig.  39,  PI.  V.).  Thus,  in  the  ordinary  myeloid  form 
the  characteristic  change  is  the  presence  of  the  abnormal  mijclocytes — 
large,  mononuclear  leukocytes  with  the  protoplasm  filled  with  fine  neu- 
trophilic granules.  These  may  make  up  25  per  cent,  of  the  white  cells, 
whereas  they  do  not  occur  in  normal  blood,  and  very  rarely,  and  only 


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Fig.  40.— Blood-tracing  of  a  case  of  leukemia.    Black,  red  corpuscles;   red,  hemoglobin;  blue, 

white  corpuscles. 

in  small  numbers,  in  leukocytosis.  They  probably  correspond  to  the 
cells  found  in  the  bone-marrow,  the  large,  oval,  and  eccentrically  placed 
nuclei  of  both  blood-  and  marrow-cells  showing  karyokinetic  figures. 
The  polymorpho-nuclear  leukocytes  may  be  normal  in  number,  but 
usually  they  are  relatively  diminished  to  about  65  per  cent,  instead  of 
75  per  cent.,  as  jn  normal"  blood.  The  polymorpho-nuclear  cells  show- 
ing coarse  basophilic  granules  are  increased,  and  may  equal  in  number 
the  eosinophiles.  When  Ehrlich's  triacid  stain  is  used  these  cells  appear 
as  non-granular  polynuclear  bodies.  The  lymphocytes  are  also  rela- 
tively less  in  number,  making  up  but  1  or  2  per  cent.,  instead  of  the 
normal  15-30  per  cent.  The  bright,  acid-stained  eosinophiles,  though 
absolutely  increased,  are  not  always  relatively  so.  They  possess  but 
little  diagnostic  value,  being  common  to  many  other  conditions. 


Fig.  39.— Fresh  preparation  from  tne  blood  of  a  case  of  leukemia  (X  £50) ;  large  mononuclear 
leukocytes  of  immature  form. 

[Grawitz.] 


LEUKEMIA.  481 

Moderate  oUgocythemm  is  noted  in  the  later  stages,  tlie  reduction 
being  seldom  lower  than  to  2,000,000  per  c.mm.  The  percentage  of 
hemoglobin  ma_y'  alsir  be  reduced  relatively  or  in  slightly  greater  propor- 
tion. Nucleated  red  corpuscles,  chiefly  normoblasts,  are  invariably  found. 
Cells  with  large,  pale  nuclei  are  occasionally  found,  and  cells  with  frag- 
mented nuclei  are  common.  Gigantoblasts  may  be  present.  Blood  of 
the  type  of  pernicious  anemia  may  subsequently  develop  a  true  leukemia. 
In  a  majority  of  cases  the  blood-plates  are  considerably  increased. 

In  lymphatic  leukemia^  which  is  rarer  and  more  ([uickly  fatal  than 
the  preceding  variety,  the  lymphocytes  are  increased,  all  other  leukocytes 
being  relatively  much  diminished  in  number.  Instead  of  the  normal 
percentage  (15  to  30  per  cent.),  the  lymphocytes  may  number  from 
90  to  97  per  cent,  of  all  the  leukocytes.  The  excess  of  leukocytes, 
however,  is  less  than  in  the  myeloid  form.  This  increase  affects  the 
small  forms  in  most  cases.  Cabot  has  shown  that  in  some  instances  this 
increase  affects  the  larger  lymphocytes.  Nucleated  red  corpuscles,  chiefly 
normoblasts,  are  present  in  small  numbers.  Myelocytes  are  not  numer- 
ous, but  quite  constant.  The  erythrocytes  show  changes  in  size,  shape, 
and  staining  out  of  proportion  to  the  degree  of  anemia  present.  Eosin- 
ophiles  are  relatively  diminished.  Mixed  forms  of  leukemia  are  not  at 
all  uncommon,  so  that  the  proportions  of  the  various  types  of  normal 
and  abnormal  cells  are  quite  variable. 

The  blood-plates  may  be  quite  abundant  in  many  leukemic  cases,  and 
Charcot's  octahedral  crystals  appear  in  specimens  of  the  blood  on  stand- 
ing.    An  unusually  dense  and  thick  fibrous  network  is  also  often  found. 

Complications. — Fatal  hemorrhages  may  occur  at  any  time,  pleu- 
ritis,  pneumonia,  septico-pyemia,  renal  disease,  severe  diarrhea,  toxemic 
jaundice,  and  edema  may  complicate  leukemia  and  cause  death. 

Dock  ^  has  shown  that  chronic  tuberculosis  does  not  distinctly  influ- 
ence the  course  of  leukemia.  Acute  miliary  tuberculosis,  however,  may 
follow  and  also  cause  a  reduction  of  the  leukocytes. 

Diagnosis. — This  can  be  made  accurately  by  the  blood-examination 
alone,  the  distinguishing  characteristics  of  the  blood  having  been  enu- 
merated above,  both  as  to  the  existence  of  leukemia  and  the  differentiation 
of  its  several  varieties.  Stained  specimens  of  the  blood  should  be  studied, 
since  the  excess  of  leukocytes  alone  is  not  proof  of  leukemia,  and  also 
because  the  disease  may  exist  without  an  excess,  owing  either  to  previous 
medicinal  treatment  or  to  temporary  improvement. 

Differential  Diagnosis. — Leukemia  is  differentiated  from  a  marked 
leukocytosis  by  the  fact  that  in  the  latter  there  is  usually  a  more  moder- 
ate increase  in  the  number  of  leukocytes,  affecting,  as  a  rule,  principally 
the  polynuclear  neutrophiles  ;  in  addition  myelocytes  are  absent. 

Hodgkins  disease  may  be  simulated  by  the  purely  lymphatic  leu- 
kemia on  account  of  the  enlarged  glands ;  but  in  leukemia  the  lymph- 
glands  are  not  found  in  such  large  bunches,  and  the  blood-examination 
will  show  the  characteristic  changes  of  lymphatic  leukemia  if  that  disease 
be  present.      Simply  a  leukocytosis  is  present  in  pseudo-leukemia. 

Malignant  growths  of  the  spleen  and  lymphatic  glands,  and  also  a 
malarial  and  passively  congested  spleen  with  anemia,  may  simulate  leu- 
kemia.    Here  again  the  blood-examination  will  exclude  leukemia. 

Prognosis. — Many  cases  ai-e  mild  in  their  progress ;  children,  how- 
1  Jour.  Amer.  Med.  Sei.,  April,  1904. 
31 


482     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

ever,  when  affected,  succumb  more  rapidly  than  do  adults.  Lymphatic 
leukemia  is  always  fatal  earlier  than  the  spleno-meduUary  variety,  and  in 
severe  acute  cases  the  larger  lymphocytes  are  found.  Although  recovery 
does  occur  occasionally,  most  cases  of  leukemia,  of  whatever  form, 
prove  fatal  certainly  within  five  years,  generally  in  two  or  three  years, 
and  sometimes  in  seven  or  eight  months  or  even  less  (from  two  weeks 
to  two  or  more  months)  in  acute  leukemia.  In  an  advanced  case  the- 
prognosis  is  hopeless.  Grave  symptoms  heralding  an  early  termination 
are  profound  debility,  anemia,  emaciation  or  edema,  severe  and  obstinate 
hemorrhages,  cerebral  apoplexy,  persistent  diarrhea,  and  high  fever. 
Intercurrent  affections  not  infrequently  cause  death,  while,  on  the  other 
hand,  cases  are  recorded  in  which  the  appearance  of  intercurrent  infec- 
tious diseases  (erysipelas,  entero-colitis,  pleuritis)  has  favorably  affected 
the  course  of  leukemia.      Remissions  may  rarely  occur. 

Treatment. — At  present  no  remedies  are  known  to  have  any  per- 
manent curative  effect.  The  application  of  the  Rbntgen  ray  over  the 
spleen,  sternum,  and  extremities  of  the  long  bones  (viscera  10-minute 
exposures,  joints  5-minute  exposures),  at  first  suggested  by  N.  Senn,^  is 
followed  by  :  disappearance  of  the  fever  ;  decided  decrease  in  the  volume 
of  the  spleen  ;  increase  in  tlie  number  of  red  cells  and  in  the  hemoglobin. 
The  leukocytes  are  at  first  reduced  and  may  fall  to  near  the  normal  num- 
ber, but  later  the  blood  again  becomes  leukemic.  Oettinger,  Fiessinger, 
and  Sauphar^  claim  that  radiotherapy  produces  a  leukolytic  ferment, 
which  by  disintegrating  the  corpuscles,  may  transform  chronic  myeloid 
leukemia  into  an  acute  phase,  or  pernicious  anemia.  Warthin  ^  believes 
that  the  Rontgen-ray  treatment  of  leukemia  finds  a  pathologic  basis  in 
the  selective  action  which  the  rays  have  for  cells  of  the  lymphocytic  and 
myelocytic  types.  Kiralyfi*  reports  constant  benefit  in  seven  cases  from 
the  use  of  benzol  (gr.  viiss — 0.5,  in  equal  quantity  of  olive  oil  in  capsule, 
q.  d.,  gradually  increased  to  gr.  Ixxv — 5.0  daily).  Larrabee^  has  used 
the  mixed  toxins  of  Coley  in  18  cases  with  results  encouraging  enough 
to  warrant  farther  trials. 

The  environment  should  be  made  as  favorable  as  possible — physically, 
mentally,  socially,  and  morally.  Out-of-door  life  in  a  mild,  dry  climate, 
an  abundance  of  nutritious  and  easily  digestible  and  assimilable  food, 
calm  and  moderate  exercise  of  mind  (depending  upon  the  endurance  of 
the  patient),  should  all  be  advised  and  encouraged.  On  the  other  hand, 
traumatism,  irregular  habits  of  body,  worry,  excitement,  and  passionate 
emotions  and  appetites  should  be  regulated  and  avoided. 

Arsenic  gives  the  best  results  in  most  cases,  and  should  be  pushed  to 
the  limit  of  tolerance,  as  in  pernicious  anemia.  It  should  be  given  con- 
tinuously, regardless  of  apparent  improvement  under  its  use,  as  the  latter 
may  be  only  the  natural  remission — a  not  uncommon  incident  in  the 
disease.  Bone-marrow,  either  raw  and  spread  upon  bread,  or  in  the  form 
of  a  glycerin  extract,  may  be  tried  when  arsenic  fails.  Oxygen-inhala- 
tions and  blood-transfusion  have  been  suggested.  The  so-called  "  splenic 
remedies,"  whether  systemic  or  local,  have  no  controlling  influences  upon 
the  disease.      Complications  may  be  relieved  by  appropriate  treatment. 

1  N.  Y.  Med.  Jour.,  Aug.  22,  1903. 

2  ArchiveJi  dea  Maladies  du  Coenr,  etc.,  Paris,  May,  1910 ;  Jour.  Amer.  Med.  Assoc,  June 
11,1910,2006. 

'Internal.  Clin.,  vol.  iv..  Fifteenth  Series,  1906.  • 

*  Wien.  klin.  Woch.,  1912,  xxv.,  1311.  ^ N.  Y.  Med.  Jour.,  Feb.  15,  1908. 


I'l.ATK     V. 


o 

CI 


'On  '^^  On 


Blood  of  Splenomedullaey  Leukemia. 

1,  Myelocytes  ;  2,  eosinoplnlic  myelocyte  ;  3,  leukocytic  shadows  ;  4,  polycbromatophllic  niega- 
loblast ;  5,  large  monoimclear  leukocyte  ;  6,  small  lymphocyte  ;  7,  eosinophile  ;  8,  megaloblast ;  9, 
polymorphonuclear  leukocyte  ;  10,  small  eosinophiles  (stained  with  eosin  and  hematoxylin.  Obj. 
B.  and  L.  one-twelfth  oil-immersion). 

[L.  Napoleon  Boston.] 


PSEUDO-LEV  KKMIA.  483 

LEUKANBMIA. 

So-called  "leukanemia"  (Loubc)  is  most  probably  cither  leukemia 
with  terminal  anemia,  or  pernicious  anemia  with  lymphoid  or  myeloid 
marrow  (Cabot). 

CHLOROMA. 

Pathologically,  it  consists  of  a  sarcomatous  growth,  the  primary  scat 
of  which  is  in  the  periosteum  and  bone  in  and  about  the  orbit.  Thread- 
gold  holds  that  the  bone-marrow  is  primarily  affected  in  chloroma.  The 
growth  shows  a  pea-green  pigmentation.  Secondary  growths  may  be 
widespread.  Gulland  and  Goodall  claim  that  there  is  no  histologic  dif- 
ference between  chloroma  and  lymphoid  leukemia.  Myeloid  chloroma  also 
occurs,  10  cases  having  been  recorded  by  Jacobaeus.i 

Symptoms. — Pain  in  the  orbital  region,  exophthalmos,  and  deafness 
are  noted  early.  The  principal  diagnostic  features  are  gangrenous  sto- 
matitis and  often  a  high-grade  anemia,  usually  associated  Avith  a  hemor- 
rhagic diathesis.  There  is  some  enlargement  of  the  lymphatic  glands 
and  spleen.  In  the  lymphoid  form  there  occur  the  tumor-like  infiltra- 
tions of  the  orbit  and  other  parts  of  the  skull,  and  it  is  seen  in  children. 
The  blood-picture  is  that  of  lymphoid  leukemia.  The  myeloid  form  is 
characterized  by  the  presence  of  neutrophilic  myelocytes,  making  up 
from  50  to  95  per  cent,  of  the  cells,  and  a  marked  leukocytosis.  It 
seldom  shows  tumor  growths.  In  those  cases  in  which  the  tumor  forma- 
tion is  not  prominent,  the  clinical  picture  may  resemble  pernicious  anemia, 
acute  sepsis,  scorbutus,  or  a  septic  diphtheria  (Bierring). 

The  course  of  the  disease — spoken  of  by  French  writers  as  "  green 
cancer  " — is  rapid,  and  death  usually  comes  on  within  a  few  months. 
The  Rontgen  rays  have  given  marked  improvement  in  the  treatment  in 
some  cases,  but  not  in  others. 

PSEUDO-LEUKEMIA. 

{Sodgkin's  Diseuse;   General  Lymphadenoma.') 

Definition. — An  anemia  characterized  by  the  anatomic  peculiarities 
resembling  those  of  lymphatic  leukemia — viz.,  progressive  hyperplasia 
of  the  lymph-glands,  occasional  secondary  lymphoid  growths  of  other 
organs  (liver,  spleen) ;  and  by  the  absence  of  the  destructive  blood- 
changes  of  true  leukemia. 

Varieties. — Although  the  disease  that  bears  his  name  was  first  de- 
scribed by  Hodgkin  of  Guy's  Hospital  in  1832  as  an  affection  of  the 
lymphatic  glands  and  spleen,  two  varieties  are  included  under  the  title 
of  pseudo-leukemia  (or  Hodgkin's  disease),  as  follows  :  (1)  that  which 
presents  simply  an  enlarged  spleen  (the  less  frequent  one) ;  and  (2)  that 
in  which  the  lymphatic  glands  are  chiefly  involved. 

Pathology. — The  lymph-glands  show  different  degrees  of  hyperplas- 
tic enlargement  and  consistency.  In  the  earlier  stages  they  are  small, 
isolated,  and  movable,  while  in  advanced  and  well-developed  cases  of 
the  disease  they  are  larger,  fused  together  into  great  bunches,  and  more 
or  less  fixed  by  fibrous  investment.  As  a  rule,  the  glands  are  soft  and 
elastic,  though  sometimes  they  are  hard  and  dense,  and  masses  as  large 
as  an  orange  or  pineapple  may  be  seen.  Single  glands  may  be  as  large 
1  Deutsch.  Archivf.  klin.  Med.,  1909,  Band  xcviii.,  Heft  1  and  2. 


484    DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 

us  a  heu's  egg,  and  tlu-  ghiiul-capsules  may  sIkuv  connective-tissue  pro- 
liferation aiul  a  thickening  periadenitis.  Extension  of  the  lymphatic 
trrowth  into  the  surrounding  tissues  by  perforation  of  the  capsule  may 
occur.  As  a  rule,  the  overlying  skin  is  freely  movable,  though  it  may 
rarelv  be  adherent.  On  section  the  tumors  display  a  smooth  Avhite  or 
reddish-gray  surface  in  the  case  of  the  soft  and  almost  fluctuating  glands, 
and  a  o-vayish  or  a  yelloAvish-\vhite  color  if  they  are  firm.  The  fusion  of 
the  swollen  glands  into  nodular  masses  is  also  seen,  and  when  ulceration 
through  the  skin  has  taken  place  sui)puration  of  tlie  glands  may  be 
reveafed.  In  the  harder  tumors  areas  of  necrosis  having  the  appearance 
of  caseation,  and  shining  masses  of  fibroid  tissue  may  be  visible. 

Microscopically,   there    is    a    typical    hyperplasia  of  the  lymph-cells 
often  obscuring  completely  the  reticulum  of  the  gland,  except   in   the 


Fig.  41.— Temperature-chart  of  a  case  of  pseudo-leukemia. 

harder  enlargements,  Avhere  the  fibrous  proliferation  shows  a  very  dis- 
tinct network.  The  change  is  a  lymphadenoma  of  the  lymphatic  glands. 
Reed '  states  that  the  true  form  of  the  disease  has  a  specific  histology, 
showing  large  numbers  of  eosinophiles  and  a  peculiar  variety  of  giant- 
cell,  different  from  that  of  tuberculosis.  Longcope,  Ruffin,^  and  others 
also  believe  that  the  disease  shows  histologic  changes  peculiar  to  itself. 
Gibbons,^  on  the  contrary,  is  strongly  inclined  to  the  malignant  theory. 

The  cervical  glands  are  most  prominently  involved.  The  supcj-ficial 
chains  of  glands— axillary,  mediastinal,  scapular,  and  pectoral— especially 
aloiiff  the  great  vessels,  are  often  found  connected,  and  the  inguinal,  bron- 
chial and  lumbar  glands  are  also  affected,  though  less  fi  ecjuently.  The  retro- 
peritoneal glands  are  more  frequently  affected  than  the  mesenteric ;  they 
have  occasionally  projected  externally  by  perforation  through  the  sternum. 

The  spleen  is  enlarged  in  about  four-fifths  of  the  cases,  but  only  slightly. 
1  Johm  Hopkins  Review,  vol.  x.,  p.  i:-!3.  ^  Amer.  Jour.  Med.  Sci.,  Apiil,  1906. 

'  Amer.  Jour.  Med.  Sci.,  November,  1906. 


PSEUDO-LEUKEMIA.  485 

The  spleen  is  enlarged  in  about  four-fifths  of  the  case.s,  hut  only  slirrhtly. 
In  the  majority  of  cases  there  are  disseminated  througliout  the  organ 
whitish,  lymphomatous  growths  or  nodules  from  the  size  of  a  pea  to  that 
of  a  nut.  Their  histologic  structure  is  like  that  of  the  lymph-glands 
(lymphadenoma).     Occasionally  the  spleen  alone  is  hypfr|)l:istic. 

Lymphoraata  may  also  develop  in  the  tonsils,  ]irigu;i,l  follicles,  intestinal 
lymphatics,  liver,  kidneys,  lungs,  brain,  spinal  cord,  licart,  testicles,  retina, 
and  skin.   The  bone-marrow  often  appears  the  same  as  in  pernicious  anemia. 

Ktiology. — There  are  no  well-established  predisposing  conditions 
to  which  Hodgkin's  disease  is  referable.  In  75  per  cent,  of  cases 
males  are  affected,  and  young  and  middle-aged  persons — between  the 
ages  of  ten  and  forty  years.  In  an  analysis  of  100  cases  30  were  under 
twenty  years,  34  between  twenty  and  forty,  and  36  after  forty  (Uowers). 
Heredity  may  possibly  be  a  cause.  The  disease  would  seem  to  belong 
to  the  group  of  infectious  granulomata,  but  the  exciting  cause  is  not 
known.  Flexner  thinks  that  certain  protoplasmic  foreign  bodies  (found 
in  the  larger  nodules  of  two  cases)  may  possibly  have  a  causal  relation. 
Malaria,  syphilis,  chronic  skin-diseases,  and  various  irritative  conditions, 
especially  of  the  mouth,  giving  rise  to  local  glandular  swellings,  have 
also  been  assigned  as  causes.  In  undoubted  instances  of  Hodgkin's  dis- 
ease the  lymphatic  glands  frequently  harbor  tubercle  bacilli ;  hence  it 
has  been  thought  that  the  latter  exercise  a  distinct  causative  influence. 
It  must  be  remembered,  however,  that  some  of  these  may  be  examples 
of  secondary  accidental  infection  ;  others  of  primary  diffuse  lymphatic 
tuberculosis,  indistinguishable  from  or  mistaken  for  Hodgkin's  disease. 
Musser^  thinks  "the  disease  is  not  improbably  an  expression  of  lymph- 
atic tuberculosis."  Sailer'^  arrives  at  much  the  same  conclusion.  Loffel- 
mann  contends  that  the  disease  is  caused  by  the  tubercle  bacillus,  having 
found  the  latter  in  six  out  of  seven  cases  by  means  of  the  antiformin 
method.  Reed'  believes  true  Hodgkin's  disease  is  not  due  to  the  tubercle 
bacillus,  but  that  it  is  of  infectious  origin.  It  is  not  uncommon  to  find 
pseudo-leukemia  developing  in  a  person  Avho  immediately  preceding  the 
beginning  of  the  disease  was  apparently  in  perfect  health. 

Symptoms. — Usually  the  first  thing  to  attract  attention  is  the  en- 
largement of  the  submaxillary  and  cervical  glands,  often  on  one  side  of 
the  neck  alone.  These  groAV  gradually  until  they  may  finally  appear  on 
both  sides  as  large  as  a  fist,  and  produce  considerable  disfigurement. 
Sometimes  several  years  may  elapse  before  other  glandular  groups  are 
affected,  but,  as  a  rule,  it  is  a  matter  of  months  only  before  the  axillary, 
then  the  inguinal,  and  perhaps  the  internal,  glands  are  invaded.  The 
changes  vary  greatly  in  rapidity  and  extent. 

At  first  the  general  health  may  be  but  slightly  affected.  A  little 
constitutional  disturbance  and  some  pallor  may  be  complained  of,  though 
seldom  before  the  glandular  swellings  are  noticed.  Then  as  the  disease 
progresses  the  paleness  increases  and  all  the  symptoms  of  a  marked 
anemia  appear — languor,  failure  of  physical  strength,  beginning  emacia- 
tion, gastro-intestinal  derangement,  headache,  giddiness,  palpitation, 
dyspnea,  and  edema  of  the  legs.  Later,  the  serous  cavities  contain 
effusion  and  there  is  a  tendency  to  hemorrhages.  Epistaxis  and  metror- 
rhagia may  occur,  and  petechial  spots,  especially  on  the  lower  extrem- 
ities, are  not  infrequent.     The  physical  signs  of  anemia — hemic  murmurs 

1  Amer.  Med.,  Jan.  4,  1902.  «  Phila..  Med.  Jour.,  April  .5,  1902.         3  Xoc.  cit. 


486    DISEASES  OF  THE  BLOOD   AND   THE  DUCTLESS  GLANDS. 

— are  also  present.  An  irregular  slight  or  moderate  pyrexia  is  common 
to  most  cases.  Fever  of  a  peculiar  intermittent  type  has  been  ob- 
served, the  intermissions  and  paroxysms  eacli  lasting  for  several  days 
or  weeks  (see  Fig.  41),  and  the  term  '*  chronic  relapsing  fever " 
has  been  applied  in  consequence.  When  these  pyrexial  exacerbations 
occur  the  cases  generally  run  a  more  acute  course.  Ague-like  paroxysms 
may  persist  for  even  months,  as  described  by  Pel,  of  Amsterdam. 

The  symptoms  due  to  mechanical  compression  by  tlie  lymphomata 
are  varieil  and  numerous,  depending  upon  the  number,  size,  and  distri- 
bution of  the  tumors.  Hundreds  of  tumors  may  be  present  tiirough- 
out  the  body,  but,  unless  they  press  upon  the  adjacent  nerves,  the  glands 
are  not  usually  painful.  Enlargement  of  the  tracheal  and  bronchial 
glands  may  cause  dysphagia,  dyspnea,  thoracic  pain,  disturbed  phonation, 
and  venous  congestion,  by  pressure  respectively  upon  the  esophagus, 
trachea,  bronchi,  thoracic  nerves,  recurrent  laryngeal  nerves,  superior 
vena  cava,  and  the  jugular  veins.  The  obstruction  to  respiration  may 
become  so  great  as  to  produce  death  by  suffocation. 

Circulato7'y  Symptoms. — (7oM^es^iow  of  the  head  and  upper  extremities 
may  be  quite  marked,  and  in  such  cases  compensatory  dilatation  of  the 
superficial  veins  is  observed.  Edema  of  the  hand  and  arm  may  result 
from  venous  obstruction  due  to  the  pressure  of  very  large  axillary  glands. 
The  heart's  action  may  be  disturbed  by  pressure  on  the  pneumogastric, 
and  the  heart  itself  may  be  dislocated  by  great  gland-tun)ors  within  the 
chest.  Under  such  circumstances  the  latter  may  be  detected  by  dulness 
on  percussion  over  the  anterior  mediastinal  space. 

Edema  of  the  feet  and  legs  maybe  an  early  indication  of  enlarged  abdom- 
inal glands  pressing  upon  the  femoral  veins.  Albuminuria  is  not  uncom- 
mon ;  ascites  and  hydrothorax  are  late  conditions.  Jaundice  is  sometimes 
attributed  to  pressure  upon  the  bile-duct.  G- astro-intestinal  disturhances 
may  be  troublesome,  and  are  usually  symptomatic  of  lymphoid  growths  in 
the  stomach  and  bowels.  In  thin  individuals  gland-masses  may  be  palpa- 
ble over  the  abdomen.  Deafness  may  be  caused  by  growths  in  the  pharynx. 

Nervous  Symptoms. — Inequality  of  the  pupils  and  unilateral  sweating  of 
the  face,  owing  to  glandular  pressure  upon  the  cervical  sympathetic,  may  be 
noticed  in  some  cases.  Sharp  lancinating  pains  along  the  nerves  may  also  be 
felt.  Pressure-paraplegia  a.ndneuralgie paiyis  variously  distributed  th roughs 
out  the  body  should  also  be  mentioned  among  the  nervous  manifestations. 

Cutaneous  SymptoJns. — It  has  been  suggested  that  the  bronzing  of 
the  skin  sometimes  seen  in  Hodgkin's  disease  maybe  due  to  the  pressure 
of  enlarged  glands  upon  the  suprarenal  capsules.  An  intense  pruritus 
has  been  complained  of,  and  the  skin  may  be  erythematous.  Occasion- 
ally the  thyroid  and  thymus  glands  are  involved. 

Spleen. — The  slightly  or  moderately  enlarged  spleen  can  usually  be 
felt  just  below  the  ribs,  projecting  toAvard  the  navel.  Tenderness  over 
the  spleen  and  bones  may  be  elicited.  The  characteristic  feature  in 
splenic  pseudo-leukemia  is  the  decided  enlargement  of  the  spleen  with- 
out involvement  of  the  lymphatics. 

The  blood  shows  a  moderate  diminution  in  the  number  of  red  cor- 
puscles, and  a  corresponding  diminution  in  the  hemoglobin,  the  former 
in  most  instances  numbering  from  2,000,000  to  4,000,000  per  cubic 
millimeter.  There  may  be  more  or  less  leukocytosis,  and  sometimes 
the  lymphocytes  may  preponderate  relatively ;  if  the  latter  be  present 


PSEUDO-LEUKKMrA.  487 

in  great  numbers,  the  blood  may  also  sliow  similarity  to  that  of  lymphatic 
leukemia.  An  occasional  normoblast  may  be  seen.  Blood-platelets  are 
abundant  (Bunting). 

Diagnosis. — Pseudo-leukemia  is  more  readily  confused  with  tuhercu- 
lous  adenitis  than  any  other  disease,  particularly  at  the  outset.  Although 
an  acute  tuberculous  adenitis  may  very  closely  simulate  Modgkin's  dis- 
ease and  render  a  diagnosis  almost  impossible,  more  often  the  glands  of 
tuberculous  adenitis  are  slower  in  enlarging  and  extending  than  in  this 
disease.  In  fact,  extension  of  the  lymphatic  enlargements  of  tuberculo- 
sis is  rarely  seen  as  compared  with  pseudo-leukemia.  Again,  tuberculous 
adenitis  is  most  common  in  the  young,  is  unilateral  rather  than  circumfer- 
ential in  the  neck,  and  attacks  the  submaxillary  glands  oftener  than  the 
cervical  chains  along  the  sterno-cleido-mastoid.  Again,  periadenitis, 
adhesion,  and  suppuration  of  the  glands  occur  in  tuberculosis.  Tubercu- 
lous foci  in  other  organs  may  also  be  found.  Intermittent  attacks  of 
pyrexia  are  an  indication  favoring  Hodgkin's  disease.  In  doubtful 
cases  a  gland  may  be  removed  for  microscopic  examination.  The  tuber- 
culin test  will  exclude  glandular  tuberculosis. 

The  blood  should  be  examined  in  order  to  differentiate  from  leukemia. 
Syphilis  must  be  carefully  excluded  by  the  history,  symptoms,  and 
therapeutic  test.     Neoplasms  of  the  lymph-glands  may  sometimes  be 
difficult  to  distinguish  from  pseudo-leukemia. 

The  diagnosis  of  splenic  pseudo-leuJcemia  is  to  be  made  on  the  decided 
splenic  enlargement  without  involvement  of  the  lymphatics.  The  fol- 
lowing conditions,  however,  must  be  distinguished :  (a)  Pernicious 
anemia  with  enlargement  of  the  spleen  ;  this  is  readily  done  by  a  blood- 
examination  ;  (b)  Cirrhosis  of  the  liver,  in  which  there  is  splenic  en- 
largement ;  ((?)  The  splenic  tumor  of  chronic  malarial  poisoning.  Here 
the  blood  should  be  repeatedly  examined  for  the  organism  of  Laveran, 
if  the  patient  resides  in  a  malarial  region ;  (c?)  Idiopathic  enlargement 
of  the  spleen  without  any  anemia. 

Prognosis. — This  affection  runs  an  almost  invariably  fatal  course.  The 
remissions  and  exacerbations  of  the  disease  are,  however,  notable.  In  some 
cases  the  termination  may  occur  in  a  few  months,  but  usually  death  ensues 
after  the  lapse  of  two  or  three  years.  It  should  be  remembered  that  some  in- 
stances of  Hodgkin's  disease  seem  to  merge  into  a  true  lymphatic  leukemia. 
Grave  indications  are  the  rapid  extension  of  the  glandular  enlarge- 
ments, great  debility,  anemia,  emaciation,  steadily  increasing  and  contin- 
uous pyrexia,  thoracic  pressure-symptoms,  hemorrhages,  and  marked  ana- 
sarca. Sometimes  the  tumors  diminish  greatly  before  death.  In  certain 
cases  general  streptococcus  infection,  intercurrent  diseases,  or  such  com- 
plications as  empyema  or  nephritis,  may  be  the  immediate  cause  of  death. 
Treatment. — Surgical  treatment  is  of  no  avail.  It  is  claimed  that 
exposure  of  the  enlarged  glands  to  the  E5ntgen  ray  is  followed  by  a  de- 
crease in  glandular  enlargements  and  an  improvement  in  all  symptoms.^ 
Hygienic  measures  and  the  use  of  all  possible  agencies  to  support  the 
strength  of  the  patient  should  be  resorted  to,  and  the  administration  of 
arsenic  in  gradually  ascending  doses,  as  for  pernicious  anemia  and  leuke- 
mia. The  value  of  Fowler's  solution  is  undoubted  in  many  cases.  Phos- 
phorus has  also  been  recommended,  and  the  galvanic  current  may  be 
applied  topically.  Tonics,  nutrients,  and  red  bone-marrow  are  of  service. 
1  Steinwald,  Jour.  Amer.  Med.  Assoc,  March  26,  1904,  p.  828. 


488    DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 


ANEMIA   INFANTUM   PSEUDO-LEUK^MICA. 

Definition. — The  above  title  ■was  given  by  von  Jaksch  to  a  form  of 
anemia  oceun-ing  in  childhood  that  bears  certain  similarities  to  leukemia, 
but  it  is  -without  the  tendency  to  a  fatal  end. 

Pathology. — Splenic  enlargement  is  the  most  striking  lesion.  The 
oriian  is  hard  and  dark  red.  The  histologic  examination  shows  a  uniform 
hyperplasia,  such  as  is  found  in  splenic  hypertrophy  due  to  various  con- 
ditions. The  liver  is  usually  enlarged ;  slight  enlargement  of  the  lym- 
phatic glands  may  occur,  though  never  lymphomatous  tumors. 

Ktiology. — Children  under  the  age  of  four,  and  particularly  during 
the  second  half  year  of  life,  are  especially  prone  to  this  condition.  It 
is  equally  common  in  the  two  sexes,  and  most  often  seen  in  rachitic 
infants,  16  to  20  cases  collected  by  Monti  and  Berggriin  having  ex- 
hibited this  etiologic  factor.  Hereditary  syphilis,  intestinal  disturb- 
ances, and  other  diseases  doubtless  play  a  part  in  the  etiology.  The 
disease  is  rare. 

Symptoms. — The  onset  is  gradual.  The  child  becomes  pale,  weak, 
and  often  emaciated,  and  enlan/einent  of  the  spleen,  until  it  reaches  an 
enormous  size,  is  the  most  striking  feature.  Hepatic  enlargement  is  fre- 
quently present,  but  does  not  correspond  to  that  of  the  spleen,  and  the 
lower  border  of  the  organ  is  sharp  instead  of  rounded,  as  is  the  case  in 
leukemia.  Gastro-intestinal  disturbances  may  occur.  Death  may  result 
from  increasing  weakness,  peritonitis,  or  pneumonia. 

Blood. — An  examination  of  the  blood  will  in  many  cases  show  an  in- 
ordinate reduction  in  the  number  of  red  corpuscles.  Nearly  always  the 
number  is  below  3,000,000.  Degeneration  of  the  red  corpuscles,  poly- 
chromatophilia,  and  poikilocytosis  are  seen.  Large  numbers  of  nucleated 
erythrocytes,  especially  normoblasts,  may  be  found.  The  reduction  in 
hemoglobin  is  often  relatively  greater  than  that  in  the  number  of  erythro- 
cytes. A  marked  increase  in  the  number  of  leukocytes  is  one  of  the 
characteristics,  the  number  ranging  from  40,000  to  over  100,000,  and 
the  proportion  of  the  red  to  the  white  at  times  being  as  low  as  12  to  1. 
Von  Jacksch  insisted  that  the  different  forms  of  leukocytes  occur  in  their 
usual  relative  proportions. 

Diagnosis. — The  lesser  grade  of  hepatic  enlargement,  and  the  char- 
acter of  the  leukocytosis  distinguish  these  cases  from  true  leukemia.  The 
evidence  is  in  favor  of  its  being  a  type  of  secondary  anemia. 

Prognosis. — Under  treatment  most  cases  terminate  favorably. 

Treatment. — Hygienic  measures  together  with  the  administration 
of  remedies  directed  to  the  anemia  constitute  the  treatment. 

SPLENIC    ANEMIA. 

Definition. — A  condition  described  by  H.  C.  "Wood  in  1871 ;  it  was 
looked  upon  by  many  authors  as  a  splenic  form  of  Hodgkin's  disease. 
The  present  tendency  is  to  regard  it  as  a  distinct  variety  of  anemia. 

Pathology. — Among  pathologic  characters,  splenic  enlargement  is 
to  be  specially  noted.  It  is  an  idiopathic  enlargement  of  the  spleen  with 
anemia  and  without  lymphatic  involvement.  Microscopically,  there  is 
hyperplasia  of  the  spleen  with  atrophy  of  the  pulp  and  hyaline  degenera- 
tion of  the  Malpighian  bodies.     In  other  cases  replacement  of  the  normal 


POLYCYTHEMIA    WITH  SPLENIC  TUMOR.  489 

structure  by  fibrous  tissue  and  large  endothelial  cells  occurs,  with  clear 
protoplasm  containing  several  nuclei  and  giant  cells  among  them.' 

Ktiology. — So-called  splenic  anemia  is  not  rare  in  persons  ■who  have 
resided  in  malarial  districts  for  a  long  period  of  time  (although  cases  are 
recorded  in  which  no  previous  history  of  malaria  existed)  and  in  rachitic 
persons.      It  is  probably  a  process  of  chronic  toxic  nature,  e.  y.,  syphilis. 

Symptoms. — The  affection  is  characlerized  by  three  stages  :^  (1)  The 
initial  stage,  which  shows  extreme  anemia,  with  marked  loss  of  power  and  mus- 
cular wasting,  emaciation,  however,  being  usually  slight,  notwithstanding. 

(2)  The  second  stage  is  characterized  by  progressive  enlargement  of. 
and  pain  in  the  region  of,  the  spleen.  Anemia  is  now  profound,  loss  of 
strength  extreme,  and  hematemesis  common.  Hemorrhages  from  other 
mucous  membranes  and,  less  often,  of  the  skin,  are  also  noted.  The 
fever  is  apt  to  be  hectic  in  type  (ranging  from  100°  to  102*^  F. — 37. G*^- 
38.0°  C. — and  rarely  even  higher), 

(3)  The  condition  is  that  of  progressive  asthenia,  ending  in  death. 

In  the  last  stage  there  may  be  cirrhosis  of  the  liver,  jaundice,  and 
ascites  (Banti's  disease). 

The  Blood  CJiaracters. — The  anemia  is  of  the  chlorotic  type.  The  red 
cells  are  usually  near  the  normal  count  (3,000,000  to  4,000,000),  while  the 
hemoglobin  is  greatly  reduced  (50  per  cent,  or  lower).  Poikilocytosis  may 
exist.  A  leukopenia  is  usually  present.  The  treatment  is  that  of  the  graver 
forms  of  anemia.  Splenectomy  is  indicated  by  recurring  hematemesis.  Har- 
ris and  Hertzog'  report  14  recoveries  in  19  cases,  with  1  result  not  stated. 

POLYCYTHEMIA   WITH    SPLENIC   TUMOR. 

This  is  a  special  complaint  of  obscure  pathogenesis.  The  spleen  is 
quite  hard  and  usually  enlarged.  A  cheesy  tuberculosis  has  been  noted, 
but  this  is  not  constant. 

l^tiologfy. — Certain  writers  regard  changes  in  the  bone-marrow  as 
primary,  leading  to  increased  erythroblastic  activity.  Defective  venous 
tone  may  play  a  role  in  the  pathogenesis.  The  Hebrew  race  is  mark- 
edly predisposed.  A  majority  of  the  cases  occur  during  middle  life, 
and  "  the  cases  are  about  equally  divided  between  the  sexes  "  (Engelbach 
and  Brown).  "  I  regard  it  as  probable  that  there  is  a  form  of  primary 
polycythemia  of  unknown  etiology,  characterized  principally  by  marked 
polyglobulism  and  other  hemic  features,  cyanosis,  headache,  vertigo,  and 
splenic  enlargement,  but  it  must  be  of  rare  occurrence."  *  On  the  other 
hand,  the  majority  of  cases  which  have  been  reported  have  had  a  diiferent 
etiologic  pathology,  circulatory  stasis  resulting  from  pressure  of  malignant 
tumors,  valvular  heart  disease,  and  the  like. 

Symptoms. — According  to  Reckzeh,^  the  first  symptoms  are  vertigo, 
headache,  mental  apprehension,  general  weakness,  and  gastro-intestinal 
disturbance.  In  fully-developed  cases  marked  cyanosis  of  the  skin  and 
mucous  membranes,  with  dilatation  of  the  veins  and  sometimes  hemor- 
rhages, are  prominent  features.  The  spleen  may  extend  downward  to  the 
level  of  the  umbilicus.  The  characteristic  blood-findings  are  an  enormous 
increase  of  the  hemoglobin,  rarely  to  150  per  cent.,  and  a  high  erythrocyte 

^  Osier,  Amer.  Jour.  Med.  Set,  November,  1902. 
^  S.  AVest,  in  Allbutt's  System  of  Medicine. 
^  Annals  of  Surgery,  July,  1901. 

*  Amer.  Jour.  Med.  Sci.,  June,  1907,  by  the  writer. 

*  Zeit.  f.  klin.  Med.,  vol.  Ivii.,  Nos.  3  and  4. 


490    DISEASES  OF  THE  BLOOD  AXD   THE  DUCTLESS  GLAyDS. 

count,  the  estimation  ranging  from  7,000,000  to  12.000,000  in  some  cases. 
The  leukocytes  vary  as  to  number,  but  often  about  normal  figures  are 
found.      The  total  volume  of  the  blood  is  decidedly  increased. 

Geisbcick  describes  a  second  form,  or  poJijcythrmid  Itypcrtonica  (ery- 
throcytosis),  in  Avhich  the  blood-pressure  is,  as  a  rule,  quite  high.  The 
majority  of  cases  are  associated  with  arteriosclerosis  and  nephritis,  but 
not  all.  Neither  is  viscosity  of  the  blood  responsible  for  the  rise  of 
arterial  pressure.  The  changes  in  the  bone-marrow,  in  one  case  at  least, 
were  identical  with  those  of  Vaquez's  disease.  In  this  variety  the  spleen 
is  not  enlarged,  but  otherwise  the  symptomatology  and  treatment  are  the 
same  as  in  polycythemia  with  splenic  enlargement. 

The  coui'se  is  exceedingly  chronic,  and  the  jji'ognosis  unfavorable. 

The  treatment  is  by  arsenic,  quinin,  and  an  iron-free  vegetable  diet 
and  a  carefully  regulated  mode  of  life.  The  iodids  have  been  advised 
in  order  to  decrease  the  viscosity  of  the  blood.  The  cerebral  symptoms 
have  been  benefited  by  the  nitrites.  A^enesection  has  proved  of  service 
in  some  cases.     Splenectomy  may  be  indicated. 


DISEASES  OF  THE  DUCTLESS  GLANDS. 

DISEASE      OF      THE      SUPRARENAL      CAPSULES. 
ADDISON'S   DISEASE. 

Definition. — A  constitutional  disease,  characterized  by  a  degenera- 
tion of  the  suprarenal  capsules  or  semilunar  ganglia,  a  bronzed  or  pig- 
mented skin,  great  bodily  and  mental  asthenia,  feeble  circulation,  and 
gastro-intestinal  irritability. 

This  afi"ection  is  named  In  honor  of  its  discoverer,  Thomas  Addison 
of  Guy's  Hospital,  London,  who  first  described  it  in  a  monograph  pub- 
lished in  1855,  entitled  "  The  Constitutional  and  Local  Eifects  of  Dis- 
ease of  the  Suprarenal  Capsules." 

Pathology. — Addison  emphasized  the  fact  that  while  the  supra- 
renal bodies  were  affected  Avith  a  fibro-caseous  alteration  in  many  cases, 
the  anatomic  changres  were  by  no  means  always  the  same.  Both  supra- 
renal capsules  are  usually  diseased  at  the  same  time.  Tuberculosis  is 
the  commonest  condition,  and  is  often  associated  with  tuberculous  lesions 
in  other  parts  of  the  body,  as  in  the  lungs,  bones,  and  other  glands. 
Rarely,  it  seems  to  be  primary,  no  other  evidences  of  tuberculous  infiltra- 
tion being  found.  The  capsules  are  enlarged,  firm  in  places,  and  nodu- 
lated on  the  surface,  owing  to  the  caseous  masses  surrounded  by  fibrous 
tissue.  Sometimes  there  is  marked  cicatricial  contraction  of  the  adrenals, 
and  the  adjacent  structures  may  be  found  matted  together  with  the  cap- 
sules. Microscopic  examination  shows  a  reticulum  of  connective  tis- 
sue surrounding  a  soft,  cheesy,  granular,  and  fatty  detritus,  lymphoid 
cells,  and  some  giant-cells.  Other  morbid,  non-tuberculous  processes  in 
the  adi'enals  are  atrophy  of  one  or  both  glands  from  interstitial  cirrhosis, 
carcinoma  or  sarcoma,  and  chronic  inflammation. 

Especial  attention  has  recently  been  given  to  the  condition  of  the 
solar  plexus  and  semilunar  ganglia  of  the  abdominal  sympathetic,  and 
implication  of  these  nervous  structures  by  compression,  cicatricial  contrac- 
tion, entangled  in  the  cicatricial  tissue  surrounding  the  suprarenal  bodies, 
or  by  chronic  inflammation,  is  not  infrequently  discovered,  together  with 
a  degeneration  and  deep  pigmentation  of  the  semilunar  ganglion-cells. 

Enlargement  of  the  solitary  and  agminated  follicles  of  the  intestine, 


ADDISON'S  DISEASE.  491 

and  slight  enlargement  and  some  softening  of  the  spleen  are  noted  at 
times  ;  parenchymatous  or  fatty  degeneration  of  the  heart,  liver,  and 
kidneys  has  also  been  noted  in  some  instances.  The  thymus  gland  may 
be  found  to  have  remained  normal,  or  even  to  have  enlarged,  perhaps. 
The  deposition  of  pigment  is  in  the  same  anatomic  elements  as  in  the 
negro — in  the  lower  layers  of  the  rete  Malpighii. 

The  pathologic  connection  between  the  symptomatic  phenomena  of 
Addison's  disease  and  the  anatomic  lesions  has  not  been  made  out. 
The  experimental  evidence  regarding  the  functions  of  the  adrenals  is 
imperfect;  but  it  seems  quite  probable  that  some  essential  "internal 
secretion,"  influencing  the  normal  metabolism  of  the  skin  and  muscles, 
is  diminished  or  absent  in  Addison's  disease.  On  the  contrary,  cases 
exhibiting  the  clinical  phenomena  of  this  affection  have  occurred  in 
which  no  suprarenal  morbid  processes  could  be  found  jjost  mortem. 
Again,  marked  changes  have  been  observed  in  these  glands,  while  dur- 
ing life  no  symptoms  of  the  disease  had  been  noted.  Hence,  it  is 
maintained  by  some  that  the  abdominal  sympathetic  nerves  and  ganglia 
are  directly  concerned  in  producing  the  clinical  manifestations,  either 
by  an  independent  morbid  process  or  by  extension  from  some  adjacent 
organ.  Others  hold  that  both  the  adrenals  and  the  sympathetic  ganglia 
are  the  seat  of  pathologic  changes.  The  data  are  not  sufficient,  however, 
to  determine  whether  the  principal  involvement  is  nervous  or  secretory. 

Htiology. — This  is  obscure.  It  has  been  held  that  some  infection 
of  the  blood  from  without  precedes  the  suprarenal  and  nervous  lesions 
of  Addison's  disease.  A  tuberculous  diathesis  or  infection  has  also  been 
emphasized  by  some  investigators,  and  Fleming  and  Miller^  have  re- 
ported a  family  with  probable  Addison's  disease.  A  history  of  injury 
to  the  trunk  has  been  noted  in  several  cases.  The  disease  is  more 
common  in  Europe  than  in  America,  though  it  is  rare  everywhere. 
Analysis  of  183  cases  showed  119  males  and  64  females  (Greenhow). 
While  the  disease  may  affect  all  ages  (it  may  even  be  congenital),  it  is 
usually  found  in  early  or  middle  life — between  fifteen  and  forty  years  of 
age.  That  Addison's  disease  is  due  either  to  a  general  neurosis  or  to  dis- 
turbed hematopoiesis  is  merely  hypothetic. 

Symptoms. — While  it  does  happen  not  seldom  that  tuberculosis 
or  carcinoma  affects  the  adrenals,  the  purest  and  most  typical  symp- 
toms of  Addison's  disease  are  apparently  primary  in  their  development, 
and  not  those  that  usually  attend  the  course  of  the  former  diseases. 

Cutaneous  Symptoms. — The  gradual  pigmentation  of  the  shin  of 
various  parts  of  the  body  may  be  one  of  the  first  evidences  of  the  affec- 
tion. This  pigmentation  may  have  either  a  dusky-yellow,  bronze  or 
yellowish-brown,  olive,  deep  or  greenish-brown,  or  even  black  color. 
Although  sometimes  diffuse,  the  discoloration  is  not  uniform  over  all 
parts  of  the  body,  but  commences  earlier,  and  becomes  deeper  especially 
on  the  exposed  parts  and  where  the  normal  pigmentation  is  marked,  as 
the  face,  neck,  backs  of  the  hands,  the  axillae,  abdomen,  groins,  genital 
regions,  and  the  areolae  of  the  nipples.  Pigment-spots,  often  somewhat 
bluish  in  color,  are  also  found  on  the  mucous  membranes  of  the  mouth, 
lips,  conjunctiva,  and  vagina.  On  the  lips  the  discoloration  takes  the 
form  of  a  dark  streak,  running  lengthwise,  near  the  junction  of  the 
skin  and  mucous  membrane ;  or  brownish  patches  or  streaks  cor- 
^Brit.  Med.  Jour.,  April  28,  1900. 


492     DISEASES   OF  THE  BLOOD   AND   THE  DUCTLESS   GLANDS 

responding  to  the  points  of  pressure  by  the  teetli  may  be  noticed. 
Irregular  stains  with  ill-defined  borders  may  also  be  shown  on  the 
skin,  corresponding  to  the  lines  of  pressure  exerted  by  garments, 
strings,  suspenders,  garters,  etc.  (Grecnhow).  White  patches  of  leu- 
koderma may  be  seen  here  and  there,  in  marked  contrast  to  the 
pigment-deposits.  The  "white  line,"  produced  by  drawing  the  finger 
lightly  over  the  skin  of  the  abdomen,  is  characteristic. 

General  Symptoms. — The  constitutional  symptoms  may  exist  in 
a  slight  degree  before  the  pigmentation  first  attracts  the  patient's 
attention.  There  is  gradual  and  progressive  asthenia  without  ap- 
parent cause,  great  lassitude  and  loss  of  physical  and  mental  energy, 
breathlessness,  headache,  dizziness,  tinnitus  aurium,  sighing,  and 
fatigue.  The  blood-examination  shows  a  moderate  reduction  of  the  ery- 
throcytes and  hemoglobin,  rarely  becoming  marked.  There  is  no  leuko- 
cytosis and  often  a  leukopenia.  The  fat,  particularly  of  the  abdomen, 
may  be  well  preserved. 

Circulatory  Symptoms. — The  heart's  action  is  weak  and  the  pulse 
small  and  feeble ;  attacks  of  faintness  and  palpitation  on  exertion  are 
common,  as  are  functional  murmurs  and  coldness  and  clamminess  of  the 
extremities.    The  blood  pressure  is  greatly  reduced  before  death  (Turner). 

G astro-intestinal  symptoms  are  usually  prominent.  There  is  a  loss 
of  appetite,  and  nausea  and  vomiting  may  occur  early  and  either  be 
paroxysmal  or  persistent.  The  tongue  may  be  clean,  and  the  gastric 
disturbances  do  not  seem  to  follow  errors  in  diet.  Diarrhea  may  be 
troublesome  in  the  latter  stage,  and  is  often  associated  with  intractable 
vomiting.  Neuralgic  attacks  of  either  sharp  or  dull,  aching  pain  are 
referred  to  the  epigastric,  hypochondriac,  and  lumbar  regions  in  about 
one-third  of  the  cases.  The  mind  is  usually  clear  until  near  the  last, 
but  mental  weariness  is  constant,  and,  as  the  latter  stages  of  the  disease 
come  on,  the  patient  often  lies  in  a  somnolent,  semi-comatose  state.  The 
physiognomy  expresses  fatigue,  dejection,  and  apathy;  the  speech  be- 
comes slow  and  incoherent,  and  in  many  cases  the  patient  passes  into 
delirium.  Prostration  is  profound,  the  weakness  being  disproportionate 
to  the  general  condition. 

Renal  Symptoms. — Polyuria  is  sometimes  evident,  but  albumin  is 
seldom  present.  The  amount  of  indican  is  increased,  as  it  is  in  the  urine 
of  all  of  the  cachectic  diseases  associated  with  destruction  of  albuminoids. 
There  is  usually  a  diminished  excretion  of  urea,  but  urobilin  and  uro- 
melanin  may  be  present  in  abnormal  quantity.  Tubercle  bacilli  may  be 
found  in  the  sputum. 

Diagnosis. — The  principal  error  in  diagnosis  is  in  the  assumption 
that  the  case  is  one  of  Addison's  disease,  simply  from  the  presence  of 
patches  of  pigmented  skin.  Other  conditions  in  which  the  discoloration 
may  simulate  that  of  Addison's  disease  are  the  following  :  (1)  Carcinom- 
atous and  tuberculous  disease,  particularly  when  seated  in  the  abdomen 
and  when  involving  the  peritoneum  ;  (2)  Hepatic  disease,  such  as  the 
cirrhosis  of  diabetes,  protracted  jaundice,  chronic  congestion,  and  lith- 
emia  ("  liver-spots  ") ;  (3)  Pregnancy,  and  uterine  disease,  in  which  the 
patchy  discolorations  (chloasmata)  appear  principally  upon  the  face : 
(4)  Irritation  of  lice  and  dirt  and  exposure,  as  in  the  case  of  tramps  and 
vagrants  ("vagabond's  disease");  (5)  Tinea  versicolor;  (6)  Melanotic 
sarcoma ;     (7)    Exophthalmic    goiter ;     (8)    Post-eruptive    staining    of 


ADDISON'S  DISEASE.  493 

syphilitic  eruptions;   (9)  l^lio  a(lminiHtr:i.tion   of  silver  nitrate  for  a  Ion;; 
time  (argyria)  ;  (10)  Marked  brunette  complexions  and  racial  admixture. 

When  the  pigmentation  is  scanty,  of  course  the  diagnosis  is  more 
difficult;  but  in  all  cases  of  pigmentation  in  which  other  causes  may  be 
excluded  the  progressive  asthenia,  unaccountable  vomiting  and  diarrhea, 
easily  compressible  pulse,  great  bodily  weakness,  mental  hebetude,  and 
lumbar  and  epigastric  pain  render  the  diagnosis  of  morbus  Addisonii, 
or  malasma  suprarenale,  justifiable.  The  bronzing  of  the  skin  may 
precede  as  well  as  follow  the  constitutional  symptoms. 

In  the  negro  the  diagnosis  of  this  affection  is  extremely  difficult,  }j(;th 
on  account  of  the  naturally  dark  skin  and  because  of  the  dark  discolora- 
tions  of  the  oral  mucous  membrane,  found  even  in  health. 

Prognosis. — The  course  of  Addison's  disease  is  almost  always  chronic, 
though  cases  have  been  reported  occasionally  in  which  the  onset  has  been 
sudden,  with  febrile  phenomena  and  a  comparatively  acute  course  of  a  few 
months,  or  weeks  even.  Usually  the  disease  lasts  about  one  year,  although 
some  cases  may  continue  over  five  or  even  ten  years.  Temporary  remis- 
sions may  be  observed,  but  death  is  inevitable  in  by  far  the  majority  of 
instances.  The  termination  is  gradual,  and  by  profound  asthenia,  or 
sometimes  by  coma,  delirium,  or  convulsions  (epileptiform). 

Treatment.- — The  hygienic  and  medicinal  treatment  must  have 
the  same  objects  in  view  as  in  the  other  grave  cachectic  diseases,  and 
is  both  sustentative  and  symptomatic.  As  quiet  a  life  as  possible  should 
be  strictly  enjoined,  owing  to  the  dangers  of  sudden  and  fatal  syncope. 
Rest  in  bed  is  necessary  in  moderate  and  advanced  cases  during  a  part 
of  the  day  for  the  former  and  constantly  for  the  latter.  The  diet  should 
be  restricted  to  light  nutritive,  concentrated,  and  easily  assimilable  food. 
Carbohydrates  in  the  diet  have  been  found  to  diminish  the  adynamia. 
An  absolute  milk  diet  may  be  necessary  in  some  cases. 

Iron  and  arsenic  may  be  administered  in  the  anemic  cases,  and 
strychnin,  guaiacol  carbonate,  phosphorus,  and  the  nuclein  preparations 
may  also  be  given,  along  with  bitter  tonics.  Bismuth  and  salol  may  be 
of  great  service  in  controlling  the  diarrhea  that  often  occurs.  The 
nausea  and  vomiting  may  be  relieved  by  unfermented  grape-juice, 
albumin-water,  champagne,  cracked  ice,  cerium  oxalate,  creasote,  and 
the  like.  Electricity  is  often  a  valuable  adjunct  in  the  treatment  of 
the  muscular  weakness  and  nervous  exhaustion,  and  even  in  reducing 
the  pigmentation. 

It  seems  quite  probable  that  the  administration  of  the  extract  of 
suprarenal  capsules  will  prove  to  be  of  considerable  value  in  causing 
marked  improvement,  if  not  a  permanent  cure,  in  a  certain  percentage 
of  cases.  In  one  instance  mentioned  by  Osier,  in  which  a  glycerin  ex- 
tract of  a  pig's  suprarenal  was  given  at  first  in  doses  of  half  a  glass 
three  times  a  day,  improvement  was  noted  in  the  temperature,  pulse, 
weight,  and  physical  and  mental  vigor  from  the  first  week  of  the 
treatment,  which  was  continued  for  three  months  and  a  half.  Eight 
months  after  the  treatment  was  begun  the  patient  appeared  to  be  well 
and  strong,  and  attended  to  business ;  the  pigmentation,  however,  was 
not  removed.  In  a  recent  case  of  my  own  this  remedy  produced  like 
results.  Robin  mentions  a  case  treated  by  the  administration  of  supra- 
renal gland  that  has  shown  persistent  good  health  for  three  years. 
For  the  present,  however,  too  positive  a  value  should  not  be  attributed 


494    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

to  the  suprarenal  extract,  and  results  contrary  to  the  above  are  to  be 
found  in  the  literature.  Grafting  of  the  gland,  inserting  only  small 
fragments,  has  been  proposed. 

DISEASES  OF  THE  THYMUS  GLAND. 
Physiologic  Pathology. — Nothing  is  known  definitely  concerning  the 
functions  of  the  thymus  gland.  At  the  end  of  the  second  year  of  life  it 
attains  its  greatest  development,  and  thereafter  slowly  and  gradually 
atrophies,  especially  after  puberty.  While  there  is  no  evidence  that  the 
thymus  produces  an  internal  secretion,  a  certain  imperfectly  understood 
"  relationship  exists  between  the  thymus  and  organs  that  do  produce  an 
internal  secretion,  such  as  the  thyroid  (in  Grave's  disease),  parathyroids, 
pituitary  body  (in  acromegaly),  the  ovaries,  testicles  (atrophying  as  the 
sexual  organs  develop),  etc.;  and  extracts  of  the  tliymus  are  said  to  cause 
a  fall  in  blood-pressure  and  rapid  action  of  the  heart  "  (A.  0.  J.  Kelly). 

ENLARGEMENT    OF    THE    THYMUS. 

The  thymus  may  become  enlarged  from  various  causes  (tumor  forma- 
tions, cyst  formations,  Grave's  disease,  acromegaly,  Addison's  disease, 
Hodgkin's  disease,  leukemia),  and  is  secondarily  affected  in  tuberculosis, 
syphilis,  and  pyogenic  infections.  On  the  other  hand,  atrophy  of  the 
thymus  has  been  observed  (e.  g.,  infantile  marasmus). 

STATUS    THYMICO-LYMPHATICUS. 
{Status  Lymphaticus;  Thymic  Asthma;  Hyperplasia.) 

Definition. — Hyperplasia  of  the  thymus  and  lymphatic  tissues, 
associated  with  corpulency  and  hypoplasia  of  the  heart  and  blood-vessels, 
and  characterized  clinically  by  stridor  and  sudden  death. 

Ktiology. — The  condition  is  met  with  in  young  children  with  persist- 
ent thymus,  although  in  most  cases  reported  hyperplasia  of  the  entire 
lymphatic  system  has  been  noted, — the  lymphatic  constitution  of  Paltauf. 
The  cause  of  the  constitutio  lymphatica^  however,  is  unknown.  Says 
Warthin,  "  Status  lymphaticus  may  be  the  consequence  of  a  number  of 
primary  morbid  processes,  such  as  syphilis,  rachitis,  some  latent  infection, 
auto-intoxication,  etc.,  that  are  characterized  by  excessive  demands  upon 
the  Wmphoid  and  myeloid  tissues."  Olniacher'  noted  in  18  cases  of 
epilepsy  a  large  thymus  gland  Avith  hyperplasia  of  the  lymphatic  glands 
throughout  the  body,  and  of  the  lymph  follicles  of  the  mucous  surfaces. 

Symptoms. — These  indicate  stenosis  of  the  air  tract.  There  is 
inspirator}'  and  expiratory  stridor,  as  a  more  or  less  audible  whistling 
respiration  (Schwinn).  There  are  cases  in  which  death  occurs  without 
previous  stridorous  dyspnea.  Avhile  in  others  the  stridor  is  congenital  or 
develops  soon  after  birth,  and  is  subject  to  exacerbations  on  slight  provo- 
cation, as  screaming  or  crying  or  as  a  result  of  an  acute  infection  (Kopp's 
asthma,  Millar's  asthma).  In  other  instances,  the  symptoms  of  suffocation 
precede  the  fatal  termination.  Potts  reports  4  cases  Avhere  children  died 
in  this  manner  after  tlie  insertion  of  a  tongue  depressor. 

Physical  Signs. — Among  jjhysical  signs  are — inspiratory  dilatation 
of  the  nostrils,  cyanosis,  and  marked  retraction  of  the  supraclavicular, 
infraclavicular,  and  intercostal  spaces.  The  fontanelles  are  sometimes 
^Philadelphia  Medical  Journal,  January  1,  1898;  Saunder's   Year-Book,  for  1899. 


THYROIDITIS.  495 

taut — this  in  the  absence  of  meningeal  retraction  is  a  sign  of  some  value. 
D'OeJsnitz^  emphasizes  tlie  unusual  extent  and  intensity  of  the  du  In  ess 
over  the  manubrium  and  toward  the  left.  Schrithle^  observed  enlarge- 
ment of  the  lingual  follicles.  For  diagnostic  purposes,  a  radiographic 
examination  gives  trustworthy  results. 

Prognosis. — The  prognosis  is  highly  unfavorable.  The  sudden 
death  is  due  to  thymic  enlargement  with  secondary  laryngeal  spasm. 

Treatment. — Any  recognizable  causative  factors,  e.  g.,  rachitis, 
anemia,  auto-intoxication,  etc.,  should  be  treated  on  accepted  therapeutic 
principles.  The  a;-rays  have  been  recommended.  Operation  with  a  view 
of  removing  the  offending  organ  should  be  undertaken,  although  there 
are  cases  in  which  the  child  expires  before  medical  aid  can  be  procured. 
Siegel  in  one  case,  a  boy  of  two  and  a  half  years,  elevated  and  stitched 
the  thymus  to  the  fascia  over  the  sternum,  with  the  result  that  the  threat- 
ening dyspnea  disappeared  and  the  child  eventually  made  a  good  recovery. 

DISEASES   OP   THE   THYROID    GLAND. 
THYROIDITIS. 

Definition. — Acute  inflammation  of  the  thyroid  gland.  The  gland 
may  either  have  been  previously  healthy  or  the  seat  of  a  goitrous  en- 
largement; when  inflammation  attacks  previously  diseased  or  enlarged 
thyroid  tissue  the  term  strumitis  is  often  used. 

Pathology. — The  gland  is  swollen,  boggy,  and,  generally,  the  seat 
of  abscesses ;  the  numerous  blood-vessels  are  engorged  ;  and  hemorrhages, 
thrombi,  and  areas  of  tissue-necrosis  are  found. 

Etiology. — Thyroiditis  is  seldom  primary  in  origin.  It  may  be 
caused  by  traumatism,  but  usually  it  is  secondary  to  one  of  the  infectious 
diseases  (small-pox,  typhus,  typhoid  fever,  malaria).  Rheumatism  has 
also  been  given  as  a  cause.  Hemorrhages  into  the  substance  of  a  goiter, 
whether  apoplectic  or  traumatic,  may  predispose  to  a  strumitis  that  may 
be  excited  by  the  introduction  of  streptococci  by  an  unclean  needle,  etc. 
Repeated  congestions  of  the  thyroid  or  a  simple  acute  congestion  may 
dispose  to  thyroiditis. 

Symptoms. — There  are  fever,  pain,  swelling,  and  suppuration  in 
one  or  the  other  lobe  of  the  gland.  Venous  obstruction  may  be  serious 
and  gives  rise  to  vertigo,  headache,  cyanosis,  and  epistaxis ;  and  com- 
pression of  the  windpipe  by  the  great  swelling  may  cause  death  before 
the  abscess  bursts.  Resolution  occurs  infrequently,  especially  in  the 
"strumous"  cases.  Indeed,  the  symptoms  of  a  strumitis  are  usually 
more  severe,  owing  to  the  greater  size  of  the  thyroid,  a  tendency  to 
metastasis,  and  to  the  burrowing  of  pus  into  adjacent  tissues  leading  to 
perforation  and  rupture  of  the  abscess  into  the  trachea  or  esophagus. 

Diagnosis. — Thyroiditis  must  be  differentiated  from  the  laryngeal 
'perichondritis  that  is  also  seen  in  the  course  of  infectious  diseases,  as 
typhoid  fever  and  small-pox.  Simple  congestion,  especially  in  women 
from  emotional  or  menstrual  disturbances  and  interference  with  the  circu- 
lation from  tight  collars  and  the  like,  must  be  excluded. 

Sclerotic  Thyroiditis. — Riedel  has  described  a  form  of  thyroiditis  of 
rapid  development  involving  the  entire  gland,  with  fibrous  connective- 
tissue  formation  and  adhesions  to  surrounding  structures.     Serious  sjmp- 

^  Bull,  de  la  Soc.  de  Pediat,  Paris,  Dec,  1911. 
^Muench.  Med.    Woch.,  Nov.  26,  1912. 


496     DISEASES  OF  THE  BLOOD  AXD   THE  DUCTLESS  GLANDS. 

toms  may  result  from  compression  of  the  trachea  and  recurrent  laryn- 
geal nerves. 

Prognosis. — The  outcome  is  usually  favorable  in  all  cases  in  which 
spontaneous  rupture  occurs  externally  or  Avhen  evacuation  of  the  pus  is 
effected.      ^lyxedema  may  result  from  destruction  of  the  gland. 

Treatment. — This  is  antiphlogistic  and  surgical.  The  pus  must  be 
evacuated,  and  tracheotomy  or  thyroidectomy  may  become  necessary. 

GOITER. 

{Simple   (loiler ;  Stnnna  ;  Bronchoede.) 

Definition. — A  chronic  hypertrophy  and  hyperplasia  of  a  portion 
or  the  whole  of  the  thyroid  gland.  It  is  of  obscure  origin,  and  is  subject 
to  various  degenerative  changes. 

Pathology. — Several  different  varieties  are  described.  In  the  simple 
Jiypertropliic  or  parenchymatous  form  there  is  a  hyperplasia  of  all  the 
original  tissue-elements.  The  foUieular  form  shows  an  increase  of  the 
true  glandular  elements  alone. 

Fibrous  f/oitcr  is  that  variety  in  which  the  interstitial  tissue  or  stroma 
is  increased  out  of  all  proportion  to  the  hyperplasia  of  the  follicles.  This 
variet}^  of  goiter  may  have  an  inflammatory  origin  (thyroiditis).  In  old 
cases  marked  sclerosis  may  be  assumed.  There  is  a  vascular  variety,  in 
which  the  blood-vessels  are  enormously  dilated.  More  commonly  the 
veins  are  affected,  but  in  the  aneurysmal  variety  the  arteries  are  chiefly 
involved.  The  intense  venous  variety  of  vascular  goiter  has  been 
denominated  "  cancerous  tumor  of  the  thyroid,"  and  the  whole  gland 
may  in  such  cases  be  quite  elastic  and  like  spongy  erectile  tissue.  Fol- 
licular hyperplasia  is  often  associated  with  vascular  enlargement. 

The  special  varieties  of  goiter  due  to  degenerative  changes  are  the 
cystic,  amyloid,  colloid,  and  calcareous,  and  of  these  the  first  named  is 
the  most  common.  It  consists  in  the  development  in  a  large  goiter  of 
one  or  more  large  or  small  cysts  filled  with  different  kinds  of  fluid  of 
varying  consistency.  Sometimes  the  liquid  is  colloid  or  mucinous  in 
nature,  and  contains  the  residue  of  hemorrhages  (cholesterin  and  fatty 
products).  Amyloid  changes  affect  principally  the  vessels;  colloid  changes 
are  also  frequent,  while  calcareous  infilti-ation  is  seen  in  old  fibrous  goi- 
ters.    Inflammation  and  suppuration  of  the  goitrous  gland  may  ensue. 

Ktiology. — Goiter  may  occur  anyw^here  sporadically.  Endemically 
and  in  its  worst  forms  it  occurs  in  the  mountainous  districts  of  Europe, 
Asia,  Mexico,  and  South  America,  particularly  in  the  Alps,  Pyrenees, 
and  Andes.  It  has  also  appeared  in  certain  limestone  regions,  such  as 
New  England  and  Ontario,  Canada,  where  the  habitual  use  of  limestone- 
water  for  drinking  purposes  seems  to  induce  the  disease.  Heredity 
undoubtedly  plays  a  part  in  its  causation,  certain  children  having  been 
born  with  goiter.  Occasionally  it  has  become  epidemic  in  certain  sec- 
tions of  the  goitrous  districts  in  Europe  where  military  garrisons  have 
been  stationed,  thus  indicating  the  possibility  of  some  infectious  influ- 
ence. Women  are  more  liable  to  goiter  than  men,  and  it  is  more  com- 
mon to  find  it  after  ten  or  twenty  years  of  age.  It  has  been  alleged 
that  pregnancy  also  influences  the  development  of  this  condition. 

Symptoms. — The  enlarged  thyroid  is  readily  recognized  and  felt. 


GOITER.  497 

though  the  patient  may  complain  of  iiothin;^  but  the  (lisfi<.njrem(;iit,  ex- 
cept when  the  tumor  is  of  sufficient  size  to  cause  sym]jtorns  of  compres- 
sion. The  goiter  develops  very  gradually,  and  may  vary  in  dimensions 
from  the  merest  perceptible  enlargement  to  a  growth  that  overhangs 
the  chest  and  greatly  hinders  the  movements  of  the  head.  It  may  or 
may  not  be  uniform  in  its  development,  and  is  often  more  enlarged  on 
the  right  side  and  in  front  than  on  the  left  side.  It  is  not  infrequently 
observed  to  increase  in  size  with  each  succeeding  pregnancy  and  during 
or  after  each  menstrual  flux. 

The  tumor  is  painless,  is  not  adherent  to  the  overlying  skin  or  to 
any  of  the  neighboring  bones,  and  rises  and  falls  during  the  act  of 
swallowing,  moving  with  the  larynx.  The  veins  covering  it  are  swollen 
and  prominent.  It  interferes  with  respiration  oftener  than  with  deglu- 
tition, causing  dyspnea ;  alteration  or  loss  of  the  voice  may  also  ensue. 
Displacement  and  distortion  of  the  trachea,  the  vessels,  and  other  cer- 
vical tissues  may  be  produced.  Large  pendulous  growths  usually  cause 
less  serious  discomfort  than  the  small  encircling  tumors  that  extend 
dowuAvard  into  the  thorax.  Headache,  somnolence,  and  marked  cere- 
bral symptoms,  such  as  tetany  and  convulsions,  have  been  described. 

The  general  health  or  nutrition  seldom  fails  unless  inflammation  and 
suppuration  (strumitis)  attack  the  goiter  during  the  course  of  some  in- 
fectious disease,  as  not  infrequently  happens,  or  in  cases  in  which  the 
thyroid  function  is  abolished,  leading  to  the  profound  nutritional  and 
cerebral  disorders  of  cretinism  in  children  or  myxedema  in  adults. 

Dettrich  and  Osier  have  each  reported  an  instance  of  a  goitrous 
growth  afi"ecting  aberrant  portions  of  thyroid  found  in  the  upper  region 
of  the  pleural  cavity,  one  on  the  right  and  one  on  the  left  side. 

Sudden  death  may  ensue  in  a  few  cases,  either  from  pressure  on  the 
vagi,  or  from  a  severe  hemorrhage. 

Auscultation  often  reveals  a  loud  blowing  murmur,  especially  marked 
in  the  vascular  bronchoceles.  Palpation  over  the  tumor  often  shows 
the  bossellated  surface  present  in  cystic  goiter ;  fluctuation  may  also 
be  detected  in  such  cases,  as  well  as  over  the  abscess  of  a  strumitis. 

Diagnosis. — Goiter  is  easily  difi"erentiated  from  other  enlargements. 
The  constant  location  and  the  character  and  course  of  growth  of  thq 
bronchocele  are  distinctive.  If  both  lobes  of  the  thyroid  are  aff"ected, 
making  a  symmetric  swelling,  the  diagnosis  is  almost  assured.  Bron- 
chocele is  not  easily  confounded  with  other  cervical  tumors,  such  as 
lymphadenoma,  glandular  tuberculosis,  carcinoma  or  abscess  of  the  thy- 
roid, or  sebaceous  cysts.  A  characteristic  feature  of  tumors  of  the  thy- 
roid is  their  vertical  movement  during  the  act  of  deglutition. 

Prognosis. — This  is  guardedly  favorable  as  to  life,  but  unfavorable 
as  to  cure.     The  course  is  chronic. 

Treatment. — Prophylaxis  should  be  practised  in  goitrous  districts 
by  the  drinking  of  boiled  water  only,  and  removal  to  a  non-goitrous  region 
is  advisable.  The  majority  of  drugs  recommended  for  internal  and  ex- 
ternal use  have  been  proved  valueless,  though  in  the  parenchymatous 
and  follicular  forms  potassium  iodid  by  the  mouth  and  the  vigorous  and 
methodic  use  of  iodin  over  the  tumor  have  been  much  lauded.  Mer- 
curial ointment — the  red  or  biniodid  especially — has  also  been  recom- 
mended for  local  application.  Ergot  or  belladonna  in  progressively 
increasing  doses  may  do  good  in  vascular  goiters.     The  younger  and 

32 


498    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

softer  goiters  may  also  be  benefited  by  electrolysis,  needles  attached  to 
the  negative  pole  being  inserted  into  Uie  substance  of  the  tumor  while  a 
large  sponge  or  clay  positive  electrode  is  placed  in  the  vicinity. 

In  the  older,  fibrous,  and  degenerated  goiters  surgical  treatment 
alone  may  be  of  service.  Injections  of  iodin,  tapping  of  cysts,  incisions 
of  the  isthmus,  and  ligature  of  the  thyroid  arteries  have  been  practised 
among  the  lesser  operations.  Thyroidectomy,  or  a  partial  extirpation 
of  the  thyroid,  is  the  radical  and  final  operation.  Recently,  the  fresh, 
chopped  thyroid  gland  of  the  sheep,  spread  on  bread,  was  given  in  20 
cases  of  follicular  and  parenchymatous  goiter  with  gratifying  results. 
Complete  recovery,  iu  an  anatomical  sense,  however,  was  realized  in  two 
cases  only.  The  administration  of  thyroid  has  transformed  several  cases 
of  simple  goiter  into  those  of  the  exoj>hthalmic  type.  McCarrison*  has 
treated  33  cases  by  means  of  a  composite  vaccine,  with  marked  success. 

EXOPHTHALMIC    GOITER. 

{Hyperthyroidism;   Graved  Disease;  Basedou^s  Disease.) 

Definition  and  Nature. — Although  the  view  cannot  be  unreservedly 
accepted,  exophthalmic  goiter  is  probably  of  thyroid  origin  and  is  de- 
pendent upon  an  abnormal  action  (or  over-action)  of  the  thyroid  gland ; 
it  is  characterized  clinically  by  tachycardia,  tremors,  enlarged  thyroid, 
and  exophthalmos.  Among  other  leading  theories  the  following  may 
be  briefly  stated :  (1)  that  it  is  due  to  disturbed  innervation  (Buschan) ; 
(2)  that  the  seat  of  the  disease  resides  in  the  medulla  oblongata ;  (3)  that 
it  is  an  afi"ection  of  the  sympathetic  nerves ;  and  (4)  that  it  is  a  disease  of 
the  central  nervous  system  associated  with  a  chronic  intoxication. 

The  theory  held  by  Mobius,  that  exophthalmic  goiter  is  attributable 
primarily  to  a  disturbance  of  the  function  of  the  thyroid  ("  hyperthyroid- 
ation  "),  a  condition  directly  opposed  to  the  lack  of  thyroid  function,  as 
in  myxedema,  is  amply  supported  by  clinical  evidence,  the  complex  symp' 
tom-group  of  the  former  being  directly  antagonistic  to  that  of  the  latter 
disease.  Thyroid-feeding,  moreover,  while  it  sometimes  causes  paren- 
chymatous goiters  to  disappear  rapidly,  usually  aggravates  the  symptoms 
of  Basedow's  disease.  Regarding  the  pathologic  changes  in  the  thyroid 
little  is  known.  Brissaud  ^  found  in  25  cases  changes  in  the  thyroid 
and,  although  the  glands  showed  no  changes  peculiar  to  this  disease,  yet 
quantitatively  the  lesions  were  always  such  as  to  make  "  hyperthyroida- 
tion  "  possible.  A  parenchyma  increase,  in  direct  proportion  to  the 
intensity  of  the  symptoms,  occurs  (L.  B.  Wilson).  Persistence,  and 
sometimes  hypertrophy,  of  the  thymus  gland  may  be  causally  related. 
Hector  Mac-Kenzie^  believes  that  atrophy  of  the  parathyroids  may  be 
the  cause  of  some  of  the  more  serious  symptoms.  Muscular  changes, 
probably  resulting  from  toxemia,  explain  the  profound  muscular  weakness 
(Askanazy).  Jaunin^  and  Gautier^  contend  that  chronic  iodism  and 
exophthalmic  goiter  are  practically  tlie  same  condition.  Minor**  affirms 
that  the  disease  may  be  due  to  gastro-intestinal  auto-intoxication. 

Htiology. — It  is  more  common  in  women  than  in  men.  A  table  of 
200  cases  showed  161  females  and  3'.l  males  (Eshner) ;  and,  although  it 
has  been  met  with  at  both  extremes  of  life,  it  is  seen  usually  in  adults. 
The  influence  of  heredity  is  undoubted,  and  several  members  of  a  family 

1  Lancet,  Lond.,  Feb.  10,  1912.  2  Mercredi  med.,  No.  34,  1895. 

3  Brit.  Med.  Jour.,  Oct.  28,  1905.  ■*  Rev.  med.  de  la  Suisse  rom.,  No.  5,  p.  30],  1899. 

5  Med.  Bee.,  Dec.  2,  1899.  ^  Jbij^ 


EXOPHTHALMIC  GOITER.  499 

may  suffer,  persons  that  possess  a  sensitive  nervous  organization  being 
especially  prone  to  the  disease.  Exophthalmic  goiter  may  develop  after 
a  trauma. 

Among  direct  causes  are  emotional  disturbance,  worry,  severe  acute  dis- 
ease (noted  in  two  of  my  cases),  and  prolonged  mental  or  physical  strain. 

The  disease  may  also  occur  as  a  secondary  complication  in  the  course 
of  simple  goiter,  affections  of  the  nose,  and  pregnancy ;  this  variety, 
however,  is  to  be  distinguished  from  the  primary  or  essential  form. 

Symptoms. — The  development  of  the  characteristic  symptoms  is 
generally  gradual,  though  it  may  rarely  be  rapid.  In  the  so-called  abor- 
tive form  the  symptoms  arise  somewhat  rapidly,  but  early  subside. 

In  acute  Basedow's  disease  the  symptoms  consist  of  an  excessively 
rapid  action  of  the  heart,  incessant  vomiting,  purging,  and  marked 
exophthalmos,  with  or  without  pronounced  cerebral  symptoms.  J.  H. 
Lloyd's  case  proved  fatal  after  an  illness  of  three  days.  Schlesinger 
insists  that  acute  exophthalmic  goiter  should  be  suspected  in  every  case 
of  rapid  loss  of  weight. 

In  the  chronic  form  heart-hurry  is  almost  constantly  a  conspicuous 
early  symptom,  and  not  seldom  have  I  found  that  it  precedes  for  a  long 
period  of  time  the  appearance  of  the  remaining  characteristic  features 
(enlargement  of  the  thyroid,  exophthalmos,  and  tremor).  The  pulse 
remains  at  or  over  100  beats  per  minute,  and  upon  unusual  exertion  or 
excitement  the  heart's  action  becomes  violent  and  irregular,  the  pulse 
even  reaching  160  or  over.  Palpitation,  often  with  breathlessness,  is  a 
distressing  symptom. 

Cardiac  Physical  Signs. — Inspection  reveals  a  forcible  impulse  that  is 
not  displaced,  though  late  in  the  affection  it  may  be  much  extended  in 
superficial  area.  The  carotids  and  the  abdominal  aorta  beat  violently, 
and  the  capillaries  and  veins  of  the  hands  may  also  pulsate  visibly. 
Palpation  detects  an  increased  force  of  the  cardiac  impulse.  The  area 
of  percussion-dulness  may  be  someAvhat  increased,  as  hypertrophy  and 
secondary  dilatation  supervene.  On  auscultation,  blowing  murmurs  over 
the  heart  and  great  vessels,  as  well  as  an  increased  accentuation  of  the 
valvular  sounds,  may  be  audible  for  some  distance  from  the  patient. 
Distinct  bruits  may  be  heard  over  the  base  and  manubrium. 

Uxophthabnos. — Protrusion  of  the  eyeballs  is  usually  present.  The 
degree  of  exophthalmos  varies  greatly  from  time  to  time  in  the  same 
case — a  fact  that  points  to  an  increased  amount  of  blood  or  lymph  in  the 
orbit  as  its  cause.  In  advanced  cases  permanent  prominence  of  the  balls 
may  be  attributable  to  augmentation  of  the  orbital  adipose  tissue.  On 
closing  the  eyes  a  rim  of  white  is  visible  above  and  below  the  cornea  ;  this 
and  Graefe's  sign,  immobility  of  the  upper  lid  when  the  eye  is  turned 
downward,  are  two  symptoms  of  great  diagnostic  importance.  Mdbius  has 
called  attention  to  the  inability  to  converge  the  eyes  upon  near  objects  ; 
and  Stellwag,  to  an  apparent  separation  of  the  eyelids,  due  to  spasm  or 
retraction  of  the  upper  lid.  The  pupils  and  the  vision  are  unaffected, 
while  the  patient  winks  less  often  than  in  health.  Slight  momentarv 
retraction  of  the  upper  eyelids  occurs  on  gazing  at  some  object  if  the 
latter  be  moved  rapidly  up  and  down  (Kocher).  Abnormalities  are 
rarely  presented  by  the  optic  nerves,  and  ulceration  of  the  cornea  may 
supervene.     The  retinal  arteries  pulsate. 


500    DISEASES  OF  THE  BLOOD  AXD    THE  DUCTLESS   GLANDS. 

TJii/roU  fnlarjjeuient  may  eitlier  accompiiny  or  follow  the  exophthal- 
mos, ami  has  for  its  cause  the  great  dilatation  of  the  vessels,  particu- 
larly of  the  arteries.  The  enlargement  is  usually  moderate,  and  may 
be  general  or  partial,  the  size  of  the  gland  exhibiting  sudden  variations, 
since  it  is  dependent  upon  the  circulatory  disturbance.  Inspection  may 
also  show  visible  pulsation  ;  palpation  feels  a  thrill,  and  Kocher  states 
that  an  important  sign  is  tenderness  of  the  thyroid.  Auscultation 
renders  audible  a  double  systolic  murmur.  The  latter  sign  is  probably 
present  in  most  instances,  though  not  constantly. 

Nervous  Symptoms. — Muscular  tremors  i'orm  an  early  symptom  ;  they 
are  involuntary,  and  fine  in  character,  numbering  about  eight  to  the 
second  (Osier).  The  characteristic  features  of  neurast/ienia  appear 
and  gradually  increase  in  intensity.  Mental  disturbances,  particularly 
marked  depression  or  great  excitability,  are  common,  and  even  mania 
(which  may  prove  speedily  fatal)  or  melancholia  may  be  observed. 

Cutaneous  Symptoms. — The  temperature  may  at  intervals  be  mode- 
rately elevated,  and  this  symptom  may  be  associated  with  profuse  sweat- 
ings. Among  other  cutaneous  phenomena,  though  these  are  for  the 
greater  part  occasional,  are  pigmentation  (which,  in  the  case  of  a  physi- 
cian whom  I  recently  saw  suffering  from  Basedow's  disease,  was  as  pro- 
nounced as  in  typical  Addison's  disease),  scleroderma,  urticaria,  pruritus, 
and  circumscribed  solid  edema.  In  the  advanced  stage  malleolar  edema 
sets  in  and  may  become  general.  A  marked  diminution  in  the  cutaneous 
resistance  to  the  electric  current  has  been  noted  by  Charcot.  The  fore- 
head is  not  wrinkled  as  in  health. 

General  Symptoms. — Muscular  weakness,  either  local  or  general,  is 
pronounced;  the  patient  becomes  anemic  and  is  at  last  extremely 
emaciated.  An  early  sign  is  leukopenia,  the  neutrophiles  being  much 
reduced,  while  the  lymphocytes  are  twice  the  normal  figure.  Vomiting 
and  purging  may  appear  at  different  times  and  gastric  achylia  is  commonly 
present,  and  in  some  cases  hemorrhages  (epistaxis,  hemoptysis,  hemate- 
mesis)  tend  to  supervene.  Fatty  stools  have  been  observed  (Bittorf, 
Falta).  Albuminuria  and  an  increased  amount  of  urine,  with  glycosuria, 
are  among  the  commoner  complications.  Louise  Bryson  has  maintained 
that  diminution  in  the  chest-expansion  is  a  characteristic  sign  of  exoph- 
thalmic goiter ;  and  Patrick,^  who  examined  40  cases,  found  that  there 
was  an  average  diminution,  but  believed  it  to  be  proportionate  to  the 
amount  of  muscular  weakness.  Rarely  a  myxedematous  condition  is  as- 
sociated ;  probably  the  disease  is  also  remotely  related  to  scleroderma. 

Diagnosis. — The  diagnosis  of  Graves's  disease  may  be  made  when 
tachycardia  or  delirium  cordis  and  fine,  general  muscular  tremors  are 
present.  Exophthalmos  and  enlargement  of  the  thyroid  are  often  late- 
appearing  symptoms,  and  are  as  often  temporarily  lacking  even  in  fully- 
developed  cases.  Rarely,  either  or  both  of  these  signs  may  be  perma- 
nently absent.  On  the  other  hand,  in  a  few  cases  exophthalmos  is  the 
sole  characteristic  feature  for  a  long  time,  though  it  is  eventually  fol- 
lowed by  an  unmistakable  symptom-group.  Dernini  emphasizes  tempo- 
rary increase  in  the  clinical  diameters  of  the  heart  after  exertion,  as  a  diag- 
nostic feature.      I'areuchymatous  goiter  presents  a  non-pulsating  tumor. 

Course  and  Prognosis. — The  chronic  form  of  the  disease  endures, 
as  a  rule,  for  a  few  years.     A  gradual  subsidence  of  the  cardinal  symp- 
>  Deutsche  med.  Woch.,  Dec.  20,  1894. 


EXOPHTHALMIC  GOITER.  501 

toms  for  a  long  period  has  been  noted,  and  in  such  cases  complete  recov- 
ery may  be  claimed.  In  fully-developed  cases  the  prognosis  formerly  was 
almost  hopeless,  but  since  the  introduction  of  the  operative  treatment 
many  cases  have  been  greatly  benefited,  and  others  cured.  The  disease 
assumes  a  more  aggravated  form  in  males  than  in  females.  Koclier  found 
that  the  coagulation  process  is  retarded — the  more  so,  the  graver  the 
infection. 

Treatment. — This  is  {a)  Hygienic,  (b)  Medicinal,  and  (c)  Operative. 

(a)  Hygienic. — The  environment,  both  physical  and  mental,  should  be 
made  as  favorable  as  possible.  A  change  of  climate,  and  especially  mod- 
erate elevation,  in  cases  not  too  far  advanced,  bring  about  beneficial  re- 
sults. Such  elevation  (3250  feet)  produces  a  sedative  effect  upon  the 
nervous  state  that  reacts  most  favorably  upon  the  circulatory  organs, 
while  the  purity  and  tonic  quality  of  the  air  have  a  general  strengthening 
and  restorative  eifect  (Yeo).  Among  other  promising  measures  may  be 
mentioned  the  wet-pack,  methodical  hydrotherapy  with  massage,  and  a 
continuous  galvanic  current.  The  electric  treatment  should  be  given  a 
thorough  trial  over  three  or  four  months  (Osier).  The  local  use  of  an  ice- 
bag  to  the  precordium  has  acted  admirably  in  reducing  the  heart-hurry  in 
a  few  cases  of  my  own.  Rest  in  bed  for  a  few  weeks  at  a  time,  at  inter- 
vals, is  often  followed  by  improvement.  The  diet  should  be  carefully 
supervised,  according  to  the  indications  of  special  cases. 

(b)  Medicinal  Treatment. — This  is  probably  secondary  to  the  hygenic 
and  operative  measures.  In  two  cases  of  my  own,  however,  recovery  fol- 
lowed the  persistent  use,  for  about  six  months,  of  the  following  prescrip- 
tion : 

]^.  Extr.  digitalis,  gr.  iv  (0.259)  ; 

Extr.  ergotae  (Squibb),  3S8      (2.0) ; 

Strychninse  sulph.,  gr.  ss  (0.032)  ; 

Ferri  arseniatis,  gr.  ij  (0.129). 
M.  et  ft.  capsulse  No.  xxiv. 
Sig.   One  t.  i.  d.  after  meals. 

In  2  other  cases  (one,  a  trained  nurse)  the  use  of  sodium  salicylate  (gr.  x- 
0.648 — four  times  a  day)  was  followed  by  almost  total  relief.  L.  Webster 
Fox,  Waller,  and  others  also  warmly  advocate  the  latter  remedy  in  this 
aff'ection.  Trachewsky,  in  Kocher's  clinic,  found  that  sodium  glycero- 
phosphate (gr.  XX — 1.296 — three  or  four  times  a  day),  had  the  eff'ect  of 
diminishing  the  size  of  the  enlarged  thyroid  glands,  and  Starr^  has  also 
found  this  remedy  of  great  service  in  several  cases.  Other  therapeutic 
agents  that  have  been  extensively  employed,  but  with  doubtful  advantage, 
are  aconite,  veratrum  viride,  and  belladonna.  From  all  of  the  clinical 
testimony  at  hand  I  feel  convinced  that  thyroid-feeding  is  contraindicated 
in  the  treatment  of  Basedow's  disease,  unless  a  myxedematous  condition 
be  associated,  when  it  may  prove  efficient.  S.  Solis-Cohen  and  others 
have  used  extract  of  suprarenal  gland  with  good  results.  W.  Gr.  Thompson 
holds  that  the  exacerbations,  which  are  of  a  toxemic  character,  may  be 
completely  checked  by  the  cytotoxic  serum  of  Rogers,  prepared  from  the 
diseased  human  glands  through  animal  inoculation.  Krumliolz^  holds 
that  serum  of  thyroidectomized  animals  is  the  most  valuable  drug  yet  offered. 
Antithyroid  preparations,  such  as  thyroidotoxin,  give  promise  of  good 
1  Medical  News,  April  18,  1896.  ^  JiUnois  Medical  Journal,  Mai-ch,  1910. 


502    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

results.  Mcibius's  thyroidin  (a  preparation  of  the  blood  of  sheep  in  which 
the  thyroid  jrland  has  been  removed  some  time  previously)  has  given  good 
results.  The  dose  is  from  2  to  12  drops  daily,  given  for  a  period  of 
twenty  days.  Shattuck  advises  neutral  bromid  of  quinin,  and  F.  Bill- 
ings, the  hydrobromid  (gr.  v — .324  four  times  daily),  for  its  vasocon- 
stricting  eftects.  Lecithin  is  found  useful  when  digestion  is  undisturbed, 
but  "  it  fails  without  the  assistance  of  a  milk  diet"  (Berkley). 

(c)  Operative  Treatment. — Starr'  has  collected  190  cases  in  which 
some  form  of  operation  was  ])erformed.  Of  these,  74  are  reported  as  com- 
pletely cured,  many  of  them  having  been  watched  two  to  four  years 
before  the  result  was  published ;  45  of  the  cases  were  improved,  and 
23  died  immediately  after  operation.  The  symptoms  preceding  the 
fatal  result  are  sudden  hyperpyrexia,  with  rapid  pulse,  nervous  distress, 
sweating,  cardiac  failure,  and  collapse.  The  statistics  of  Kinnicutt  and 
of  Abram  -  (particularly  the  latter)  show  less  encouraging  results  from 
operation.  It  is  to  be  remembered  that  under  the  most  favorable  cir- 
cumstances a  complete  cure  will  not  be  attained  immediately.  In  cases 
unimproved  by  non-operative  treatment  in  a  reasonable  time,  partial 
thyroidectomy  may  also  be  advised.  Bilateral  resection  of  the  sym- 
pathetic nerve  has  been  done  by  Schwartz  and  others  with  marked 
benefit.  Rehu  ^  presents  a  statistical  report  of  32  resections  of  the  sym- 
pathetic :  31.1  per  cent,  were  cured;  50  per  cent,  improved,  12.5  per 
cent,  were  unimproved,  and  9.5  per  cent,  proved  fiital.  F.  Hartley  * 
states  that,  compared  with  sympathectomy,  partial  thyroidectomy  yields 
better  results,  both  as  regards  mortality  and  cures.  Crile  claims  benefits 
from  ligation  of  the  thyroid  artery,  which  breaks  the  nerve  supply 
between  the  brain  and  the  thyroid  gland.  Both  in  acute  exophthalmic 
goiter  and  during  an  acute  exacerbation  of  the  chronic  form  operative 
intervention  is  contraindicated.  Kuh^  employed  the  serum-treatment  in 
11  cases  with  marked  improvement  in  the  subjective  condition  of  the 
patients.  Pfahler  noted  decided  improvement  from  the  2;-ray  treatment 
in  about  75  per  cent,  of  51  cases.  Berger  and  Schwab  also  contend 
that  this  agent  is  fully  equal  to  any  therapeutic  measure. 

MYXEDEMA. 
(Hypothyroidism ;  Sporadic  Crelinis.m.) 

Definition. — A  nutritional  disorder,  consequent  upon  atrophy  and 
loss  of  function  of  the  thyroid  gland,  characterized  by  a  myxedematous 
infiltration  of  the  subcutaneous  tissue  and  a  cretinoid  cachexia. 

Three  varieties  occur,  as  follows  :  (1)  True  myxedema ;  (2)  Cretinism 
(the  absence  of  thyroid  function — congenital,  or  lost  during  childhood)  ; 
(3)  Operative  myxedema,  due  to  total  removal  of  the  glands  for  surgical 
reasons  or  in  experiments  upon  lower  animals. 

Nature  of  Myxedema  Proper  of  Adults. — Charcot,  who  gave  the  name 
of  cachcxie  yacJiyilermique  to  this  disease,  believed  it  to  be  of  tropho- 
neurotic origin.  Atrophy  of  the  thyroid  is  pretty  constantly  present, 
and  the  gland  may  either  be  converted  into  a  small  fibrous  mass  or  be 
entirely  absent,  so  that  the  causal  relation  between  myxedema  and 
functional  and  structural  alterations  of  the  thyroid  seems  to  be  conclu- 

1  Loc.  cit.  2  American  Year-Book  of  Mediciim  aiul  Surgery,  1897. 

3.S'oc.  Rep.,  Munch,  med.  Woch.,  No.  41,  p.  1357,  1899. 

*  Annah  of  Surgery,  July,  1905.  ^  Medicine,  September,  1905. 


MYXEDEMA.  503 

sive.  Moreover,  the  therapeutic  test  of  improvement  under  the  admin- 
istration of  thyroid  extract  sustains  this  view.  It  is  probable  that  the 
active  thyroid  supplies  some  essential  secretion  wiiicli  maintains  normal 
metabolism,  though  tliis  j)roduct  has  not  been  isolated.  Its  existence 
being  inferred,  however,  it  has  been  called  iodothi/rin.  Ponfick  has 
pointed  out  that  the  hypophysis  sometimes  shows  changes  resembling 
those  in  the  thyroid  gland.  The  fact  that  in  a  good  many  cases  of 
myxedema  a  considerable  portion  of  the  thyroid  gland  is  unaltei-ed  and 
partly  capable  of  functionating  ai'ouses  a  suspicion  that  the  hypophysis 
may  share  in  the  production  of  this  disease.  The  thymus  has  been  found 
to  be  enlarged  in  myxedema. 

Ktiology. — The  thyroid  was  destroyed  by  actinomycoHis  in  a  case 
of  myxedema  reported  recently.  Myxedema  may  also  be  secondary  to 
exophthalmic  goiter,  but  it  is  then,  as  in  the  case  of  a  simple  acute  goiter, 
only  a  transient  condition.  Women  are  much  more  frequently  affected 
than  men,  and  a  neurotic  condition  may  precede  some  cases.  The  dis- 
ease may  affect  several  members  of  a  family,  and  hereditary  transmission 
through  the  mother  has  been  observed.  Sisters  may  suffer,  one  from 
myxedema  and  the  other  from  exophthalmic  goiter.  Doderlein  ^  reports 
the  case  of  a  child  born  with  typical  myxedema.  Pregnancy  may  cause 
a  disappearance  of  the  myxedematous  symptoms  (Osier).  The  vSymptoms 
may  reappear  after  delivery. 

Symptoms. — The  myxedematous  condition  is  most  plainly  noted  in 
the  face,  the  skin  being  swollen,  but  inelastic,  rough,  dry,  and  firm. 
The  lines  of  facial  expression  are  obliterated,  and  the  features  are 
broad,  coarse,  immobile,  and  bulky.  The  physiognomy  is  stupid,  dull, 
and  phlegmatic,  and  simulates  imbecility.  The  hair  falls  out,  owing 
to  deficient  nutrition :  and  the  general  bulk  of  the  body  is  mark- 
edly increased.  Pressure  does  not  produce  'pitting,  as  in  true  edema. 
According  to  Ord,  the  local  tumefaction  of  the  skin  and  subcutaneous 
tissue  is  most  frequently  prominent  in  the  supraclavicular  regions. 
The  mucous  membranes  are  also  infiltrated,  and  the  teeth  may  become 
loosened.  The  tongue,  lips,  and  nose  are  thickened,  and  the  voice  is 
monotonous,  slow,  and  has  a  "leathery  tone,"  "with  curious  nasal 
explosions  at  short  intervals  during  speaking."  Bodily  movements 
are  slow,  and  the  gait  is  uncertain  on  account  of  disturbed  coordination. 

Nervous  Symptoms. — There  is  obvious  retardation  of  psycomotor 
action.  Mental  perception  and  thought  are  also  slow,  and  the  memory, 
while  retentive,  is  slow  to  respond.  Not  infrequently  there  may  be  con- 
siderable irritability,  or  hebetude  alternating  with  sudden  excitability. 
The  patient  may  become  suspicious,  and  later  is  subject  to  delusions  and 
hallucinations ;  or  the  apathy  may  pass  into  a  melancholia,  ending  at 
last  in  dementia.  Ord  mentions  "  the  aggravation  of  all  symptoms 
during  low  climatic  temperatures;  "  and  "among  the  minor  or  accessory 
signs  may  be  quoted  abnormal  subjective  sensations,  belonging  particu' 
larly  to  taste  and  smell ;  occipital  headache ;  marked  alterations  of 
temper ;  and  a  curious  persistence  of  thought  and  action,  overriding  all 
attempts  at  interruption  by  friends  or  observers." 

The  temperature  in  myxedema  is  usually  more  or  less  subnormal. 
Albumin  and  sugar  are  occasionally  found  in  the  urine,  but  the  quantity 

^  Norsk  Magazin  for  Lcpgevidenskaben,  Christiana,  July  4,  1910. 


504    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

of  nitrogen  excreted  is  small,  owing  to  the  diminished  metabolism  of 
proteids.  Hemorrhiuies  from  the  nose,  gums,  and  bowels  may  occur. 
Ascites  may  be  present  in  some  cases,  and  may  simulate  ovarian  tumor. 
The  thyroid  is  not  palpable,  partly  because  of  its  atrophy,  and  partly 
because  of  tlie  tliickened  myxedematous  tissues  of  the  neck. 

The  diagnosis  is  not  difficult  if  one  bears  in  mind  the  character- 
istic manifestations  described  above.  Myxedema  could  hardly  be  mistaken 
for  acute  or  chronic  nephritis  in  the  absence  of  pitting,  etc.,  as  some  have 
supposed.  Chapman^  mentions  a  solid  appearance  of  the  conjunctiva  as 
an  early  sign  of  diagnostic  value. 

The  prog^nosis  is  guardedly  favorable  in  a  majority  of  the  cases 
since  the  introduction  in  the  treatment  of  thyroid-feeding.  The  course 
of  the  disease  is  slow,  however,  often  lasting  from  five  to  fifteen  years, 
and  death  from  intercurrent  disease  is  not  uncommon.  The  coagulation 
time  is  shortened  ;  markedly  so  in  grave  cases. 

Treatment. — Until  the  advent  of  thyroid-feeding  the  treatment  of 
myxedema  was  palliative,  and  usually  unsuccessful. 

A  warm  and  equable  climate  is  very  desirable,  owing  to  the  sub- 
normal temperature  from  which  the  patients  frequently  suffer.  The 
various  warm  baths — as  the  Turkish,  Russian,  and  electric — should  be 
employed  for  the  same  reason.  Pilocarpin  has  been  recommended,  and 
strychnin  and  arsenic  have  been  administered  for  their  tonic  efi'ect. 

Since  the  brilliant  results  obtained  by  Murray,  however,  the  internal 
use  of  the  thyroid  gland  of  sheep  or  calves  has  come  into  a  well- 
deserved  favor  in  the  treatment  of  all  cases  of  myxedema,  whether  of 
the  so-called  true  form,  of  sporadic  cretinism,  or  of  the  cachexia 
strumipriva.  The  gland  may  be  given  raw  or  cooked,  in  the  form  of 
the  glycerin  extract,  or  in  the  powdered  extract ;  the  last  named  is  some- 
times put  into  tabloid  form.  If  cooked,  the  gland  should  be  only 
partially  "done."  The  fresh  thyroid  is  minced  and  often  spread  on 
bread,  and  from  one-quarter  to  one-half  a  gland  may  be  taken  daily. 

If  used  for  hypodermic  injection,  to  a  dram  (4.0)  of  the  glycerin  extract 
is  added  half  a  dram  (2.0)  of  a  1  per  cent,  solution  of  carbolic  aciil  in 
distilled  water,  of  which  mixture  from  10  to  15  minims  (0.66—1.0)  may 
be  injected  three  or  four  times  a  week.^ 

It  is  safest — for  reasons  that  will  be  pointed  out  below — to  begin 
with  quite  small  doses,  and  gradually  increase,  especially  if  there  is 
much  gastric  irritation.  Not  more  than  5  minims  (0.333)  of  the  glycerin 
extract  should  be  given  at  the  start.  This  dose  may  be  increased  grad- 
ually until  15  or  20  minims  (1.0-1.83)  are  taken  three  times  daily. 
From  3  to  5  grains  (0.194-0.324)  of  the  powdered  gland  or  tabloid  form 
will  be  a  safe  commencing  dose  in  adult  myxedema:  a  caution,  however, 
is  necessary  regarding  the  various  manufactured  preparations  of  the 
thyroid  gland,  some  of  Avhich  are  impure  and  even  dangerous. 

The  toleration  of  thyroid-feeding  does  not  depend  upon  the  volume, 
but  upon  the  functional  activity,  of  the  gland,  and  this  fact,  together 
Avith  the  evidences  of  toxic  action  reported  in  some  instances  of  the 
administration  of  thyroids  to  a  maximum  degree,  make  it  important  to 
urge  again — as  intimated  above — the  necessity  of  small  dosage  at  the 
beginning  of  treatment,  and  the  most  careful  and  judicious  increase  in 
1  Laiicet,  Sept.  30,  1899.        2  Osler,  in  the  Amer.  Text-Book  of  Therapeutics,  pp.  926,  927. 


MYXEDEMA.  505 

the  quantity  given.  ^Flie  a<l(litional  fact  of  an  occasional  cumulative 
action  should  also  be  emphasized.  Should  vomiting,  renal  pain,  tachy- 
cardia, suffusion  of  the  face,  syncope,  vertigo,  or  marked  headache 
supervene,  the  rem.edy  should  be  stopped  at  once.  The  treatment 
may  be  resumed  again  cautiously,  alternating  with  intervals  of  cessa- 
tion. I  have  observed  that  by  combining  arsenic  with  any  of  the 
preparations  of  thyroid  the  toxic  effects  of  the  latter  can  be  largely 
obviated.  Good  results  are  obtained  usually  within  a  month,  though  it 
is  probable  that  even  after  all  the  symptoms  have  subsided  the  treatment 
may  have  to  be  continued  at  intervals.  The  activity  of  the  thyroid  is 
enhanced  by  the  presence  of  iodin  (Hunt  and  Seidell). 

Cretinism,  Sporadic  and  Endemic. — Here  there  is  a  congenital  atrophy 
or  absence  of  the  thyroid  gland,  or  an  enlargement  by  the  growth  of 
fibrous  tissue  at  the  expense  of  the  glandular  elements.  Cretinism  may 
also  develop  in  early  infancy.  The  patients  are  often  the  children  of 
parents  having  various  neuroses  and  goiter,  and  syphilis  has  also  been 
supposed  to  have  a  causative  influence.  Congenital  myxedema  is  quite 
common  only  in  regions  where  goiter  is  endemic.  A  marked  sporadic 
case  has  been  in  the  Philadelphia  Hospital  for  many  years. 

Symptoms. — Cretins  are  dwarfs  with  large  heads  and  faces,  thick 
lips,  thick  protruding  tongues,  broad  bodies  and  members,  and  promi- 
nent abdomens.  The  subcutaneous  tissues  are  myxedematous.  Umbili- 
cal hernia  is  often  present.  The  mental  condition  is  that  of  idiocy,  and 
physical  growth  is  retarded  and  slow.  Speech  is  unintelligible  or  nearly 
so,  and  the  voice  harsh.  Walking  may  never  be  accomplished,  and  is 
always  slowly  developed.  There  is  anemia,  the  blood  being  of  a  fetal 
type.     Rheumatic  symptoms  sometimes  occur. 

Prognosis. — The  disease  is  progressive  untii  about  the  fifteenth 
year  in  those  cases  developing  during  early  childhood.  Congenital 
cases  usually  die  shortly  after  birth.  At  the  twentieth  or  thirtieth 
year  "the  mental  and  physical   characters  are  those  of  childhood." 

Treatment. — Thyroid-feeding  has  been  followed  by  benefioial  results, 
the  checked  growth  having  recommenced  and  the  cretinic  aspect  having 
been  largely  lost.  S.  Klih  ^  has  employed  iodothyrin  in  one  case  with 
quite  as  satisfactory  results  as  those  from  the  dried  thyroid.  Pahr^  has 
implanted  a  portion  of  the  thyroid  gland  of  the  mother  into  the  spleen 
with  manifest  amelioration  of  the  mental  state  of  the  child. 

Operative  Myxedema,  or  Cachexia  Strumipriva. — Extirpation  of  the 
thyroid  for  surgical  reasons  has  given  rise  to  the  gradual  production  of 
symptoms  and  conditions  identical  either  with  true  myxedema  or  with 
the  cretinoid  state.  Partial  removal  of  the  gland  is  not  followed  by 
cachexia  strumipriva,  nor  is  complete  thyroidectomy  when  accessory 
glands  are  present  elsewhere. 

The  administration  of  raw  or  broiled  thyroids,  or  of  their  various 
extracts  or  preparations,  must  also  be  employed  in  this  form  of  myx- 
edema, and  should  be  continued  throughout  the  rest  of  the  patients 
life,  perhaps  with  intervals  of  withdrawal  of  the  feeding  until  the  im- 
provement gained  begins  to  lapse. 

1  Fhiladdphia  Medical  Journal,  April  8, 1899.         ^  La  Bulletin  Medical,  June  13, 1906. 


606    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 


DISEASES    OF    THE    PARATHYROID    GLANDS. 

The  parathyroid  bodies  consists,  as  a  rule,  of  two  pairs,  upper  and 
lower,  on  either  side  of  the  lateral  lobes  (posterior  inner  edge)  of  the  thyroid 
gland.  These  are  small  ovoid  structures  from  1  to  3  mm.  in  diameter  and 
6  to  8  mm.  in  length.  Recent  studies  by  Halstcd  and  others  show  that 
their  removal  in  animals  gives  rise  to  symptoms  simulating  tetany  (^vide 
p.  12:^1),  which  disappear  as  a  result  of  parathyroid  feeding  or  transplan- 
tation. MacCallum  has  shown  that  the  parathyroid  bodies  control  calcium 
metabolism  ;  they  also,  to  .some  extent,  influence  carbohydrate  metabolism. 
While  j)arathyr()id  preparations  have  been  used  with  success  in  tetany, 
they  have  no  therapeutic  effect  in  diseases  of  the  thyroid  gland,  convulsive 
disorders,  and  the  like. 


PART   V. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


I.   DISEASES  OF  THE  NOSE. 


ACUTE  RHINITIS. 

(Acute  Nasal  Catan-h ;  Acute  Coryza.) 

Definition. — An  acute  catarrh  of  the  Schneiderian  membrane,  some- 
times tending  to  involve  the  adjacent  sinuses  and  passages.  It  is  known 
to  the  laity  as  "  cold  in  the  head." 

l^tiology. — Its  most  conspicuous  cause  is  exposure  to  draughts  of 
air  and  to  the  influence  of  the  atmospheric  vicissitudes  that  are  espe- 
cially prevalent  during  the  winter  and  spring  seasons.  It  often  results 
from  the  inhalation  of  irritants  (physical,  chemical,  or  biological).  It 
may  also  display  epidemic  behavior,  and  this  fact  points  strongly  to  its 
microbic  origin.  Hence  local  disturbances  of  the  circulation  due  to 
exposure  are  to  be  regarded  as  the  accidental  means  of  preparing  the  soil 
for  bacterial  invasion.  Acute  rhinitis  may  be  also  secondary  to,  or  pro- 
pagated from,  inflammations  of  the  faucial  mucosa  by  contiguity. 

Symptoms. — Sensations  of  chilliness,  succeeded  by  feverishness 
(the  temperature  reaching  100°  to  101°  F.  ;  37.7°-38.3°  C),  frequent 
sneezing,  headache,  and  a  feeling  of  general  ill-health  are  among  the 
prominent  features  that  attend  the  development  of  coryza.  Pains  in 
the  extremities  and  back  tend  to  appear  only  in  severe  cases.  The  pulse 
is  frequent,  the  skin  dry  and  unduly  warm,  thirst  is  increased,  while  the 
appetite  is  impaired,  and  constipation  often  attends.  The  nasal  mucosa 
is  swollen,  and  thus  interferes  both  with  the  nasal  respiration  and  the 
senses  of  smell  and  taste  ;  its  color  is  deepened,  its  surface  covered  at  first 
with  opaque  mucus,  and  later  with  a  muco-purulent  secretion.  Among 
early  symptoms  is  the  discharge  of  a  watery,  irritating  secretion  from  the 
nares  and  a  maceration  of  the  epidermis,  with  resulting  abrasions.  On 
account  of  the  swelling  of  the  mucosa  of  the  lacrymal  ducts  the  tears 
flow  down  over  the  cheeks.  Adjacent  mucous  surfaces  may  become  in- 
volved, giving  rise  to  conjunctivitis,  catarrhal  pharyngitis,  laryngitis, 
and  finally,  in  the  severer  types,  bronchitis.  Naso-labial  herpes  is  not 
uncommon.  As  the  aff'ection  progresses  the  secretion  becomes  more 
abundant  and  turbid  and  more  or  less  pyoid.  The  symptoms  due  to 
extension  of  the  catarrhal  inflammation  vary  with  the  organs  or  struc- 
tures involved.     The  disease  runs  its  course  within  five  or  six  days,  but 

507 


508  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  nasal  discharge,  Avhich  gradually  diminishes,  usually  persists  for  a 
few  days  longer. 

Diagnosis. — In  the  presence  of  the  ahove-nientioned  symptoms  the 
disease  is  reailily  recognized.  In  well-marked  cases  the  possibility  that 
an  infectious  disease  may  be  developing,  the  beginning  of  which  is  char- 
acterized bv  nasal  catarrh  (measles),  is  to  be  recollected. 

Prognosis. — Except  in  neglected  cases,  which  result  in  bronchitis, 
and  occur  at  one  or  other  e.xtreme  of  life,  the  disease  is  free  from  danger. 
The  nursing  infant  may  have  to  be  fed  with  a  spoon  temporarily. 

Treatment. — At  the  outset  a  purge,  consisting  of  calomel  (gr.  ij — 
0.129),  or  a  i)ili  of  blue  mass  (gr.  v — 0.324)  at  night,  followed  by  a 
Seidlitz  poAvder  in  the  morning,  is  advisable.  To  children  a  dose  of 
castor  oil  may  be  given.  The  early  administration  of  a  diaphoretic,  such 
as  Dover's  powder  (gr.  v-x — 0.324-0.648)  at  night  may  arrest  the  com- 
plaint, and  quinin  in  a  large  dose  (gr.  xij-xv — 0.777-0.972)  at  night, 
or  hexamethylenamine  (gr.  v-0.o24,  q.  d.),  may  cut  short  the  course  of 
the  disease.  When  the  above-mentioned  abortive  measures  fail,  the  fol- 
lowing tablet  produces  good  results; 

I^.   Quinin.  sulphat.,  gr.  ijss  (0.162); 

Fluidext.  belladonnse,  mjss      (0.099); 

Sodii  salicylatis,  gr.  xxx  (1.944); 

Camphorjie,  gr.  ijss  (0.162). 

M.  et  ft.  tablet  No.  x. 
Sig.   One  tablet  every  hour  or  two. 

For  the  fever  aconite  may  be  employed,  and,  if  the  throat  be  involved, 
bryonia  may  be  given  in  conjunction. 

Local  Treatment. — This  aims  at  soothing  as  well  as  at  reducing  the 
swelling  of  the  Schneiderian  membrane.  The  compound  tincture  of 
benzoin  forms  a  soothing  inhalation  (gij  to  a  pint — 8.0  per  half  liter — 
of  water)  when  raised  nearly  to  the  boiling-point ;  the  vapor  is  inhaled 
for  ten  or  fifteen  minutes  at  a  time.  With  a  view  to  reducing  the  swell- 
ing a  solution  of  cocain  (strength  2  to  4  per  cent.)  may  be  temporarily 
used ;  Mackenzie  recommends  this  admirable  combination  : 

Menthol,  gr.v  (0.324); 

Pinol  mv    (0.324); 

Benzoinol,  f.5J      (32.0). 

In  severe  cases  the  patient  should  be  kept  in-doors  and  in  an  atmosphere 
of  even  temperature. 


CHRONIC  RHINITIS. 

{Chronic  Nasal  Catarrh^) 

Two  forms  are  recognized,  the  hypertrophic  and  atrophic,  and  these, 
though,  as  a  rule,  occurring  separately,  may  be  found  in  combination. 

Pathology. — The  morbid  changes  in  hypertrophic  rhinitis  consist 
in  an  enlargement  of  the  lower  turbinated  processes,  together  with  red- 
ness  and  swelling  of  the  nasal  mucosa  that  may  be  general  or  limited 


CHRONIC  RHINITIS. 


509 


eitter  to  the  anterior  or  poBterior  narcs.  As  the  diKoase  progresses  the 
thickening  of  the  membrane  increases,  until  it  finally  encroaches  upon 
the  nasal  chambers  at  every  point.  In  addition  to  the  nasal  obstruction 
there  is  a  hypersecretion  of"  mucus.  Opposite  changes  occur  in  atrophic 
rhinitis,  such  as  thinning  or  atrophy  of  all  the  structures,  witli  enlarge- 
ment of  the  nasal  cavities.  The  nasal  mucosa  is  coated  with  thick,  yel- 
lowish-green, decomposing  crusts,  which  emit  a  characteristically  fetid 
odor,  and  the  frontal,  ethmoid,  or  other  accessory  sinuses  may,  by  an 
extension  of  the  inflammation  from  the  nasal  chambers,  be  invaded  by 
mucopurulent  inflammation.  The  atrophic  process  does  not  affect  the 
glandular  structures  of  the  upper  third  of  the  nose,  and  this  fact  ex- 
plains the  most  unpleasant  feature  of  the  affection — namely,  the  hor- 
rible secretion. 

Htiology. — Frequently  occurring  attacks  of  acute  rhinitis  may  pro- 
duce the  chronic  form,  and  syphilis  and,  less  commonly,  tuberculosis 
are  also  among  its  causes.  Abel  ^  regards  atrophic  rhinitis  as  infectious, 
claiming  that  the  cause  is  the  bacillus  mucosis  ozence,  which  resembles 
closely  the  pneumobacillus,  but  is  distinguishable  from  it. 

Symptoms. — (a)  In  the  hypertrophic  form  nasal  respiration  is  im- 
peded, owing  to  the  hypertrophy  of  the  turbinated  bodies.  The  sense 
of  smell  is  impaired,  and  there  is  a  discharge  of  secretion  from  the 
nares,  particularly  the  posterior, 
inducing  "hawking."  The  diag- 
nosis is  set  at  rest  by  a  rhino- 
scopic  inspection  of  the  parts. 
While  this  is  a  common  affec- 
tion everywhere,  it  is  wellnigh 
universal  in  this  country. 

(6)  In  chronic  atrophic  ca- 
tarrh there  is  some  degree  of 
nasal  obstruction,  occasioned  by 
the  presence  of  the  thick  crust, 
but  the  most  conspicuous  symp- 
tom is  the  disgusting  odor, 
which  makes  the  patient  re- 
pellent in  society.  The  sense 
of  smell  is  lacking.  After 
cleansing  the  membrane  the  rhinoscope  Avill  show  the  nasal  chambers 
to  be  unduly  capacious. 

Treatment. — (1)  Chronic  Hypertrophic  Rhinitis. — The  treatment  is 
divisible  into  general  and  local.  The  physician  should  procure  an  envi- 
ronment for  his  charge  most  favorable  for  promoting  the  general  nutrition, 
which  is  often  below  the  health-standard.  The  selection  of  a  suitable 
climate,  then,  forms  an  important  part  of  the  management,  and  a  resi- 
dence in  a  locality  that  possesses  a  mild,  equable,  comparatively  dry 
and  pure  atmosphere  is  to  be  advised  and  encouraged.  Various  tonics 
may  then  be  demanded  by  the  general  condition  of  the  patient,  and 
strychnin  and  electricity  are  useful  in  restoring  the  loss  of  power  in  the 
contractile  elements  of  the  intercellular  walls. 

Local  measures  are  employed  to  facilitate  thorough   cleanliness  and 

^  Zeit.  /.  Hyg.  u.  Tnfektionskrank.,  Bd.  xxi.  H.  1. 


Fig.  42.- 


-Apparatus  for  cleansing  the  nasal  passages 
in  chronic  rhinitis. 


510  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

disinfection  of  the  affected  parts,  though  in  incipient  and  mild  cases 
energetic  treatment  is  scarcely  needful.  The  best  method  of  cleansing 
the  nasal  passages  is  by  means  of  the  coarse  spray  (Fig.  42).  The 
apparatus  of  Lefferts  is  also  to  be  employed  when  the  secretion  is  in- 
spissated or  tightly  adherent.  An  excellent  combination  for  use  in 
this  manner  is   the  following : 

IB^.   Sodii  biborat., 

Sodii  bicarb.,  da.  3J  (4.0) ; 

Phenolis,  gr.  viij   (0.518); 

Listerin.,  SJ  (32.0) ; 

Aqune  destillat,       q.  s.  ad  giv  (128.0). — M. 

Sig.  Use  as  a  spray  three  times  daily. 

It  is  often  desirable  to  use  warm  or  even  hot  liquids,  in  which  case 
the  application  is  made  by  the  use  of  the  anterior  and  posterior  nasal 
syringe.  Powders  are  harmful,  and,  as  the  nasal  douche  is  dangerous 
in  unskilled  hands,  these  should  both  be  abandoned. 

In  hypertrophic  rhinitis  the  obstruction  to  nasal  breathing  is  to  be 
removed,  and  to  accomplish  this  caustics  (chromic,  glacial  acetic,  and 
nitric  acids)  are  used,  of  which  the  most  efficacious  is  chromic  acid. 
This  should  be  applied  by  means  of  a  pointed  glass  rod,  the  application 
being  followed  by  a  sloughing  away  of  the  diseased  tissues.  Among 
other  modes  of  removing  the  nasal  obstruction  that  may  be  mentioned 
are  the  galvano-cautery,  the  thermo-cautery,  and  the  cold-wire  snare ; 
these  modes,  however,  are  practised  chiefly  by  the  specialist. 

(2)  In  atrophic  rhinitis  a  cure  is  to  be  despaired  of,  but  the  patient 
can  be  rendered  free  from  the  offensive  discharge,  and  hence  to  a  great 
degree  comfortable.  As  this  is  often  but  an  advanced  stage  of  hyper- 
trophic nasal  catarrh,  the  general  treatment  is  similarly  directed :  it  is 
therefore  well  to  overcome,  as  far  as  possible,  by  a  mental  stimulus,  the 
depressed  mental  state  due  to  the  fetor.  If  the  diathesis  be  tuberculous, 
cod-liver  oil,  iron,  arsenic,  and  strychnin,  together  with  a  generous  diet, 
are  to  be  advised.  If  syphilis  is  associated,  appropriate  measures  must 
be  instituted.  Moreover,  since  a  subject  of  atrophic  rhinitis  is  a  fertile 
source  of  atmospheric  contamination,  his  living  and  sleeping  apartments 
must  be  highly  ventilated. 

Local  Measures. — An  antiseptic  spray  of  Seiler's  or  Dobell's  solu- 
tion, and  oiling  the  nasal  cavities,  are  measures  to  be  first  tried. 
If  they  prove  non-efficacious,  the  crusts  may  then  be  removed  with  a 
cotton  applicator  coated  with  a  solution  of  hydrogen  peroxid.  We  may 
then  use  a  spray  of  liquid  albolene  and  menthol ;  this  serves  not  only 
to  lubricate,  but  to  supply  moisture,  both  of  which  are  important  thera- 
peutic indications.  Small  ulcerations  occur  in  this  affection  and  induce 
oft-repeated  epistaxis  ;  consequently,  an  attempt  should  be  made  to  heal 
the  latter  and  to  obtain  an  even,  moist  surface.  To  accomplish  this  the 
method  of  Clarence  C  Rice  may  be  followed — ^'.  e.  to  rub  the  ulcer- 
ations thoroughly  by  means  of  a  cotton-carrier  Avith  a  small  hard 
pledget  of  cotton  moistened  wdth  listerin  or  borolyptol  for  a  few  sec- 
onds at  a  time.  These  antiseptic  frictions  are  made  at  intervals  of  two 
or  three  days  for  two  or  three  weeks. 


AUTUMNAL   CATARRH.  511 

AUTUMNAL   CATARRH. 

{JIai/  Asthma;  Hoy   Fever.) 

By  this  term  is  meant  a  form  of  asthma  that  occurs  exclusively 
during  the   warm   season  (spring  and  late  summcjr,   particularly). 

Htiology. — The  direct  causes  are  the  odorous  principles  given  off 
from  certain  plants  (the  pollen  of  the  Anthoxanthum  odoraturn.,  of  the  rose, 
etc.),  and  inorganic  dusts  of  various  sorts.  In  some  instances  it  appears 
to  arise  without  obvious  exposure  to  a  special  irritant — for  example,  it 
may  be  excited  by  strong  emotional  disturbance.  Kyle^  has  advanced 
the  theory,  based  on  experimental  studies,  that  the  disease  is  caused  by 
chemic  changes  of  the  mouth  secretions. 

Predisposing  Factors. — The  male  sex  suifers  more  frequently  than  the 
female.  Age  has  a  slight  though  decisive  influence,  more  than  33  per 
cent,  of  the  cases  occurring  before  the  twentieth  year.  Often  some 
abnormality  of  the  nasal  passages  {e.  g.  a  polypoid  tumor,  hypertrophy 
of  the  mucosa,  a  deflected  septum)  acts  as  a  source  of  reflex  irritation. 
Heredity  is  among  the  potent  contributing  causes.  The  inhabitants  of 
cities  are  more  liable  than  those  in  rural  districts,  though  the  air  of  agri- 
cultural regions  intensifies  the  condition.  Perfect  immunity  is  enjoyed 
by  the  dwellers  in  certain  climates — chiefly  mountainous  and  marine. 
Perfect  health  probably  confers  immunity. 

Symptoms. — The  symptoms  are  {a)  local  and  (5)  general. 

(a)  Local. — Hay  fever  has  an  abrupt  onset,  and  the  attacks  return 
annually  at  or  about  the  same  time.  The  invasion  is  marked  by  pro- 
nounced coryzal  symptoms,  with  much  sneezing,  stoppage  of  the  nasal 
passages,  copious  rhinorrhea,  the  discharge  being  thin  and  watery  as  a 
rule,  and  rarely  mucopurulent.  Suffusion  of  the  eyes,  with  itching  of 
the  lids  and  free  lacrymation  are  constant  features ;  the  decided  itch- 
ing sensation  of  the  palate  and  pharynx  is  also  at  times  a  very  distress- 
ing symptom.  The  sense  of  smell  may  be  lost,  and  taste  and  hearing 
are  often  impaired. 

The  course  as  regards  the  local  symptoms  is  marked  by  alternate 
amelioration  and  aggravation  of  the  symptoms,  the  exacerbations  being 
due  to  exposure  to  the  open  air,  especially  in  changeable  weather. 
Later  the  catarrhal  process  invades  the  bronchi,  and  cough  and 
asthmatic  seizures  appear,  these  often  becoming  very  distressing. 

(h)  General  disturbances  comprise  subjective  sensations — anorexia, 
insomnia,  lassitude,  and  chilliness  alternating  with  slight  feverishness. 

The  course  is  from  four  to  six  weeks,  and  cases  that  develop  in 
August  are  terminated  by  the  occurrence  of  a  decided  frost.  Wyman 
also  describes  the  "rose  cold,"  which  comes  on  in  the  spring. 

Diagnosis. — The  recognition  of  hay  asthma  is  unattended  with 
difficulty,  provided  that  such  facts  as  the  time  of  its  occurrence  (June) 
and  its  annual  periodicity  are  carefully  noted.  The  sudden  onset  of 
severe  coryza-like  symptoms  in  a  neurotic  person,  particularly  in  the  month 
of  August,  should  direct  attention  to  autumnal  catarrh. 

Prognosis. — This  is  favorable  both  as  to  life  and  length  of  days, 
though  a  permanent  cure  is  a  rare  event  unless  permanent  removal  from 
the  influence  of  the  specific  causes  can  be  eflected. 

Treatment. — Whenever  possible   the  patient  should  travel  till  he 

^  Jour.  Amer.  Med.  Assoc,  October  ],  1904. 


512  DISEASES  OF  THE  RESPIEATOEY  SYSTEM. 

finds  a  locality  in  ^vbich  he  ceases  to  suft'er,  and  subsecjuently  lie  should 
there  spend  the  period  of  annual  attack,  and  by  these  means  escape  the 
exciting  causes.  The  Adirondacks  and  White  Mountains  usually  bestow 
immunity.  If  the  patient  cannot  make  the  necessary  change,  the  gen- 
eral nutrition  is  to  be  improved  by  hygienic  means  and  the  use  of  such 
measures  as  phosphorus,  strychnin,  quinin,  and  arsenic. 

The  local  symptoms  demand  the  topical  application  of  various  agents 
to  the  nasal  chambers,  such  as  cocain  hydrochlorate  solution  (1  per  cent.); 
if  applied  on  cotton  with  a  probe,  followed  by  a  4  per  cent,  solution  of 
antipyrin,  the  palliative  effect  is  prolonged  (Gleason).  Beaudoux  recom- 
mends destruction  of  the  nerve  supply  to  sensitive  areas.  Hollopeter 
has  had  good  success  by  daily  sterilizing  the  nasal  chambers  by  means  of 
Dobells  solution  used  first  with  an  atomizer;  then  swabbed  thoi'oughly  over 
the  naso-pharynx.  The  membrane  is  then  dried  and  the  nose  loosely  plugged 
with  cotton  saturated  with  a  mild  solution  of  menthol  in  albolene.  Of 
1240  patients  who  used  serum-therapy  (Pollantin)  correctly,  56.1  per 
cent,  either  remained  free  from  attacks,  or  could  abort  attacks  already 
started  (Dunbar).  Atropin  allays  the  irritability  of  the  mucous  mem- 
brane involved  and  diminishes  the  rhinorrhea,  thus  mitigating  the 
constitutional  disturbances  and  sometimes  relieving  the  asthmatic 
paroxysms.  When  given  internally  the  dose  should  not  exceed  gr.  -^-^ 
(0.0002),  to  be  repeated  every  hour  till  dryness  of  the  throat  appears. 

Mv  best  results  have  been  derived  from  the  hypodermic  use  of  this 
drug  (gr.  2-0-0 — 0.0003)  at  intervals  of  three  to  four  hours  till  the  desired 
effect  is  produced.  Gleason  obtained  satisfiictory  results  from  nitro- 
muriatic  acid  freshly  prepared  (dose  Itlv  t.  i.  d.  after  meals  in  a  tumbler 
half  full  of  Avater).  Recently  the  internal  use  of  5-grain  tabloids  of 
suprarenal  extract  has  met  with  success  in  the  hands  of  S.  Solis-Cohen 
and  others.     Adrenalin  chlorid  applied  locally  has  given  good  results. 


EPISTAXIS. 

(Nose-bleed.) 


i^tiology. — The  causes  of  nose-bleed  are  various,  and  a  convenient 
grouping  is  the  following:  (a)  Affections  of  the  nasal  mucosa  (t^.  ^.  ulcer, 
polypi,  intense  hyperemia).  (b)  Injuries,  either  external,  as  from  a 
blow,  or  internal,  as  from  plugging  with  a  foreign  body,  nose-picking, 
etc.  In  this  category  may  also  be  included  epistaxis  due  to  fracture  at 
the  base  of  the  skull.  (^')  Acute  infectious  fevers,  particularly  typhoid 
(at  the  onset)  and  influenza,  (d)  Chronic  affections,  such  as  pernicious 
anemia,  leukemia,  and  hemophilia,  [e)  A^icarious  menstruation.  (/) 
Rarefaction  of  the  air.  (g)  Plethora ;  here  may  be  mentioned  cerebro- 
congestion  with  intense  headache.  (A)  Severe  over-exertion,  (i)  Fre- 
quent epistaxis  may  be  caused  by  arterio-sclerosis  even  in  the  earlier 
stage  while  yet  amenable  to  treatment.  (,/)  Chronic  interstitial  nephritis  ; 
mitral  disease. 

Symptoms. — Except  when  due  to  traumatism  the  blood  usually 
drops  slowly  from  one  and  occasionally  from  both  nostrils.  Rarely,  the 
blood  may  flow  as  a  continuous  stream  or  the  nares  may  present  a  pro- 
jecting coagulum.     The  blood  may  also  gravitate  into  the  pharynx  and 


DISEASES  OF  THE  LARYNX.  513 

be  coughed  up,  or  it  may  bo  swallowed"  and  vomited.  A  rliinoscopic 
examination  often  reveals  the  source  in  cases  in  which  a  previous  diag- 
nosis of  hemoptysis  or  hematemesis  has  been  made. 

The  immediate  results  of  nose-bleed  are  weakness  and  a  moderate 
anemia,  but  these  are  not  prolonged,  aS  a  rule.  Cases  arising  from 
fracture  at  the  base  of  the  skull  will  generally  prove  fatal. 

Treatment. — A  careful  search  for  a  local  cause  is  especially  de- 
manded in  cases  in  which  tliere  are  frequently  recurring  attacks.  In 
most  cases  a  spontaneous  arrest  occurs,  but  if  not,  a  resort  to  simple 
household  measures,  such  as  the  application  of  ice  to  the  nose  or  to  the 
back  of  the  neck,  holding  the  hands  up,  or  the  injection  of  very  cold  or 
very  hot  water  into  the  nares,  are  to  be  encouraged.  Various  astrin- 
gents (tannic  acid,  acetate  of  lead,  alum,  zinc)  may  be  employed,  and 
a  saturated  solution  of  antipyrin  is  also  highly  praised.  Adrenalin  chlo- 
rid  is  valuable.  When  an  ulcerated  bleeding  point  can  be  reached, 
there  may  be  applied  to  it  a  solution  of  chromic  acid  or  it  may  be  cauter- 
ized by  solid  silver  nitrate.  Prolonged  pressure  applied  upon  the  facial 
artery  as  it  passes  over  the  inferior  maxilla  may  be  efficacious.  A  solu- 
tion of  gelatin  may  be  injected  into  the  nostril.  I  have  little  confidence 
in  internal  astringent  remedies.  The  oil  of  erigeron,  administered  in 
large  doses,  has  seemed  to  do  good  in  a  few  of  my  own  cases,  but  in 
obstinate  cases  the  posterior  nares  should  be  plugged,  preferably  with 
gauze  lubricated  with  oil  or  petrolatum,  to  avoid  recurrence  when 
packing  is  removed.  Tincture  of  aconite  or  nitroglycerin  may  be  used 
in  arterio-sclerotic  conditions. 


II.  DISEASES  OF  THE  LARYNX. 
ACUTE  CATARRHAL  LARYNGITIS. 

{Acute  Endolaryngitis.) 

Definition. — An  acute  catarrhal  inflammation  of  the  larynx,  cha- 
racterized by  cough,  hoarseness,  and  painful  deglutition. 

Pathology. — The  anatomic  changes  present  during  life  are  all 
lacking  post  mortem. 

Htiology. — Acute  laryngitis  may  be  a  primary  affection — and  par- 
ticularly laryngitis  sicca  (Molinie) — but  oftener  it  is  associated  with  and 
secondary  to  catarrh  of  the  nose  and  nasopharynx.  Wright  attributes 
laryngitis  sicca  to  the  coccus  of  Lowenburg. 

Catarrhal  laryngitis  has  for  its  chief  direct  causes  traumatism,  ex- 
posure to  cold  and  dampness,  the  inhalation  of  irritating  vapors  or 
gases,  rheumatism  (rarely),  and  the  corrosive  effect  of  certain  poisons 
and  hot  fluids.  A  certain  degree  of  predisposition  is  engendered  by 
immoderate  smoking,  particularly  by  the  cigaret-habit.  and  by  the  use 
of  concentrated  alcoholic  drinks.  These  agencies  induce  hyperemia  of 
the  laryngeal  mucosa,  which  is  easily  converted  into  active  inflammation. 
Acute  laryngitis  is  often  associated  with  acute  infectious  diseases. 

Symptoms. — There  are  two  conspicuous  symptoms — alteration  in 
the  voice  (hoarseness)  and  cough.  At  first  there  is  merely  a  huskiness 
33 


514 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


of  the  voice,  but  later  there  may  be  pronounced  hoarseness  or  even  com- 
plete aphonia.  The  cough  is  dry  and  characteristically  painful  until 
secretion  is  free.  In  the  early  stages  the  patient  complains  of  sensa- 
tions of  tickling  or  the  presence  of  some  small  object  in  the  larynx, 
causing  a  frequent  desire  to  clear  the  throat.  In  severe  instances  deg- 
lutition is  painful.  Edema  of  the  larynx  may  tend  to  supervene  and 
cause  intense  dyspnea,  with  a  feeling  of  distressing  oppression.  There 
is,  as  a  rule,  a  slightly  elevated  temperature. 


Fig.  43.— Method  of  making  a  laryngoscopic  examination. 


The  patient  is  placed  in  front  of  the  operator,  on  an  arm-chair,  with  the  back  of  the  chair 
high  enough  to  afford  his  head  a  comfortable  rest,  and  with  the  source  of  the  light  over  the  right 
8ho\ilder.  The  operator  then  adjusts  the  head-mirror  (the  fixed  apparatus),  warms  the  throat- 
mirror  over  a  light  sufficiently  to  prevent  the  moisture  of  the  breath  from  being  deposited  upon 
it,  and  touches  the  hand  with  the  mirror  before  passing  it  into  the  mouth,  so  as  not  to  use  it  too 
hot.  Tlie  patient's  tongue  is  then  protruded,  and  by  means  of  a  napkin  is  seized  between  the 
thumb  and  the  fore-finger  and  drawn  well  forward  to  lay  the  fauces  open  to  observation.  The 
throat-mirror  is  then  held  in  the  right  hand  in  the  same  way  as  one  holds  a  pen.  "  Finally,  it  is 
introduced  into  the  m.outh,  its  handle  being  inclined  downward  and  outward,  its  base  being 
parallel  with  the  dorsum  of  the  tongue :  it  is  then  passed  backward  without  altering  this  relation 
until  the  edge  of  the  mirror  nearly  touches  the  soft  palate,  the  shaft  of  the  mirror  in  this  move- 
ment striking  the  angle  of  the  mouth  as  a  resting-place  and  fulcrum.  The  subsequent  movement 
consists  in  turning  the  mirror  by  twisting  its  shaft  between  the  fingers  until  it  is  inclined  at  an 
angle  of  4i  degrees  to  the  line  of  vision  :  then  it  is  carried  backward  and  downward  until  the 
uvula  rests  upon  its  posterior  surface,  when  it  is  lifted  boldly  upward  and  backward  until  its 
lower  edge  comes  entirely  into  view  again  and  rests  firmly  against  the  posterior  wall  of  the  pha- 
rynx. The  patient  should  then  be  directed  to  sound  in  a  somewhat  high  key  'a,'  which  lifts  the 
larynx  and  at  the  same  time  the  epiglottis,  and  exposes  and  brings  into  view  the  laryngeal 
cavity  "  (Bosworth). 

It  is  important  that  the  mirror  itself  should  be  kept  in  the  median  line,  with  its  plane  always 
at  right  angles  with  the  field  of  vision,  as  shown  in  the  illustration.  In  making  a  laryngoscopic 
examination  we  note  any  abnormalities  of  color-appearance  (the  natural  beinga  rose-pinkish  tint), 
of  the  outline  of  the  different  parts,  and  the  deviations  from  the  symmetrical  movements  of  cords, 
if  any,  etc. 

The  laryngeal  mirror  brings  to  view  a  characteristic  picture — a 
swollen,  tumefied,  and  reddened  mucosa.  These  changes  affect  the 
vocal  cords  (whose  pearly-white  appearance  is  now  lacking)  and  the  ary- 
epiglottidean  folds.  It  is  usual  to  note  also  redness  and  swelling  of  the 
epiglottis  above  and  of  the  trachea  below.  After  secretion  has  occurred 
a  mucoid  covering  in  streaks  or  patches  is  noticeable. 


CimONIC  LARVNaiTIK  515 

Diagnosis. — This  is  easy  in  the  presence  of  marked  hoarseness, 
dry  cough,  and  the  image  afforded  by  the  laryngeal  mirror  (Kig.  4o).  In 
very  early  life  the  larynx  cannot  be  successfully  examined  ;  still,  loryiujiH- 
mus  stridulus  (owing  to  the  absence  of  fever,  coryza,  etc.)  could  hardly 
be  mistaken,  as  has  been  supposed,  for  acute  catarrhal  laryngitis.  The 
same  is  true  of  memhrmiouH  laryngitiss,  if  we  bear  in  mind  the  charac- 
teristic local  features  and  the  more  intense  constitutional  disturbances 
of  the  affection. 

Treatmetlt. — The  physician  must  enjoin  against  the  use  of  the  voice. 
The  very  young  and  the  aged  should,  in  severe  or  even  moderate  cases,  be 
kept  in  bed^  and  should  occupy  a  single  apartment  in  which  the  at- 
mosphere is  uniformly  moist  and  warm,  the  temperature  ranging  from 
75°  to  80°  F.  (23.8°-26.6°  C).  Inhalations  of  moist  air  or  steam  are 
of  great  service,  and  I  have  long  been  in  the  habit  of  recommending 
the  following  simple  apparatus  and  method  of  carrying  out  this  mode 
of  treatment :  An  ordinary  tin  cup,  small  pitcher,  or  other  vessel  is 
filled  with  boiling  water  to  which  1  or  2  drams  (4.0-8.0)  of  the  com- 
pound tincture  of  benzoin  have  been  added  ;  the  steam  is  then  collected 
by  inverting  over  the  vessel  an  ordinary  funnel.  The  patient  is 
allowed  to  inhale  the  steam  by  placing  the  mouth  over  the  narrow  neck 
of  the  funnel  above,  or  a  piece  of  rubber  tubing  may  be  attached  to  the 
end  of  the  funnel  that  is  uppermost. 

Steam  atomizers  admirably  meet  the  necessities  of  the  case ;  and  in 
the  case  of  children  the  vapor  of  benzoin,  eucalyptol,  and  other  equally 
sedative  and  stimulating  substances  may  be  diffused  in  the  air  of  the 
sick-room.  Concentrated  solutions  or  insufflations  of  powders  are  not 
without  harmful  influence,  and  neither  the  cotton-carrier  nor  the  mop 
should  be  allowed  to  enter  the  larynx  in  this  aff"ection.  The  external 
application  of  the  ice-bag  or  cold  compress  tends  to  mitigate  the  inflam- 
matory process  and  to  obviate  spasm. 

The  general  treatment  diff'ers  with  the  special  stages  of  the  com- 
plaint. If  the  case  is  seen  early,  a  full  dose  of  quinin  (gr.  xij-xvj — 
0.777-1.036)  may  serve  to  successfully  abort  the  attack,  and,  in  con- 
junction Dover's  powder  (gr.  v— x — 0.324—0.648)  may  be  prescribed. 
Codein  sulphate  may  be  given  at  prolonged  intervals  during  the  attack, 
and  frequently  at  night,  to  allay  cough  ;  this  remedy  may  be  combined 
with  ipecac,  aconite,  and  liquor  ammonii  acetatis  to  facilitate  secretion 
and  render  the  cough  humid.  If  we  except  the  abortive  measures,  the 
constitutional  is  wholly  inferior  to  the  topical  treatment  of  this  variety, 
though  the  existence  of  any  particular  diathesis  may  require  special  in- 
ternal remedies. 


CHRONIC  LARYNGITIS. 

( Chronic  Endolaryngitis.) 

Pathology. — The  laryngeal  mucosa  is  thickened  and  somewhat 
reddened,  and  erosions  amounting  to  superficial  ulcerations  are  rarely 
seen.  A  prominence  of  the  mucous  glands,  especially  of  the  ventricles 
and  epiglottis,  is   noticeable.     Fine  villous  projections  from,   and  nod- 


516  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ular  swellings  in.  the  vocal  cords  are  among  the  rarer  morbid  changes. 
Minute  vesicles   may  arise  upon    the  surface  [herpetic  laryngitis). 

Ktiology. — Oft-repeated  acute  attacks  frequently  cause  chronic 
laryngitis,  and  the  long-continued  use  of  the  voice  (as  in  public  speak- 
ing or  singing),  the  inhalation  of  an  atmosphere  laden  with  mildly  irri- 
tating impurities  (tobacco  smoke,  etc.),  and  an  immoderate  indulgence 
in  alcoholic  stimulants,  respectively  or  unitedly,  predispose  to,  if  they 
do  not  excite,  the  disorder. 

Symptoms. — As  in  the  acute  form,  hoarseness  and  cough  are  the 
two  especially  prominent  symptoms.  The  former  may  be  so  slight  as  to 
present  merely  a  rough  tone,  or  it  may  involve  an  almost  total  loss  of 
voice.  The  cough  shows  similar  variations  in  severity,  sometimes  con- 
sisting of  a  short  hack,  and  again  occurring  in  spasmodic  and  ringing 
paroxysms,  due  to  a  sense  of  tickling  in  the  larynx.  There  may  be  a 
small  amount  of  mucous  or  muco-purulent  expectoi*ation,  but  for  pro- 
longed periods  the  cough  may  be  dry  and  ineffectual.  Local  pain  and 
discomfort  sometimes  supervene,  and  are  excited  generally  by  attempts 
at  speaking  or  singing — events  that  aggravate  all  the  other  symptoms. 
To  complete  the  diagnosis,  the  laryngeal  mirror  is  required  to  show  a 
swollen  and  slightly  red  membrane,  with  a  distention  of  the  mucous 
glands  in  the  immediate  vicinity  of  the  epiglottis  and  ventricles,  and 
occasionally  superficial  erosions. 

Prognosis. — This  is  unpromising  as  to  complete  recovery,  although 
it  presents  no  grave  dangers.  It  is  incurable  in  those  instances  in 
which  the  causal  influences  cannot  be  removed,  and  in  all  cases  in 
which  the  patient  fails  to  lend  hearty  co-operation. 

Treatment. — This  is  (a)  hygienic  and  (/>)  medicinal,  (a)  The  sani- 
tary measures  embrace  preventives  that  are  directed  to  the  removal  of 
all  the  etiologic  factors,  whether  merely  predisposing  or  exciting.  The 
voice  demands  rest  and  the  prohibition  of  smoking  and  the  use  of  alco- 
holics in  excess,  and  the  patient  must  also  avoid  the  close,  contaminated 
air  of  the  crowded  hall,  theatre,  and  like  places.  In  addition,  a  tonic 
regimen,  with  a  view  to  energizing  the  nutritive  processes,  is  to  be  en- 
couraged. In  many  instances  the  environment  is  best  arranged  with 
reference  to  the  commonly  associated  conditions — especially  the  morbid 
processes  in  the  nasal  and  naso-pharyngeal  cavities.  "  A  sea-voyage  or 
residence  at  the  sea-shore  is,  in  the  large  majority  of  instances,  pro- 
ductive of  good,  and  the  effects  of  surf-bathing  are  often  magic " 
(Mackenzie).  My  own  practice  has  been  to  send  subjects  of  chronic 
laryngitis  to  pine-forest  resorts  at  low  elevations  that  afford  a  pure, 
equable,  and  somewhat  stimulating  atmosphere,  and  I  have  found  that 
in  many  cases  the  selection  of  a  proper  climate  constitutes  the  most  im- 
portant part  of  the  treatment,  {h)  The  medicinal  treatment  is  both 
local  and  general.  The  latter  should  include  creasote.  cod-liver  oil.  and 
other  tonics.  Expectorants  are  of  little  if  any  value.  The  local  meas- 
ures, however,  are  important.  Moderate  exposure  of  the  neck  and  daily 
ablution  with  cold  water  are  to  be  advised,  and  attention  to  the  nose  and 
naso-pharyngeal  cavity  is  of  prime  importance.^ 

A  long  list  of  applications  to  the  larynx  from  within,  including  local 
astringents,  disinfectants,    and   alcoholics,    might   be   enumerated.     Of 

^  J.  C.  Wilson's  American  Text-book  of  Applied  Therapeutics,  p.  791. 


SPASMODIC  LARYNGITIS.  517 

astringent  solutions,  however,  the  best*are  tannic  acid  (1-2  per  cent.) 
or  alum  (.5—1  per  cent.)  and  zinc  sulphate  (3-5  per  cent.).  ^These  may 
be  sprayed  into  the  larynx  by  means  of  a  compressed-air  machine  with 
spraying-tubes,  although  all  of"  the  different  kinds  of"  inhaling  apparatus 
more  commonly  used  will  answer  the  purpose.  If  the  ordinary  hand- 
atomizer  be  used,  the  patient  should  be  taught  to  draw  the  vapor  into 
the  larynx  by  gentle  and  frequent  acts  of  respiration.  Disinfectants, 
such  as  creasote,  potassium  chlorate  (the  latter  if  ulcerations  be  present) 
in  solutions  of  suitable  strength,  may  be  used  in  like  manner.  I  can 
confidently  advise  as  useful  alteratives  both  iodin  and  silver  nitrate, 
commencing  with  a  weak  solution  of  the  latter  (gr.  v-3j — 0.324-4.0), 
and  the  strength  being  gradually  increased  until  the  maximum  strength 
that  can  be  endured  without  distress  is  reached  (gr.  xx-^ij — 1. 296-8. Oj. 
These  topical  applications  should  be  made  directly  with  a  cotton-carrier 
or  brush  at  intervals  of  three  or  four  days,  preceded  by  the  use  of  a 
cleansing  spray.  The  many  astringent  and  sedative  lozenges  found  in 
the  market  are  only  slightly  palliative  in  their  effects,  and  their  pro- 
longed use  tends  to  excite  gastric  disturbance.  I  am  unalterably  opposed 
to  the  insufflation  of  powders,  believing  that  they  are  capable  of  aug- 
menting the  laryngeal  irritation  and  of  adding  fresh  irritation  in  adjacent 
parts,  particularly  in  the  tracheo-bronchial  tract. 


SPASMODIC  LARYNGITIS. 

{Laryngismus  Stridulris ;  False   Croup.) 

Definition. — An  affection  peculiar  to  children,  chiefly  of  nervous 
origin,  though  also,  according  to  Strlimpell  and  others,  often  associated 
with  acute  catarrhal  laryngitis. 

^^tiology. — The  affection  is  almost  solely  limited  to  children  be- 
tween six  months  and  five  or  more  years  of  age.  It  is  sometimes  ex- 
cited by  strong  passion  or  emotion,  and  it  may  be  associated  with  tetany. 
Rachitic  subjects  are  peculiarly  liable.  The  causes  of  spasmodic  croup 
are  in  great  part  those  of  acute  laryngitis. 

The  mode  of  action  of  the  direct  causes  is  unknown,  but  the  spasm 
of  the  adductors  that  causes  the  urgent  dyspnea  is  probably  reflex  and 
due  to  peripheral  irritation. 

Symptoms. — Two  clinical  varieties  are  to  be  distinguished :  (1) 
That  in  which  the  larynx  is  free  from  catarrhal  inflammation,  or  the 
purely  nervous  type.  This  is  especially  characterized  by  sudden  brief 
attacks  of  dyspnea,  either  by  day  or  night  (often  on  awakening),  that 
terminate  in  a  high-pitched  crowing  inspiration  ("child-crowing"). 
The  face  during  the  spasm  is  cyanotic.  General  convulsions  have  been 
noted,  but  there  is  neither  cough,  fever,  nor  hoarseness.  The  attacks 
may  be  frequently  repeated   within   a  single  day. 

(2)  Spasm  of  the  larynx,  associated  icith  mild  catarrhal  laryngitis. 
The  attacks  generally  begin  suddenly,  about  midnight  or  toward  morn- 
ing on  awakening  from  a  sound  sleep.  Positive  evidence  of  the  affection 
is  afforded  by  the  croupy,  ringing  cough,  combined  with  the  hard,  strid- 
ulous  breathing.     An  approaching  spasm  may  be  announced  by  a  harsh 


518  DISEASES  OF  THE  RESPIBATORY  SYSTEM. 

cough  and  slightly  stridulous  breathing  in  the  sleeping  child.  During 
the  attack  the  countenance  may  be  cyanotic  and  the  breathing  most  dis- 
tressing, but  these  and  the  above-mentioned  severer  symptoms  generally 
cease  abruptly  in  an  hour  or  two,  and  the  child  resumes  its  slumber.  In 
my  experience  the  attacks  have  been  repeated  for  two  or  three  nights  in 
succession,  and  rarely  oftener  except  in  the  severest  cases.  Not  infre- 
quently the  child  manifests  the  symptoms  of  mild  catarrhal  laryngitis 
between  the  attacks.      A  brassy,  croupy  cough  may  also  attend. 

Diagnosis. — Membranuus  larynyitis  may  be  mistaken  for  spasmodic 
croup.  The  development  of  the  dyspnea,  however,  is  more  gradual,  is 
without  intermission,  and  without  relation  to  the  period  of  the  day. 
Albuminuria  and  a  false  membrane  in  the  throat  or  nares  are  usually 
present  in  htri/ngcal  diphtheria. 

Prognosis. — Although  the  appearance  of  a  paroxysm  is  alarming, 
the  disease  is  j»ractically  free  from  danger. 

Treatment. — 1.  The  treatment  of  laryngismus  stridulus  is  quite 
similar  to  that  of  infantile  convulsions.     A  warm  bath  at  a  temperature 


Fig.  44.— Croup- kettle  in  use. 

Four  upright  rods  (5.7  inches  in  length)  are  fastened  to  the  legs  of  the  bedstead  by  a  wire  or 
string.  Two  side-rods  are  tied  on  the  npriplits,  and  two  end-rods  (length  dependent  on  width  of 
bed)  rest  upon  the  side-rods,  These  rods  form  a  complete  framework  for  the  sheets  to  hang  upon. 
Four  sheets  are  required  (11-4  size)— three  to  cover  the  ends  and  sides,  and  one  to  be  placed  on  top. 
One  side  should  be  completely  closed,  while  the  opposite  is  to  be  left  open  for  ventilation  or  to  be 
adjusted  according  to  circumstances. 

of  98°  to  105°  F.  (36.4°-40.5°  C.)is  the  best  means  of  breaking  up  the 
spasm.  While  in  the  bath  cold  sponging  of  the  back  and  chest  is  ser- 
viceable. The  finger  may  be  passed  into  the  fauces,  and  should  the 
epiglottis  "become  wedged  in  the  chink  of  the  glottis,  it  must  be  re- 
leased by  the  finger."  After  the  attack  active  treatment  should  be  di- 
rected at  the  discoverable  causes,  and  I  have  been  in  the  habit  of  giving 


EDEMATOUS  LARYNGITIS.  519 

small  doses  of  the  bromids  thrice  daily,  together  with  warm  cod-liver 
oil  inunctions,   with  striking  effect. 

2.  In  spasmodic  croup  an  emetic  is  to  be  given  at  once,  the  best  be- 
ing a  mixture  of  alum  and  syrup  of  ipecac,  of  which  the  dose  is  3j 
(4.0),  to  be  followed  by  irritation  of  the  fauces  with  the  finger  in  ordei' 
to  facilitate  emesis.  In  severe  paroxysms  a  hot  bath  may  be  given  to 
aid  the  emetic.  In  case  the  dyspnea  is  not  checked  by  the  above  meas- 
ures, chloral  hydrate  may  be  exhibited  by  enema  (gr.  ij— v ;  0.129- 
0.324)  or  a  whiff  of  chloroform  may  be  given.  The  local  application  of 
cold  (ice-collar,  ice-water  cloths)  is  useful,  and  sinapisms  placed  around 
the  throat  and  over  the  chest  also  tend  to  arrest  the  spasm.  The  use  of 
steam-inhalations  from  the  so-called  croup-kettle  (Fig.  44)  is  of  signal 
service,  and  should  be  more  widely  employed,  particularly  when  it  is 
inconvenient  to  use  the  hot  bath. 

Between  the  paroxysms  the  patient  should  receive  a  mild  laxative, 
such  as  calomel  or  castor  oil,  and,  in  addition,  the  treatment  appro- 
priate in  acute  catarrhal  laryngitis.  To  prevent  recurrences  an  envi- 
ronment calculated  to  increase  the  nervous  tone  of  the  child  is  to  be  pro- 
cured, and  it  is  especially  advisable  to  accustom  him  to  the  outer  air, 
though  protected  by  suitable  dress  and  without  undue  exposure  to 
draughts. 

EDEMATOUS  LARYNGITIS. 

Definition. — An  infiltration  of  the  mucous  membrane  of  the  larynx 
with  serum.     In  most  cases  it  is  a  true  inflammatory  edema. 

Ktiology. — Two  chief  classes  of  causes  are  operative  :  (1)  Those 
that  excite  inflammation.  The  condition  may  complicate  acute  laryn- 
gitis, though  oftener  it  appears  in  chronic  affections  of  the  larynx,  and 
particularly  if  ulceration  be  associated  {e.  g.  tuberculosis,  syphilis) ;  it 
may  also  appear  in  connection  with  certain  infectious  diseases  (erysipe- 
las, diphtheria,  typhoid  fever).  The  inflammation  inducing  the  edema 
may  extend  from  adjacent  parts,  as  the  neck,  pharynx,  and  other  organs. 
(2)  Factors  that  tend  to  excite  dropsical  effusion.  These  may  be  gen- 
eral, as  Bright's  disease,  heart-affections,  etc. ;  or  they  may  be  local. 
Among  the  latter  are  enlargements  of  the  cervical  and  mediastinal  lym- 
phatics, aneurysm  of  the  arch  of  the  aorta,  thyroid  tumors,  etc. — L  e. 
conditions  that  exercise  pressure  upon  the  jugular  veins.  Rice,  who 
studied  41  cases,  thinks  it  doubtful  whether  edema  of  the  larynx  ever 
occurs  from  simple  catarrhal  inflammation. 

Symptoms. — In  acute  cases  the  initial  disturbance  is  both  sudden 
and  severe.  There  is  dyspnea  that  tends  to  increase  rapidly,  accompa- 
nied by  a  husky,  suppressed  voice,  with  augmenting  obstruction.  The 
respirations  may  become  stridulous,  but  there  is  no  cough.  The  laryn- 
goscope reveals  marked  swelling  of  the  epiglottis  and  of  the  ary-epi- 
glottic  folds.  Rarely  the  swelling  occurs  in  or  even  wholly  below  the 
vocal  cords.  The  inserted  finger  may  detect  the  swollen  epiglottis, 
which  may  also  be  seen  if  the  tongue-depressor  be  used. 

Diagnosis. — This  can  be  made  with  ease  from  the  rapidly  develop- 
ing dyspnea  soon  reaching  the  climax,  the  absence  of  cough  and  hoarse- 
ness, and  by  the  use  of  the  laryngoscope.  In  cases  in  which  the  epi- 
glottis can  be  felt  or  seen  a  laryngoscopic  examination  is  superfluous. 


520  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  prognosis  is  decidedly  unfavorable  except  iu  the  event  of  early 
operative  interference. 

Treatment. — If  of  inflammatory  origin,  the  ice-bag  should  be  ap- 
plied to  the  larynx,  and  ice  should  be  allowed  to  constantly  dissolve  in 
the  patient's  mouth.  Local  depletion,  preferably  by  leeching  the  front 
of  the  neck,  is  also  to  be  tried,  and  Levy  and  Laurens '  record  a  case  in 
which  a  cure  followed  this  measure.  If  intense  dyspnea  tends  to  per- 
sist, scarification  of  the  edematous  parts  with  a  curved  bistoury,  the 
point  of  which  is  covered  with  adhesive  plaster,  must  be  promptly  insti- 
tuted, and,  if  asphyxia  threatens,  tracheotomy  must  immediately  be  per- 
formed. Dropsical  edema  demands  scarification  and,  if  relief  does  not 
follow,  intubation  or  tracheotomy. 


TUMORS  OF   THE  LARYNX. 

These  may  be  either  benign  (fibroma,  myxoma,  lipoma,  chondroma, 
adenoma,  angioma,  cyst)  or  malignant  (sarcoma,  carcinoma).  Of  these, 
papillomata  or  papillomatous  fibromata  occur  most  frequently,  especially 
in  infancy.  Navratil  *  records  42  cases  of  multiple  laryngeal  papillomata 
in  children  whose  larynges  were  extensively  filled.  These  growths  may 
also  occur  in  chronic  laryngitis,  and,  like  other  tumors  of  the  larynx,  they 
commonly  spring  from  the  vocal  cords.  Their  shape,  size,  and  tendency 
to  pedunculation  do  not  diff"er  from  their  characteristics  when  noted 
elsewhere  in  the  body. 

Symptoms. — Small  tumors  may  occupy  the  larynx  without  produ- 
cing symptoms.  The  first  feature  then  noted  is  hoarseness^  which  gradu- 
ally grows  worse  and  may  end  in  complete  aphonia.  If  situated  in  the 
upper  larynx,  cough  is  common,  and  when  the  tumor  causes  obstruction 
of  the  larynx  dyspnea  supervenes  and  tends  to  increase  in  severity.  A 
mobile  growth  may  cause  sudden  occlusion  of  the  glottis,  exciting 
orthopnea  and  threatening  asphyxiation.  To  confirm  the  diagnosis  a 
laryngoscopic  examination  is  required. 

The  prognosis  is  favorable  in  the  benign,  but  unfavorable  in  the 
malignant  forms. 

Treatment. — This  is  altogether  surgical,  though  Delavan  states 
that  3  cases  of  papilloma  have  been  cured  by  frequently  repeated  sprays 
of  absolute  alcohol.  Curetting  is  often  followed  by  a  recurrence,  while 
laryngo-fissure  and  thorough  removal  of  the  growths  restore  speech  and 
prevent  recurrence. 


III.  DISEASES  OF  THE  BRONCHI. 
CATARRHAL  BRONCHITIS. 

( Tracheo-bronchitis.) 

Definition. — A  catarrhal  inflammation  of  a  part  or  the  whole  of 
the   mucous   membrane   of    the   bronchial   tubes.      The  mucosa  of  the 

^  Arch.  gen.  de.  Med.,  Dec,  1895. 
^  Bed.  klin.    Woch.,  Mar.  9,  1896. 


ACUTE  BRONcnrns.  521 

trachea  is  also  involved  to  a  greater  or  less  extent,  and  hence  the 
term  tracheo-bronchitis  is  quite  appropriate,  being  descriptive  of  the 
seat  and  character  of  the  disease.  Involvement  of  the  bronchioles  may 
also  take  place,  but  not  without  an  involvement  of  the  corresponding 
alveolar  structure,  the  condition  being  then,  w^ith  propriety,  termed 
"broncho-pneumonia."  Hence  the  term  "capillary  bronchitis,"  still 
often  employed  to  describe  the  latter  condition,  is  not  pertinent.  A 
certain  class  of  cases  is  met  with,  however,  in  whirh  the  catarrhal 
inflammation,  as  the  result  of  downward  extension,  implicates  the  smaller 
bronchial  tubes  without  involving  the  bronchioles  ;  to  such  the  term 
"  capillary  bronchitis  "  might  be  appropriately  given. 

The  disease  may  be  acute  or  chronic,  both  of  these  forms  occurring 
either  as  a  primary  or  secondary  aff'ection. 

ACUTE  BRONCHITIS. 

Pathology. — The  portions  of  the  mucous  membrane  of  the  trachea 
and  bronchi  that  are  implicated  become  reddened  and  swollen  ;  they  are 
covered  with  mucus  mingled  with  epithelial  cells,  and  later  muco-pus. 
Some  of  the  smaller  bronchial  tubes  are  dilated.  The  mucous  glands  are 
swollen. 

The  histologic  changes  may  be  briefly  stated  as  follows  :  desquama- 
tion of  the  ciliated  epithelium,  edema  and  swelling  of  the  submucosa, 
and,  in  the  severer  grades,  infiltration  of  the  latter  with  leukocytes. 

Ktiology. — With  rare  exceptions  tracheo-bronchitis  is  produced  by 
the  direct  extension  of  a  catarrhal  inflammation  from  the  nares,  phar- 
ynx, and  larynx.  Rarely  the  bronchi  are  the  seat  of  primary  acute 
catarrh,  and  in  the  latter  instances  the  upper  air-passages  may  be  im- 
plicated secondarily,  constituting  a  reversal  of  the  direction  of  extension. 

The  immediate  causes  are  mechanical,  chemical,  and  biologic  irri- 
tants, which  act  directly  upon  the  tracheo-bronchial  mucosa ;  and  that 
bronchitis  is  frequently  due  to  infection  at  a  time  when  the  resisting  power 
of  the  system  is  low  there  can  be  little  doubt.  Among  organisms  com- 
monly met  with  is  the  so-called  micrococcus  c'atarrhalis.  The  circum- 
stances disposing  to  bronchitis  are  many,  those  pertaining  to  the  indi- 
vidual being — (1)  Age,  the  old  and  very  young  being  most  liable ;  (2) 
Debility ;  (3)  Occupation,  as  in  certain  trades  that  expose  to  irritating 
vapors  and  sedentary  pursuits.      Among  the  external  conditions  are — 

(1)  Climatic  factors,  particularly  variability  of  temperature  and  humidity: 

(2)  Seasons  of  the  year.  "  Catching  cold"  often  results  from  exposure 
during  the  spring  and  autumn  months.  These  two  conditions  depend 
substantially  upon  the  same  factors.  (3)  Epidemic  influence,  which  may 
be  independent  of  influenza.     (4)  Severe  contusion  of  the  chest. 

Acute  tracheo-bronchitis  arises  as  a  secondary  condition  in  a  great 
variety  of  diseases,  as,  for  example,  the  exanthemata  and  other  acute 
infectious  diseases  (typhoid  fever,  measles,  Avhooping-cough,  influenza, 
etc.).  As  shown  elsewhere,  among  this  class  of  diseases  the  bronchitis 
may  be  dependent  upon  the  primary  infectious  process ;  but  in  many 
others  it  is  due  either  to  the  inhalation  of  pathogenic  irritants  or  to  the 
retention  of  bronchial  secretions  that  are  apt  to  accumulate  and  decom- 
pose with  resulting  bronchitis.      The  accidental  inhalation  of  particles 


522  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  food  and  saliva  may  also  lead  to  secondary  bronchitis,  or  the  condi- 
tion may  be  secondary  to  chronic  affections — e.  g.,  Pott's  disease,  gout, 
Bright's  disease.  Among  the  toxic  causes  the  poison  of  uremia  must  be 
embraced. 

Symptoms. — Bronchitis  of  the  larger  tubes,  which  extends  down 
to  about  the  second  division  of  the  bronchi,  is  spoken  of  usually  as  a 
"cold."  In  such  cases  the  onset  is  marked  by  recurring  sensations  of 
chilliness^  and  by  coryza,  slight  sore  throaty  and  hoarseness ;  while  in  young 
and  feeble  children  convulsions  may  occur  early.  Mild  febrile  symp- 
toms may  appear,  the  temperature  ranging  from  101°  to  103°  F.  (38.3° 
to  39.4°  C.)-  with  slight  acceleration  of  the  pulse;  and  there  may  be 
languor  and  aching  in  the  limbs  and  lumbar  region.  With  the  fully-devel- 
oped attack  substernal  soreness,  sometimes  even  paiti,  is  experienced, 
especially  on  coughing,  and  the  pain  may  be  referred  to  the  intercostal 
muscles  and  the  line  of  insertion  of  the  diaphragm.  The  respirations 
are  increased  in  frequency,  but  there  is  no  dyspnea.  There  may  be 
thoracic  oppression  and  discomfort  until  the  bronchial  secretions  become 
free,  and  there  is  a  cough  which  is  at  first  dry  and  hard.  It  often  man- 
ifests itself  in  longer  or  shorter  paroxysms,  particularly  on  lying  down 
and  on  rising  after  a  full  night's  sleep.  At  the  end  of  one,  two,  or 
more  days  the  cough  is  moist  and  attended  with  an  expectoration  which 
is  at  first  mucoid  and  scanty,  often  viscid,  then  muco-purulent  and  free ; 
later  still  it  is  sometimes  distinctly  purulent.  With  free  expectoration 
comes  relief  to  the  patient.  Histologically,  the  sputum  consists  mainly 
of  pus-corpuscles  with  large  cells,  in  which  may  be  seen  the  so-called 
myelin  droplets  of  Virchow  and  carbon  particles. 

Physical  Signs. — Upon  laryngoscopic  examination  the  mucous  mem- 
brane of  the  larynx  and  trachea  may  be  seen  to  be  reddened  and  cov- 
ered  by  more  or  less  secretion. 

Inspection  and  palpation  of  the  chest  are  negative,  except  when  the 
finer  tubes  become  implicated  or  fever  is  present,  in  which  case  the  res- 
pirations may  be  observed  to  be  slightly  accelerated.  In  children  the 
increased  rapidity  of  the  respirations  is  more  common  and  reaches  a 
higher  degree.  Bronchial  fremitus  may  sometimes  be  felt.  Percussion 
yields  negative  results,  save  in  very  rare  instances,  in  which  there 
occurs  a  decided  accumulation  of  secretion  in  the  tubes,  when  there 
may  be  found  impairment  of  resonance  posteriorly  below  the  scapulne. 
Auscultation  usually  renders  audible  a  harsh  respiratory  murmur,  and 
less  frequently  piping,  sibilant,  and  sonorous  rales.  In  the  advanced 
stage  (with  relaxation  of  the  mucosa)  large  and  medium-sized  mucous 
rales  are  present.  The  rales  change  in  position  from  time  to  time,  and 
after  coughing  may  be  altogether  absent,  only  to  reappear  later. 

The  diagnosis  is  reached  without  difficulty  through  the  symptoms 
(slight  fever,  cough,  and  expectoration),  the  acute  course,  and  the  physi- 
cal signs  (harsh  respiratory  murmur,  dry  followed  by  moist  rales,  heard 
on  both  sides  of  the  chest).  The  recognition  of  the  long  list  of  cases 
that  constitute  the  secondary  forms  will  be  made  easily  possible  by 
noting  the   circumstances  under  which  they  arise. 

Differential  Diagnosis. — Bronchitis  can  readil}"  be  separated  from 
pneumonia  and  from  pleural  effusion  by  its  history,  its  lighter 
course,  and  especially  by  the  absence  of  the  signs  of  consolidation  and 
effusion. 


ACUTE  BRONCnrTfS.  523 

When  broncho-pneumonia  develops  in  tlie  course  of  bronchitis,  dys- 
pnea and  fever  are  increased,  cyanosis  is  present,  and  the  general  con- 
dition becomes  much  more  grave.  There  are  small  patches  that  yield 
dulness  on  percussion,  and  broncho-vesicular  breathing  with  moist  rales 
can  be  detected  on  auscultation. 

Bronchitis  cannot  be  separated  from  the  early  stage  of  vjhooping- 
cough,  but  when  the  characteristic  cough  of  the  latter  is  heard  all  doubt 
vanishes. 

The  bronchitis  of  measles  before  the  characteristic  eruption  appears 
is  distinguished  by  the  red  spots  ("  Koplik's  spots  ")  upon  the  anterior 
half-arches  of  the  soft  palate. 

The  acute  suffocative  catarrh  of  Laennec  may  be  confused  with  the 
severer  forms  of  bronchitis.  Examination  of  the  chest  shows  nothing 
beyond  coarse  rhonchi,  the  chief  distinguishing  feature  being  the  acute 
suffocation.  Both  pulmonary  tuberculosis  and  influenza  are  apt  to  be 
confused  with  bronchitis  {vide  pp.  135,  273). 

The  prognosis  varies  with  the  previous  constitutional  state  of  the 
individual.  In  healthy  adults,  after  a  period  ranging  from  a  few  days  to 
two  weeks,  the  fever  subsides,  but  the  cough,  though  less  marked,  and 
the  expectoration  usually  continue  for  a  variable  length  of  time.  In  old 
persons  and  in  those  of  a  gouty  or  tuberculous  diathesis  the  cases  pursue 
a  more  protracted  course.  The  cases  in  which  streptococci  are  found  in 
the  sputum  are  severe  and  in  the  old  may  prove  fatal.  There  is  in  these 
subjects  a  tendency  on  the  part  of  the  catarrhal  process  to  extend  down- 
ward until  the  finer  tubes  are  implicated,  sometimes  endangering  life.  In 
the  old  the  secretions  are  imperfectly  expectorated ;  they  gravitate  to 
the  most  dependent  parts  and  induce  bronchiectasis.  In  young  children 
this  downward  extension  of  the  affection,  with  resulting  broncho-pneu- 
monia and  areas  of  collapse  in  consequence  of  dilatation  and  occlusion 
of  the  bronchioles  by  muco-pus,  is  a  not  uncommon  and  serious  event 
{e.  g.,  in  measles,  whooping-cough,  vide  Broncho-pneumonia). 

Treatment. — There  are  many  instances  in  which  but  little  treat- 
ment is  required,  apart  from  the  usual  household  measures  and  protection 
against  cold  and  damp.  If  seen  early,  Avhile  the  coryza  is  present,  the 
attack  may  often  be  aborted  by  the  use  at  bedtime  of  a  Dover's  powder 
in  combination  with  quinin  (gr.  iv-viij — 0.259-0.518) ;  this  may  be 
seconded  by  a  glass  of  hot  lemonade,  with  or  without  a  portion  of  whisky, 
and  either  a  hot  bath  or  a  mustard  foot-bath.  The  following  morning  a 
saline  laxative  should  be  taken.  To  children  a  mild  calomel  purge  fol- 
lowed by  a  dose  of  castor  oil  may  be  administered.  The  patient  should 
be  kept  in  a  warm,  moist,  equable  atmosphere — preferably  in-doors — and 
during  this  period  he  should  take  divided  doses  of  quinin  for  a  day  or 
two.  Vanderhoof  lauds  hexamethylenamine  given  in  large  doses  (gr.  x 
dissolved  in  a  glassful  of  water  four  times  daily) ;  it  shortens  the  stage 
of  coryza  and  lessens,  or  even  prevents,  the  succeeding  bronchitis.  If 
the  above  mode  of  treatment  fail  or  if  the  patient  does  not  come  under 
observation  early,  the  main  objects  of  treatment  should  be  {a)  to  render 
the  secretions  free,  and  (b)  to  hasten  the  expulsion  of  the  sputum  after  it 
has  been  loosened.  The  first  leading  indication  is  to  be  met  by  the  use 
of  diaphoretics,  diuretics,  and  relaxants.  The  subjoined  formula  com- 
bines these  classes  of  agents : 


524  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

!^.   Potassii  citrat.,  3vj    (23,3); 

Liq.  ammonii  acetat.,  5v     (148.0) ; 

Spt.  a?th.  uit.,  5j      (30.0) ; 

Vini  ipecac,  oij     (8,0); 

Syr.  pruni  virg.,  q.  s.  ad  sviij  (216.0). — M. 

Sig.  5SS  (7.0)  in  water  every  two  hours  until  the  secretions 
are  loosened. 

If  the  temperature  in  any  given  case  be  maintained  at  a  consid- 
erable elevation,  such  as  102°-103°  F.  (38.8°-o9.4°  C.)  or  over,  tinc- 
ture of  aconite  (TTLxvj — 1.065)  may  be  added  to  the  above  mixture;  and 
if  there  be  present  much  tickling  with  distressing  cough,  due  to  irrita- 
bility of  the  afieeted  mucosa,  codein  (gr.  ij-iij — 0.129-0.194)  may  be 
added  to  the  same.  For  the  incessant  irritative  cough  which  is  present 
in  severe  forms  of  catarrh  opium  alone  is  really  effective.  When  the 
above  prescription  is  not  productive  of  free  secretion  and  troublesome 
cough  continues,  I  employ  the  following  : 

I^.  Ammon.  chloridi,  gv  (20.0) ; 

Codeine,  gr.  iv  (0.259-0.388); 

Spt.  junip.  CO.,  3SS  (16.0) ; 

Mist,  glycyrrh.  comp.,      5iiss  (80.0) ; 

Syr.  pruni  virg.,    q.  s.  ad  5iv  (120.0). — M. 
Sig.   oj  (4-0)  every  two  hours. 

Apomorphin  is  also  excellent  as  a  soothing  relaxant  in  doses  of  gr. 
TO"  ^  TU"  (O-*-^*^^  to  0.006)  every  two  hours.  Mild  counter-irritation  by 
means  of  mustard-paste,  followed  by  the  application  of  iodin  once  daily, 
is  also  helpful.  The  patient  should  keep  to  his  room,  in  which  the  at- 
mosphere should  be  kept  moist  and  of  even  temperature,  (b)  The  expul- 
sion of  the  sputum  may  demand  stimulating  expectorants,  though  rarely. 
It  is  to  be  recollected  that  when  the  tracheal  secretion  becomes  copious 
the  period  of  convalescence  is  usually  reached,  and  stimulating  expec- 
torants are  then  entirely  unnecessary.  When,  on  the  other  hand,  the 
cough  is  no  longer  dry,  and  on  auscultation  the  rales  are  found  to  be 
moist,  and  whilst,  at  the  same  time,  the  expectoration  is  expelled  with 
difficulty,  or  if  the  bronchitis  tends  to  become  chronic,  then  such  s4;im- 
ulating  expectorants  as  senega,  squills,  and  ammonium  chloride  are  to 
be  employed.  In  cases  in  which  expectoration  continues  to  be  too 
abundant  terebene,  tar  syrup,  and  oil  of  sandal  are  to  be  resorted  to. 

Debility  and  secondary  anemia  must  be  speedily  overcome  by  exhib- 
iting quinin,  bitter  tonics,  iron,  and  arsenic ;  and  a  suitable  change  of 
air  often  yields  prompt  and  excellent  results  in  protracted  cases.  The 
treatment  of  the  various  forms  of  secondary  bronchitis  will  be  consid- 
ered in  their  appropriate  connections  in  this  work.  In  the  aged  the 
general  strength  must  be  maintained  ;  the  patient's  position  must  be 
changed  at  short  intervals  and  stimulants  are  usually  needed. 

In  children,  acute  bronchitis  is  in  the  main  to  be  treated  in  the 
same  manner  as  when  it  occurs  in  the  adult.  Opium,  however,  is  to  be 
used  very  sparingly,  and  generally  in  the  form  of  paregoric.  If  the 
secretion  is  abundant  and  imperfectly  raised,  it  is  well  to  administer  an 


CHRONIC  BRONCHITIS.  525 

emetic,  such  as  the  wine  of  ipecac  (^ss-j — 2.0-4.0),  and  repeat  in  ten 
minutes  if  necessary.  If  dyspnea  be  urgent  and  cyanosis  be  marked 
in  the  lips  and  finger-tips,  a  prompt  emetic  is  imperative  in  order  to  save 
life.  A  child  suffering  from  acute  bronchitis  should  be  kept  in  bed  until 
the  fever  subsides. 

The  diet  during  the  dry  stage  should  consist  of  li(juid  forms  of  nour- 
ishment, which  should,  for  the  greater  part,  be  taken  hot.  After  the 
"cold"  has  been  loosened  solid  food  should  be  resumed. 


CHRONIC    BRONCHITIS. 

Pathology. — The  lesions  of  chronic  bronchitis  manifest  considerable 
variety  both  as  regards  their  nature  and  extent.  The  epithcliMl  layer 
is,  in  part,  missing,  and  sometimes  the  mucous  membrane  is  quite  thin. 
In  consequence  the  longitudinal  elastic  fibers  appear  unduly  prominent. 
The  mucous  glands  and  the  muscular  coat  undergo  atrophy  in  long- 
standing cases,  and  the  bronchial  tubes  are  dilated  (bronchiectasis).  In 
another  large  group  of  cases  the  mucosa  is  irregularly  thickened  or  infil- 
trated and  granular.  Small  ulcers  corresponding  to  the  mucous  follicles 
are  common,  and  almost  constantly  emphysema  develops  in  consequence 
of  secondary  changes  in  the  vesicular  structure. 

Ktiologfy. — Chronic  bronchitis  may  either  be  primary  or  secondary. 
The  affection  is,  however,  almost  always  a  secondary  one,  and,  though 
sometimes  the  result  of  repeated  attacks  of  acute  bronchitis,  it  is  oftener 
caused  by  certain  chronic  complaints  and  certain  diatheses,  as  chronic 
alcoholism,  rheumatism,  gout,  syphilis,  pulmonary  tuberculosis,  and  pul- 
monary emphysema.  Organic  valvular  affections,  obesity,  and  chronic 
Bright's  disease  cause  hypostatic  bronchitis.  The  primary  form,  which 
is  rare,  is  the  result  of  exposure  to  wet  or  cold  or  to  the  daily  inhalation 
of  some  irritant  that  maintains  a  low  grade  of  catarrhal  inflammation 
(dust,  vapors).  When  chronic  bronchitis  follows  the  acute  form  w^e  are 
often  able  to  detect  the  operation  of  some  favoi'ing  cause,  as  age,  climate, 
or  season.  It  is  most  common  in  the  aged,  and  occurs  by  preference 
during  the  cold  season,  often  recurring  regularly  in  the  cold  and  variable 
weather  of  autumn  and  winter,  and  disappearing  in  summer.  Hoxie  and 
Lamar  report  two  cases  of  tracheo-bronchitis  due  to  the  presence  of 
fungus  stalks  as  the  only  causative  agent. 

Symptoms. — The  symptoms  are  similar  to  those  of  acute  bron- 
chitis, though  rather  less  severe.  Pain  is  rarely  present,  the  patient 
complaining  merely  of  a  feeling  of  substernal  constriction.  There  may 
be  soreness  at  the  base  of  the  chest  if  the  cough  be  frequent  and  severe, 
and  occasionally  in  the  epigastrium  as  a  result  of  traction  of  the  dia- 
phragm on  the  ribs.  Cough,  while  not  a  constant  accompaniment,  is 
paroxysmal  and  varies  in  severity  and  frequency.  The  degree  of  the 
violence  of  the  paroxysm  depends  upon  two  factors — the  character  of  the 
bronchial  secretion  and  the  seat  of  the  catarrhal  inflammation.  Thus 
when  the  expectoration  is  tenacious  and  scanty,  and  wdien  the  small-sized 
tubes  are  affected,  cough  is  most  violent.  It  also  varies  both  with  the 
w^eather  and  the  season,  as  is  evident  from  the  fact  that  there  is  often  an 
absence  of  cough  in  summer,  while  it  returns  unfailingly  with  each  new 
winter. 


526  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  expectoration  differs  >videly  in  different  cases.  It  is  sometimes 
abundant  and  sero-mucous  in  character.  On  the  other  hand,  there  are 
cases  of  dry  cough  in  which  there  is  little  or  no  expectoration.  As  a 
rule,  however,  it  is  rather  copious,  and  either  muco-purulent  or  dis- 
tinctly purulent  in  character.  Fever  is  usually  absent,  though  rarely 
a  slight  rise  of  temperature  occurs  at  night.  The  appetite  is  good  as  a 
rule ;  the  bodily  weight  and  nutrition  are  also  well  maintained. 

Physical  Signs. — On  inspection  we  usually  note  undue  enlargement 
of  the  thorax,  with  a  decrease  in  expansile  movements  due  to  the  asso- 
ciated emphysema.     Hence  dyspnea  is  commonly  observed. 

Percussion  yields  a  clear  or  hyperresonant  note.  Dulness  or  im- 
paired resonance  is  sometimes  met  with,  however,  during  acute  exacer- 
bations, especially  over  the  bases,  and  is  due  to  congestion  and  edema 
(Fox).  On  auscultation  rhonchi  of  various  forms  and  moist  rales  are 
heard,  their  number  and  size  being  in  proportion  to  the  extent  of  the 
swelling  of  the  mucous  membrane  and  the  amount  and  fluidity  of  the 
secretory  products.  The  respiratory  murmur  is  enfeebled,  though 
roughened,  and  the  expiratory  sound  is  prolonged  and  wheezy.  The 
right  heart  may  be  dilated  from  increased  tension  in  the  pulmonary  cir- 
cuit. 

Clinical  Varieties. — Special  forms,  depending  largely  upon  spe- 
cific causal  factors,  remain  to  be  described : 

1.  The  commonest  variety  of  chronic  bronchitis  has  been  called  the 
"  vrinter  cough  of  the  aged,"  and,  as  before  intimated,  is  usually  accom- 
panied by  emphysema  and  cardiac  disease.  For  this  form  the  gouty 
diathesis  is  often  responsible.  The  cough  occurs  in  paroxysms  that  are 
most  severe  at  night,  and  during  the  early  morning  hours  it  is  attended 
with  free  expectoration  of  the  secretion  that  has  accumulated  during 
the  night. 

2.  Bronchorrhea. — In  this  form  there  may  be  an  abundant  bronchial 
secretion,  composed  largely  of  serum  {hronchorrhoea  serosa).  More 
frequently  perhaps  the  expectoration  is  purulent  and  thin,  containing 
greenish  or  greenish-yellow  masses.  It  may  at  times  be  thick  and  puru- 
lent. Dilatation  of  the  tubes  and  resulting  fetid  bronchitis  may  be  de- 
veloped as  secondary  conditions. 

3.  Fetid  Bronchitis. — In  this  variety  the  expectoration  emits  the 
characteristic  odor  of  decomposing  animal  substances.  The  fetor  may 
indicate  gangrene  of  the  lungs,  abscesses,  bronchiectasis,  decomposition 
of  matter  within  phthisical  cavities,  or  empyema  with  perforation  of  the 
lung.  Hence  these  conditions  must  be  carefully  excluded  before  the 
diagnosis  of  true  fetid  bronchitis  is  made.  In  the  latter  disease  the  expec- 
toration is  usually  copious,  and  on  standing  separates  into  three  layers, 
of  which  the  uppermost  is  composed  of  frothy  mucus,  the  intermediate 
of  a  serous  liquid,  and  the  lowest  of  a  thick  sediment,  that  presents  a 
granular  appearance  and  is  made  up  chiefly  of  small  yellow  masses — the 
characteristic  Dittrich's  plugs.  Microscopically,  the  Dittrich's  plugs 
are  seen  to  be  composed  of  microorganisms,  chief  among  which  is  the 
Leptothrix  pulmonalis ;  they  may  also  contain  pus-corpuscles,  fat- 
granules,  and  crystals  of  margarin.  Dem^tre  found  the  colon  bacillus 
and  ascribes  the  fetor  to  its  presence. 


CHRONIC  BRONCHITIS.  527 

The  condition  may  be  a  grave  one,  and  associated  with  it  may  be 
observed  ulceration  of  the  bronchial  tubes,  with  dihitation,  pneumonia, 
abscess,  gangrene,  and  rarely  metastatic  cerebral  abscesses.  When 
putrefactive  changes  take  place  in  the  bronchial  secretion  in  the  course 
of  chronic  bronchitis  a  new  group  of  symptoms,  as  a  rule,  immediately 
appears.  This  comprises  rigors  occurring  at  irregular  intervals  and 
associated  with  high  fever  and  increased  prostration.  Cough  and  pain 
in  the  chest  also  become  aggravated,  but  these  acute  symptoms  may 
shortly  subside  and  the  usual  course  of  chronic  bronchitis  be  resumed. 
Even  under  the  latter  conditions  fetor  of  the  breath  and  sputum  may 
persist. 

4.  Dri/  Catarrh. — The  cough  is  both  severe  and  paroxysmal,  and 
there  is  little  or  no  expectoration.  When  expectoration  is  present  the 
sputum  is  very  tenacious  and  is  expelled  with  great  difficulty.  An 
asthmatic  disposition  is  sometimes  noticeable  in  this  variety,  and  emphys- 
ema is  commonly  associated.  The  dry  condition  of  the  bronchial  mu- 
cosa is  evidenced  by  sibilant  and  sonorous  rales.  This  form  occurs  in 
old  persons,  as  a  rule. 

5.  Osier  has  described  a  form  of  chronic  bronchitis  that  occurs 
most  frequently  in  women,  and  dates  its  onset  from  a  comparatively 
early  period  of  life.  It  does  not  undermine  the  general  health.  The 
cough  is  most  pronounced  in  the  morning,  and  is  accompanied  by  a  rela- 
tively small  amount  of  muco-purulent  expectoration.  An  examination 
of  the  chest  yields  negative  results.  The  condition  seems  to  proceed 
from  a  gouty  or  tuberculous  diathesis  in  some  instances.  I  have  had 
under  observation  for  several  years  a  young  woman  in  whom  this  form 
of  bronchitis  alternated  with  eczema  of  the  face. 

6.  Teichmiiller  has  described  an  eosinophilic  bronchitis.  The  expec- 
toration is  mucoid,  as  a  rule,  though  occasionally  muco-purulent.  It  is 
characterized  particularly  by  the  presence  of  a  considerable  number  of 
eosinophile  cells  in  the  sputum.  It  is  not  dependent  upon  adenoid  dis- 
ease of  the  naso-pharynx.      Some  writers  doubt  its  existence. 

Diagnosis. — The  diagnosis  of  chronic  bronchitis  is  rarely  difficult. 
Since  it  is  usually  a  secondary  condition,  it  is  of  the  utmost  importance 
to  determine  the  nature  of  the  primary  affection.  An  examination  of 
the  heart  and  of  the  urine  should  not  be  overlooked. 

Pulmonary  tuberculosis  is  to  be  discriminated  from  chronic  bronchi- 
tis, and  the  distinctive  points  are — (1)  A  clear  tuberculous  history.  In 
phthisis  there  are  fever  and  loss  of  flesh  and  strength,  while  in  chronic 
bronchitis  fever  is  absent  and  the  general  health  is  not  impaired.  (2) 
In  pulmonary  tuberculosis  the  signs  of  localized  consolidation  (usually 
at  one  or  other  apex)  appear  early,  while  in  chronic  bronchitis  these  are 
absent.  (3)  In  phthisis  the  sputum,  when  examined  microscopically, 
shows  the  presence  of  the  tubercle  bacillus. 

In  acute  pulmonary  tuberculosis  the  fever,  dyspnea,  cyanosis,  and  in- 
creased prostration  constitute  a  group  of  features  that  should  distinguish 
it  from  chronic  bronchitis.  Coexisting  pulmonary  emphysema  is  to  be 
recognized  by  the  characteristic  symptoms  and  signs  of  this  com- 
plaint. Primary  fetid  bronchitis  must  be  differentiated  from  the  vari- 
ous other  conditions  previously  mentioned,  giving  fetor  of  the  sputum  and 
breath.  In  abscess  of  the  lung  the  sputum  contains  shreds  of  lung- 
tissue,  including  elastic  fibers,  crystals  of  hematoidin,  cholesterin,  and 


528  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

amorphous  blood-pigment ;  usually  localized  dulness  and  broncho-cav- 
ernous breathing  coexist.  In  gangrene  there  are  contained  in  the  spu- 
tum shreds  of  lung-tissue,  but  separate  elastic  fibers  are  often  absent,  on 
account  of  the  presence  of  a  ferment  that  causes  a  solution  of  the 
elastic  tissue  (v.  Jaksch).  Bronchiectasis  is  usually  unilateral,  and 
gives  rise  to  dulness  and  other  physical  signs  that  are  confined  to 
limited  areas,  while  in  chronic  bronchitis  the  signs  are  general. 

Prognosis. — Recovery  is  the  exception,  though  improvement  may 
frequently  be  observed.  The  course  is  exceedingly  protracted,  and  the 
danger  from  the  late  development  of  certain  complications  and  secjuels, 
such  as  emphysema  or  right-sided  cardiac  disease,  must  be  borne  in 
mind.  Since  the  disease  is  generally  a  secondary  affection,  the  prognosis 
in  most  instances  depends  upon  the  outlook  in  the  primary  disease. 

Treatment. — The  treatment  falls  naturally  under  two  main  head^ 
— (1)  Hygienic,  and  (2)  Medicinal. 

1.  Hygienic. — Thi-s  has  reference,  frequently,  to  the  removal  of 
various  noxious  influences.  When  the  patient  cannot  make  a  suitable 
change  of  air  during  the  cold  season,  he  must  keep  his  room  during  in- 
clement weather :  he  should,  however,  be  allowed  to  spend  as  much  time 
as  possible  in  the  open  air  during  clear  and  pleasant  weather.  The 
vitiated  atmosphere  of  saloons  or  public  halls  is  to  be  avoided.  The 
patient  should  be  carefully  clad ;  he  should  wear  flannels  next  the  skin 
during  all  seasons  of  the  year,  but  his  outer  clothing  need  not  be  unu- 
sually cumbersome.  If  the  case  be  of  an  aggravated  type  and  the  cir- 
cumstances of  the  patient  permit,  he  should  be  sent  to  a  warm  latitude 
in  the  autumn,  in  order  to  escape  the  effects  of  a  severe  northern  win- 
ter. Patients  in  whom  the  bronchial  secretions  are  abundant  should  be 
sent  to  a  dry,  warm  climate  or  to  a  region  whose  atmosphere  is  impreg- 
nated with  the  balsamic  vapors  of  the  pine.  On  the  other  hand,  patients 
Avith  dry  bronchial  catarrh  are  most  relieved  by  an  equable,  moist, 
warm  climate.  Among  suitable  resorts,  those  that  should  be  mentioned 
are  the  Riviera,  Cannes,  San  Remo,  Sicily,  and  Algiers  abroad,  and 
Florida,  Southern  Georgia,  and  Southern  California  at  home.  Change 
of  air  may  also  become  an  effective  means  of  prevention. 

Prophylaxis  also  includes  the  removal  of  any  diseased  conditions 
that  are  casually  related.  The  coexistence  of  cardiac  disease,  the  gouty 
diathesis,  obesity,  and  particularly  any  renal  disturbance,  call  for  the 
primary  treatment  of  these  conditions.  Hardening  (^('^//a?'^«mr/)  is  an  im- 
portant preventive  method,  and  is  accomplished  by  hydriatic  measures — 
the  cold  sponge,  douche,  or  plunge — if  there  be  no  contraindications. 

The  diet  should  be  generous,  but  not  stimulating,  and  articles  easy 
of  digestion  should  be  selected.  Wines  and  liquors  are  to  be  avoided 
unless  particular  indications  for  their  use  exist.  Special  conditions,  how- 
ever {e.  g.  albuminuria),  may  render  necessary  a  special  dietary. 

2.  Medicinal. — In  this  disease  medicines  are  palliative  in  their  effects 
rather  than  curative.  Relaxing  expectorants  are  to  be  avoided,  owing 
to  their  depressing  action,  and  the  stimulating  expectorants  are,  in  a 
majority  of  cases,  not  only  valueless,  but  hurtful,  tending  to  lessen  the 
appetite  and  disorder  the  digestion.  When,  however,  the  sputum  is 
muco-purulent  and  is  dislodged  with  difliculty,  expectorants  of  this  class 
(squills,  senega,  ammonium  chloi'ide)  may  be  tried.  I  have  obtained  good 
results  from  the  use  of  the  following  in  severe  paroxysms  of  cough : 


BRONCHIECTASIS.  529 

i;^.    01.  eucalypti,  ^jss-^iij  fG.0-12.0); 

Codcinjc,  gr.  vj       (0.388). 

M.  et  ft.  ciipsuljic  No.  xviij. 
Sig.   One  every  four  hours,  as  required. 

Occasionally  potassium  iodid  exerts  a  curative  influence,  but  its  use 
may  be  limited  to  cases  that  are  due  to  the  syphilitic,  rheumatic,  and 
gouty  diatheses.  Five  or  ten  grains  of  the  iodid  four  times  daily  may 
be  exhibited,  and  should  there  be  present  a  syphilitic  taint  the  remedy 
should  be  pushed  to  the  limit  of  tolerance.  The  balsam  of  copaiba  is 
sometimes  efficacious : 

I^i.  Balsami  copaibse,  3J-3U  (4.0-8.0) ; 

Ammon.  chloridi,  3ij        (8.0); 

Extr.  glycyrrh.  pulv.,  3J  (4-0). 

Mist,  ammoniaci,     q.  s.  ad  fsiij  (96.0). — M. 
Sig.  3ij  (8.0)  every  four  hours. 

Other  remedies  that  possess  great  value  in  certain  cases  are  creasote 
(in  ascending  doses),  turpentine,  terpine,  tar,  the  balsams  of  tolu  and 
Peru,  and  sandal-wood.  Box^  advises  the  emptying  of  the  cavities  by 
the  process  of  inversion — night  and  morning. 

If  the  vital  powers  are  poor,  bitter  tonics,  as  iron,  quinin,  and 
strychnin,  and  other  measures  calculated  to  invigorate  the  system,  are 
indicated.  When  the  sputum  is  excessive  in  amount,  astringents  (zinc 
sulphate  and  oxid)  are  sometimes  useful.  In  this  class,  Barnes  recom- 
mends the  internal  use  of  ichthyol  (dose,  gr.  v-0,3,  t.  i.  d.).  Astringents 
may  also  be  used  with  advantage  in  the  form  of  a  spray  when  the  expec- 
toration is  too  free.  On  the  other  hand,  sprays  from  properly  selected 
solutions  (<?.(/.,  ammonium  chloridi,  gr.  v-x  ad  §j — 0.324—0.648  ad  32.0) 
are  valuable  in  assisting  expectoration.  In  fetid  bronchitis  sprays  of 
antiseptic  solutions  are  to  be  used,  and  the  following  will  be  found  ser- 
viceable : 

^.   Phenolis,  gr.  ij-iv  (0.129-0.259); 

Olei  eucalypti,  mi^-iv    (0.133-0.266); 

Aquae,  ^j  (32.0). 

Sig.  To  be  inhaled  from  a  steam-  or  hand-atomizer. 

Pneumato-therapy  has  given  brilliant  results  in  certain  instances. 
After  deciding  what  microorganism  is  responsible,  the  corresponding 
vaccine  (autogenous)  should  be  employed.  If  different  organisms  be 
found,  the  results  are  unsatisfactory. 


BRONCHIEOTASIS. 

Definition. — The  universal  or  circumscribed  dilatation  of  the  bron- 
chial tubes. 

Pathology. — Two  main  forms  are  recognized — the  cylindrical  or 

^  Lancet,  Jan.  5,  1907. 
34 


530  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

simple,  and  the  saccular,  ami  both  of  these  may  be  met  with  in  the  same 
lung.  It  may  be  general  or  jiartial.  the  former  variety  being  always 
unilateral,  the  latter  sometimes  bilateral.  In  universal  broncJiiectasis  the 
bronchial  tubes,  throughout  their  extent,  are  the  seat  of  numerous  sacculi 
communicating  with  one  another.  These  present  smooth,  shining  walls, 
except  in  the  most  de]iendent  parts,  where  ulcers  are  sometimes  seen. 
Extreme  conditions  of  dilatation  may  take  the  form  of  huge  cysts,  which 
may  extend  to  the  peripliery  of  the  lung :  the  lung-tissue  lying  between 
the*  sacculi  then  becomes  cirrhotic  as  a  rule.  In  jiartial  dilatation  the 
bronchial  mucous  membrane  is  implicated,  with  an  occasional  narrowing 
of  the  lumen.  Usually  these  dilatations  are  cylindrical,  though  they 
may  be  saccular,  and  rarely  fusiform.  The  partial  is  the  most  common 
variety. 

Hiitology. — When  the  walls  of  the  larger  dilatations  are  examined 
microscopically,  the  cylindrical  epithelium  is  seen  to  be  replaced  by  a 
pavement  epithelium.  The  elastic  and  muscular  layers  are  thin,  and 
the  fibers  are  usually  separated.  Contained  in  these  dilatations  are 
found  secretions  that  may  frequently  be  fetid. 

Htiology. — In  the  majority  of  instances  the  condition  doubtless 
arises  from  an  involvement  of  the  bronchial  mucosa  that  extends  to  the 
submucous  tissue  and  leads  to  muscular,  fibrous,  and  cartilaginous  atrophy. 
These  changes  render  the  wall  of  the  tube  unable  to  resist  the  pressure 
of  the  air  in  violent  paroxysms  of  cough,  and,  once  the  process  of  dila- 
tation is  commenced,  the  accumulated  secretions  may  tend  by  their  weight 
to  distend  further  the  already  weakened  walls.  Thus  the  elasticity  of 
the  latter  is  impaired,  and  finally  destroyed.  The  etiologic  factors 
show  the  affection  to  be  secondary  as  a  rule,  and  are — (1)  Chronic 
bronchitis  and  emphysema,  chronic  phthisis  (usually  when  the  seat  of 
the  dilatation  is  at  the  apex),  broncho-pneumonia  (in  children),  and 
compression  of  a  bronchus  {e.g..  by  aneurysm).  Heubner  believes  that 
bronchiectasis  in  adults  may  be  sometimes  traced  to  whooping-cough  and 
measles  in  young  children.  (2)  Great  thickening  of  the  pleura,  espe- 
ciallv  when  associated  with  bronchitis  or  interstitial  pneumonia,  with 
contraction  of  the  lung.     (3)  Rarely  it  is  congenital. 

Among  predisposing  conditions  are — {a)  Age,  bronchiectasis  being 
most  common  in  adult  or  middle  life ;  and  (6)  Sex^  being  more  common 
in  males  than  females. 

Symptoms. — There  is  always  cough,  usually  in  prolonged  and 
severe  paroxysms.  The  attacks  take  place  most  generally  in  the 
morning  when  the  dilated  tubes  are  full,  and  may  be  excited  by  a 
change  of  posture.  Accompanying  the  cough  there  is  profuse  expectora- 
tion., which  may  amount  to  a  pint  or  more  in  twenty-four  hours.  The 
sputum  is  grayish-brown  in  color  and  muco-purulent,  emitting  a  sour  or, 
more  frequently,  a  horrWAj  fetid  odor.  On  standing,  the  expectoration 
separates  into  three  strata — the  uppermost,  of  brownish  froth  ;  the  mid- 
dle, of  a  thin,  sero-mucous  fluid ;  and  a  thick  sediment,  of  cells  and 
cranular  debris.  Examined  microscopically,  the  sediment  is  seen  to  be 
composed  chiefly  of  pus-corpuscles,  with  Avhich  are  intermingled  Charcot- 
Leyden  and  fatty-acid  crystals,  the  latter  arranged  in  bundles  ;  lepto- 
thrices,  vibrios,  and  bacteria  are  also  found.  Elastic  fibers  may  be 
observed  if  ulcers  be  present. 


BRONCHIECTASIS.  5:51 

Dyspnea  is  noted,  but  is  not  a  prominent  symptom,  nnless  some 
other  chronic  affections  of  the  chest  coexist  or  some  complication  arises. 
Hemoptysis  occurs  rarely,  and  may  be  due  to  the  bronchiectatic  lesion. 
Abscess  of  the  brain  may  develop,  though  rarely. 

Physical  Signs. — These  differ  in  character  according  to  the  size,  situ- 
ation, and  nature  of  the  dilatation,  and  also  according  to  the  condition 
of  the  surrounding  lung-tissue. 

On  inspection  retraction  of  the  chest-wall  may  be  noted  when  chronic 
pleurisy  and  interstitial  pneumonia  are  associated.  The  tactile  fremitus 
is  usually  increased,  but  may  rarely  be  diminished.  The  pjercussion 
resonance  is  impaired  or  even  flat,  and  on  auscultation  bronchial  breath- 
ing is  heard,  with  occasional  rales  that  have  a  metallic  quality.  A  sac- 
cular dilatation  immediately  beneath  the  pleura  may  give  a  tympanitic 
note,  and  may  also  give  typical  cavernous  or  amphoric  respiration.  A 
tympanitic  resonance  over  a  circumscribed  area  which  prior  to  cough 
and  expectoration  presented  dulness,  is  a  significant  sign  (Babcock). 
These  signs  are  generally  discoverable  at  the  base  of  one  or  other  lung. 

Diagnosis. — Simple  dilatation  of  slight  degree  may  exist  without 
appreciable  signs,  and  in  other  instances  the  breathing  is  broncho-vesic- 
ular over  localized  areas,  with  rales  displaying  increased  metallic  quality. 

Saccular  Bronchiectasis.  Pulmonary  Tuberculosis. 

History  of  chronic  bronchitis,  chronic  History  of  cough,  hemoptysis,  with  pro- 
pleurisy,  and  interstitial  pneumonia,  or  gressive  loss  of  flesh  and  strength, 
of  foreign  body.  Family  history. 

Cough  is  paroxysmal,  and  sputum  cha-  Cough  less  paroxysmal.     Sputum  num- 

racteristic  and  copious.  mular  in  the  stage  of  cavity. 

Tubercle  bacillus  absent.  Tubercle  bacillus  present. 

Course  longer,  with  little  impairment  of  Course  relatively  shorter,  powers  of  the 

the  general  health.  system  progressively  undermined. 

Physical  Signs. 

The  condition  is  persistent,  but  non-pro-  More  apt  to  be  progressive,  commonly 
gressive.     Usually  located  at  base.  at  one  or  other  apex. 

Circumscribed  empyema  with  a  fistulous  connection  with  the  lung 
may  simulate  bronchiectasis.  There  is  often  in  such  cases  a  clear  his- 
tory of  an  acute  illness  with  a  sudden  onset,  the  symptoms  pointing  to 
pleural  inflammation.  The  patient  suddenly  expectorates,  at  irregular 
intervals,  large  quantities  of  purulent  matter.  Actinomycosis  may  also 
cause  conditions  that  simulate  bronchiectasis.  The  diagnosis  may  be  made 
by  finding  granular  particles  containing  the  actinomyces  in  the  sputum. 

Prognosis. — Apart  from  certain  remote  dangers  (e.  g.  abscess,  gan- 
grene, fatal  hemorrhage  from  an  aneurysm  in  the  wall  of  the  cavity), 
these  cases  pursue  a  favorable  but  exceedingly  long  course. 

Treatment. — The  lesion  being  a  .permanent  one,  there  is  no  known 
remedy  that  Avill  either  abridge  or  influence  the  course  of  the  affection. 
Again,  since  the  cough  is  protracted  and  attended  with  profuse  expec- 
toration, sedatives  and  ordinary  expectorants  are  contraindicated.  For 
the  fetor,  antiseptics  are  to  be  employed  both  topically  and  internally, 
and  a  solution  of  carbolic  acid  (1-3  per  cent.)  or  thymol  (1 :  1000)  is 
to  be  used  by  inhalation.  Internally,  terebene  (TTiv-x — 0.333-0.666) 
in  capsules  every  four  hours  is  valuable;   also   creasote  in  increasing 


532  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

doses  (Trm_0.0G6,  increasing  by  r\\}  each  day,  till  irivj— 0.399— are 
taken  three  times  daily)  is  to  be  persistently  employed.  Intrathoracic 
injections  arc  often  resorted  to  -with  gratifying  results. 

If  tiie  dilatation  is  situated  superticialiy  and  not  amenable  to  thera- 
peutic measures,  it  may  be  freely  opened  "and  thoroughly  drained.  By 
raising  the  foot  of  the  bed  or  lowering  the  head  of  the  patient  in  otheV 
ways  we  favor  the  discharge  of  the  accumulated  secretions  from  the 
sacculations.  Iloppe-Seyler  recommends  the  continuous  nocturnal  pos- 
tural method  in  cases  in  which  no  contraindications  exist. 


BRONCHIAL  STENOSIS. 

Definition. — Narrowing  of  the  bronchus,  due  either  to  constriction 
or  to  compression. 

Pathology  and  Etiology. — (a)  Stenosis  due  to  Constriction. — 
This  form  is  most  frequently  occasioned  by  the  presence  of  foreign 
bodies ;  by  new  growths  (polypoid)  within  the  bronchi,  or  the  cicatrices 
of  healed  ulcers,  and  in  the  smaller  bronchi  by  swelling  of  the  mucosa. 
The  bronchial  walls  also  sometimes  become  thickened  by  inflammatory 
exudates  in  certain  acute  and  chronic  affections,  such  as  syphilis,  tuber- 
culosis, and  glanders. 

{h)  Stenosis  Due  to  Comjiressioyi. — Compression  of  one  or  more 
bronchi  may  be  met  in  enlargements  involving  the  thoracic  organs,  e.  /y., 
aneurysm,  cchinococcus  cyst,  solid  tumors,  enlarged  glands,  mediastinal 
and  pulmonary  abscesses,  and  pleural  effusion. 

Symptoms. — The  symptoms  depend  upon  the  size  of  the  bronchus 
affected  and  the  degree  of  stenosis.  Dyspnea  is  the  most  conspicuous 
symptom,  but  the  proper  filling  of  the  lungs  with  air  is  not  accomplished. 
Under  these  circumstances  the  air  in  the  lungs  becomes  rarefied,  and 
instead  of  normal  expansion  everywhere  the  loAver  part  of  the  sternum 
and  the  lower  ribs  are  retracted  on  inspiration.  Obstruction  of 
the  primary  bronchus  on  either  side  of  the  chest  would  naturally  be 
followed  by  inspiratory  retraction  of  the  inferior  part  of  the  chest- 
wall  and  intercostal  spaces  upon  the  affected  side.  The  movoments 
of  the  larynx  are  slight  in  bronchial  stenosis,  while  they  are  marked 
in  laryngeal  obstruction.  Cough,  expeetoration,  and/(?rt'r  are  sometimes 
present. 

Physical  Signs. — InsjJection  shows  defective  respiratory  movement 
upon  the  side  involved.  The  local  tactile  fremitus  is  diminished  or 
absent  upon  the  affected  side.  The  pej'cussion-note  remains  unaltered, 
though  less  influenced  by  forced  respiration  and,  particularly,  expiration 
than  in  health.  Pulmonary  atelectasis  may  occur  as  a  secondary  event, 
and  is  shown  by  dulness  on  percussion.  The  auscultatory  signs  consist 
of  a  greatly  diminished  vesicular  murmur  on  inspiration,  due  to  the 
diminished  amount  of  air  entering  the  air-cells,  and  the  presence  of  rales, 
sibilant  and  sonorous,  at  the  seat  of  obstruction.     Obstruction  of  a  small 


ASTHMA.  53ri 

bronchus  may,  however,  be  present  without  appreciable  physical  signs, 
owing  to  collateral  empbyBema. 

Diagnosis. — The  nature  and  site  of  the  affection  may  be  determined 
by  auscultation,  and  sibilant  and  sonorous  rales  wiJl  be  consfjicuous  at 
the  point  of  constriction.  A  clear  history,  together  with  a  careful  in- 
vestigation of  antecedent  affections  of  the  thoracic  organs  leading  up 
to  the  stenosis,  are  factors  that  must  furnish  the  etiological  data  in  indi- 
vidual cases  after  the  exclusion  of  foreign  bodies  as  the  possible  cause. 
Tracheal  or  laryngeal  stenosis  may  be  eliminated  by  careful  laryngo- 
scopic  examination. 

Prognosis. — The  duration  is  indefinite,  though  usually  protracted, 
and  most  cases  yield  an  unfavorable  prognosis.  In  those  instances, 
however,  in  which  the  narrowing  is  due  to  foreign  bodies  the  latter 
may  rarely  be  dislodged  and  fortunately  ejected. 

Treatment. — The  treatment  must  be  addressed  to  the  cause  in  in- 
dividual cases.  Obviously,  the  question  of  the  removal  of  foreign 
bodies  from  the  bronchi  falls  within  the  domain  of  surgery,  though  the 
administration  of  an  emetic  has  been  followed  by  complete  success  in 
certain  instances.  Obstruction  due  to  stenosis  of  a  main  bronchus 
may  be  treated  by  dilatation  with  bougies,  the  treatment  of  course  being 
carried  out  by  a  specialist. 


ASTHMA. 

{Bronchial  Asthma.) 

Definition. — A  chronic  affection,  characterized  by  paroxysmal 
dyspnea,  due  to  contraction  of  the  muscles  of  the  bronchioles.  The 
paroxysmal  dyspnea  caused  by  arterial  contraction  is  also  termed  asthma. 

Pathology. — In  many  cases  there  is  hyperemia  of  the  bronchial 
mucosa,  due  to  pneumogastric  or  vasomotor  functional  disturbances,  and 
also  a  characteristic  exudate  of  mucin.  In  others  there  may  be  no  lesions 
whatsoever,  and  the  condition  is  a  pure  neurosis,  often  of  reflex  origin. 
Von  Leyden  considers  asthma  to  be  a  reflex  neurosis,  the primum  movens 
of  which  may  be  situated  almost  anywhere  in  the  body.  The  morbid 
changes  peculiar  to  chronic  bronchitis,  pulmonary  emphysema,  and  right 
ventricular  hypertrophy  with  dilatation  are  found  at  autopsy. 

Etiology. — There  is  present  either  a  constitutional  peculiarity  or  a 
singular  susceptibility  of  the  local  muscular  fibers  to  spasmodic  con- 
traction, both  of  which  are  of  unknown  nature.  The  exciting  factors 
are  very  various,  but  may  be  grouped  under  five  heads : 

(1)  Acute  Bronchitis. — It  must  not  be  forgotten,  however,  that  a 
bronchitis  may  be  set  up  by  the  paroxysms.  Curschmann  has  observed 
also  a  local  croupous  inflammation  of  the  smaller  bronchioles  in  some  of 
his  cases,  which  he  describes  as  bronchiolitis  exfoliativa.,  and  which  seems 
to  have  given  rise  to  the  seizures  in  grave  cases.  Roentgenoscopy  re- 
vealed swollen  lymph-nodes  encircling  the  bronchi  (Chelmonski). 

(2)  The   inhalation    of   numerous   and   widely    various   irritants,   as 


534  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

chemical  vapors,  smoke,  fog,  dust,  and  emanations  from  plants  or  certain 
animals.  A  person  may  be  immune  in  the  city  and  sufter  greatly  on 
going  into  certain  rural  districts. 

(3)  Jiejiex  Causes. — The  causal  connection  between  obstructive  affec- 
tions of  the  nose  and  asthma  is  a  subject  that  is  appreciated  by  the 
specialist.  Gastric  disturbances,  intestinal  irritation,  pregnancy,  and 
uterine  disorders  may  cause  this  complaint.  In  dyspeptic  asthma  Boas 
found  the  diaphragm  elevated  above  its  normal  position. 

(4)  Asthma  may  be  secondary  to,  and  most  probably  excited  by, 
cardiac  disease  ("  cardiac  asthma,"  due  to  an  acute  rise  in  blood-pressure 
— Petreu^),  emphysema,  gout,  rheumatism,  syphilis.  Bright's  disease, 
emotional  excitement,  and  irritating  lesions  in  the  region  of  the  medulla. 
Possibly,  some  of  the  latter  affections  merely  constitute  predisposing  fac- 
tors. In  this  connection  it  is  to  be  pointed  out  that  individual  liability 
to  the  disease  depends  upon  the  special  etiologic  factor. 

(5)  The  spasm  may  be  due  to  some  chemical  substance  or  toxin  acting 
on  the  respiratory  center. 

Predisposing  Causes. — Ho'edit//  takes  first  place,  and  is  noted  in  about 
50  per  cent,  of  all  cases.  The  complaint  is  about  twice  as  frequent  in  males 
as  in  females,  and,  if  we  except  hay  asthma,  it  is  more  prevalent  in  winter 
and  early  spring  than  during  the  warm  season. 

Clinical  History. — Hyde  Salter's  collective  statistics  show  that 
prodromal  symptoms  appeared  in  about  one-half  the  instances  (in  111 
out  of  226  cases).  They  differ,  but  are  chiefly  )n'rvous  in  most  cases, 
and  appear  as  irritability  of  temper,  either  depression  or  unusual  buoy- 
ancy of  spirits,  headache,  drowsiness,  and  vertigo.  Abundant  diuresis 
and  digestive  disturbances  may  be  seen. 

The  paroxysm  usually  comes  on  in  the  night  during  sleep,  and  at  a 
definite  time.  It  may  develop,  however,  while  awake  or,  rarely,  during 
the  day.  The  onset  may  be  sudden,  but  perhaps  more  frequently  the 
patient  first  experiences  a  moderate  grade  of  dyspnea  and  thoracic  con- 
striction. This  augments  with  unwonted  rapidity,  and  often  attains  to 
an  inordinate  degree,  until  the  patient  feels  smothered,  sits  up,  grasps 
his  knees  with  his  hands,  or  places  the  palms  upon  the  bed  so  as  to  raise 
the  shoulders  and  thus  reinforce  the  accessory  muscles  of  respiration. 
When  the  attack  is  severe,  he  rushes  to  an  open  window  if  able  to  leave 
his  bed,  or  sits  on  a  chair  and  places  his  arms  on  the  back  of  another 
chair,  so  as  to  fix  the  shoulders  and  thus  give  purchase  to  the  auxiliary 
muscles  of  respiration  while  frantically  endeavoring  to  maintain  the  act 
of  breathing.  The/at'g  is  pale,  anxious,  and  soon  bedewed  with  cold  per- 
spiration, while  the  lips,  eyelids,  and  finger-tips  are  livid,  owing  to  defec- 
tive oxygenation  of  tlie  blood.  The  temperature  is  subnormal  and  the 
yulse  feeble  and  rapid.     The  clinical  picture  wears  an  alarming  aspect. 

Physical  Signs. — Inspection  shows  enlargement  of  the  chest,  which  in 
the  advanced  stage  becomes  barrel-shaped.  The  reason  for  this  is  the 
presence  of  an  increased  amount  of  air  in  the  thorax  with  a  total  inabil- 
ity to  expel  it.  The  respirations  are  diminished  in  frequency  to  12  or 
10  per  minute.  The  natural  rhythm  is  also  greatly  disturbed,  and  in- 
spiration is  seen  to  be  short  and  gasping,  and  followed  immediately  by 
greatly  prolonged  expiration.  The  expansile  movement  of  the  chest  is 
»  Berliner  klinische  Wochenschrift,  Dec.  27,  1909,  xlvi.,  52. 


ASTHMA. 


535 


very  limited,  and  in  inverse  ratio  to  the  patient's  efforts  at  breathing. 
There  is  lowering  of  the  diaphragm.  Palpation  is  negative  in  its  practi- 
cal results.  Percussion  yields  a  hyper-resonance  ;  in  advanced  carses 
with  associated  emphysema  semi-tympanic  resonance  is  common.  On 
auscultation  inspiration  is  found  to  be  short  and  feeble,  and  expiration 
much  prolonged  and  accompanied  by  a  low-toned  wheezing  sound  that 
may  also  be  audible  to  onlookers.  A  great  variety  of  dry  rales  are 
heard,  chiefly  high-pitched,  sibilant,  and  sonorous,  that  are  more  marked 
on  expiration  than  inspiration.  They  also  change  their  character  and 
situation  frequently.  At  the  close  of  the  attack  moist  rales  may  be 
heard,  and  occasionally,  when  bronchitis  complicates  asthma,  the  moist 
r^les  may  be  combined  throughout  the  paroxysms. 

The  duration  of  the  attack  is  various,  ranging  from  a  few  minutes 
to  several  hours,  though  rarely  it  may  endure  a  week  or  two,  Avith 
spontaneous  remissions  during  the  day  (e.  g.  when  chronic  bronchitis 
coexists).  Usually  it  subsides  abruptly,  with  the  expectoration  of 
rounded  gelatinous  masses  and,  later  still,  of  muco-purulent  material. 
The  former,  when  floated  in  water,  are  found  to  be  composed  of  the  so- 
called  Curschmann' s  spirals  (mucous  moulds  of  the  smaller  tubes),  and 
the  spiral  character  of  these  small,  ball-like  pellets  may  even  be  detect- 
able with  the  naked  eye.  When  examined  microscopically  their  spiral 
structure  is  evident.  Two  forms  are  recognized :  (1)  Composed  of 
mucin,  arranged  spirally ;  in  its  meshes  may  be  observed  alveolar  cells, 
many  of  which  have  undergone  fatty  degeneration.  (2)  A  perfectly 
clear  and  translucent  filament  that  is  most  probably  composed  of  trans- 
formed mucin  and  occupies  the  center  of  the  coiled  spiral  of  mucin.  In 
the  early  stage  of  the  attack  Curschmann's  spirals  (Fig.  45)  are  invariably 


g^^i* 


Fig.  45.— Curschmann's  spirals  (bronchial  spirals). 


present  in  the  expectoration,  and  in  many  instances  Charcot-Leyden 
octahedral  crystals  are  also  visible.  The  latter  are  a  product  of  the 
eosinophile  leukocytes  and  are  found  also  in  the  semen,  in  leukemia,  and 
in  the  stools  of  patients  suff'ering  with  intestinal  parasites.  Miiller, 
Fink,  Ley  den,  and  others  have  demonstrated  extremely  large  numbers 
of  eosinophile  leukocytes  in  the  sputum.  Fink  and  Gabritchewski  have 
found  a  large  excess  (ranging  from  15  to  35  per  cent.)  of  eosinophile 
leukocytes  in  the  blood.  Y.  Noorden  and  Swerchewski  found  the  same 
increase,  but  only  at  the  times  of  the  attacks. 


536  DISEASES  OF  THE  EESPIRATOEY  SYSTEM. 

Diagnosis. — A  clear  history,  together  with  the  physical  signs  and 
a  microscopic  examination  of  the  sputum,  should  lead  to  correct  results. 
The  history  alone  is  inadequate  to  put  the  physician  upon  the  right 
track.  Laryngeal  affections,  -which  give  rise  to  spasm  of  the  glottis 
and  dyspnea,  are  excluded  by  the  hoarseness  and  aphonia  "which  are  usually 
present,  "while  the  characteristic  physical  signs  of  asthma  are  absent. 
Again,  the  dyspnea  is  inspiratory,  not  expiratory  as  in  asthma.  If 
tuberculosis  be  suspected,  the  Kuntgeu  rays  should  be  employed. 

Emphysema  may  be  confounded  -with  asthma.  The  presence  of  recog- 
nized causes,  of  typical  physical  signs,  and  the  paroxysmal  dyspnea  in 
asthma  are  the  chief  points  of  distinction  from  emphysema.  The  spu- 
tum should  be  examined  microscopically  if  doubt  remain.  The  so-called 
cardiac  astlima  is  distinguishable  by  the  presence  of  indications  of  chronic 
nephritis  with  oncoming  failure  of  the  left  ventricle. 

Course  and  Prognosis. — In  mild  cases  of  asthma  there  may  be  but 
one  or  two  nocturnal  paroxysms,  with  entire  freedom  from  cough  and  dysp- 
nea during  the  following  day,  Avhile  in  severe  ones  there  is  a  repetition 
of  the  paroxysms  from  three  to  five  or  six  nights.  Under  these  circum- 
stances in  the  intervals  (usually  corresponding  to  the  period  of  day)  there 
are  slight  Avheezing  and  some  cough.  In  long-standing  cases  asthma 
leads  constantly  to  the  development  of  chronic  bronchitis  and  emphysema, 
hence  these  aflFections  are  often  combined.  The  paroxysmal  character  of 
the  aflfection  is  often  partly  or  wholly  lost,  the  patient  rarely  being  en- 
tirely free  from  asthmatic  dyspnea,  combined  with  cough  and  mucopur- 
ulent expectoration.  The  periodicity  of  the  attacks  varies  ;  in  some  it 
recurs  monthly  or  at  shorter  intervals,  and  in  others  only  annually. 

There  is  rarely  any  danger  to  life,  except  when  the  secondary  affection 
is  emphysema,  and  its  remote  consequence  is  dilatation  of  the  right  ven- 
tricle ;  but  the  percentage  of  cases  in  which  recovery  actually  takes  place 
is  comparatively  small,  since  the  affection  may  reappear  long  after  the 
paroxysms  have  ceased  to  recur  in  the  usual  manner. 

Treatment. — The  indications  for  treatment  are — (1)  to  cut  short  the 
paroxysms  and  (2)  to  prevent  a  recurrence  of  subsequent  attacks. 

(1)  To  bring  relief  during  the  paroxysms  Ave  should  ascertain  the  ex- 
citing cause,  and  remove  it  promptly  if  possible  to  do  so.  In  one  of  my 
own  cases  a  prolonged  paroxysm  was  cut  short  by  a  calomel  purge  fol- 
lowed by  an  enema.  An  overloaded  stomach  calls  for  an  emetic,  and 
other  causal  factors  are  sometimes  removable  [e.  ^.,  congestion  of  the 
nasal  mucosa,  dust,  vegetable  emanations).  If  the  cause  is  irremovable, 
the  patient  should  be  kept  in  a  freely  ventilated  apartment,  and  every- 
thing that  tends  to  impede  respiration  must  be  removed.  The  choice  of 
posture  as  affording  the  greatest  relief  may  usually  be  left  to  the  patient. 

To  cut  short  the  paroxysms  :  The  particular  mode  of  treatment  that 
will  afford  most  speedy  relief  differs  widely  in  different  cases,  and  not 
infrequently  the  patient,  as  the  result  of  experience,  is  aware  of  the  most 
efficacious  remedies.  As  a  rule,  however,  sedative  antispasmodics,  relaxants, 
and  stimulants  are  the  classes  of  medicinal  agents  from  whicb  a  careful  selec- 
tion is  to  be  made ;  and  while  a  great  variety  of  these  have  been  em- 
ployed, I  shall  content  myself  by  adducing  here  only  the  most  valuable. 
In  the  hands  of  some  observers  a  few  whiffs  of  chloroform  have  proved 
highly  efficacious,  but  in  my  own  they  have  produced  only  momentary 
good  effects  ;  ether  is  the  safer  remedy  and  may  be  tried  in  like  manner. 


ASTHMA.  537 

In  a  certain  proportion  of  the  cases  from  four  to  six  drops  of  arnyl  nitrite 
thrown  upon  cotton-wool  or  a  handkerchief,  and  inhaled,  bring  speedy 
and  permanent  relief.  Of  stimulants,  coffee  is  the  best :  immediately 
upon  the  appearance  of  the  paroxysm  about  one  pint  of  strong  coff'ee  is 
to  be  taken  hot  (without  cream  or  sugar),  and  in  this  way  the  seizure 
may  sometimes  be  arrested.  Alcohol  when  given  hot  and  in  sufficiently 
large  doses  to  induce  mild  intoxication  may  be  found  very  useful ;  and 
with  "hot  toddy,"  spirits  of  chloroform  may  be  combined. 

The  inhalation  of  the  fumes  of  niter-paper'  often  gives  quick,  tempo- 
rary, and,  less  frequently,  permanent  relief.  When  employed,  the  atmo- 
sphere of  the  room  occupied  by  the  patient  must  be  well  filled  with  the  fumes. 

Among  depressant  antispasmodics  are  belladonna,  hyoscyamus,  stra- 
monium, and  lobelia,  and  these  seem  to  be  of  most  value  when  used  in 
the  form  of  cigarets.  The  leaves  of  the  plant  employed  are  first  steeped 
in  a  concentrated  solution  of  potassium  nitrate  or  chlorate,  and  a  trial 
should  be  made  of  different  sorts  of  cigarets  or  pastilles  (which  are  simi- 
larly prepared),  since  all  cases  are  not  benefited  by  the  same  brand.  The 
inhalation  of  tobacco-smoke  is  equally  beneficial  in  rare  instances, 

A  large  number  of  cases,  despite  the  use  of  the  measures  above  indi- 
cated, exhibit  an  obstinate  tendency,  and  for  their  treatment  no  remedy 
bears  favorable  comparison  with  morphin,  administered  hypodermically. 
It  has  occasionally  led  to  the  establishment  of  the  morphin-habit ;  hence 
it  must  not  be  used  indiscriminately.  It  is  best  given  in  full  doses 
(gr.  ^-| — 0.0216-0.0324),  and  may  be  combined  with  atropin.  V. 
Noorden  uses  atropin  in  ascending  doses  (gr.  yto  increased  to  -^  daily), 
then  gradually  diminishes  the  dose ;  this  treatment  is  repeated  every  few 
months,  though  lessening  the  dose  and  shortening  each  course  of  treat- 
ment.    The  following  formula  has  proved  efficient  in  my  hands : 

^.  Tr.  lobelise,  3J         (4.0); 

Tr.  nitro-glycerini  (1  per  cent.),       ITlxvj  (1.06); 

Sodii  bromid.,  3v        (20.0); 

Vini  ipecac,  3v        (20.0); 

Ext.  hyoscyami,  gr.  viij  (0.518) ; 

Elix.  simplicis,  q.  s.  ad  liv       (128.0). — M. 
Sig.  3j  (4.0)  every  one  or  tvfo  hours  in  water. 

S.  Solis-Cohen  lauds  hyoscin  hydrobromate  (gr.  2^7)  administered 
hypodermically.  Ergot  and  adrenal  extract  are  among  promising  reme- 
dies ;  they  probably  act  by  promoting  vascular  tone.  Bullowa  and 
Kapman,^  in  conformity  with  the  angioparetic  theory  of  an  attack, 
recommend  the  hypodermic  administration  of  adrenalin  chlorid,  and 
claim  that  it  cuts  short  an  attack  in  from  two  to  ten  minutes.  The  dose 
is  3  to  6  minims  of  the  1 :  1000  solution.  Gunzel  reports  striking  results 
from  the  high-frequency  interrupted  current  to  the  vagus,  accessorius, 
phrenic,  and  sympathetic  nerves.  In  the  protracted  cases,  associated 
Avith  chronic  bronchitis  and  emphysema,  the  above  mixture  may  also  be 
employed,  though  sodium  iodid  (gr.  v — 0.324)  should  be  substituted  for 
the  bromid,  and  given  at  intervals  of  three  or  four  hours. 

(2)  In  order   to  prevent  subsequent  attacks :    During  the  intervals 

1  Niter-paper  is  prepared  by  dipping  bibulous  paper  (filter-  or  blotting-paper)  in  a 
solution  of  saltpeter.  ^  Medical  News,  October  24,  1903. 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  physician  must  ascertain  whether  any  of  the  numerous  causes  (bron- 
chitis, gastric  disorders,  dust,  emanations  from  plants)  are  discover- 
able ;  if  so,  efforts  to  remove  them  should  be  instituted.  A  methodical 
interrogation  of  the  various  organs  of  the  body  and  their  functions 
must  be  carried  out,  and  the  therapeutic  or  hygienic  indications  pre- 
sented by  them,  if  any,  must  be  met  judiciously.  The  nasal  passages 
should  be  examined  by  a  specialist,  and  any  causal  conditions  found 
therein  promptly  removed.  Rochester^  emphasizes  the  importance  of 
"so  regulating  the  intake  of  food  and  stimulating  the  eliminating  of 
waste  products,  that  proper  metabolic  balance  may  be  maintained."  The 
patient  should  dine  early,  so  that  digestion  may  be  completed  before  he 
retires.  Bowel  regulation  is  highly  important.  If  the  affection  be  a  pure 
neurosis  or  due  to  bronchitis,  a  suitable  climate  may  often  be  found  in 
which  the  patient  will  enjoy  complete  immunity  from  asthma.  The  choice 
of  the  locality  cannot,  however,  be  determined  by  any  known  rules.  To 
those  who  cannot  adopt  this  plan,  potassium  iodid  offers  the  best  hope  of 
relief,  though  its  use  must  belong  continued  (gr.  x-xx — 0.648-1.296  three 
times  daily).  The  systematic  use  of  compressed  air  in  the  pneumatic 
cabinet  and  also  the  inhalation  of  oxygen  are  worthy  of  trial.  In  the 
belief  that  asthma  is  a  special  form  of  neurasthenia,  Treupel  aims  to 
regulate  the  breathing,  training  the  patient  to  breathe  deeply  with  a  slow 
inspiration,  at  the  same  time  raising  the  arms  over  the  head,  and  then 
during  expiration  applying  the  hands  to  the  front  and  sides  of  the  chest, 
squeezing  the  Avails  together  to  aid  in  expelling  the  last  traces  of  air. 
Calcium  chlorid  (dose,  gr.  x — 0.65,  every  two  hours)  is  lauded  by  Kayser 
for  its  prophylactic  and  therapeutic  effects.  The  presence  of  any  condition 
of  ill-health  calls  for  appropriate  treatment. 

There  are  also  certain  means  of  prophylaxis  for  impending  attacks. 
Thus,  if  there  be  premonitory  symptoms,  the  use  of  such  measures  as 
strong  coffee  or  the  "hot  toddy"  above  mentioned,  Hoffman's  anodyne, 
stramonium  or  belladonna  cigai'ets,  the  inhalation  of  the  fumes  of  niter- 
paper  or  of  a  few  drops  of  amyl  nitrite,  may  suffice  to  ward  off  the  attack. 


FIBRINOUS  BRONCHITIS. 

(Plastic  Bronchitis  ;    Croupous  Bronchitis  :   Mucous  Bronchitis.) 

Definition. — A  rare  acute  or  chronic  catarrhal  affection  of  the 
bronchial  mucosa,  attended  with  the  production  of  fibrinous  casts  (?) 
that  are  expectorated  in  severe  paroxysms  of  cough  and  dyspnea. 
These  casts,  when  unfolded,  are  found  to  be  molds  of  the  bronchial  tubes 
from  which  they  come,  being  shaped  like  the  branches  of  a  tree,  and  thus 
proving  that  a  bronchial  tube  and  its  subdivisions  had  been  blocked. 

Patholog^^. — The  pathology  is  but  little  understood.  When  ex- 
amined microscopically  they  are  seen  to  consist  of  a  fibrillated  base,  a 
few  scattered  leukocytes  and  mucous  corpuscles,  and,  rarely,  gland-  and 
blood-cells.  Curschmann's  spirals  are  often  found,  and  within  these  or 
associated  with  them  the  Leyden  crystals.  First,  Beschorner  and  later 
Grandy  have  shown  the  casts  to  be  composed  of  mucin.     In  other  cases, 

'  Jour.  Amer.  Med.  Assoc,  vol.  xlvii.,  Dec.  15,  1906. 


FIBRINOUS  BRONCHITIS.  &^9 

however,  similar  studios  show  fibrin.  In  one  of  my  own  cases  I  found 
the  composition  of  these  casts  to  he  identical  with  that  of  croupous  exu- 
dates met  with  elsewhere,  though  more  dense,  perliaps,  tliarj  the  hitter. 
Croupous  bronchitis  is  attended  with  loss  of  epithelium  in  the  implicated 
bronchi,  as  is  the  case  in  croupous  inflammation  wherever  it  occurs  ;  but 
the  answers  to  the  questions,  "  Why  should  the  affection  be  limited  to  a 
definite  portion  of  the  bronchial  treeV"  and  "Why  does  it  recur  from 
time  to  time?"  are  obscure  indeed.  In  fatal  cases  the  lesions  of  asso- 
ciated or  antecedent  complaints,  such  as  chronic  pleurisy,  pneumonia,  and 
pulmonary  tuberculosis,  have  been  found. 

etiology. — What  the  irritant  is  that  causes  the  condition  is  un- 
known, though  streptococci  and  pneumococci  have  been  found  in  the 
molds  and  in  the  mucosa.  Some  of  the  predisposing  causes  recognized  are — 
(1)  Sex  :  it  being  about  twice  as  frequent  in  males  as  in  females.  (2)  Age : 
though  met  with  at  all  periods  of  life,  it  is  relatively  more  frequent  from 
the  twentieth  to  the  fortieth  year.  (3)  Season:  the  seizures  are  moat 
common  in  the  spring  months.  (4)  Epidemic  influences :  Pichini  has 
described  a  group  of  instances  that  occurred  in  individuals  in  the  same 
locality.  (5)  Hereditary  influence  has  been  traceable  in  a  few  cases. 
(6)  Infective  diseases,  such  as  tuberculosis  (quite  frequently),  pneumonia, 
influenza,  erysipelas,  scarlatina,  etc.,  and  certain  skin  affections,  as  herpes, 
impetigo,  and  pemphigus,  form  antecedent  and  associated  conditions. 

Symptoms. — (a)  The  acute  form  is  rare.  It  begins  with  rigors  and 
fever,  soon  followed  by  urgent  dyspnea  and  severe  paroxysms  of  cough, 
which  are  usually  attended,  soon  or  late,  by  the  expulsion  of  bronchial 
casts,  and  sometimes  rather  profuse  hemorrhage.  Abundant  expectora- 
tion usually  causes  amelioration  of  the  severer  symptoms.  On  the  other 
hand,  urgent  dyspnea,  oppressiveness,  and  severe  cough,  with  little  expec- 
toration, are  grave  symptoms,  often  leading  to  fatal  asphyxia. 

(b)  The  Chro7iic  Form. — The  attacks  are  less  severe  than  in  the  acute 
form  and  recur  at  irregular  intervals,  the  interim  varying  from  one  week 
to  a  year  or  more.  In  a  case  observed  by  myself  the  patient  has  expe- 
rienced a  recurrence  once  annually  (on  or  about  May  1st).  The  parox- 
ysms may  occur  at  regular  though  much  briefer  intervals.  The  cases 
usually  manifest  ordinary  bronchitic  symptoms,  with  or  without  fever  at 
the  outset.  The  cough  soon  becomes  troublesome  and  is  paroxysmal. 
There  is  expectoration  of  rounded  masses,  which,  when  unravelled,  are 
found  to  be  true  moulds  of  the  affected  tubes  exhibiting  a  laminated 
structure.  The  larger  casts  (which  are  of  the  size  of  a  goose-quill  or 
even  larger)  may  be  hollow.  They  are  of  whitish  or  grayish-white  color. 
Hemorrhage  may  occur. 

Physical  Signs. — Owing  to  the  obstruction  offered  by  the  casts,  there 
is  a  diminished  amount  of  air  entering  the  corresponding  part  of  the 
lung.  Hence  the  tactile  fremitus,  localexpansion,  and  respiratory  murmur 
are  diminished  over  the  affected  area.  The  percussion  note  over  the  un- 
involved  portions  of  the  lung  is  clear  or  hyper-resonant.  The  portions 
of  the  lung  supplied  by  the  affected  tubes  give  impaired  percussion-reso- 
nance, and  if  they  collapse,  there  is  a  dulness  on  percussion.  Dislodge- 
ment  of  the  casts  is  followed  by  a  normal  respiratory  murmur. 

Diagfnosis. — The  presence  of  mucous  or  of  fibrinous  casts  of  the 
finer  bronchial  tubules  serves  to  distinguish  this  condition.  The  fibrin- 
ous moulds  met  with  in  diphtheria  and  pseudo-membranous  croup,  with 


540  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

extension  into  the  bronolii,  must  also  be  eliminated.  In  doubtful  eases 
a  bacteriologic  examination  of  the  membranous  casts  should  be  made. 
If  the  Klebs-Liiffler  bacilli  are  then  found,  its  diphtheritic  nature  is 
proven.  In  truly  diphtheritic  cases  the  membrane  docs  not  present  the 
laminated  structure. 

ProgHOSis.^The  prognosis  in  the  acute  form  is  quite  grave ;  the 
chronic  variety,  though  pursuing  an  exceedingly  long  course  that  ranges 
from  five  to  fifteen  j^ears,  rarely  terminates  fatally. 

Treatment. — This  is  to  be  conducted  on  the  same  principles  as  those 
in  simple  acute  bronchitis.  In  the  acute  form  an  attempt  should  be  made 
to  soften  and  separate  the  casts  by  the  topical  application  of  steam,  by 
inhalation,  and  alkaline  sprays  (e.  g.  lime-water).  Pilocarpin  was  em- 
ployed in  one  instance  under  my  own  observation  with  apparent  good 
results ;  it  tends  to  excite  free  bronchial  secretion.  Emetics  should  be 
resorted  to  without  delay  when  the  signs  of  cyanosis  show  themselves. 

In  the  chronic  form  nothing  can  be  accomplished  by  treatment,  dur- 
ing the  intervals  between  the  acute  exacerbations,  that  Avill  tend  to  obviate 
a  recurrence  of  the  attacks  or  to  mitigate  their  severity. 


IV.   DISEASES   OF  THE   LUNGS. 
CIRCULATORY  DISTURBANCES  IN  THE  LUNGS. 

CONGESTION    OF    THE   LUNGS. 

[Hyperemia  of  the  Lungs.) 

Definition. — The  surcharge  of  the  pulmonary  vessels  with  blood. 
Two  forms  are  recognized :  (1)  Active  hyperemia,  and  (2)  Passive  hy- 
peremia. 

ACTIVE    HYPEREMIA. 

Pathologfy. — The  blood-vessels  in  the  bronchial  mucosa  often  appear 
intensely  injected,  and  the  capillaries  in  the  alveolar  walls  are  prominent, 
while  on  section  a  scarlet-colored,  frothy  liquid  flows.  The  alveolar  epi- 
thelium may  become  swollen  and  granular. 

etiology. — Active  hyperemia  is  usually  a  symptomatic  condition, 
though  rarely  it  may  arise  as  a  distinct  primary  aifection.  Active  con- 
gestion of  the  lungs  exists  as  an  associated  condition  in  many  pulmonary 
afiections,  as  pneumonia,  pleurisy,  bronchitis,  and  tuberculosis.  On 
the  other  hand,  active  congestion  of  the  lungs  may  be  engendered  as  an 
independent  affection  by  the  inhalation  of  hot  air,  highly  irritative  sub- 
stances, as  well  as  by  violent  physical  exercise,  the  ingestion  of  large 
amounts  of  alcohol,  and  strong  mental  emotion.  Collateral  hyperemia 
may  arise  from  anemia  of  the  opposite  lung. 

Symptoms. — The  capacity  of  the  air-cells  is  diminished  ;  hence  the 
oxygenation  of  the  blood  is  markedly  interfered  with.  There  is  a  degree  of 
di/sjjnea  proportionate  to  the  extent  and  intensity  of  the  congestion.  There 
is  some  fever  (101  °  F.),  cough,  accompanied  hy  frothy,  bloody  expectoration. 

The  physical  signs  are  bilateral,  as  a  rule,  and  are  generally  confined 


PASSIVE  HYPKREMIA.  541 

to  the  bases.  Palpatiorc  shows  increased  tactile  fremitus.  ^h(r  jx'/rcuHKion- 
yiote  is  impaired  or,  rarely,  dull,  and  it  is  generally  exceedingly  difficult 
to  determine  the  pitch  of  the  note,  owing  to  the  fact  that  both  sides  are 
usually  involved.  When  the  condition  is  unilateral  and  not  associated 
with  diseases  of  the  opposite  side,  the  impairment  is  readily  appreciated. 
The  breath-sounds  are  broncho-vesicular  in  character;  less  frequently 
bronchial. 

Diagnosis. — In  the  presence  of  the  etiologic  factors,  the  sudden 
development  of  dyspnea,  cough,  and  a  frothy,  bloody  expectoration,  with 
the  physical  signs  before  enumerated  render  the  diagnosis  easy.  When 
fever  is  present  it  is  of  a  mild  grade  and  short  duration. 

Prognosis. — Active  hyperemia  is  frequently  followed  by  collateral 
edema.  Its  course  is  brief,  and  terminates  either  fatally  in  a  few  hours, 
in  perfect  recovery  in  a  few  days,  or  in  pneumonia.  The  condition  is 
therefore  ominous. 

Treatment. — Prompt  measures  must  be  instituted  in  order  to  arrest 
the  active  fluxion.  The  special  causative  factors  must  be  actively  treated; 
dry  and  wet  cups  over  the  entire  seat  of  congestion  must  be  tried ;  and 
in  the  worst  cases  venesection  is  demanded.  Following  the  application 
of  the  cups,  turpentine  stupes,  sinapisms,  and  linseed  poultices  may  be 
employed.  I  have  observed  excellent  results  from  the  use  of  veratrum 
viride  combined  with  saline  purgatives.  Other  cardiac  sedatives  may 
also  be  employed,  including  nitroglycerin  in  full  doses. 

PASSIVE    HYPEREMIA. 

Passive,  unlike  active,  hyperemia  is  always  a  secondary  condition,  and 
is  quite  common.  Two  forms  are  distinguishable  :  (a)  Mechanical,  and 
(6)  Hypostatic. 

{a)  Mechanical  Hyperemia  {Brown  Induration). — Pathology. — The 
pulmonary  vessels  are  distended,  the  lungs  as  a  whole  enlarged,  and  the 
air-cells  crepitate  but  little,  owing  in  great  part  to  the  encroachment  upon 
the  air-spaces  by  the  dark  venous  blood.  The  lungs  are  of  a  reddish-brown 
color  and  afford  increased  resistance  to  efforts  at  cutting  or  tearing.  On 
section  the  reddish-brown  tint  rapidly  changes  to  a  vivid  red,  from  "oxi- 
dation of  the  hemoglobin  when  exposed  to  the  atmosphere.  The  process 
commences  at  the  extreme  base,  extends  upward,  and  may  finally  become 
general.  The  interstitial  connective  tissue  is  increased,  and  is  often  edem- 
atous, while  the  alveolar  cells  contain  altered  blood-pigment,  usually  in 
the  form  of  hemosiderin  and  responding  to  the  usual  tests  for  iron. 

Etiology. — Mechanical  hyperemia  results  from  the  obstruction  of  the 
return  of  blood  to  the  left  heart,  and  among  special  causative  conditions 
are  mitral  constriction,  mitral  regurgitation,  dilatation  of  the  right  ven- 
tricle, and  certain  cerebral  injuries  and  diseases.  It  may  also  be  a  symp- 
tom of  asphyxia,  and  rarely  it  arises  from  pressure  of  tumors. 

Symptoms. — The  most  marked  feature  is  dyspnea,  particularly  when 
secondary  to  organic  cardiac  diseases  with  failure  of  the  right  ventricle. 
Qough  is  common,  and  an  expectoration  oi frothy  serum  or  blood  (hemop- 
tysis) containing  pigmented  alveolar  epithelial  cells,  is  the  most  charac- 
teristic clinical  feature. 

Diagnosis. — With  a  clear  history,  in  addition  to  the  dyspnea,  cough. 


542  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

and  the  characteristic  expectoration,  the  recognition  of  passive  hyper- 
emia of  the  lungs  is  a  simple  matter.  The  prognosis  and  treatment  will 
be  considered  in  connection  with  the  causative  aifections. 

[b)  Hypostatic  Hyperemia. — Pathology. — The  parts  of  the  lung  that 
are  aft'ected  are  dark  in  color  and  the  vesicles  distended  with  a  transudate 
of  blood  and  seriim.  In  this  way  the  air-cells  may  become  emptied  of 
air  [splenization,  hypostatic  pneumonia),  and  the  resulting  condition  is 
in  most  instances  to  be  regarded  as  a  mild  grade  of  lobular  pneumonia. 

Etiology. — Feeble  cardiac  action,  as  in  long-continued  fevers,  debili- 
tating chronic  affections  in  old  persons,  combines  with  a  prolonged 
dorsal  position  of  the  body  (gravitation  thus  favoring  its  development)  in 
producing  the  condition.  This  explains  why  the  condition  is  found  usu- 
ally at  the  bases  of  the  lungs,  and  is  most  marked  posteriorly.  It  is 
common  for  the  same  reason  in  carcinoma,  tuberculosis,  chronic  rheuma- 
tism, typhoid  fever,  etc.  Hypostatic  congestion  has  followed  morphin- 
poisoning,  and  is  particularly  apt  to  occur  in  persons  suffering  from  brain 
lesions,  notably  those  which  induce  paralysis  or  coma  (Hare). 

Symptoms. — The  symptoms  are  wholly  indefinite ;  indeed,  none  may 
be  present.  Priory  has  pointed  out  that  old  persons  in  the  incipiency  of 
the  disease  begin  to  sleep  with  the  mouth  open,  so  as  to  effect  the  entrance 
of  more  air.  Commencing  cyanosis  may  indicate  the  development  of 
hypostasis,  and  a  careful  physical  examination  of  the  lower  lobes  of  the 
lungs  will  show  increased  fremitus,  slight  dulness,  diminished  vesicular 
murmur,  and,  in  the  higher  grades,  bronchial  breathing,  with  liquid  bub- 
bling rS,les. 

The  prognosis  is  based  upon  the  character  of  the  underlying  affection. 

Treatment. — This  is  an  affection  in  which  the  treatment  of  causes 
alone  will  suffice,  save  in  instances  secondary  to  organic  heart-affections, 
in  which  prompt  bleedings  are  to  be  advocated.  From  a  pint  to  a  quart 
of  blood  should  be  taken,  and  I  have  seen  happy  results  from  the  employ- 
ment of  this  measure  in  extreme  cases.  Tapping  the  right  auricle  when 
the  blood  refuses  to  flow  from  an  arm  vein  has  been  successfully  accom- 
plished by  competent  surgeons.  The  patient's  posture  must  be  changed 
from  the  dorsal  to  the  lateral,  and  even  ventral,  and  as  soon  as  possible  he 
should  be  gotten  out  of  bed. 

PULMONARY  EDEMA. 
{Edema  of  the  Lungs.) 

Definition. — An  effusion  of  serous  fluid  into  the  air-vesicles  and  in- 
terstitial lung-tissue.  Pulmonary  edema  is  scarcely  to  be  regarded  as  an 
independent  affection,  but  as  a  secondary  condition,  being  in  most  in- 
stances associated  with  pulmonary  congestion. 

Pathology. — It  consists  of  a  transudation  of  serum  into  the  alveolar 
walls,  interstitial  connective  tissue,  and  air-cells.  Rarely  the  process  is 
limited  to  the  interstitial  tissue.  Two  forms  may,  for  the  sake  of  conve- 
nience, be  recognized: 

(a)  Collateral  Edema  {Inflammatory  Edema). — This  is  usually  local  in 
character,  circumscribing  an  area  of  the  lung  affected  by  pneumonia, 
abscess,  or  pulmonary  infarction,  and  is  the  result  of  a  mild  inflamma- 
tory  process  affecting  the  vessel-walls.      When    the   condition  follows 


PULMONARY  EDEMA.  543 

hypostatic  conf^cstion  tlio  terms  "liypostatic  edema"  and  "  splenization  " 
have  been  applied. 

{l>)  General  Pulmonary  Edema. — If  congestion  he  not  associated,  the 
portions  of  the  lungs  involved  look  pale;  when  pulmonary  congestion  or 
pigmentation  of  the  tissue  is  present,  the  lung  appears  darker  than  the 
normal  and  the  serum  is  blood-tinged.  The  weight  of  the  lung-tissue, 
owing  to  the  more  or  less  airless  condition  of  the  alveoli,  is  increased,  and 
yet,  though  heavier  than  the  normal  lung,  the  affected  tissue  does  not  sink 
in  water.  To  the  feel  it  is  boggy,  and  pits  (m  pressure,  while  on  section 
a  serous  or  sero-sanguinolcnt  (if  congestion  be  present)  fluid  of  low  specific 
gravity,  and  poorer  in  albumin  than  plasma,  flows  from  the  cut  surface. 
Edema  is  most  frequently  observed  at  the  bases  of  the  lungs,  though  it 
may  become  general.      Hydrothorax  may  be  present. 

The  mode  of  production  of  pulmonary  edema  is  not  definitely  known. 
Increased  fluidity  of  the  blood  on  the  one  hand,  and  increased  tension  in 
the  pulmonary  vessels  on  the  other,  seem  to  be  influential  factors  in  many 
cases.  The  heightened  blood-pressure  may  be  in  great  part  due  to  a  fail- 
ure of  cardiac  power,  and  particularly  to  failure  of  the  left  ventricle 
(Welch).  When  weakness  of  the  left  is  out  of  proportion  to  the  weak- 
ness (paralysis)  of  the  right  ventricle,  the  tension  in  the  pulmonary 
capillaries  is  apt  to  be  greatly  increased,  at  least  until  transudation  of 
serum  is  induced.  Edema  also  occurs  as  a  result  of  weakness  of  the 
right  ventricle  alone.  Obstruction  to  the  outflow,  such  as  occurs  in 
weakening  of  the  left  ventricle,  or  even  obstruction  in  the  aorta,  leads 
to  heightened  tension  and,  secondarily,  to  paralysis  of  the  right  ven- 
tricle. The  third  factor  entering  into  the  production  of  pulmonary 
edema  is  the  increased  permeability  of  the  vessel-walls,  due  to  im- 
pairment of  their  nutrition  and  "disturbance  of  the  cardiopulmonic 
innervation  "  (Huchard).  This  usually  arises  in  connection  with  toxic 
and  infectious  diseases,  when  the  blood  also  exhibits  more  or  less  change, 
as  in  cachectic  states,  uremia,  general  septicemia,  and  the  like.  In- 
stances are  met  with  in  which  pulmonary  edema,  due  to  vasomotor  relax- 
ation from  toxic  states,  develops  suddenly. 

Htiology. — Pulmonary  edema  is  secondary  to  pneumonia  and  acute 
and  chronic  affections,  but  not  with  any  degree  of  constancy  ;  nor  is  it 
especially  liable  to  be  associated  Avith  congestion  or  with  low  grades  of 
inflammation  of  the  lungs.  Among  the  diseases  of  which  it  forms  a  ter- 
minal condition  are — valvular  affections  of  the  heart,  fatal  forms  of  anemia, 
acute  and  chronic  Bright's  disease,  cerebral  lesions  (hemorrhage,  trauma- 
tism), and  acute  infectious  fevers  with  failure  of  cardiac  power.  Edema  may 
follow  thoracentesis  and,  rarely,  the  intravenous  injections  of  saline  solutions. 

Symptoms. — In  edema  of  the  lungs  the  air-space  is  lessened  in  di- 
rect proportion  to  the  amount  of  serum  occupying  the  alveoli ;  hence 
dyspnea  is  always  present  and  is  often  a  conspicuous  symptom.  There 
are  cough  and  bronchorrhea.  The  sputum  is  usually  abundant  and  frothy, 
and  is  expectorated  with  difiiculty.  At  times,  and  especially  in  the  acute 
forms,  it  is  tenacious  and  may  give  rise  to  alarming  laryngeal  obstruction. 
It  is  blood-stained  if  congestion  be  combined.  The  condition  does  not 
give  rise  to  elevation  of  temperature,  except  in  the  inflammatory  type,  in 
which  fever  is  constantly  present.  The  pulse  is  accelerated  and  feeble, 
and  cyanosis,  particularly  in  cases  of  collateral  edema,  usually  appears. 
The  extremities  are  cool  and  often  livid. 


544  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Physical  Signs. — The  reasons  adduced  to  explain  the  dyspnea  likewise 
render  intelligible  the  physical  signs  encountered.  There  is  dulness, 
though  rarely  complete,  over  the  areas  involved ;  the  vesicular  murmur 
is  feeble  or  absent  or  there  may  be  broncho-vesicular  breathing.  Since 
the  bronchioles  contain  serum,  small  bubbling  rales  are  audible  "with 
inspiration  and  at  the  beginning  of  expiration  over  the  seat  of  the  edema. 

A  recurrent  variety  has  been  studied  by  Crummer,  Riesman,  and  others, 
coming  on  -without  any  apparent  exciting  cause  and  often  proving  fatal. 
"  The  chief  symptoms  are  agonizing  dyspnea,  cyanosis,  cough,  expecto- 
ration of  frothy,  albuminous  fluid,  and  profound  prostration""  (Riesman). 
Recovery  from  an  attack  is  frequent  and  sudden. 

The  diagnosis,  with  a  clear  history,  is  based  upon  the  incomplete 
dulness  that  is  usually  bilateral  and  most  marked  at  the  bases,  upon  the 
bubbling  rales  heard  over  the  corresponding  area,  and  upon  the  absence 
of  any  febrile  movement,  except  the  latter  be  due  to  some  underlying 
affection.  Hydrotliorax  bears  some  points  of  resemblance  to  edema  of 
the  lungs,  but  in  this  condition,  unlike  edema,  the  upper  level  of  dulness 
is  movable  on  change  of  position  of  the  patient.  Moist  rilles,  audible  in 
pulmonary  edema,  are  absent  in  hydrothorax.  Broncho-pneumonia  may 
be  mistaken  for  pulmonary  edema,  though  it  has  a  different  mode  of  on- 
set. It  is  also  accompanied  by  fever,  glairy,  tenacious  expectoration, 
and  more  sharply  localized  areas  of  dulness  than  appear  in  edema. 

The  prognosis  is  governed  by  the  pre-existing  condition  to  which 
the  edema  is  due.  Thus,  if  secondary  to  a  general  dropsy  due  to  renal 
or  cardiac  disease,  it  often  destroys  life  with  great  rapidity.  Inflammatory 
edema,  following  lobar  pneumonia,  is  also  grave  in  the  extreme. 

Treatment. — The  treatment  is  that  of  the  associated  or  causative 
affections.  These  must  be  sedulously  treated,  and  the  limitation  of  the 
transudation  and  the  direct  removal  of  the  serous  effusion  from  the 
lungs  is  of  great  importance.  We  should  frequently  change  the 
position  of  the  patient's  body,  so  as  to  prevent  the  gravitation  of 
blood  to  the  dependent  portions  of  the  lungs.  I  have  Avitnessed  excel- 
lent results  from  the  use  of  dry  cups  placed  over  the  thorax,  particularly 
over  its  posterior  and  lateral  aspects,  and  renewed  at  intervals  of  six  to 
eight  hours.  The  number  applied  should  range  from  one  and  a  half 
dozen  to  three  dozen.  In  aggravated  forms  that  develop  quickly  prompt 
venesection  is  imperatively  demanded.  This  is  a  measure  which,  if 
resorted  to  at  the  proper  moment,  will  often  rescue  the  patient  from 
imminent  danger.  The  condition  of  the  heart  and  kidneys  must  receive 
attention.  Nitroglycerin  and  atropin,  particularly  the  latter  in  full  dosage 
(gr.  Jq,  to  be  repeated  in  one  hour  if  required),  are  often  serviceable. 
Stengel  advocates  morphin  in  small  doses  in  the  recurrent  variety. 
Tincture  of  strophanthus  (iTtiij  every  three  hours)  is  effective  in  pulmonary 
edema  in  children. 

HEMOPTYSIS. 
{Broncho-pulmonary  Hemorrhage!) 
Definition. — An  expectoration  of  blood.  Its  source  may  be  the 
bronchial  mucous  membrane  (usually  the  small  bronchi),  and  less  fre- 
quently eroded  vessels  in  lung-cavities  or  their  walls ;  rarely  the  larynx, 
trachea,  and  larger  bronchi.  When  from  the  bronchial  tubes,  the  term 
hronchorrhagia  should  be  applied.     The  source  of  the  hemorrhage,  how- 


HEMOPTYSIS.  545 

ever,  is  not  always  easily  demonstrable,  even  when  it  has  resulted  fatally 
and  the  lungs  are  minutely  examined. 

Pathology. — The  lesions  are  often  microscopic,  and  consist  for  the 
most  part  of  ruptured  capillary  blood-vessels,  though  larger  vessels  may  also 
become  the  seat  of  erosion  or  rupture.  After  death  the  bronchial  mucosa 
is  sometimes  found  to  be  swollen,  bleeds  easily,  and  is  of  a  dark-red  color 
— soon  becoming  decidedly  pale.  The  lung-tissue  proper  may  look  paler 
than  in  the  sound  lung.  In  advanced  pulmonary  tuberculosis  the  lung- 
cavity  may  contain  a  ruptured  aneurysm,  or  mere  ulceration  of  an  exposed 
vessel  may  be  observed.  I  have  witnessed  small,  dark-red  dense  masses 
in  the  air-sacs  scattered  throughout  the  lung  whence  came  the  hemor- 
rhage. Doubtless  these  are  blood-coagula,  which  result  from  the  clotting 
of  the  blood  after  the  latter  has  been  carried  into  the  alveoli.  Various 
associated  lesions  may  be  observed. 

[J^tiology. — (1)  Pulmonary  AflFections. — (a)  Pulmonary  congestion 
from  whatever  source  may  result  in  hemoptysis,  usually  of  small  amount. 
There  are  many  causes  that  excite  congestion  of  the  lungs,  some  of  which 
reside  in  adjacent  organs,  it  being  common  m  organic  disease  of  the  heart, 
and  particularly  in  disease  of  the  mitral  segments.  That  form  of  pul- 
monary congestion  which  is  associated  with  other  affections  of  the  lungs, 
as  well  as  primary  active  congestion  due  to  inhalation  of  hot  air,  irritating 
substances,  and  violent  physical  exercise,  may  also  result  in  hemor- 
rhage, (h)  Hemorrhagic  infarction  may  lead  to  slight  hemorrhage  {vide 
Pulmonary  Embolism).  (c)  Croupous  Pneumonia. — In  this  disease 
hemorrhage  is  caused  by  rupture  of  the  capillaries,  and  the  blood, 
when  expectorated,  has  undergone  a  change  and  become  rusty-colored. 
{d^  Pulmonary  Tuberculosis. — This  is  pre-eminently  the  most  common 
cause.  Of  5302  cases  analyzed  by  the  writer,  hemoptysis  was  found  in 
1950,  or  36.6  per  cent.  It  is  to  be  recollected  that  hemorrhages  due  to 
tuberculosis  are  less  apt  to  take  place  in  higher  altitudes  than  at  sea-level ; 
but,  as  pointed  out  by  Bonney,^  they  are  decidedly  more  severe  and  asso- 
ciated with  more  shock  when  they  occur.  Hemorrhage  may  take  place 
early  when  it  originates  from  a  sharply  limited  and  minute  tuberculous 
focus,  and  it  may  also  be  attributable  to  congestion.  Undoubtedly  its 
exact  source  is  the  mucosa  of  the  small  bronchi ;  later  it  is  the  direct  con- 
sequence of  the  ulceration  of  an  artery  or  of  the  rupture  of  an  aneurysmal 
sac  that  has  its  seat  in  a  branch  of  the  pulmonary  artery.  After  the  tuber- 
culous cavities  have  healed,  calcareous  masses  are,  from  time  to  time,  expec- 
torated, together  with  more  or  less  blood,  (e)  Ulcers  of  the  Larynx. 
Trachea^  or  Bronchi, — Rarely,  ulcers  in  adjacent  structures  erode  the 
larger  branches  of  the  pulmonary  artery  and  cause  copious  and  speedily 
fatal  hemorrhages.  Osier  observed  a  fatal  hemorrhage  in  a  case  of  chronic 
bronchitis  with  emphysema.  (/)  Fibrinous  bronchitis  induces  hemop- 
tysis by  rupturing  the  capillaries  in  the  bronchial  mucosa  at  the  time  of 
separation  of  the  bronchial  casts,  (g)  Carcinoma  of  the  lung  produces 
frequent  expectoration  of  blood,  (h)  G-angrene  and  abscess  of  the  lung, 
(i)  Parasites  (Paragonimus  Westermanii).     (;/)  Injuries  to  the  thorax. 

(2)  Diseases  of  Other  Organs  than  the  Lung. — (a)  Affections  of  the 
heart  act  as  a  cause,  and  especially  advanced  mitral  disease  with  pul- 
monary congestion.  It.  not  infrequently  develops  during  the  stage  of 
adequate  compensation.     In  a  preponderating  proportion  of  the  latter 

1  Pulmonary  Tuberculosis  and  its  Complicatioiis,  p.  130. 
35 


546  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

instances  the  hemorrhage  is  slight,  but  it  may  be  profuse  and  recur  at 
intervals  for  many  years,  (b)  Aneurysm  of  the  branches  of  the  pulmo- 
nary  artery  and  of  the  arch  of  the  aorta  (usually  with  rupture  of  its  coats) 
is  a  rare  cause  of  hemoptysis. 

(3)  Certain  diseases,  such  as  purpura  hotmorrhagica,  scurvy,  anemia, 
hemophilia,  Siud  malignant  forms  of  certain  acute  infectious  diseases 
{e.  g.  yellow  fever),  cause  hemoptysis.  In  this  class  of  cases  the  hemor- 
rhages are  due  either  to  a  diseased  condition  of  the  vessel-walls  or  to 
blood-changes. 

(4)  Vicarious  hemoptysis  is  not  uncommon  during  menstruation  or 
when  amenorrhea  is  present.  Unless  occurring  at  the  time  of  the  regular 
menses  it  is  not  to  be  regarded  lightly,  and  is  of  the  same  significance  as 
when  taking  place  in  the  male. 

(5)  Arthritic  (Gouty)  Endarteritis. — According  to  Sir  Andrew  Clarke 
this  is  a  common  cause  of  recurring  hemorrhages  in  aged  persons. 

Symptoms. — Hemoptysis  is  so  commonly  a  symptom  of  that  most 
frequent  and  dread  disease,  phthisis,  as  to  raise  suspicions  of  the  latter 
in  the  minds  of  the  laity  and  physicians  as  soon  as  it  occurs.  It  is 
appropriate,  therefore,  to  note,  first,  the  features  of  hemoptysis  when 
dependent  upon  pulmonary  tuberculosis,  and  then  to  point  out  its  clin- 
ical peculiarities  when  due  to  other  conditions. 

In  incipient  pulmonary  tuberculosis  hemoptysis  develops  suddenly  as  a 
rule,  a  warm,  saline  taste,  lasting  but  a  few  moments,  generally  pre- 
ceding the  expectoration  of  blood.  The  blood  is  coughed  up,  and  the 
bleeding  may  last  only  a  few  minutes  or  may  continue  for  days,  the 
sputum  being  apt  to  remain  blood-stained  for  a  longer  period.  The 
immediate  efi'ect  of  the  hemorrhage,  however  slight,  is  to  alarm  the 
patient,  inducing,  besides  mental  agitation,  cardiac  palpitation  and  other 
nervous  concomitants.  A  small  hemorrhage  is  not  attended  with  any 
other  results,  but  large  ones  give  rise  to  the  symptoms  of  shock,  com- 
bined with  those  of  symptomatic  anemia.  When  the  hemorrhage  is  large, 
blood  to  the  amount  of  a  mouthful  may  be  ejected  with  each  cough,  and 
in  these  instances  the  effect  of  the  profuse  bleeding  is  evidenced  by  such 
symptoms  as  vertigo,  syncope,  cold  extremities,  excessive  pallor,  perspi- 
ration, and  a  rapid,  small,  feeble  pulse.  This  is  followed,  if  the  attack 
does  not  prove  speedily  fatal,  by  considerable  restlessness,  and  later  not 
infrequently  by  mild  delirium  and  more  or  less  fever. 

In  comparatively  rare  instances  the  same  patient  has  a  single  hemor- 
rhage ;  more  frequently  he  has  several  at  shorter  or  longer  intervals. 
Large  or  small  bleedings  may  precede  by  weeks,  months,  or  even  years 
any  rational  symptoms  or  physical  signs  of  pulmonary  tuberculosis.  In 
such  instances  the  pre-existence  of  latent  foci  of  disease  may  be  assumed. 

In  quantity  the  hemorrhage  varies  greatly,  ranging  from  less  than  an 
ounce  to  a  pint  or  more.  In  advanced  cases  in  which  cavities  have 
formed  large  vessels  may  become  eroded,  followed  by  copious  and  danger- 
ous hemorrhage.  Fatal  hemorrhage  may  take  place  into  a  cavity  without 
the  occurrence  of  hemoptysis,  as  in  a  case  dissected  by  Osier  at  the 
Philadelphia  Hospital.  The  distinctive  characters  of  the  blood  dis- 
charged are  mainly  as  follows :  bright  color,  very  frothy  (being  mixed 
with  air),  and  not  clotted.  In  the  case  of  hemorrhage  proceeding  from 
a  large  cavity,  the  blood  may,  rarely,  pour  forth  in  a  free,  dark  stream. 


HEMOPTYSIS.  rAI 

Physical  Signs. — These  are,  for  the  most  part,  negative.  Quite  fx>m- 
monly  moist  bronchial  rS,les  are  audible  on  auscultation;  palpation  and 
percussion  should  not  be  practised  either  during  or  immediately  after 
the  hemoptysis. 

Hemoptysis  Not  Due  to  Pulmonary  Tuberculosis. — {a)  In  affections  of 
the  mitral  and  aortic  valves.,  especially  in  mitral  stenosis,  hemorrhage 
from  the  bronchi  is  not  uncommon,  and  the  way  in  which  these  lesions 
lead  to  pulmonary  congestion  {vide  discussion  of  Organic  Affections  of 
the  Heart).  During  the  progress  of  these  cases,  hemorrhages  often  occur 
at  considerable  intervals ;  they  may  either  be  slight,  lasting  only  a  few 
minutes,  or  quite  free,  extending  over  periods  of  a  few  days  or  a  week. 

(J)  As  a  rule,  in  the  beginning  small  hemorrhages  occur  for  several 
weeKS  from  pressure  of  an  aneurysmal  dilatation  upon  the  bronchial  mu- 
cosa, or  there  may  be  weeping  of  blood  through  the  exposed  layers  of 
fibrin  composing  the  walls  of  the  sac.  The  bleeding  point  can  be  dis- 
covered with  the  laryngscope,  when  an  aneurysm  of  the  innominate  or  of 
the  aorta  impinges  upon  the  trachea.  A  large  and  often  quickly  fatal 
hemorrhage  occurs  from  rupture  into  the  respiratory  tract. 

{c)  '"'' Arthritic  hemoptysis''  is  undoubtedly  associated  with  gouty, 
degenerative  changes  in  the  terminal  blood-vessels  of  the  lung,  though 
no  coarse  pulmonary  lesions  are  induced  by  the  recurring  hemorrhages. 
Although  the  hemorrhages  may  occur  at  intervals  for  years,  as  a  rule 
they  finally  become  arrested,  and  only  rarely  lead  to  a  fatal  issue.  I 
have  never  observed  this  form  of  hemoptysis  occurring  independently 
of  chronic  bronchitis.  In  emphysema  and  chronic  bronchitis  small  hem- 
orrhages may  occur,  and  occasionally  coagula  in  the  form  of  casts  are 
formed  in  the  bronchi  and  afterward  ejected.  It  is  probable  that  the 
source  of  the  large  bleedings  is  an  ulcer  in  the  bronchial  mucosa. 

(d)  The  hemoptysis  that  is  connected  with  the  menstrual  function  is 
of  frequent  occurrence.  I  saw  recently  a  patient  in  whom  free  bleeding 
has  occurred  at  intervals  of  four  weeks  for  a  couple  of  years,  with  an 
absence  of  the  menses.  In  another  instance,  a  patient  of  Dr.  Byers, 
recurring  hemorrhages  of  the  lungs  took  place  instead  of  the  regular 
menstrual  discharge  for  three  successive  months,  and  a  comparatively 
rapid  and  fatal  form  of  phthisis  was  developed.  This  case  typifies  a 
large  class  that  is  especially  prone  to  develop  pulmonary  tuberculosis. 

[e)  The  preceding  group  is  to  be  distinguished  from  those  cases  in 
which  trivial  bronchial  hemorrhages  sometimes  occur,  and  in  delicate, 
hysterical  females.  Although  these  bleedings  are  accompanied  by 
cough,  it  is  not  uncommon  to  find,  upon  careful  examination,  that  the 
blood  comes  from  the  upper  air-passages. 

(/)  Hemoptysis  may  result  from  severe  injuries  inflicted  upon  the 
thorax,  and  last  for  days. 

{g')  A  person  may  have  a  single  or  many  recurring  attacks  of  hemop- 
tysis without  assignable  cause,  if  we  except  severe  muscular  strain  or  in- 
tense mental  excitement.  Although  pulmonary  tuberculosis  does  not 
supervene  in  instances  of  this  sort,  yet  not  a  few  may  be  excited  by  a 
permanently  limited  tuberculous  focus  which  may  be  indeterminable  by 
the  usual  methods  of  examination.  I  have  more  than  once  seen  a  cure 
result  from  an  active  course  of  treatment  with  creosote  and  appropriate 
hygienic  measures.  In  well-marked  instances  of  the  kind  a  complete 
arrest  of  the  trouble  resulted  from  a  change  of  climate 


548  DISEASES  OF  THE  RESPIRATORY  SYSREM. 

(//)  Parasitic  hemoptt/sis  due  to  paragonimus  Westermanii.  The 
sputuiu  rt'somblc's  that  of  lobar  pneumonia  "with  intermittent  hemoptysis. 

Diflferential  Diagnosis. — A  reliable  diagnosis  necessitates  the  ex- 
elusion  of  hemorrhage  from  the  higher  air-passages,  pharynx,  esophagus, 
and  stomach.  In  ejjista.vii<  the  bh)od  may  directly  enter  the  nasopharynx, 
excite  cough,  and  be  discharged  as  in  hemoptysis.  An  examination  of 
the  nasal  chambers  should  be  made  when  epistaxis  is  suspected.  Bleed- 
ing may  take  place  from  the  gums,  from  chinks  in  the  pharynx,  or  from 
varicose  veins.  If  the  seat  of  the  bleeding  be  the  phari/nj\  the  hemor- 
rhage is  not  free,  the  blood  being  commingled  "with  a  preponderating  pro- 
portion of  mucus  ;  if  from  the  gums,  it  may  be  more  copious  (as  in  ptyal- 
ism  or  scurvy).  An  inspection  of  the  mouth  will  decide  the  question. 
Striimpell  distinguishes  hysteric  hemoptysis  by  the  smaller  bleedings, 
the  absence  of  pus-elements,  and  the  large  amount  of  squamous  epithe- 
lium, leptothrix,  and  the  food-remnants  present. 

Hemoptysis  must  be  distinguished  from  hcinatoneus  ((/.  v.). 

Prognosis. — The  gravest  apprehensions  are  constantly  entertained 
by  sufterers  from  hemoptysis,  but  imm!?diately  fatal  results  are  of  rare 
occurrence;  and  of  this  fact  the  patient  should  be  repeatedly  assured  by 
his  physician.  In  case,  how^ever,  of  thoracic  aneurysm  the  consequences 
of  hemoptysis  are  fatal.  With  reference  to  the  effect  of  hemoptysis  upon 
tuberculous  pulmonary  disease,  opinions  differ  "widely.  Prior  to  the 
existence  of  cavities  it  often  exerts  a  favorable  influence  upon  the  disease. 
On  the  other  hand,  if  cavities  exist,  an  opposite  eflect  is  observed.  Some 
blood  finds  its  way  into  the  bronchi  below  the  point  of  bleeding  and 
into  the  air-cells,  causing  at  times  irritation  and  even  lobular  inflamma- 
tion. Thus  hemorrhages  may  aid  in  rendering  the  tissues  susceptible  to 
tuberculous  infection.  In  cases  of  profuse  hemorrhage,  due  to  the  ero-" 
sion  of  large  branches  of  the  pulmonary  artery  in  phthisical  cavities, 
death  may  be  suddenly  induced,  and  is  caused  largely  by  inundation  of 
the  lung  and  the  consequent  impossibility  of  respiration.  Fatal  hemor- 
rhages are  less  common  in  the  female  than  in  the  male  sex.^ 

Treatment. — Since  the  hemorrhage  is  ascribable  to  (1)  congestion 
of  the  bronchial  mucosa,  (2)  erosion  of  the  vascular  walls,  and  (3)  blood- 
changes,  obviously  the  treatment  of  individual  cases  must  be  modified 
according  to  the  character  of  the  causative  condition. 

In  many  instances  of  hemoptysis  due  to  congestion  of  the  bronchial 
mucosa  the  hemorrhages  are.  comparatively  speaking,  slight ;  hence,  apart 
from  keeping  the  patient  at  absolute  rest  for  from  twenty-four  to  forty-eight 
hours  after  the  cessation  of  the  bleeding,  little  treatment  is  required.  If 
free,  the  physician's  aim  should  be  to  decrease  the  force  of  the  heart's  con- 
traction, and  to  accomplish  this  end  the  patient  should  be  placed  in  bed, 
and  not  allowed  to  change  his  position  nor  to  speak  above  a  Avhisper.  The 
patient  should  lie  on  the  diseased  side  (if  this  be  known).  The  affected  side 
of  the  chest  may  be  strapped  with  adhesive  plaster.  The  diet  should  be 
light,  nutritious,  and  non-stimulating,  all  hot  drinks  and  alcoholics  being 
prohibited.  Among  cardiac  sedatives  employed  with  a  view  to  I'oducing 
the  rapidity  of  the  heart's  action  and  loAvering  the  blood- pressure  are  the 
ice-bag  to  the  precordia,  and  aconite  and  other  arterial  sedatives  internally. 

1  Trans.  Amer.  Climat.  Assoc,  1909,  xxv.,  27,  by  the  writer. 


HEMOPTYSIS.  549 

Arthur  Foxwell  ^  recommends  vene.section  in  cases  in  Avhich  venoun  con,- 
(jestion  is  present,  and  also  lii,ys  stress  upon  measures  that  confine  the 
blood  to  the  systcinic  circulation — /.  e.,  nutritions  food,  large  doses  of  the 
nitrites,  hot  foot-ba,ths,  leeclies  to  the  anus,  and  ligatures  "applied  to  the 
thighs  and  arms.  Brown,  Otis,  and  others  advise  that  the  blood-pressure 
be  frequently  observed,  and  if  found  to  be  high,  nitrite  of  sodium  or  nitro- 
glycerin should  be  employed.  The  pulmonary  capillaries  may  also  be 
effectually  depleted  by  the  use  of  salines.  I  have  found  dry  cupping  over 
the  chest  of  the  greatest  service  in  cases  dependent  upon  congestion. 
Eating  ice  and  partaking  freely  of  iced  drinks  are  also  useful  measures. 
If  the  attack  tends  to  become  prolonged  and  exhausting,  we  may  increase 
the  coagulability  of  the  blood  by  the  use  of  gallic  acid,  acetate  of  lead, 
sodium  chlorid,  or  calcium  chlorid.  Hemoptysis  is  usually  accomp;inie(l 
by  eough  that  constantly  disturbs  the  vascular  serenity  and  excites  fresh 
bleeding;  it  demands  opium  or  morphin  (hypodermically).  In  blood- 
spitting  due  to  the  gouty  diathesis  Mays  recommends  the  salicylate  of 
sodium.  Wilkinson  claims  that  tuberculin  has  an  extraordinary  effect  in 
preventing  and  arresting  hemorrhage.  Amyl  nitrite  in  doses  of  from  3 
to  9  minims  often  promptly  arrests  the  bleeding  by  causing  an  immediate 
fall  in  blood-pressure  at  the  bleeding  points,  "  thus  giving  time  for  clot- 
ting to  take  place"  (Calvert).  Fish^  reports  excellent  results  from  the 
use  of  chloroform  in  19  cases;  he  gives  from  2  to  4  c.c.  by  inhalation. 
Subsequently  the  inhalation  of  15  to  20  drops  every  hour  is  continued  for 
a  few  days. 

When  hemoptysis  is  associated  with  organic  disease  of  the  heart,  the 
main  indication  is  to  strengthen  that  organ  by  bodily  rest  and  quiet  and 
by  the  use  of  cardiac  tonics,  especially  digitalis.  I  have  had  under  ob- 
servation for  several  years  a  young  physician  who  has  been  suffering  from 
frequent,  marked  hemoptysis,  due  to  mitral  regurgitation,  and  in  whose 
case  the  bleedings  are  readily  controlled  by  the  free  use  of  digitalis. 

When  in  thoracic  aneurysm  or  advanced  pulmonary  tuberculosis  the 
blood  is  ejected  in  mouthfuls,  we  may  safely  infer  that  erosion  of  a  ves- 
sel or  rupture  of  the  aneurysm  has  taken  place.  Here  the  object  is  to 
bring  about  the  formation  of  a  thrombus  that  will  arrest  the  hemorrhage. 
Perfect  quiet  in  the  horizontal  position  tends  to  allay  the  vascular  excite- 
ment, and  the  induction  of  fainting  by  venesection  is  a  measure  worthy 
of  a  trial.  Opium  is  conti-a-indicated  in  these  cases,  since  if  cough  be 
checked  inundation  of  the  bronchial  system  with  the  blood  (the  chief 
danger)  will  be  favored.  R.  H.  Babcock  gives  an  immediate  injection 
of  atropin  sulphate  (gr.  -^^—^)  when  hemorrhage  occurs  from  a  cavity. 
Finzi  reports  good  results  from  the  induction  of  artificial  pneumo-thorax. 

In  all  instances  of  hemoptysis  treatment  should  not  end  with  cessation 
of  the  hemorrhage.  A  tendency  to  recurrence  is  manifested  in  many 
cases,  and  for  small,  repeated  hemorrhages,  turpentine  and  aromatic 
sulphuric  acid  may  prove  of  service.  The  patient  should  not  be  allowed 
to  indulge  in  a  stimulating  diet ;  he  should  eschew  tobacco  and  alcoholic 
stimulants,  and  avoid  all  physical  and  mental  strain.  Every  source  of 
bronchial  irritation  should  be  carefully  avoided,  and  attacks  of  bronchitis, 
however  mild,  should  receive  the  most  careful  attention.  A  climate  far 
removed  from  the  seaside  is  best.  Moderate  exercise  is  serviceable,  as 
well  as  a  liberal  amount  of  nutritious  food. 

^Brit.  Med.  Jour.,  1894,  p.  194.  ^Jour.  Amer.  Med.  Assoc,  1909,  lii.,  1918. 


560  diseAjSes  of  the  respiratory  system. 


PNEUMORRHAQIA. 
(Pulmo)uiry  Apoplexy.) 

Definition. — An  escape  of  blood  into  the  air-cells  and  interstitial 
tissue,  with  or  without  laceration  of  the  pulmonary  parenchyma. 

Pathology. — It  may  be,  though  rarely,  ((/)  diffuse,  when  the  lung- 
tissue  is  lacerated,  iis  in  cerebral  apoplexy  ;  or  (/>)  circumscribed,  as  when 
the  blood  is  efl'used  into  the  air-cells  and  the  interstitial  tissue,  without 
rupture  of  the  parenchyma.     (See  Pulmonary  Infarction,  infra.) 

Etiology. — iJljf'uxc  pulmonary  apophwy  is  caused  by  the  rupture 
of  a  thoracic  aneury.sm  that  has  become  adherent  to  the  surface  of  the 
lung.  Its  most  common  cause  is  traumatism,  especially  penetrating 
wounds,  but  adult  life  and  the  male  sex  are  to  be  regarded  as  predispos- 
ing factors.      Septico-pyemia  and  cerebral  disease  are  causes. 

Symptoms. — These  are  ill-defined.  Profuse  hemoptysis,  urgent 
dyspnea,  and  cyanosis,  followed  by  increasing  evidences  of  collajyse, 
together  with  a  clear  history,  should  raise  suspicions  of  the  existence  of 
difl'use  pneumorrhagia. 

The  physical  signs  are  indicative  of  extensive  consolidation  arising 
suddenly,  but  not  of  the  nature  of  the  lesion. 

The  prognosis  is  practically  hopeless,  and  abscess  or  gangrene  may 
result  if  those  cases  recover  from  the  immediate  effects  of  the  hemorrhage. 

Treatment. — Absolute  rest  of  the  body  in  the  horizontal  position  is 
the  one  measure  that  oflt'ers  a  slight  prospect  of  alleviation,  for  thus  the 
formation  of  a  clot,  followed  by  arrest  of  the  hemorrhage,  is  encouraged. 
It  is  unwise  to  use  opium  to  allay  the  cough,  since  the  action  involved 
assists  in  ejecting  the  extravasated  blood,  which  will,  in  consequence  of 
gravitation  and  the  effect  of  respiration,  submerge  speedily  so  much  of 
the  lung-tissue  as  to  hasten  the  fatal  termination.  Ergot  is  contra- 
indicated,  but  the  internal  and  external  use  of  cold  has  been  highly 
recommended.  With  the  onset  of  collapse  cardiac  stimulants  become 
absolutely  necessary,  though  many  cases  are  so  rapidly  progressive  as  to 
reach  a  moribund  state  before  remedial  agents  can  be  applied  by  the 
physician. 

PULMONARY  EMBOLISM. 
{ Hermorrhagic  Infarction;  Etnholism  of  the  Lungs.) 

Pathology. — Embolic  infarctions  are  firm,  airless,  brown  or  black, 
wedge-shaped  masses,  with  their  bases  usually  at  the  pleura,  which  soon 
becomes  lustreless  and  covered  with  fibrin.  The  infarctions  may  be 
single  or  multiple,  and  may  occupy  the  greater  portion  of  the  lobe;  in 
most  ca«e8,  however,  their  size  equals  that  of  a  walnut.  Their  most  fre- 
quent seat  is  at  the  back  of  the  lower  lobe.  The  microscope  shows  the 
presence  of  leukocytes  and  red  blood-corpuscles  in  the  air-cells  and  in 
the  alveolar  septa.  Collateral  congestion  and  edema  are  frequent  con- 
comitants, and,  rarely,  pneumonic  consolidation. 

Ktiology. — The  condition  is  produced  by  the  blocking  of  the  pulmo- 
nary arteries  by  an  embolus  or  thrombus.  When  the  circulation  in  the 
pulmonary  capillaries  is  feeble,  hemorrhagic  infarction  may  be  the  result 
of  stasis,  and  this  is  probably  the  most  frequent  form.  It  is  met  in 
diseases  of  the    lungs  and    also  in  mitral   aflfections.      The   plug   that 


PULMONARY  EMBOLISM.  551 

occludes  the  blood-vessel  may  be  composed  of  leukocytes,  as  in  leukemia, 
and  the  chief  sources  of  the  emboli  are  the  thrombi  in  the  right  heart,  in 
consequence  of  dilatation,  and  in  the  systemic  veins.  Infectious  emboli, 
resulting  in  abscesses,  occur  {vide  Abscess  of  the  Lungs).  An  embolism 
of  placental  cells  in  cases  of  eclampsia  has  been  described.  Occlusion  of 
a  branch  of  the  pulmonary  artery  cuts  off  completely  the  circulation  to  the 
territory  supplied  by  that  branch,  and  hemorrhagic  infarction  occurs — 
venous  extravasation,  with  expression  of  air. 

Symptoms. — Not  all  infarctions  give  rise  to  symptoms  ;  on  the  con- 
trary, occlusion  of  a  main  branch  of  the  pulmonary  artery  usually  ter- 
minates life  speedily.  The  latter  accident  occurs  not  infrequently  in 
connection  with  organic  disease  of  the  heart,  and  if  death  be  not  the 
immediate  result  or  if  a  narrower  branch  be  occluded,  alarming  symp- 
toms ensue,  such  as  syncope,  dyspnea,  pain  in  the  side,  and  convulsions 
with  unconsciousness.  The  first  and  most  distressing  symptom  is  dysp- 
nea, attended  by  frantic  efforts  at  breathing  and  by  great  mental  anxiety. 
Occasionally  hemoptysis  is  an  early  symptom,  and  of  primary  significance 
if  it  occur  in  a  patient  suffering  from  mitral  disease.  Cough  usually 
supervenes,  accompanied  by  the  expectoration  of  dark,  gelatinous,  mucoid 
masses.  Large  lymph-cells  containing  blood-corpuscles  are  found  in  the 
sputum,  most  commonly  in  instances  of  organic  cardiac  affections. 

The  physical  signs  may  either  be  negative — as,  for  example,  when 
the  infarctions  are  small  or  deeply  located — or  they  may  give  informa- 
tion as  to  the  seat  and  extent  of  the  affected  part.  When  present  they 
are  those  of  sharply-localized  consolidation  (increased  fremitus,  percussion- 
dulness,  moist  rales,  bronchial  or  broncho-vesicular  breathing).  It  is  not 
improbable  that  in  many  cases  the  physical  signs  are  due,  in  great  part, 
to  associated  conditions,  such  as  bronchitis,  edema,  or  collateral  consoli- 
dation. The  appearance  of  the  friction-sound  in  the  course  of  suspected 
cases  is  a  great  aid  in  diagnosis.  The  heart's  action  becomes  enfeebled, 
the  pulse  is  small  and  frequent,  and  the  surface  of  the  body  is  cool  and 
frequently  bedewed  with  cold  sweat.  Fever  may  either  be  present  at  the 
onset  or  absent  throughout.  The  signs  of  embolic  abscesses  in  the  lungs 
will  be  elsewhere  detailed  {vide  Pulmonary  Abscess). 

Diagnosis. — To  establish  the  diagnosis  of  pulmonary  embolism  there 
must  be  a  clear  history  of  some  etiologic  condition,  and  the  sudden  appear- 
ance of  such  symptoms  as  dyspnea,  cough,  bloody  expectoration  (in  par- 
ticular), chest- pain,  loss  of  consciousness,  and  convulsions,  corroborated 
by  the  physical  signs  of  a  sharply-defined  spot  or  spots  of  consolidation. 

Prognosis. — The  prognosis  differs  with  the  character  of  the  primary 
condition.  On  the  whole,  it  is  exceedingly  grave,  though  the  absorption 
of  an  embolism,  followed  by  the  disappearance  of  the  urgent  symptoms, 
is  not  impossible.  In  case  death  does  not  occur  soon,  infarcts  may  give 
rise  to  abscess  or  gangrene,  due  either  to  bacteria  in  an  original  embolus 
or  to  their  entrance  through  the  air-passages.  In  other  cases  an  infarct 
may  undergo  fibroid  change  and  contraction,  and  may  even  calcify. 

Treatment. — Beyond  procuring  absolute  rest  of  the  body  and  a 
relief  from  the  distressing  symptoms,  the  treatment  should  be  aimed  at 
the  affections  on  which  this  form  of  embolism  depends.  Dyspnea  and 
pain  may  require  the  hypodermic  use  of  atropin  and  morphin,  preferably 
in  combination.     Heroin  relieved  the  dyspnea  in  one  of  my  cases. 


552  DISEASES  OF  THE  EESPIRATORY  SYSTEM. 


CHRONIC  INTERSTITIAL  PNEUMONIA. 

{Fibroid  Iiidiiraiion  ;    Cirrhosis  of  the  Luni/.) 

Definition. — A  chronic  inflammation  of  the  lungs,  characterized 
by  thf  formation  of  fibrous  or  connective  tissue.  It  may  occur  as  a 
primary  or  as  a  secondary  aftection. 

Pathology. — Two  leading  forms  may  be  recognized:  (a)  Local, 
and  (/')  Diffuse,  though  these  do  not  demand  separate  description.  It  is 
a  unilateral  aftection,  and  the  lung  of  the  side  involved  is  much  shrunken, 
its  dimensions  in  some  cases  being  incredibly  small.  It  lies  tightly 
against  the  spine,  and  has  frequently  been  overlooked.  The  heart 
occupies  the  affected  side,  being  drawn  in  that  direction  during  the 
progress  of  the  disease,  and  it  is  enlarged,  principally  owing  to  hyper- 
trophy of  the  right  ventricle.  The  pulmonary  artery  is  the  seat  of 
atheromatous  change.  The  other  lung  is  overdistended  {compensatory 
emphysema)  and  may  encroach  upon  the  mediastinum.  Intrapleural  and 
pleuro-pericardial  adhesions  may  be  exceedingly  firm  and  tiiick  or  only 
moderately  so,  and  rarely  the  pleurae  are  intact.  The  cut  surface  of  the 
aff'ected  lung  is  hard,  dry,  airless,  shiny,  and  usually  light  gray  in  color 
(rarely  reddish-yellow),  and  the  lung-tissue  cuts  with  great  resistance. 
The  blood-vessels  and  bronchi  may  be  observed  gaping  in  the  cut  section. 
Cavities  may  be  due  to  bronchiectasis  or  to  the  superaddition  of  a  tubercu- 
lous process.  Phthisical  cavities  may  often  be  discriminated  by  their 
usual  situation  at  the  extreme  apex.  The  lung  that  is  unaffected  by  the 
fibroid  process  is  also  quite  often  the  seat  of  tuberculous  change. 

Ktiology. — The  disease  is  almost  invariably  secondary,  and  very 
generally  accompanies  prolonged  inflammatory  and  chiefly  local  changes 
in  the  lungs.  It  may  also  follow  acute  inflammatory  processes.  Ex- 
amples of  localized  interstitial  pneumonia  are  seen  in  connection  with  pul- 
monary tubei'culosis,  emphysema,  syphilis,  hydatids,  and  fibroid  indura- 
tion secondary  to  thickening  of  the  pleura. 

Diffuse  interstitial  pneumonia  has  a  variety  of  causes  :  (a)  It  may  fol- 
low acute  lobar  pneumonia  in  cases  in  which  resolution  is  delayed,  and 
here  the  fibrinous  exudate  filling  the  air-cells  becomes  organized  into 
connective  tissue.  Fibrous  tissue  is  also  substituted  for  the  alveolar  walls. 
The  condition  is  exceedingly  rare. 

(6)  Pneumonia,  appearing  as  a  complication  in  influenza,  is  very  liable 
to  produce  chronic  interstitial  pneumonia. 

(<•)  The  disease  may  also  result  from  atelectasis  due  to  compression,  as 
by  aneurysms  or  neoplasms. 

(cZ)  It  most  frequently,  ho\vever,  follows  hroncho-pneumo7iia  of  either 
acute  or  subacute  form  (Charcot).  The  process  starts  in  the  bronchi 
and  extends  to  the  surrounding  lung-tissue,  till  finally  an  entire  lobe,  or 
even  an  entire  lung,  may  become  involved.  Tuberculous  broncho-pneu- 
monia also  leads  to  the  production  of  new  fibrous  tissue,  but  here  the  proc- 
ess is  a  conservative  one  {vide  Pulmonary  Tuberculosis),  and  hence  is 
not  to  be  classed  with  chronic  interstitial  pneumonia. 

{e)  The  initial  lesions  may  be  located  in  the  adherent  pleura, 
with  secondary  involvement  of  the  lung,  connective-tissue  bands   ex- 


CHRONIC  INTERSTITIAL  PNEUMONIA.  553 

tending  into  its  substance.  The  bronchi  are  infianied  and  sometimes 
dilated. 

Chronic  interstitial  pneumonia  may,  however,  exist  without  implica- 
tion of  the  pleura,  and  in  view  of  this  fact  the  primacy  of  pleural  thick- 
enings cannot  be  granted  without  reserve  when  they  form  a  part  of  the 
lesions  of  fibroid  induration. 

The  various  forms  of  the  disease  thus  far  described  arise  secondarily. 
It  may  also  occasionally  originate  as  a  primary  aifection  (1)  from  the 
inhalation  of  different  forms  of  dust  {vide  Pneumonokoniosis).  (2) 
Delafield  describes  "a  special  form  of  lobar  pneumonia."  Tie  contends 
that  lobar  pneumonia  terminates  only  in  resolution  or  in  death,  and 
that  this  special  disease,  with  its  production  of  newly-formed  connective 
tissue,  is  a  distinct  form  of  inflammation.  The  variety  described  by 
Delafield  runs  a  subacute  or  even  chronic  course,  and  terminates  by 
crisis.  It  is  an  exudative  inflammation,  with  the  formation  of  new  tissue 
from  the  onset.  The  consolidated  areas  are  not  so  large  as  in  ordinary 
pneumonia,  and  sections  lack  the  granular  character  of  the  latter. 

Symptoms. — The  patient  suffers  from  cough.,  which  increases  in 
intensity  with  the  progress  of  the  affection.  There  is  a  mucous,  sero-mu- 
cous,  or  rarely  bloody  expectoration  ;  dyspnea  occurs  early,  and  fre- 
quently is  present  only  on  ascending  heights  ;  uneasiness,  or  even  pain, 
over  the  side  of  the  chest  involved  may  be  experienced.  In  cases 
in  which  the  bronchi  become  dilated  the  characteristic  symptoms  of  bron- 
chiectasis are  superinduced.  The  general  symptoms  consist  merely  in  a 
loss  of  flesh  and  of  strength.     Fever  is  altogether  absent. 

Physical  Signs. — Inspection. — The  chest-wall  of  the  affected  side  is  re- 
tracted, while  the  healthy  lung  is  enlarged  {compensatory  emphysema). 
The  spinal  column  is  curved  laterally.  The  affected  side  is  fixed  during 
respiration,  and  the  heart  is  displaced  by  traction  toward  the  affected  side. 
If  the  left  lung  be  involved,  the  apex-beat  will  be  displaced  to  the  left 
and  slightly  upward ;  if  the  right,  the  apex-beat  will  be  observed  to  the 
right  of  its  normal  position.  The  ribs  approximate,  thus  obliterating  the 
interspaces,  and  the  shoulder  droops  over  the  shrunken  chest-wall. 

Palpation. — The  tactile  fremitus  is  usually  increased  ;  if  the  pleura  be 
much  implicated  or  thickened,  however,  fremitus  may  be  decreased.  Pal- 
pation discovers  no  expansile  motion. 

Percussion. — The  percussion-note  varies.  Dulness  is  common,  owing 
to  consolidation  of  the  lung,  but  flatness  is  sometimes  met  with,  and  a  tym- 
panitic or  amphoric  note  is  occasionally  elicited  over  a  dilated  bronchus. 

Auscultation. — The  breathing  is  bronchial  or  more  or  less  sonorous  a& 
a  rule,  and  over  bronchiectatic  cavities  it  is  cavernous  or,  rarely,  amphoric. 
Near  the  base  it  is  frequently  feeble,  distant,  or  even  altogether  sup- 
pressed. Subcrepitant,  sonorous,  sibilant,  or  gurgling  rales  may  be  audi- 
ble, and  dry,  creaking,  or  leathery  friction-sounds  may  also  be  heard. 

Prognosis. — The  course  of  the  complaint  is  exceedingly  chronic, 
lasting  over  many  years.  Death  may  result  from  an  intercurrent  attack  of 
acute  pneumonia  affecting  the  other  lung.  The  disease  always  shortens 
life,  and  may  be  the  direct  cause  of  death.  Rarely  a  fiital  issue  is  due  to 
dilatation  of  the  right  heart,  followed  by  tricuspid  regurgitation. 

Treatment. — The  condition  is  incurable.  The  patient  should,  how- 
ever, be  placed  under  the  best  sanitary  conditions,  and  if  practicable  he 


55-4  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

should  make  a  permanent  change  of  climate.  A  suitable  resort  should 
be  selected  in  accordance  with  the  rules  indicated  in  the  treatment 
of  Pulmonary  Tuberculosis,  and  every  effort  should  be  put  forth  to 
improve  the  general  nutrition  of  the  patient.  Due  attention  should  be 
given  to  the  associated  bronchitis,  as  well  as  to  any  symptoms  that  may 
arise  during  aciite  exacerbations. 


BRONCHO-PNEUMONIA. 

[Capillary  Bronchitis;    Catarrhal  Pneumonia.) 

Definition. — An  inflammation  of  the  minute  bronchi  and  air-veai- 
cles,  due  either  to  the  extension  of  inflammation  from  the  capillary 
bronchi  to  the  air-vesicles  or  to  an  inflammatory  process  set  up  in  ate- 
lectatic lobules. 

Pathology. — Macroscopically ^  the  lungs  present  decided  variations 
in  persons  who  have  died  of  broncho-pneumonia.  On  the  pleural  sur- 
face may  be  noticed  purplish  or  slaty  patches,  often  sunken  (atelectasis), 
intermingled  with  the  more  elevated  patches  of  healthy  lung  and  gray- 
ish consolidation,  and  smoother  and  more  moist  than  croupous  pneu- 
monia. Similar  appearances  are  presented  by  the  cut  surface.  On 
pressure  fluid  exudes — edematous  from  the  healthier  areas,  and  gray- 
ish and  puriform  from  the  consolidated  areas.  The  mucosa  of  the 
large  bronchi  may  look  natural,  though  frequently  it  is  congested,  while 
the  small  bronchi  usually  contain  more  or  less  muco-purulent  mate- 
rial. Their  walls  are  greatly  thickened,  and  on  section  the  cut  sur- 
face presents  a  nodular  appearance.  Dilatation  of  the  smaller  bronchi 
may  be  observed,  and  minute  consolidated  areas,  varying  in  size  from 
that  of  a  pin's  head  to  that  of  a  pea,  may  be  seen  surrounding  the  thick- 
ened walls  of  the  bronchi.  When,  as  frequently  happens,  they  become 
confluent,  large  areas — an  entire  lobe  and  even  an  entire  lung — of  lung- 
tissue  may  become  consolidated.  The  solidified  zones  are  firm  to  the 
touch,  being  destitute  of  air,  and  at  first  they  contain  blood  ;  hence  their 
color  is  a  dark  red,  later  turning  to  a  grayish  hue.  The  condition  is  usually 
bilateral.  As  a  rule  the  bronchial  glands  are  swollen  and  inflamed.  In 
the  non-consolidated  portions  of  the  lung  the  air-cells  are  considerably 
dilated. 

The  essential  lesion  is  a  productive  inflammation  of  the  bronchi  and 
of  the  immediately  surrounding  air-spaces.  The  inflammation  is  from 
the  first  not  exudative,  but  productive ;  that  is,  with  the  formation  of 
new  tissue  (Delafield).  This  form  of  inflammation  may  merge  into 
sclerosis  of  the  lung  or  chronic  thickening  of  the  pleura.  Microscop- 
ically, the  walls  of  the  bronchioles  and  alveolar  passages  are  seen 
swollen  and  infiltrated  with  cells;  they  likewise  contain  plugs  of  mu- 
cous exudate,  most  marked  near  the  centre  of  the  process.  The  air- 
cells  toward  the  periphery  show  much  less  exudate.  The  latter  con- 
sists of  serum,  some  mucus,  and  many  swollen  cells  from  the  alveoli 


BR ONCHO-PNE UMONIA  .  555 

(soon  showing  fatty  degeneration),  leukocytes,  and  also  red  blood-cells 
in  small  numbers.     Fibrin  is  seen  in  small  quantity  if  at  all. 

In  deglutition-  and  asj)iration-pneumonia  the  leukocytes  are  present 
in  much  larger  numbers,  and  the  exudate  tends  to  suppuration,  while  in 
the  hemorrhagic  forms  the  red  blood-cells  are  relatively  increased. 

Among  the  associated  lesions  to  be  mentioned  are — (a)  Catarrhal  in- 
flammation of  the  mucous  membrane  of  the  bronchi ;  and  (b)  Exudative 
inflammation  of  the  air-cells,  which  become  filled  with  epithelium,  fibrin, 
and  pus,  with  resulting  consolidation  of  the  lung.  The  epithelial  cells 
lining  the  air-sacs,  since  they  are  more  numerous  in  young  children  than 
in  adults,  form  a  larger  part  of  the  inflammatory  exudate  in  the  former 
than  in  the  latter,  (c)  The  pulmonary  pleura  is  often  coated  with  fibrin, 
but  less  regularly  than  in  croupous  pneumonia. 

Ktiology. — (1)  A  marked  predisposing  influence  is  age,  the  disease 
being  most  prevalent  amongst  young  children.  In  them  it  may  appear  in 
association  with  measles,  whooping-cough,  scarlet  fever,  and  diphtheria, 
but  not  infrequently  it  is  entirely  independent  of  these  diseases.  Infants 
are  especially  susceptible  to  the  afi"ection,  most  instances  of  pneumonia 
at  this  period  of  life  being  of  the  lobular  form.  Other  conditions  that 
act  as  predisposing  factors  in  children  are  improper  exposure  to  cold, 
unsanitary  surroundings  (especially  impure  air),  rickets,  and  chronic 
diarrhea.  Broncho-pneumonia  is  also  frequent  in  the  aged,  often  being 
occasioned  by  certain  debilitating  causes  and  chronic  diseases  that  are 
common  to  advancing  years  (emphysema,  gout,  chronic  valvulitis). 

(2)  Season. — The  affection  prevails  especially  in  the  winter  and 
spring  months ;  particularly  is  this  the  case  in  those  forms  that  are 
unassociated  with  the  acute  infectious  group  of  diseases. 

(3)  It  also  supervenes  as  a  complication  in  such  acute  infectious  dis- 
eases as  influenza,  typhoid  fever,  erysipelas,  and  small-pox,  and  is  of 
serious  import.  According  to  my  own  observations,  it  is  more  com- 
monly met  with  in  the  diseases  above  mentioned  than  is  lobar  pneumonia. 

(4)  The  inhalation  of  food-particles  and  other  substances  often  serves 
to  convey  the  agents  of  inflammation  to  the  lobules  of  the  lungs.  A 
long-continued  recumbent  posture  predisposes  the  patient  to  broncho- 
pneumonia. It  is,  however,  in  conditions  in  which  the  larynx  and 
bronchi  have  totally  or  in  part  lost  their  sensitiveness — as  in  coma  due 
to  apoplexy,  uremia,  and  allied  cerebral  states — that  retention  of  bron- 
chial secretions  occurs,  and  that,  owing  to  gravitation,  these  secretions 
reach  the  minute  bronchi.  Pneumonia  is  similarly  produced  when  we 
cut  the  vagus  nerves,  the  paralyzed  structures  permitting  irritants  to  be 
carried  to  the  lung  by  inspiration.  Inhalation  pneumonia  may  follow 
operations  upon  the  nose,  mouth,  larynx  (tracheotomy  particularly), 
and  is  often  secondary  to  carcinoma  of  the  larynx  and  esophagus.  It 
is  also  the  pneumonia  of  new-born  children. 

(5)  It  must  not  be  forgotten  that  quite  commonly  broncho-pneumonia 
is  caused  by  the  tubercle  bacillus  {vide  Pulmonary  Tuberculosis). 

Bacteriology. — Weichselbaum  has  shown  the  presence  of  strepto- 
cocci with  the  greatest  frequency  in  the  usual,  secondary  form.  The 
pneumococcus  is  often  found,  and  in  a  goodly  number  of  cases  the 
Btaphylococcus  aureus  (Neumann),  while  in  influenza  the  specific  organ- 
ism may  itself  cause   broncho-pneumonia  (Pfeifl"er).      Numerous    other 


556.  DISEASES  OF  THE  EESPIRATORY  SYSTEM. 

organisms  have  been  found  (typhoid  bacilhis,  hacilhis  coli  communis). 
Mixed  infection  Avitli  the  Diploeoccus  pneumonic^  is  ahnost  the  ride 
Avhen  lobuhir  ]»neumonia  is  secondary  to  the  acute  infections. 

Sj^mptoms. — Two  clinical  forms  may  be  distinguished  : 

{(i)  Primary  broncho-pneumonia,  -which  occurs  in  30  to  35  per  cent,  of 
all  cases,  is  met  Avitii  generally  in  children,  and  presents,  in  great  part, 
the  symptoms  of  an  acute  bronchitis  of  severe  grade  {coug/i,  dyspnea, 
pain,  fever).  When  occurring  in  ^veakly  subjects  the  onset  may  be 
gradual.  The  cough  is  attended  with  expectoration  (glairy  and  tenacious), 
that  may  be  blood-tinged,  in  the  form  of  droplets  or  points.  The  fever 
is  moderate,  the  temperature  ranging  from  101°  to  104°  F.  (38.3°— 40° 
C),  and  is  of  irregular  type ;  in  severe  cases,  however,  continued  high 
temperature  may  occur.  IMiysical  examination  gives  the  same  result  as 
in  the  secondary  form.  The  duration  is  from  two  to  four  weeks,  the 
fever  terminating  by  lysis.  West  holds  that  primary  broncho-pneumonia 
in  children  is  of  pneumococcic  origin. 

(h)  Secondary  broncho-pneumonia  is  the  variety  usually  met  with.  The 
symptoms  are  frequently  veiled  by  those  of  the  primary  affection,  and, 
indeed,  a  moderate  grade  of  lobular  pneumonia  is  frequently  unsuspected 
during  life  when  arising  in  the  course  of  other  grave  diseases. 

It  is  usuall}^  preceded  by  bronchitis  affecting  the  larger  bronchi,  and 
in  this  common  event  the  first  symptom  that  directs  attention  to  the  dis- 
ease is  the  sudden  increase  in  the  frequency  of  the  respirations,  which 
rise  as  high  as  60  or  even  80  per  minute.  An  initial  chill  is  rare.  Fever 
develops  suddenly,  or,  if  previously  present,  increases  rapidly.  An  early 
symptom  is  the  cough,  which  is  usually  hard,  harassing,  frequently  pain- 
ful, and  accompanied  by  expectoration.  The  pulse  is  frequent,  and  in 
the  later  stages  may  be  quite  rapid,  feeble,  and  irregular.  The  type  of 
the  fever  is  similar  to  that  of  the  primary  form. 

Blood. — There  is  usually  marked  leukocytosis  of  the  polynuclear  type. 
Absence  of  leukocytic  increase  is  of  serious  meaning,  implying  lack  of 
resistance.  On  the  other  hand,  a  high  leukocyte  count  does  not  neces- 
sarily indicate  a  favorable  prognosis,  but  a  good  reaction. 

Physical  Signs. — At  the  beginning  of  the  attack  the  only  sign  is  the 
presence  of  subcrepitant  and  sibilant  rales,  pointing  to  general  bron- 
chitis. Shortly  larger  or  smaller  areas  of  consolidation  become  manifest. 
At  first  rapid  breathing,  and  soon  cyanosis,  aff"ecting  first  the  lips  and 
conjunctivae,  may  be  observed;  later,  the  face  becomes  dusky  and  the 
finger-tips  blue.  Palpation  shows  defective  expansion  and  increased 
tactile  fremitus  over  the  consolidated  areas.  The  percussion-note  is  dull 
or,  less  frequently,  hyperresonant  if  the  area  be  small.  Auscultation 
reveals  numerous  fine,  subcrepitant  rales,  corresponding  to  the  consoli- 
dated portions.  The  respiratory  murmur  may  be  bronchial,  though  more 
often  broncho-vesicular.  The  signs  are  usually  noted  in  both  lungs. 
Confluence  of  the  numerous,  small,  consolidated  areas  may  result  in  large 
fields  of  dulness,  and  true  bronchial  breathing.  In  cases  of  extensive 
consolidation,  there  may  be  inspiratory  retraction  of  the  lower  sternum 
and  lower  ribs,  indicative  of  deficient  lung  expansion  (Butler). 

Duration. — (1)  In  children  this  varies  in  diflTerent  cases.  Rarely 
do  fatal  instances  last  more  than  two  or  three  weeks,  while  they  may  be 
as  brief  as  two  or  three  days.    On  the  other  hand  cases  in  which  recovery 


BRONCHO-PNEUMONIA . 


557 


ensues  frequently  last  from  six  to  eight  weeks,  thouprh  rarely  from  one 
to  three  weeks  only.      Two  special  forms  demand  brief  description  : 

(a)  The  cerebral,  in  which  restlessness,  convulsions,  and  delirium  be- 
come so  marked  as  to  overshadow  entirely  the  pulmonary  symptoms.  Not 
infrequently  the  onset  is  characterized  by  convulsions,  high  fever,  pros- 
tration, and  alternating  stupor  and  delirium.  After  the  lapse  of  from 
two  to  five  days,  pulmonary  symptoms  appear,  while  the  cerebral  decline. 

(h)  Other  cases  may  manifest  a  subacute  onset,  in  which  there  is  ano- 
rexia and  occasional  vomiting,  with  the  nervous  symptoms  before  noted. 

(2)  The  protracted  forms  are  those  in   which    (a)  the  symptoms  of 


Fig.  46.- 


-Illustrating  broncho-pneumonia.    The  dark  spots  represent  the  consolidated  areas ;  the 
white  dots  indicate  rales :  A,  coalescence  of  two  areas  of  consolidation. 


acute  broncho-pneumonia  give  place  to  those  of  a  similar  though  chronic 
state.  The  general  disturbances  may  not  be  marked  in  some  in- 
stances, but  usually  there  are  cough,  loss  of  appetite,  or  inability  to 
gain  in  flesh  and  strength,  and  the  signs  of  consolidation  persist. 
(6)  Those  presenting  fever  of  an  irregular  type,  together  with  decided 
prostration,  in  addition  to  the  symptoms  of  the  preceding  variety.  In 
many  cases  belonging  to  this  form  the  lesions  are  tuberculous. 


55S  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  adolescence  the  cerebral  symptoms  are  not  as  well  marked  as  in 
children.     Two  anomalous  varieties  are  met  with  in  practice : 

General  Broncho-pneumonia. — The  attack  develops  suddenly  and  is 
severe.  There  are  chills,  high  fever,  marked  prostration,  headache, 
chest  and  loin  pains,  a  rapid  pulse  (soon  becoming  feeble),  rapid  and 
labored  respirations,  cyanosis,  restlessness,  delirium,  and  cough  that  is  at 
first  dry,  and  followed  by  muco-purulent,  blood-tinged  sputum. 

The  physical  signs  are  defective  expansion  and  an  increased  tactile 
fremitus.  The  percussion-note  may  be  either  normal,  tympanitic,  or 
dull  ;  the  auscultatory  signs  are  large  moist,  subcrepitant,  crepitant,  sib- 
ilant, and  sonorous  rales  over  both  lungs,  and  a  harsh  or  broncho- vesicular 
respiratory  murmur.      The  affection  is  very  grave. 

Resembling  Tuberculous  Broncho-pneumonia. — The  symptoms  appear 
slowly,  and  the  case  pursues  an  insidious  course.  Cough,  catarrhal 
expectoration,  moderate  fever  (hectic  type),  and  night-sweats  are 
noted. 

Physical  examination  discloses  generalized  bronchitis,  coupled  with  cir- 
cumscribed areas  of  consolidation.  Resolution  may  take  place  at  the  end 
of  eight  or  ten  weeks,  and  complete  recovery  ensue  ;  when,  however,  this 
favorable  event  does  not  occur,  the  case  drags  on  for  an  indefinite  period, 
and  finally  ends  fatally.     There  are  no  tubercle  bacilli  in  the  sputum. 

Diagnosis. — This  can  be  arrived  at  by  considering — 

(a)  The  nature  of  the  antecedent  affections  and  their  etiologic  circum- 
stances : 

(6)  The  distribution  of  the  consolidated  areas  in  both  lungs ; 

{c)  The  fact  that  the  physical  signs  of  consolidation  are  subsidiary  to 
those  of  generalized  bronchitis; 

(d)  The  intense  dyspnea  and  cyanosis  ; 

(e)  The  type  of  the  fever,  irregular  as  a  rule,  and  its  gradual  decline ; 
(/)  The  frequent  long  duration. 

Differential  Diagnosis. — Doubtless,  lobar  pneumonia  is  constantly  mis- 
taken for  broncho-pneumonia,  and  particularly  when,  in  the  latter  disease, 
a  large  portion  of  one  or  both  lungs  becomes  inflamed  in  consequence  of 
the  coalescence  of  small  foci  of  consolidation.  The  points  of  distinction 
may  be  tabulated  as  follows  : 

Broncho-pneumonia.  Lobar  Pneumonia. 

Etiology. 

Preeenceof  pathogenic  organisms' (strep-      Presence  of  the  Diplococcus  pneumoniae, 
tococci). 

Usually  secondary  to  bronchitis  and  acute      Usually  a  primary  disease, 
infectious  diseases  (e.  g.  measles,  whoop- 
ing-cough). 

Clinical  History. 

Onset  firadual,  without  rigor.  Onset     abrupt,    with     rigor ;     previous 

health  generally  good. 
Fever   is,  in  proportion  to  the  extent  of       Fever  is  high,   of   continued   type,    and 

intlainmation,  of  irregular  type,  and  de-  falls  between  the  fifth  and  ninth  days 

clines  by  lysis  after  a  variable  duration.  by  crisis. 

'  The  diagnostic  value  of  the  discovery  of  streptococci  is  not  pronounced.  Numer- 
ous other  organisms  have  been  found  in  broncho-pneumonia,  and  a  similar  organism 
{Streptococcut  pneumonice,  Weichselbaum)  in  cases  of  croupous  pneumonia. 


BRONCHO-PNEUMONIA.  559 

Sputum  glairy,  tenacious,  and  in  adults  Sputum  characteristic  (rusty,  or  prune- 
may  be  blood-tinged.  juice). 

Dyspnea   and    evidence   of    carbon-dioxid  Dyspnea     and     cyanoKJs     reJativeiy     U-m 

poisoning  prominent.  marked  ;  anxiouH  countenance. 

Herpes  labialis  absent.  llerpen  lahialis  commonly  preeent. 

Physical   signs   of    generalized    bronchitis  Signs     of     bronchitis     generally     abwent, 

always  marked,  and   usually  preponder-  tliose    of     lobar     consolidation    always 

ating  over  those  of  consolidation.  preponderating. 

Consolidation  commonly  bilateral.  Commonly  unilateral. 

Duration  indefinite,  often   extending  over  Duration  definite  as  a  rule,  convalescence 

many  weeks.  following  crisis. 

Consolidated  areas   liable  to    become  the  Far  less  likely  to  become  the  seat  of  tu- 

seat  of  tuberculous  infection.  berculous  infection. 

It  may  be  difficult  to  distinguish  tuberculous  broncho-pneumonia  from 
the  disease  under  consideration.  Indeed,  a  non-tuberculous  broncho-pneu- 
monia may  be  located  at  the  apex  of  the  lung.  The  differentiation  is 
to  be  based  upon  the  presence  or  absence  of  the  signs  of  softening,  and 
upon  a  microscopic  examination  of  the  sputum  (which  in  a  child  may  be 
vomited),  and  the  tuberculin  test.  The  softening  in  tuberculous  pneu- 
monia does  not,  however,  begin  very  promptly  ;  but  if  elastic  fibers  and 
tubercle  bacilli  be  found,  the  diagnosis  is  at  once  set  at  rest.  Hemop- 
tysis confirms  the  diagnosis  of  the  tuberculous  form. 

Prognosis. — In  broncho-pneumonia  the  severity  and  gravity  of  the 
symptoms  and  the  extent  of  the  involvement  of  lung-tissue  are  propor- 
tionate to  one  another  ;  hence  it  follows  that  the  disease  may  either  be 
devoid  of  serious  import  or  fraught  with  great  danger  to  life.  Its 
course  is  subject  to  decided  fluctuations,  the  periods  of  exacerbation 
in  the  symptoms  often  marking  the  time  of  the  development  of  the 
gravest  features.  Apart  from  the  extent  of  the  lung-tissue  involved,  how- 
ever, we  must  consider  especially  the  condition  of  the  patient  at  the  time 
of  invasion.  If  the  constitution  have  been  previously  undermined,  broncho- 
pneumonia is  very  apt  to  be  fatal.  The  disease  is  less  dangerous  when 
it  develops  in  the  course  of,  or  follows,  measles  than  when  secondary  to 
whooping-cough,  influenza,  or  diphtheria.  Wiry,  thin  children  seem  to 
stand  broncho-pneumonia  better  than  fat,  flabby  ones  (Osier).  During 
childhood,  the  younger  the  subject,  the  higher  the  death  rate  (Hare). 
Deglutition  and  inspiration  lobular  pneumonia,  especially  when  occurring 
after  operations  upon  the  larynx  or  trachea,  are  frequently  fatal.  The 
mortality  rate  in  this  disease  varies  from  25  to  50  per  cent.  In  primary 
broncho-pneumonia,  however,  the  mortality  is  decidedly  lower. 

Treatment. — Prophylaxis. — There  are  few  diseases  that  can  be  so 
effectually  prevented  as  can  broncho-pneumonia.  In  the  first  place, 
proper  attention  to  the  mouth  as  well  as  to  the  position  of  the  patient 
(which  should  be  changed  frequently)  during  attacks  of  acute  infectious 
diseases  will  prevent  its  development  in  a  great  proportion  of  this  large 
class  of  cases.  Adequate  protection  against  exposure  to  cold  during  con- 
valescence from  measles,  whooping-cough,  etc.  is  also  a  potent  factor  in 
preventing  the  disease,  as  is  the  timely  handling  of  catarrhal  affections 
of  the  nose,  pharynx,  larynx,  and  larger  bronchi. 

Treatment  of  the  Attack. — Certain  sanitary  arrangements  are  of  the 
utmost  practical  importance.  The  sick-room  should  be  well  ventilated 
and  its  atmosphere  kept  at  a  uniform  temperature — 68°  to  70°  F.  (20'^- 
21.1°  C).  The  air  of  the  room  should  also  be  well  laden  with  moisture, 
which  may  be  generated  from  a  croup-kettle  or  other  suitable  vessel. 


560  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Local  Measures. — In  young  children  the  chest  shouhl  be  enveloped 
in  a  ja.cket-})oultiee  of  linseed  meal,  which  should  be  covered  with  a 
layer  of  oiled  silk  or  waxed  paper  to  prevent  its  growing  cool.  This 
should  be  renewed  at  intervals  of  about  six  hours.  After  the  more 
active  symptoms  have  subsided  the  linseed  jacket-poultice  may  be  re- 
placed by  one  of  absorbent  cotton,  which  should  also  be  covered  with  oiled 
silk  or  wax  paper.  In  older  subjects  the  application  of  iced  poultices 
to  the  chest  exercises  a  most  favorable  influence,  not  only  upon  the  local 
inflammation,  but  also  upon  the  fever  and  the  nervous  symptoms. 

General  Measures. — High  fever  calls  for  tub-baths,  the  temperature 
of  the  water  at  first  being  set  at  95°  F.  (35°  C),  and  then  gradually 
cooled  to  75°  or  80°  F.  (26.6°  C).  The  gradually  cooled  bath  or  the 
cold  pack  may  be  used  two  or  three  times  daily.  The  eff"ects  are  to 
reduce  temperature,  to  promote  refreshing  sleep,  and  to  improve  the 
character  of  the  respiration.  This  mode  of  treatment  is  especially 
effective  in  cases  that  begin  abrupth^  In  such  the  tincture  of  aconite 
or  veratrum  viride  may  be  employed  temporarily.  In  cases  presenting 
moderate  pyrexia  cold  spongings,  combined  with  the  use  of  the  ice-bag 
to  the  head,  may  suffice.  The  following  fever-mixture  may  be  employed, 
though  it  is  not  to  be  regarded  as  a  substitute  for  hydrotherapy,  but  is 
merely  supplemental  to  the  latter : 

i^.   Potassii  citrat.,  ^ijss  (10.0); 

Spts.  aramon.  aromat.,       l^ij    (8.0); 
Spts.  aether,  nitrosi,  f^ss  (16.0); 

Liq.  ammon.  acetat.,  fgiij  (96.0); 

Glycerin i,  q.  s.  ad  f.5iv  (128.0). — M. 

Sig.  .5j  (4.0)  every  two  hours  for  a  child  of  five  years. 

In  children  a  mild  mercurial  purge  at  the  outset  is  advantageous, 
and  subsequently  by  the  use  of  salines  or  glycerin  suppositories  a  daily 
evacuation  of  the  bowels  is  to  be  secured. 

The  Diet. — The  bodily  strength  is  to  be  maintained  by  careful, 
methodical  feeding,  milk,  eggs,  albumin,  and  broths  being  the  best 
forms  of  food.  The  milk  should  be  predigested  if  there  be  marked 
pyrexia,  and  egg-white  may  be  given  in  cold  water  or  as  egg-lemon- 
ade. The  cough  is  often  wellnigh  constant  and  very  distressing.  Fre- 
quently the  use  of  remedies  that  promote  secretion,  combined  with  a 
small  dose  of  opium,  will,  under  these  circumstances,  aff"ord  relief.  A 
useful  formula  is  the  following : 

^.  Vini  antimonii,  3j       (4.0); 

Spts.  seth.  nit.,  Sijss  (10.0); 

Tr.  opii  camph.,  3ijss  (10.0); 

Liq.  ammon.  acetat.,  q.  s.  ad  5ij      (64.0). — M. 
Sig.  3j  (4.0)  every  two  hours,  diluted,  for  a  child  of  from  three 
to  five  years. 

Dover's  powder  is  also  of  value  in  relieving  the  cough.  When  the 
expulsion  of  the'sputum  is  attended  with  great  difficulty  the  preparations 
of  ammonium  often  meet  the  indications.  Of  these  the  muriate  is  the 
most  eff"ective,  but,  unfortunately,  this  is  often  objected  to,  and  we  must 


PULMONARY  ATELECTASIS.  561 

then  rely  upon  the  carbonate  or  the  aromatic  spirits.  The  hronchi  may 
contain  an  abundance  of  .secretion  that  cannot  be  expeUed,  despite  the 
use  of  the  above  measures.  Under  these  circumstances  an  emetic  may 
be  given,  composed  of  the  wine  of  ipecac  (.5j — 4.0),  combined  with  alum 
(gr.  XX  to  XXX — 1.296-1.944),  and  administered  to  a  child  every  ten  or 
fifteen  minutes  until  emesis  occurs.  Oxygen  by  inhalation  is  to  be  used 
early  and  persistently  to  overcome  the  cyanosis. 

Cardiac  stimulants  (alcohol,  strychnin,  Hoffman's  anodyne)  are  required 
if  the  pulse  fails,  with  increasing  cyanosis.  The  preparations  of  ammo- 
nium owe  much  of  their  reputation  in  this  disease  to  their  stimulating 
properties.  These  agents  when  boldly  used  may  suffice  to  re-establish 
the  cardio-pulmonary  circulation.  Sudden  heart  exhaustion  may  occur, 
associated  with  mucous  r^les  in  the  larger  bronchi  and  rapidly  developing 
cyanosis;  atropin  (dose,  gr.  -g-^  to  y^ — 0.0001-0.0012  gm.  every  sec- 
ond or  third  hour)  tends  to  arrest  this  mucous  secretion.  Alternating 
douching  with  hot  and  cold  water  and  electricity  should  be  given  a  trial. 
Injections  of  salt  solution  increase  arterial  tension  and  act  as  a  "  whip  " 
to  all  emunctories,  aiding  in  the  elimination  of  toxins.  They  should  be 
used  in  serious  cases.  In  streptococcic  broncho-pneumonia  antistrepto- 
coccus  serum  may  be  tried. 


PULMONARY  ATELECTASIS. 

[Collapse  of  the  Lungs  ;   Compression  of  the  Lungs.) 

Definition. — Atelectasis  of  the  lungs  is  a  condition  occasioned  by 
the  removal  of  the  air  from  the  air-cells — a  state  directly  the  opposite 
of  emphysema.  The  air  disappears  largely  in  consequence  of  the  process 
of  absorption. 

Pathology. — The  affected  lung-spots  sink  in  water,  being  non-crep- 
itant.  They  present  through  the  pleura  a  bluish-red  tint,  and  on  cross- 
section  a  brownish-red  color.  The  surface  of  the  affected  areas  is  smooth 
and  depressed.  The  bronchi  supplying  the  collapsed  parts  may  be  oc- 
cluded by  inflammatory  products,  but,  as  shown  by  Legendre  and  Bailly, 
the  air-cells  involved  may  be  inflated  by  means  of  a  blowpipe. 

Apart  from  more  or  less  capillary  distention,  there  are  no  histologic 
changes  in  the  atelectatic  areas,  though  they  are  of  firm  consistence 
(splenization,  carnification).  There  can  be  no  longer  any  doubt  as  to  the 
entire  propriety  of  the  pathologic  distinction  between  lobular  pneumonia 
and  atelectasis. 

Ktiology.^— The  condition  occurs  most  frequently  in  the  new-born, 
and  is  then  due  to  defective  respiration.  Thus  in  children  dying  soon 
after  birth  the  lower  lobes  may  be  found  to  be  atelectatic.  When  ac- 
quired, however,  there  are  three  modes  of  production  :  (1)  The  first  step 
consists  in  a  more  or  less  complete  plugging  of  the  smaller  bronchi  with 
muco-pus  and  other  products  of  bronchial  inflammation.  If  complete, 
air  can  no  longer  enter  on  inspiration,  and  as  the  contained  air  gradu- 
ally becomes  absorbed  atelectasis  is  the  natural  result.  This  condition 
is  very  commonly  associated  with  broncho-pneumonia,  especially  in  chil- 
dren.    New  growths    may  occlude   the   smaller  bronchi   and  produce  a 

36 


562  DISfJASES  OF  THE  EESPIRATOEY  SYSTEM. 

similar  result.  (2)  A  frequent  mode  of  origin  is  through  compression  of 
the  lungs,  resulting  from  positive  intrathoracic  pressure,  after  the  normal 
contractility  of  the  lung  has  been  overcome.  Instances  of  this  may  be 
produced  by  pleural  effusion,  hydrothorax,  pneumothorax,  pericardial 
effusion,  great  cardiac  hypertrophy,  a  solid  tumor,  or  an  aneurysm  of 
the  arch.  Not  iufretjuently  abdominal  tumors,  excessive  meteorism,  and 
ascites  make  sufficient  upward  ))ressure  against  the  diaphragm  to  cause 
compression  of  the  lower  lobes  of  the  lungs.  (3)  Conditions  that  weaken 
and  obstruct  the  inspiration  may  produce  this  disease,  such  as  certain 
brain-affections,  paralysis  of  the  pneumogastric,  and  paralysis  of  the 
chest-walls.  Thoracic  deformities  may  produce  pulmonary  atelectasis, 
and  in  extreme  grades  of  kyphoscoliosis  the  lung  occupying  the  side  cor- 
responding to  the  convexity  of  the  spinal  column  is  small.  Whilst  the 
lung-expansion  and  the  growth  of  the  organ  are  greatly  interfered  with, 
true  atelectasis  rarely  occurs  from  this  cause,  particularly  if  the  condition 
arises  in  j'^outh,  owing  to  the  natural  retractility  of  the  lung.  Among 
conditions  arising  from  deformities  of  the  chest  is  the  so-called  aplasia  of 
the  lungs. 

Symptoms. — Atelectasis  is  a  secondary  condition,  and  its  symp- 
toms are  very  generally  veiled  by  those  of  the  primary  disease.  It 
arises  frequently  in  the  course  of  broncho-pneumonia,  but  passes  unno- 
ticed unless  it  becomes  very  extensive.  Respiration  is  carried  on  by 
the  upper  and  anterior  portions  of  the  lungs,  is  increased  in  frequency, 
and  is  laborious.  The  pulse  is  small,  rapid,  and  feeble ;  the  skin- 
surfaee,  especially  that  of  the  extremities,  is  cool. 

The  form  presenting  the  most  typical  symptoms  is  that  occurring 
in  the  new-born.  It  is  evidenced  by  shallow,  rapid  breathing,  livid- 
ity,  cold  extremities,  a  faint  whining  cry,  droivsiness,  and  sometimes 
by  evidences  of  motor  irritation,  such  as  muscular  twitching  and  con- 
vulsions. Congenital  anomalies  of  the  circulatory  organs  are  asso- 
ciated. 

Physical  Signs. — When  it  involves  a  goodly  portion  of  the  lower  lobes 
posteriorly,  as  frequently  happens,  there  is  marked  retraction  during  in- 
spiration over  the  lower  portion  of  the  thorax,  due  partly  to  external 
atmospheric  pressure,  and  partly  to  the  contractile  efforts  of  the  dia- 
phragm. Dulness  on  percussion  is  only  revealed  when  the  atelectasis  is 
extensive,  and  the  tactile  fremitus,  though  very  various,  is  generally 
decreased  or  even  absent.  Localized  compensatory  onipliysema  may 
present  semitympanitic  resonance  over  small  areas  of  collapse. 

Auscultation  shows  a  greatly  diminished  or  absent  vesicular  murmur, 
and,  if  the  area  of  collapse  be  large,  bronchial  breathing.  Among  asso- 
ciated sounds  is  the  subcrepitant  rale,  due  to  broncho-pneumonia,  and, 
indeed,  capillary  bronchitis  and  atelectasis  are  often  combined,  there 
being,  moreover,  no  reliable  signs  that  will  separate  them  clinically. 

The  aplasia  of  the  lung  that  is  produced  by  spinal  curvature  [kypho- 
scoliosis) richly  deserves  brief  separate  description,  owung  to  its  clinical 
importance.  In  many  instances  the  chest  is  more  or  less  twisted  on  its 
own  axis,  shortened  in  the  vertical  diameter,  and  thoroughly  fixed. 
Under  these  circumstances  lung-expansion  is  impossible,  and  hence  res- 
piration is  purely  diaphragmatic.  In  many  other  patients  life  may  be 
prolonged  for  an  indefinite  period,  nothing  more  being  observed  than 


PULMONARY  ATELECTASIS.  563 

slightly  labored  breathing.  Such  pcrsonss,  liowcver,  upon  great  phyHi- 
cal  exertion  sufter  from  urgent  dy.spnea,  and  tiie  development  of"  an 
ordinary  bronchitis  may  lead  to  similar  results,  and  even  to  speedy 
death. 

The  physical  signs  are  those  of  localized  emphysema,  combined  with 
those  of  more  or  less  compression  of  the  lungs.  There  is  an  extension 
of  the  cardiac  dulness  to  the  right,  and  other  evidence  of  right  ventricu- 
lar enlargement,  to  which  may  succeed  dilatation  witli  its  usual  clinical 
events.     Death  is  not  rarely  due  to  this  failure  of  compensation. 

Autopsies  have  shown  the  lungs  to  be  small  and  more  or  less  com- 
pressed, some  portions  being  almost  airless.  Areas  of  emphysema  are 
often  associated.  The  right  ventricle  may  be  hypertrophied  merely,  or 
dilatation  may  also  have  taken  place.  Congenital  atelectasis,  by  keep- 
ing up  high  pulmonary  pressure,  may  lead  to  persistence  of  the  ductus 
Botalli  and  of  the  foramen  ovale. 

Diagnosis. — Atelectasis  may  be  distinguished  from  lobar  pneu- 
monia by  the  absence  of  an  initial  rigor,  fever,  crepitant  rales,  and  the 
pain  of  the  latter  disease,  and  by  the  characteristic  inspiratory  retrac- 
tion of  the  lower  portions  of  the  chest  and  the  smaller  areas  of  dulness. 

Pleuritic  effusion  gives  a  flat  percussion-note,  the  upper  level  of 
which  varies  with  a  change  in  the  position  of  the  patient — a  sign  that 
is  wanting  in  atelectasis. 

Prognosis. — When  the  condition  is  limited  to  small  areas  it  is 
rarely  serious,  but  equally  seldom  does  extensive  atelectasis  lead  to 
recovery.  The  outlook  depends  to  some  extent  upon  the  nature  of  the 
associated  affections  ;  thus,  when  secondary  to  whooping-cough  and  wide- 
spread broncho-pneumonia,  it  is  very  fatal.  Other  diseases  that  may 
complicate  and  increase  the  gravity  of  the  atelectasis  are  pleurisy  and 
pulmonary  tuberculosis.  On  the  other  hand,  compensating  emphysema 
often  coexists,  and  is  to  be  regarded  as  salutary  in  its  effects.  When 
due  to  conipression  by  pyo-pneumothorax,  tumors,  and  the  like,  the 
prognosis  is  especially  gloomy. 

Treatment. — The  treatment  corresponds  with  that  of  the  primary 
disease.  Capillar^/  bronchitis,  which  is  so  apt  to  be  followed  by  collapse 
of  the  lobules,  must  receive  active  treatment,  and  prophylactic  measures 
are  of  the  utmost  practical  importance.  The  patient  should  be  instructed 
to  practise  full  inspiration  at  regular  intervals  ;  he  should  not  be  allowed 
tO  lie  continuously  in  the  dorsal  decubitus,  but  should  change  his  position 
frequently.  Another  useful  preventive  measure  is  the  use  of  cold  shower- 
baths  (^.  e.,  a  stream  of  cold  water  poured  over  the  region  of  the  neck), 
and  this  can  sometimes  be  depended  upon  as  a  curative  agency  when  the 
condition  already  exists.  Tonics  and  the  judicious  use  of  stimulants,  to- 
gether with  a  nourishing  diet,  are  invariably  required.  I  have  also  seen 
good  results  follow  the  inhalation  of  compressed  air  and  of  oxygen. 

In  kyphoscoliosis  tepid  baths  are  indicated.  The  heart-condition  de- 
mands careful  attention,  and  cardiac  stimulants  are  to  be  resorted  to  at 
the  first  loss  of  compensation  or  when  compensation  fails  to  become 
established. 


564  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


EMPHYSEMA. 

Definition. — In  general  this  *erm  implies  the  presence  of  air  in  the 

interstitial  alveolar  tissue.  As  applied  to  the  lungs,  however,  two  forms 
are  recognized  :  (1)  Interlobular ;  and  (2)  Vesicular,  an  abnormal  dila- 
tation of  the  alveoli. 

INTERLOBULAR   EMPHYSEMA. 

This  is  produced  by  the  rupture  of  the  air-cells,  the  air  contained  in 
the  lung  escaping  into  the  interlobular  connective  tissue.  Among  its 
causes  are — (a)  Injuries  of  the  lung  (usually  by  a  fractured  rib)  and 
penetrating  wounds  of  the  chest ;  (b)  A'^iolent  paroxysms  of  coughing, 
as  in  whooping-cough  ;  and  rarely  defecation,  parturition,  and  hysterical 
convulsions.  When  arising  in  this  way  its  favorite  situation  is  the  an- 
terior margin  of  the  upper  lobe. 

Pathology. — In  the  interlobular  septa  immediately  beneath  the 
pleura  air-bubbles  are  sometimes  seen  to  be  arranged  in  well-defined 
rows.  The  pulmonary  pleura  may  become  detached,  and  the  air-tumors 
may  then  become  as  large  as  an  English  walnut  or  even  of  greater  size. 
Unlike  the  condition  in  vesicular  emphysema,  these  sacs  are  freely  mov- 
able, and  the  air  may  find  its  way  from  the  root  of  the  lung  into  the 
mediastinal  connective  tissue,  and  thence  into  the  subcutaneous  tissue 
of  the  neck  and  the  wall  of  the  thorax.  Rarely  these  air-sacs  perforate 
the  pleura,  setting  up  pneumothorax,  with  or  without  pleuritis. 

Interlobular  emphysema  is  sometimes  associated  with  advanced  vesic- 
ular emphysema. 

VESICULAR  EMPHYSEMA. 

[Alveolar  Ectasis.) 

Definition. — Dilatation  or  enlargement  of  the  alveoli  and  infundib- 
ular passages. 

Varieties. — The  cases  are  classified  into — (1)  Compensating,  (2) 
Hypertrophic,  and  (3)  Atrophic  forms. 

COMPENSATING     EMPHYSEMA. 

This  variety  is  limited  to  certain  parts  of  the  lung,  and  arises  in 
consequence  of  pathologic  changes  in  other  parts  of  the  same  organ 
that  prevent  full  expansion  of  the  lung  on  inspiration.  Hence  a  vica- 
rious increase  in  the  volume  of  the  air-cells  is  observed  in  circumscribed 
morbid  processes  such  as  occur  in  pulmonary  tuberculosis,  lobular  pneu- 
monia, cirrhosis,  and  pleurisy  with  adhesions  (particularly  when  the 
latter  is  situated  at  the  inferior  border  of  the  lung).  An  entire  lung, 
unaffected  by  the  primary  disease,  may  be  the  seat  of  compensating  em- 
physema when  the  causal  disease  invades  the  whole  or  a  greater  portion 
of  the  other  lung,  as  in  cirrhosis,  extensive  pleurisy  with  effusion,  lobar 
pneumonia,  and  pyo-pneumothorax.  When,  however,  the  latter  condi- 
tions are  confined  to  a  portion  of  one  lung,  the  remainder  of  the  same 
organ  becomes  distended  also.  The  term  acute  emphysema  is  applicable 
to  many  of  the  cases. 


HYPERTROPHIC  EMPHYSEMA.  r,r,o 

As  a  rule,  this  pulmonary  change  is  physiologic  and  henoficial  :  only 
rarely  secondary  atrophy  of  the  walls  of  the  air-cells  develops. 

Symptoms  are  not  presented  by  the  lungs  in  consequence  of  the 
changes  met  with  in  compensating  emphysema.  The  condition  is  some- 
times recognizable  by  means  of  the  usual  physical  signs,  but  even  these 
are  not  always  to  be  relied  upon.  Fortunately,  its  existence  may  be 
safely  inferred  when  there  is  conclusive  evidence  of  the  presence  of  the 
local  causative  diseases  (broncho-pneumonia,  pulmonary  tuberculosis, 
pleurisy,  lobar  pneumonia). 

HYPERTROPHIC   EMPHYSEMA. 

Nature  of  Emphysema. — The  symptoms  are  dependent  upon  a  loss 
of  elasticity  in  the  lungs,  and,  the  latter  condition  being  the  result  of 
overstretching,  the  contractile  energy  of  the  lungs  is  in  great  part 
destroyed ;  hence  they  become  permanently  enlarged.  We  may  in  some 
cases  account  for  the  loss  of  elasticity  in  the  lungs  by  the  operation  of 
causes  that  produce  an  abnormal  degree  of  stretching,  either  temporarily 
or  constantly  ;  but  under  these  circumstances  emphysema  would  be  de- 
veloped despite  the  pre-existence  of  normal  contractility  of  the  lung.  In 
true  emphysema,  however,  which  develops  at  a  comparatively  early 
period  in  life,  we  may  safely  assume  that  the  retractile  energy  is  defective 
(probably  a  congenital  condition),  and  hence  in  such  cases  the  action  of 
the  usual  causal  factors  will  speedily  engender  over-distention,  or  emphy- 
sema may  develop  even  in  the  absence  of  causative  influences.  In  these 
instances  there  is  probably  a  quantitative  as  well  as  a  qualitative  defect  in 
the  elastic-tissue  element  of  the  lungs. 

Pathology. — The  thorax  is  enlarged  (barrel-shaped),  and  upon  re- 
moving the  sternum  the  lungs  are  found  completely  to  fill  the  mediasti- 
num, and  do  not  retract  as  in  health.  They  present  a  pale,  anemic 
appearance,  although  pigmented  patches  and  streaks  may  be  noted.  To 
the  touch  they  appear  soft  and  feathery,  though  dry.  They  readily  pit 
on  pressure  (a  leading  characteristic). 

Immediately  beneath  the  pleura  enlarged  air-cells  can  be  distinguished 
macroscopically,  and  air-sacs  as  large  as  a  walnut  may  project  above 
the  lung  surface.  Occasionally  they  may  be  pedunculated.  At  the 
anterior  borders  a  series  of  air-blebs,  resembling  a  frog's  lung,  may  be 
observed.  Here,  and  near  the  root  of  the  lung,  distention  is  usually 
more  marked,  owing  to  the  direction  taken  by  the  distending  force. 
The  pleura  is  pale,  and  in  patches  the  pigment  may  be  absent  ( Vir- 
chow's  albinism). 

Upon  microscopic  examination  it  is  observed  that  the  dilatation 
starts  in  the  infundibular  and  alveolar  passages.  The  septa  are  partially 
obliterated,  the  alveolar  walls  thinned  and,  lastly,  perforated,  while  in 
consequence  of  these  changes  the  air-cells  communicate  with  one  another, 
forming  larger  or  smaller  air-sacs.  The  process  is  an  atrophic  one,  the 
smaller  elastic  fibers  disappearing,  while  the  larger  become  less  prominent, 
and  often  ruptured.  After  the  latter  changes  have  begun  the  capillaries 
likewise  disappear,  and  the  epithelium  of  the  air-cells  undergoes  fatty  de- 
generation, though  in  the  larger  bulljfi  a  pavement-layer  is  retained.  The 
smooth  muscular  element  may  also  occasionally  be  found  hypertrophied 


50t>  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

(Rindfleisch).  The  clinical  phenomena  probably  arise  fruiu  the  loss  of 
the  capillary  blood-vessel  system  and  collateral  hyperemia  of  the  larger 
bronchial  vessels. 

The  bronchial  mucous  membrane  is  usually  the  seat  of  chronic  inflam- 
mation. It  may  be  roughened  and  thickened,  or  the  submucous  elastic 
tissue  may  present  prominent  longitudinal  lines,  while  the  bronchial 
mucosa  is  covered  with  muco-pus.  The  smaller  tubes  may  be  dilated 
(bronchiectasis),  and  hyperplasia  of  the  peribronchial  connective  tissue 
may  be  associated.  The  diaphragm  is  lowered  and  the  subjacent  viscera 
correspondingly  depressed. 

Physiologic  Pathology. — Tlie  heart  is  pushed  downward  and  somewhat 
baclcward.  The  right  side  shows  well-marked  changes  ;  the  cavities  are 
dilated  and  hypertrophied,  due  to  obstruction  in  the  pulmonary  circula- 
tion ;  and  in  long-standing  cases  hypertrophy  of  the  left  chambers  may 
also  develop.  The  pulmonary  artery  and  its  branches  are  enlarged  and 
the  seat  of  atheromatous  degeneration.  The  liver,  kidneys,  and  other 
viscera  pi-esent  the  changes  that  belong  to  chronic  venous  engorgement. 

Ktiology. — The  affection  is  often  secondary  to,  and  develops  in 
conseciuence  of,  other  affections  of  the  lung — notably  whooping-cough 
and  chronic  bronchitis,  particularly  the  dry  form.  The  disease  is  attrib- 
utable to  the  mechanical  influences  to  which  the  alveolar  walls  are  sub- 
jected during  respiration.  This  abnormal  strain  attends  inspiration  to 
some  extent,  but  mainly  expiration,  owing  to  the  obstruction  to  the  egress 
of  the  air  in  the  smaller  bronchi,  with  increased  intra-alvcolar  air 'pressure. 
The  increased  tension  in  the  air-cells  may  be  accounted  for  partly  by  the 
severe  and  persistent  cough,  the  air  being  thus  driven  into  the  apices  of 
the  lungs,  forcibly  expanding  them  and  causing  emphysema.  Syphilis 
and  alcoholism  are  among  the  recognized  causes. 

Bronchial  asthma,  on  account  of  the  obstruction  of  the  exit  of  the 
air  from  the  lungs,  produces  during  the  attacks  an  acute  emphysema 
that  may  result  finally  in  a  condition  of  permanent  overdistention. 
Certain  occupations,  such  as  blowing  wind-instruments,  or  those  that 
entail  severe  muscular  strain  {e.  g.  blacksmithing),  act  as  predisposing 
causes,  and  hence,  emphysema  is  of  common  occurrence  among  the 
working  classes,  and  is  more  common  in  males  than  females.  Edsall's 
studies,  however,  show  that  glass-blowers  and  players  on  wind  instru- 
ments are  not  especially  liable.  The  constant  straining  in  certain  pelvic 
disorders  may  induce  emphysema.  The  disease  is  often  hereditary. 
During  advanced  years  the  lung-elasticity  often  diminishes,  and  as  a  con- 
se((uence  a  disposition  to  emphysema  is  engendered.  On  the  other  hand, 
emphysema  is  not  infrequently  met  with  in  children,  and  in  such  there 
may  be  a  temporary  respite,  with  a  recurrence  at  a  later  period.  An 
emphysematous  tendency  also  results  from  congestion  of  the  lungs  asso- 
ciated with  mitral  valvular  disease. 

Clinical  History. — In  nearly  all  cases  the  disease  develops  insidi- 
ously, the  symptoms  being  gradually  added  to  those  of  the  primary  affec- 
tions (chronic  bronchitis,  asthma,  etc.).  When  due  to  occupation  its 
development  is  also  slow,  and  not  infrec^uently  its  origin  dates  back  to 
childhood  or  beyond  the  recollection  of  the  patient.  Rarely  it  may  ex- 
hibit a  more  acute  development,  e.  g.,  after  whooping-cough. 

The  first  symptom  is  a  variable  degree  of  dyspnea,  and  to  this  may 


HYPERTROPHIC  EMPHYSEMA.  507 

be  added  temporary  cyanosin  and  cough.  The  severity  of  tlic  dyspnea 
varies  with  the  degree  of  distention  of  the  air-cells,  even  though  addi- 
tionally aggravated  by  the  coexistence  of  the  primary  disease.  In 
moderate  emphysema  the  dyspnea  is  only  apparent  on  going  up  stairs, 
running,  walking  rapidly,  or  after  a  hearty  meal ;  on  the  other  hand, 
in  advanced  grades  of  the  affection  it  is  constant,  and  is  intensified 
by  the  slightest  exertion,  even  to  orthopnea.  Speech  is  interfered 
with,  the  patient's  utterances  taking  the  form  of  fragmentary  sen- 
tences or  syllables.  The  labored  breathing  is  shown  particularly  in 
expiration,  and,  as  in  asthma,  in  Avhich  the  alveolar  spaces  are  acutely 
distended,  so  in  emphysema  the  rhythm  of  the  respiration  is  changed. 
The  inspiration  is  shortened,  and  the  expiration  is  greatly  prolonged 
and  accompanied  by  wheezing  when  chronic  bronchitis  coexists. 

In  the  later  stages  cyanosis  becomes  more  marked,  and  is  noticeable 
in  proportion  to  the  loss  of  compensation  and  interference  with  the  car- 
dio-pulmonary  circulation.  It  often  attains  to  an  extreme  degree,  and 
the  patient's  alarming  appearance  may  be  in  striking  contrast  with  his 
apparent  degree  of  comfort.  In  mild  forms  the  cyanotic  tint  is  con- 
fined to  the  lips,  lobes  of  the  ears,  and  the  extremities.  Any  increase 
in  the  degree  of  dyspnea  after  exertion  results  in  an  increased  blueness 
of  the  surface. 

The  cough  is  dependent  upon  the  presence  of  chronic  bronchitis, 
which  frequently  co-exists,  particularly  during  the  winter.  The  expecto- 
ration is  identical  with  that  of  chronic  bronchitis,  and  when  this  disease 
reaches  an  advanced  stage  the  cough  persists  throughout  the  year  [vide 
Chronic  Bronchitis).  Intercurrent  acute  attacks  of  bronchitis  are  often 
followed  by  temporary  attacks  of  asthma;  and  since  chronic  bronchitis 
in  its  highest  grades  is  met  with  at  an  advanced  period  of  life,  so,  as 
would  be  expected,  the  cases  of  advanced  emphysema  are  also  met  with 
at  the  same  period.  Osier  has  described  a  group  of  cases  occurring  in 
patients  "  from  twenty-five  to  forty  years  of  age  who,  winter  after  winter, 
have  had  attacks  of  intense  cyanosis  in  consequence  of  an  aggravated 
bronchial  catarrh."  These  patients  are  short-breathed  from  infancy,  and 
their  condition  is  attributed  to  a  primary  defect  of  structure  in  the  lung- 
tissue. 

G-eneral  Symptoms. — There  is  no  fever,  the  temperature  being  gen- 
erally subnormal,  and  the  pulse,  though  sometimes  feeble,  is  not  increased 
in  frequency.  There  is  a  very  gradual  loss  of  flesh  and  strength,  and 
the  patient  is  stoop-shouldered,  presenting  a  peculiar  cachectic  appearance 
— in  strong  contrast  with  the  dusky  appearance  of  the  face,  the  swollen 
neck,  and  the  enlarged  chest. 

Finally,  other  symptoms  may  be  mentioned  that  are  for  the  most 
part  secondary  to  hypertrophy,  followed  by  dilatation,  of  the  right  ven- 
tricle. This  hypertrophy  is  the  result  of  pulmonary  congestion  and 
obliteration  of  the  pulmonary  capillaries  induced  by  the  emphysema. 
Under  these  circumstances  severe  attacks  of  cough  occur,  attended  with 
extreme  dyspnea  and  lividity,  and  later  the  conditions  that  usually 
succeed  a  moderate  grade  of  tricuspid  insufficiency  supervene^  such 
as  congestion  of  various  viscera  and  edema  of  the  feet.  Anasarca 
is  rare. 

Physical  Signs, — The    shape  of  the    chest   is    characteristic  :    owing 


568 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


to   the   increased   antero-posterior  diameter,   it  becomes  barrel-shaped 
(Fig.  47),   and   the   sternum   bulges,  as   do    also   the  costal   cartilages. 

The  infraclavicular  and  mam- 
mary regions  are  also  promi- 
nent, and  give  the  thorax  an 
abnormally  rounded  appearance. 
The  episternal  notch  is  deeper 
than  the  normal,  the  clavicles 
and  muscles  of  the  neck  are 
unduly  prominent,  and  the  neck 
itself  appears  to  be  shortened, 
owing  to  the  elevated  position 
of  the  clavicles  and  the  ster- 
num. There  is  an  antero-pos- 
terior curvature  of  the  spine 
and  a  winged  condition  of  the 
scapulae.  Below,  the  thorax  ap- 
pears contracted.  The  intercostal 
spaces  are  widened  and  depressed, 
and  a  network  of  dilated  venules 
frequently  extends  laterally  above 
the  inferior  costal  border. 

The  movements  of  the  chest 
are  vertical  rather  than  expansile, 
and  the  lungs  are  constantly  in  a 
state  of  extreme  expansion ;  in  the 
lower  thoracic  and  upper  abdominal  regions  there  may  be  observed  re- 
traction rather  than  expansion  during  the  act  of  inspiralion.  The 
respiratory  acts,  as  a  Avhole,  are  labored,  and  the  diaphragm  and 
abdominal  muscles  are  seen  working  with  considerable  violence.  The 
heart's  apex-beat  is  invisible,  but  marked  epigastric  pulsation  is  fre- 
quently noticeable.  Venous  pulsation  may  be  seen  in  the  neck  after 
failure  of  the  right  ventricle  has  occurred. 

On  palpation  the  character  and  direction  of  the  chest-movements 
may  be  accurately  appreciated.  The  tactile  fremitus  is  decreased,  but 
not  absent.  In  the  early  stages  the  apex-beat  is  feeble,  while  in  advanced 
cases  it  cannot  be  felt.  Owing  to  displacement  of  the  heart  and  engorge- 
ment of  the  right  ventricle  there  is  a  distinct  systolic  shock  over  the  ensi- 
form  cartilage,  and  also  a  pulsation  in  the  epigastrium. 

Percussion  yields  a  characteristic  hyper-resonance.  This  may  be  dis- 
tinctly "  Skodaic  "  or  semi-tympanitic,  and  in  extreme  instances  the 
tone  may  be  woodeny.  The  area  of  percussion-hyper-resonance  extends 
higher  above  the  clavicles  than  naturally.  The  area  of  cardiac  dulness 
is  lessened  and  finally  obliterated  by  the  distended  lungs ;  while  the 
upper  limit  of  liver-dulness,  both  anteriorly  and  posteriorly,  is  found  to 
be  one  or  two  interspaces  lower  than  normal,  owing  to  the  fact  that  the 
diaphragm  is  depressed.  The  upper  level  of  splenic  dulness  is  also  low- 
ered. 

On  anseultation  the  inspiration  is  short  and  feeble,  while  the  expira- 
tion is  greatly  lengthened,  the  normal  ratio  of  these  sounds  being  reversed. 
Their  pitch  is  somewhat  lowered,  particularly  that  of  expiration  ;  and 


Fig.  47. — Barrel-shaped  chest  iu  emphysema. 


HYPERTROPHIC  EMPHYSEMA.  TM) 

when  rS/les  are  present  the  respiratory  Tnurrnur  (particularly  the  inspira- 
tory) may  be  scarcely  audible.  In  wcil-inarked  instances  of  emphysema 
inspiration  and  expiration  may  rarely  he  of  equal  lenf.4}i.  It  is  a  fact 
worthy  of  emphasis  that  the  parts  of  the  lungs  less  markedly  emphyse- 
matous than  others  give  a  harsh,  exaggerated  vesicular  murmur,  owing  to 
the  great  efforts  of  breathing.  Rales  of  various  sorts  are  frequently  aud- 
ible, due  to  the  accompanying  bronchitis  usually  present;  less  frequently 
the  auscultatory  signs  of  asthma,  pleuritis,  and  phthisis  are  encountered. 
Rarely,  rubbing  sounds,  attributed  to  the  friction  of  enlarged  air- 
cells  against  the  pleura,  are  audible,  and  when  the  interlobular  variety 
supervenes  upon  vesicular  emphysema  a  crumpling  sound  is  heard.  The 
so-called  '■'■  Laennes' s  rdle,"  which  resembles  somewhat  the  subcrepitant 
r^le,  is  not  infrequently  present.  The  vocal  resonance  varies  from  an 
almost  total  absence  to  a  greatly  increased  intensity.  The  tricuspid  in- 
sufficiency that  develops  late  in  this  affection  is  betrayed  by  its  charac- 
teristic murmur. 

Diagnosis. — A  positive  diagnosis  may  be  arrived  at  from  a  consid- 
eration of  the  history,  including  such  points  as  heredity,  occupation, 
the  long  duration  of  the  condition,  coupled  with  the  most  characteristic 
symptoms  (dyspnea,  cyanosis,  signs  of  chronic  bronchitis),  and  from  the 
physical  signs.  In  a  case  of  beginning  emphysema,  particularly  among 
children,  a  certain  diagnosis  is  not  to  be  attempted. 

Differential  Diagnosis. — Pneumothorax  is  the  disease  most  apt  to  be 
confounded  with  emphysema.  It  develops  suddenly,  however,  while 
emphysema  is  of  slow  development,  and  the  rational  symptoms  of 
pneumothorax  are  more  constant  and  urgently  distressing  than  those  of 
emphysema.  Pneumo-thorax  is  unilateral,  and  gives  a  purely  tympanitic 
percussion-note,  while  hypertrophic  emphysema  is  bilateral  and  its  per- 
cussion-note is  hyper-resonant.  Amphoric  breathing,  metallic  tinkling, 
the  characteristic  succussion  splash,  and  an  absence  of  the  vesicular  mur- 
mur, usually  present  in  pneumo-thorax,  are  absent  in  emphysema. 

Another  affection  giving  rise  to  dyspnea,  cough,  and  cyanosis  is  pleu- 
risy with  effusion.,  but  the  slow  course,  the  absence  of  fever,  and  the 
universal  hyper-resonance  that  characterize  emphysema  do  not  belong 
to  pleurisy.     The  latter  affection  yields  a  flat  percussion-note. 

Prognosis. — Hypertrophic  emphysema  of  acute  form  [e.  g.,  resulting 
from  whooping-cough)  is  often  curable  ;  but  the  usual  slowly  generated 
variety  gives  an  unfavorable  prognosis  as  to  recovery.  In  many  cases, 
however,  life  is  not  materially  shortened.  Temporary  improvement  is 
possible  when  the  lesion  consists  merely  of  a  distention  of  the  air-cells, 
and  is  shown  by  a  corresponding  improvement  in  the  physical  signs.  If 
the  vital  capacity,  as  shown  by  the  spirometer,  is  reduced  one-half  or 
more,  the  prospect  is  unfavorable.  Recurring  attacks  of  bronchitis  inten- 
sify the  symptoms  of  a  disease  that  is  innately  progressive.  Intercurrent 
affections,  such  as  pneumonia  (lobar  and  lobular)  and  pulmonary  tubercu- 
losis, may  prove  fatal.  Dropsy,  following  broken  compensation,  is  a 
dangerous  complication ;  other  late  accidents  are  hemoptysis  and  sudden 
dilatation  of  the  right  heart. 

Individual  circumstances,  such  as  the  patient's  social  condition,  the  stage 
of  the  affection  in  which  he  comes  under  proper  treatment,  and  the  degree 
of  care  he  is  willing  to  exercise,  greatly  influence  the  outcome  of  the  case. 


570  DISEASES  OF  THE  EESFIBATOBY  SYSTEM. 

Treatment. — The  treatment  is  to  be  directed  toward  the  removal 
of  the  causes  of  emphysema,  and  chieHy  of  the  chronic  bronchitis. 
From  personal  observation  1  am  tirmly  convinced  that  the  progress  of 
the  disease  can  be  arrested,  and  that  the  condition  is  sometimes  improved, 
by  relieving  the  chronic  bronchitis.  The  iodids  (potassium,  sodium,  and 
ammoniumj  at  times  produce  eftects  that  are  truly  remarkable.  If  not 
well  borne  by  the  stomach,  the  syrup  of  hydriodic  acid  may  be  employed. 
If  the  occupation  of  the  patient  tends  to  aggravate  the  disease,  it  must 
be  foi*saken  for  a  less  harmful  one.  Violent  paroxysms  of"  cough  and 
intercurrent  attacks  of  asthma  contribute  to  the  production  of  alveolar 
distention,  and  hence  must  be  alleviated  promptly  by  appropriate  ther- 
apeutic measures.  Attacks  of  acute  bronchitis  are  to  be  prevented  by 
suitable  clothing,  by  avoidance  of  exposure  to  inclement  Aveather,  dust, 
and  the  vitiated  atmosphere  of  overcrowded  halls,  churches,  and  the  like; 
whenever  practicable  the  result  can  be  most  successfully  obtained  l)y  a 
residence  in  an  ecjuable  climate.  Since  a  severe  bronchitis  is  apt  to  in- 
crease the  severity  of  the  emphysematous  symptoms,  it  must  be  relieved 
as  speedily  as  possible.  Passive  congestion,  flatulence,  and  constipation, 
with  other  gastro-intestinal  symptoms,  demand  careful  regulation  of  the 
diet  and  especially  a  restriction  in  the  use  of  carbohydrates.  The  bowels 
must  also  be  moved  regularly  with  the  same  end  in  view. 

The  heart  needs  to  be  carefully  watched,  and  as  soon  as  signs  of 
broken  compensation  appear  digitalis  and  strychnin  Avill  be  found  highly 
useful.  Diuretics  and  cathartics  may  also  become  necessary.  The  sud- 
den development  of  urgent  dyspnea  and  extreme  lividity,  especially  if 
associated  with  weak  cardiac  action  and  a  rapid,  feeble,  irregular  pulse, 
calls  for  free  bleedings.  In  my  hospital  practice  I  have  seen  the  lives 
of  patients  suffering  from  emphysema  saved  by  timely  venesection. 

To  assist  the  patient  in  expiration  Gerhardt  has  suggested  system- 
atic mechanical  compression  of  the  thorax  during  expiration.  Pressure  is 
made  by  an  attendant,  Avho  places  his  hands  flat  on  the  lower  lateral  por- 
tions of  the  thorax,  and  the  manipulation  is  to  be  continued  for  from  ten  to 
fifteen  minutes  daily.  The  results  obtained  by  certain  German  authors 
have  been  encouraging,  but  in  my  own  hands  the  method  has  failed,  ex- 
cept in  two  instances  occurring  in  young  adults  with  yielding  chest-walls, 
in  whom  it  was  of  the  greatest  service.  The  aim  should  be  to  strengthen 
the  muscles  of  the  diaphragm  by  prolonged  expiration,  supplemented  by 
drawing  in  the  abdominal  walls  as  the  act  of  expiration  draws  to  a  close 
— not  before.  The  p7ieumatic  treatment,  comprising  the  inhalation  of 
compressed  air  and  the  breathing  into  rarefied  air.  richly  deserves  further 
trial,^  its  use  having  been  productive  of  permanent  improvement  in  a 
number  of  cases,  as  shown  by  physical  examination  (including  mensura- 
tion).     Oxygen  by  inhalation  has  proved  serviceable. 


SENILE   EMPHYSEMA. 

This   variety  is  a  senile  atrophy  of  the  lungs,  and  has  been  appro- 
priately termed  "small-lunged  emphysema  "  by  Sir  Wni.  Jenner.     In 
consequence  of  the  complete  atrophy  of  the  alveolar  walls,  coalition  of 
the  air-cells  takes  place,  with  the  production  of  large  air-sacs.    The  lungs 
1  Waldenbergfs  portable  apparatus  is  not  convenient  for  use. 


QANQRENK  OF  TJf/<J  LUNGS.  571 

contain  less  than  the  normal  volume  of  air,  instead  of  an  abnormal  (juun- 
tity  as  in  hypertrophic  emphysema,  hence  occupy  less  space  in  the  che>t- 
cavity  than  do  healthy  lungs.  The  pulmonary  tissue  is  deeply  pigmented. 
The  condition  does  not  produce  right  ventricular  hypertrophy. 

The  symptoms  are  negative,  although  subjects  in  whom  senile  em- 
physema develops  may  have  previously  had  chronic  bronchitis  with 
more  or  less  dyspnea.  They  quite  frequently  present  a  withered  ap- 
pearance, and  the  chest  on  inspection  is  seen  to  be  contracted,  owing 
to  the  fact  that  the  ribs  approximate  more  closely  and  take  a  more 
oblique  direction  than  in  health. 

Treatment  is  unavailing. 


GANGRENE  OF  THE  LUNGS. 

Pathologfy. — The  affection  presents  itself  in  two  forms — as  a  (a) 
diffuse,  and  a  (b)  circumscribed  process. 

(a)  The  diffuse  variety  is  rare.  It  may,  however,  be  met  with  in 
lobar  pneumonia,  and  very  rarely  in  consequence  of  occlusion  of  the 
large  branch  of  the  pulmonary  artery ;  it  may  also  be  secondary  to  the 
circumscribed  form.  The  greater  part  of  the  lobe,  or  even  an  entire 
lung,  may  be  involved,  the  pulmonary  parenchyma  degenerating  into  a 
putrid,  greenish-black,  pulpy  mass,  with  no  obvious  line  of  demarcation. 

(b)  The  circumscribed  form  may  involve  either  one  or  both  lungs, 
though  the  right  is  affected  somewhat  oftener  than  the  left.  To  this 
category  belongs  the  so-called  embolic  gangrene,  the  nodules  of  which 
have  their  favorite  seat  in  close  proximity  to  the  pulmonary  pleura.  All 
etiologic  varieties  of  the  circumscribed  form  more  frequently  implicate 
the  lower  than  the  upper  lobe  of  the  lung,  occurring  in  sharply  defined 
areas,  which  may  either  be  single  or  multiple.  The  affected  area  first 
presents  a  greenish-brown  appearance ;  its  central  portion  soon  under- 
goes softening,  and  a  cavity  is  thus  formed  whose  walls  are  ragged  and 
irregular  and  contain  a  foul-smelling,  dark,  greenish  liquid.  The  sur- 
rounding lung  is  inflamed,  and  the  air-sacs  contain  inflammatory  prod- 
ucts (fibrin,  epithelium,  pus),  while  the  highly-irritating  and  putrid 
material  sets  up  an  intense  bronchitis.  These  gangrenous  foci  may  in- 
crease in  size  by  a  peripheral  extension,  and  thus  the  adjacent  veins 
may  become  plugged  Avith  infectious  thrombi  or  the  vessels  may  become 
eroded.  Emboli  may  then  be  detached  from  the  infectious  thrombi,  and, 
entering  the  circulation,  may  set  up  foci  of  septic  inflammation  in  re- 
mote organs.  A  truly  remarkable  connection  exists  between  circum- 
scribed gangrene  of  the  lung  and  cerebral  abscess.  When  the  gangren- 
ous spot  is  situated  near  the  pleura,  simple  or  gangrenous  pleurisy  may 
arise  as  a  complication,  or  the  pulmonary  pleura  may  be  perforated  and 
pyo-pneumothorax  result.  When  recovery  ensues  the  cavities  formed 
as  the  result  of  the  conversion  of  lung-tissue  present  a  limiting  wall  of 
dense  connective  tissue.  Such  cavities  may  remain  permanently  or  may 
slowly  become  contracted. 

Etiology. — Gangrene  of  the  lungs  is  caused  by  the  bacteria  of  putre- 
faction (probably  the  staphylococcus  albus  (^"^  aureus).     The  disease  is 


572  DISEASES-  OF  THE  RESPIRATORY  SYSTEM. 

rare.  It  is  onl}'  when  the  lung-tissue  has  become  impaired  or  peculiarly 
altered  that  the  specific  bacteria  are  capable  of  producing  gangrene.  It 
may  occur  in  several  "ways  : 

(1)  Secondary  to  lobar  pneumonia,  hemorrhagic  infarctions,  cavities 
in  the  lungs,  bronchiectasis,  wounds  of  the  lung,  contusions  of  the 
thorax,  carcinoma  of  the  esophagus,  or  to  compression  or  embolism  of 
the  pulmonary  artery  or  of  the  bronchial  vessels. 

(2)  By  lodgement  of  an  embolus,  derived  from  a  gangrenous  area  in 
distant  parts ;  this  form  is  common,  especially  in  children.  The  embolus 
is  often  the  result  of  otitis  media,  mastoiditis,  or  thrombosis  of  the  lateral 
sinus.     There  is  a  post-operative  gangrene  of  the  lungs. 

(3)  Pressure  from  a  thoracic  aneurysm  may  give  rise  to  gangrene. 

(4)  The  most  important  causal  factor,  however,  is  the  entrance  of 
foreign  bodies,  especially  bits  of  food,  into  the  bronchi  and  lungs. 
Whether  or  not  the  specific  bacteria  of  putrefaction  enter  the  lungs 
with  the  foreign  bodies,  the  latter  render  the  tissue-soil  receptive  to  the 
former,  and  once  the  process  has  been  initiated  it  is  apt  to  extend  itself. 
There  are  several  ways  in  which  these  foreign  particles  gain  entrance 
into  the  bronchi  and  lungs :  (a)  By  a  faulty  swallowing  of  the  food ;  (b) 
by  inhalation ;  (c)  by  a  carcinomatous  perforation  of  the  esophagus  into 
the  bronchus  or  into  the  lung. 

(5)  In  debilitated  states  of  the  system,  as  during  convalescence  from 
protracted  fever  (rarely),  and  in  diabetes  mellitus  (frequently). 

Symptoms. — These  are  local  and  general. 

Local  Symptoms. — There  is  severe  cough,  which  is  accompanied  by  an 
exceedingly  fetid  expectoration  that  is  usually  quite  profuse.  When 
abundant,  and  when  expectorated  into  a  conical  glass  and  allowed  to  stand 
for  a  time,  it  separates  into  three  layers :  (a)  the  uppermost,  being 
frothy,  opaque,  and  of  a  grayish-yellow  color ;  (6)  the  middle,  clear 
and  watery ;  and  (c)  the  lowest,  appearing  as  a  greenish-brown  sedi- 
mentary layer  containing  shreds  of  lung-tissue  and  sometimes  blood. 
The  microscope  shows  it  to  consist  of  numerous  elastic  fibers,  bacteria, 
fat-crystals,  muco-pus,  granular  matter,  and  leptothrices.  Small  quan- 
tities of  blood  in  the  sputum  are  very  common.  Kannenburg  and  Streng 
have  also  described  ciliated  monads  as  occurring  in  the  sputum.  The 
patient's  breath  is,  as  a  rule,  intensely  fetid,  even  though  there  be  no 
expectoration,  but  this  fetor  of  breath  may  be  absent,  as  in  a  case  of  my 
own  (which  came  to  autopsy),  in  which  the  localized  gangrenous  process 
had  no  fistulous  connection  with  the  bronchus.  If  any  of  the  large 
branches  of  the  pulmonary  artery  be  eroded,  free  and  even  fatal  hemop- 
tysis will  result.  Pain  in  the  chest  is  complained  of  when  the  lesions 
are  superficially  situated. 

Physical  Signs. — The  physical  signs  are  sometimes  obscure,  as  when 
the  areas  involved  are  smaller  and  deeply  situated,  and  in  such  instances 
signs  of  bronchitis  only  may  be  detectable.  When  large  and  favorably 
situated,  however,  the  affected  spots  usually  give  signs  of  consolidation, 
rapidly  followed  by  those  of  cavity.  In  addition  bronchial  rales — usually 
moist — and  coarse  cavernous  r^les  are  usually  audible.  It  is  obvious 
that  when  the  pleura  is  implicated  the  signs  of  pleurisy  are  added,  and 
if  pneumothorax  be  present  those  belonging  to  the  latter  condition  also. 

The  chief  general    symptoms    are  irregular  fever,   emaciation,   and 


ABSCESS  OF  THE  LUNGS.  573 

profound  prostration.  Leukocytosis  is  found.  A  septic  condition  of  the 
system  is  coinraonly  developed,  and  the  patient  sinks  from  exiiaiistion. 
The  serious  general  features  may  overshadow  the  local  in  the  lungs. 
Rarely  there  may  be  an  almost  total  absence  of  constitutional  disturb- 
ances, and  such  instances  terminate  in  recovery. 

Diagnosis. — The  distinctive  feature  is  fetidity,  both  of  the  sputum 
and  the  breath.  The  physical  signs  may  readily  determine  tlie  existence 
of  the  pulmonary  lesion,  but  it  is  difficult  to  eliminate  abscess  'dud  fetid 
bronchitis  associated  with  bronchiectasis.  The  results  of  a  careful  exam- 
ination of  the  sputum,  together  with  the  less  horribly  fetid  odor  of  the 
breath,  in  abscess  will  usually  suffice  to  eliminate  the  latter  affection.  In 
fetid  bronchitis  the  fetor  of  the  breath  and  sputum  is  less  marked,  while 
its  course  is  slower  and  more  favorable  than  in  gangrene. 

Prognosis. — The  prognosis  is  always  grave,  though  rarely  recovery 
in  circumscribed  gangrene  of  the  lungs  ensues.  The  chief  dangers  are 
exhaustion  and  hemorrhage.  Improved  methods  of  surgical  treatment, 
however,  have  saved  life  in  a  few  instances,  and  promise  to  reduce  still 
further  the  mortality-rate  of  this  serious  affection. 

Treatment. — The  leading  indications  are — 

(a)  The  disinfection  of  the  gangrenous  focus  or  foci  in  the  lungs. 
This  may  be  accomplished  by  the  internal  administration  of  creasote  or 
carbolic  acid  or  by  the  use  oi  an  antiseptic  spray. 

(6)  The  patient's  nutrition  must  be  maintained,  if  possible,  by  a  con- 
centrated liquid  diet,  administered  in  fixed  quantities  and  at  regular 
intervals;  also  by  the  judicious  cultivation  of  the  digestive  functions, 
together  with  the  use  of  stimulants  and  tonics.  Morphin  is  indispensable 
for  the  cough,  which  would  otherwise  rapidly  induce  exhaustion.  Traube 
suggests  lead  acetate  when  the  sputum  contains  blood.  For  a  description 
of  the  surgical  treatment  of  gangrenous  cavities  of  the  lungs  the  reader  is 
referred  to  special  works  on  surgery.  It  is  the  physician's  duty,  however, 
to  determine  whether  or  not  the  patient's  general  condition  will  admit  of 
surgical  intervention,  and  also  to  localize  as  nearly  as  may  be  the  affected 
zones  for  the  surgeon's  guidance. 


ABSCESS  OF  THE  LUNGS. 

{Suppurative  Pneumonitis.) 

Pathology. — This  affection  is  characterized  by  the  formation  of 
pus  and  the  degeneration  of  lung-tissue.  It  may  be  (a)  a  mere  infiltra- 
tion of  the  blood-vessels,  bronchi,  or  interstitial  tissue,  but  more  fre- 
quently is  seen  as  (b)  an  ordinary  abscess.  In  size  the  abscesses  range 
from  that  of  a  walnut  to  an  apple,  and  I  have  observed  in  one  case  in- 
flammation of  the  whole  of  the  middle  lobe  of  the  right  lung.  The 
abscess-walls  are  irregular  and  decidedly  ragged ;  and  in  the  case  of  old 
lesions  there  is  a  dense  fibrous  wall ;  the  contents  are  purulent  and  rarely 
necrotic.  The  most  common  seat  ("  80  per  cent.")  is  in  the  lower  lobes. 
If  the  contour  of  an  abscess  touches  the  pleura,  empyema  is  the  result. 
Rupture  of  the  abscess  into  the  pleura  may  also  occur. 


574  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

^Etiology. — Streptococci  are  found,  though  they  are  not  the 
only  direct  causes  of  abscess  of  the  lung.  The  diplococcus  pneumo- 
niae and  Friedlanders  bacillus  have  been  found,  as  well  as  certain  other 
organisms.  Predisposition  is  noted  in  certain  conditions,  as  (1)  during 
or  following  the  occurrence  of  inflammation,  as  in  lobar  and  lobular 
pneumonia.  Suppurative  infiltration,  however,  more  frequently  arises 
under  these  circumstances  than  abscess,  and  in  the  rare  instances  in 
which  the  latter  occurs  it  is  apt  to  be  comparatively  small  and  multiple. 
In  all  forms  of  inhalation  and  deglutition  broncho-pneumonia,  hoAvever, 
abscess  of  the  lung  is  a  fre((uent  sequela. 

(2)  Perforation  of  the  lung  from  without  or  from  adjacent  organs, 
e.  (J.,  esophageal  carcinoma,  hepatic  abscess,  or  suppurating  hydatid  cyst. 

(3)  Infectious  emboli,  found  in  connection  with  septico-pyemia,  fre- 
quently cause  metastatic  abscesses  in  the  lungs.  In  a  mechanical  manner 
they  may  produce  hemorrhagic  infarctions,  followed  by  suppuration,  or 
the  latter  process  may  occur  independently  of  the  former.  The  abscesses 
are  usually  situated  close  to  the  pleura,  and  are  frequently  wedge-shaped  ; 
they  vary  in  number  from  one  to  several  hundred,  and  in  size  from  a 
pin's  head  to  an  orange. 

(4)  Inward  extension  of  a  purulent  pleurisy. 

(5)  As  elsewhere  stated  {vide  Pulmonary  Tuberculosis),  suppuration 
is  quite  generally  associated  with  chronic  pulmonary  tuberculosis. 

Symptoms  and  Diagnosis. — The  examination  of  the  sputum  is 
of  the  greatest  value  in  the  diagnosis  of  this  disease,  since,  being  puru- 
lent, it  usually  presents  a  yellow,  or  less  frequently  a  greenish-  or 
brownish-yellow,  color.  It  emits  a  fetor  that  is  less  pronounced  than 
that  of  either  gangrene  or  putrid  bronchitis.  Particles  of  lung-tissue 
may  be  visible  in  the  pus,  and  on  microscopic  examination  of  the  latter, 
elastic  fibers,  the  presence  of  which  is  of  the  utmost  importance  in  the 
diagnosis,  may  be  found  in  profusion.  The  physical  signs  of  cavity  are 
of  the  greatest  assistance  in  distinguishing  abscess  of  the  lung  ;  these, 
however,  are  wanting  unless  the  abscess  is  of  a  considerable  size.  Thq, 
signs  of  cavitation,  together  with  the  characteristic  sputum,  leave  no  room 
for  doubt.  Chills  and  suppurative  fever  often  attend.  Leukocytosis  is 
present.  The  history  is  of  considerable  importance,  as  confirming  the 
more  characteristic  features.  Thus  antecedent  pneumonia  or  septicopyemia 
would  be  strongly  corroborative.  Tuberculosis  distinguishes  itself  by  the 
history,  the  diminished  amount  of  pus  present,  and  the  sputum  test. 

Prognosis. — The  prognosis  is  often  hopeless,  as,  for  example,  when 
the  disease  is  associated  with  pyemic  processes  in  other  parts  of  the  body. 
On  the  other  hand,  those  rare  instances  in  which  it  is  secondary  to 
pneumonia  give  a  comparatively  favorable  outlook. 

Treatment. — The  chief  aim  in  the  therapeusis  should  be  to  support 
the  system  by  the  administration  of  tonics,  stimulants,  and  antiseptics,  as 
well  as  by  energetic  feeding  Avith  light  forms  of  nourishment.  Inhalation 
of  antiseptic  sprays  (phenol,  creosote,  thymol)  should  be  tried.  When 
the  abscess  is  situated  near  the  periphery  of  the  lung,  surgical  interfer- 
ence is  to  be  advised  as  soon  as  the  first  indications  of  increasing  weak- 
ness appear.  Pulmonary  abscess  occurring  as  a  sequel  of  pneumonia 
with  free  expectoration  should  receive  an  expectant  treatment,  unless 
it  tend  to  become  progressive,  when  it  calls  for  operative  intervention. 
For  the  details  of  the  operation  of  pneumonotomy  for  pulmonary  abscess 


PNEUMONOKONIOSIS.  575 

the  reader  is  referred  to  works  on  surgery.  Tlie  statistics  of  Eisendratli,' 
relating  to  abscess  following  pneumonia,  may,  however,  be  rri(;ntione(l.  as 
follows :  of  25  cases  of  acute  simple  abscess,  24  recovered  and  1  w  as  im- 
proved ;  in  chronic  abscess  the  results  were  much  less  favorable. 


PNEUMONOKONIOSIS. 

(Anthracosis,  ChaUcosis,  etc.) 

Definition. — A  form  of  chronic  interstitial  pneumonia  that  arises 
from  the  inhalation  of  dust-like  particles.  Different  terms  have  been 
applied  to  the  condition  according  to  the  nature  of  the  dusts  inhaled, 
the  chief  among  these  being — (1)  Anthracosis  (coal-miners'  disease), 
due  to  the  inhalation  of  coal-dust ;  (2)  Chalicosis  (stone-cutters'  phthi- 
sis), caused  by  the  inhalation  of  mineral  dusts;  and  (3)  Siderosis, 
caused  by  inhaling  metallic  particles,  particularly  iron  oxid. 

(1)  Anthracosis. — Among  dwellers  in  cities  a  moderate  degree  of 
pigmentation  of  the  lung-tissue  with  coal-dust  is  the  rule,  while  in  those 
residing  in  rural  districts  the  condition  is  decidedly  less  common.  True 
anthracosis,  however,  has  reference  to  such  an  accumulation  of  the  car- 
bon particles  as  can  be  due  only  to  the  inhalation  of  a  well-laden  atmo- 
sphere, or  under  other  circumstances  e.  g.,  when  the  mucous  membrane  is 
unhealthy  or  without  perfect  ciliary  action.  Under  such  conditions  the 
normal  scavengers  of  the  respiratory  organs — the  mucous  corpuscles 
lining  the  trachea,  the  bronchi,  and  the  alveolar  cells — fail  to  deal  suc- 
cessfully with  the  numerous  dust-particles  that  gain  entrance  along  with 
the  inspired  air ;  hence  some  of  the  latter  pierce  the  mucosa  and  I'each 
the  lymph-spaces  and  lymph-vessels.  Here  they  are  taken  up  by  the 
leukocytes  and  are  conveyed  to  a  more  remote  destination.  Arnold 
shows  that  after  the  pai'ticles  enter  the  lymph-system  they  are  carried 
"  (a)  to  the  lymph-nodules  surrounding  the  bronchi  and  blood-vessels ; 
(6)  to  the  interlobular  septa  beneath  the  pleura,  where  they  lodge  in  and 
between  the  tissue-elements ;  and  (c)  along  the  larger  lymph-channels  to 
the  substernal,  bronchial,  and  tracheal  glands,  in  which  the  stroma-cells 
in  the  follicular  cord  dispose  of  them  permanently,"  with  resulting  indu- 
rative enlargement  of  these  structures.  Rarely  the  carbon  particles  may 
find  their  way  into  the  general  circulation ;  this  may  occur,  as  shown  by 
Weigert,  when  the  pigmented  bronchial  glands  become  adherent  to  the 
pulmonary  veins.  Petit  ^  claims  that  anthracosis  may  be  of  intestinal 
origin  in  cases  in  which  the  mesenteric  barrier  has  already  been  broken 
down  by  tuberculosis. 

Anthracosis  leads,  primarily,  to  chronic  bronchitis,  to  be  soon  fol- 
lowed by  emphysema ;  but  extensive  anthracosis  may  be  present  without 
any  other  changes  in  the  lung  than  the  presence  of  cai'bon  particles 
stored  in  the  protoplasmic  cells.  The  lung-tissue  presents  great  varia- 
tions in  its  degree  of  susceptibility  to  these  foreign  particles.  Sooner  or 
later  there  is  usually  produced,  as  the  result  of  their  irritant  action.^  a 

1  Phda.  Med.  Jour.,  Nov.  9,  1901. 

'  La  Presse  MMieale. 

'Cohnheim  contends  that  coal  particles  do  not  produce  irritative  changes  inthe 
lung,  and  that  the  latter  are  due  to  irritating  substances  inhaled  with  the  particles 
of  ooal. 


576  DISEASES  OF  THE  RESPIBATORY  SYSTEM. 

proliteratiou  of  the  connective-tissue  elements — i.  e.,  a  chronic  interstitial 
inflammation.  This  fibroid  change  usually  starts  in  the  peribronchial 
lymph-structures,  though  the  bronchial  and  tracheal  glands  are,  as  a  rule, 
similarly  involved  at  a  comparatively  early  period.  The  aflected  lung- 
tissue  is  frequently  coal-black,  dense,  and  airless.  The  pneumcnoko- 
iiiotic  areas  vary  greatly  in  size  and  numbers,  and  not  infrequently 
coalesce,  in  which  case  large  portions  of  the  lung-tissue  may  become  the 
seat  of  fibroid  change.  The  alveolar  walls  are  much  thickened  in  some 
instances,  and  firm  pleuritic  adhesions  exist.  Bronchiectatic  cavities 
may  be  present,  and  later  necrotic  softening  of  the  indurated  areas  occurs, 
leading  to  the  formation  of  small  cavities  that  contain  a  dark  fluid.  When 
the  latter  communicate  with  the  bronchi  their  walls  are  prone  to  ulcerate. 
I  have  noticed  that  the  process  almost  invariably  terminates  in  pulmonary 
tuberculosis,  and  particularly  is  this  true  of  cases  that  follow  the  inhala- 
tion of  mineral  and  vegetable  dusts  {vide  infra). 

(2)  Chalicosis. — Changes  similar  to  those  previously  described  are  in- 
duced in  the  pulmonary  connective  tissue  by  the  inhalation  of  stone-dust 
by  those  who  follow  such  occupations  as  stone-cutting,  knife-  and  axe- 
grinding,  and  millstone-making.  The  irritating  properties  of  this  form 
of  dust  are  proved  by  the  great  disposition  in  this  subvariety  of  pneumo- 
nokoniosis  to  the  formation  of  fibrous  nodules  and  diffuse  areas  of  sclerosis 
in  the  lungs.  The  nodules  have  a  gray  center  and  a  darker  periphery  ; 
they  are  exceedingly  dense,  and  sections  are  made  with  much  difficulty. 

(3)  Siderosis. — This  term  implies  a  collection  of  iron  oxid  in  the 
lungs,  also  due  to  the  pursuit  of  certain  occupations  (dyeing,  iron- 
smithing,  etc.).  Cases  of  much  the  same  nature  are  caused  by  the  in- 
halation of  vegetable  dusts  by  grain-shovellers,  cotton-spinners,  cigar- 
makers,  etc.  The  pathologic  changes  are  identical  with  those  in  anthra- 
cosis,  though  the  color-appearance  is  red  instead  of  black. 

Symptoms. — Rarely  the  07iset  is  marked  by  the  symptoms  of  acute, 
followed  by  those  of  chronic,  bronchitis  ;  but  in  a  vast  majority  of  in- 
stances chronic  bronchitis  gradually  develops  after  long  exposure  to  the 
action  of  the  exciting  cause.  The  symptoms  of  emphysema  are  soon 
superadded,  the  patient  now  suff'ering  from  dyspnea,  and  less  frequently 
from  asthma.  The  sputum  is  diagnostic  in  anthracosis.  being  quite 
dark ;  in  chalicosis  a  microscopic  examination  is  essential  to  show  the 
particles  of  silica ;  while  in  siderosis  the  expectoration  presents  a  red- 
dish color.  Apart  from  the  foreign  particles,  the  sputum  is  for  a  long 
period  of  years  muco-purulent  in  character,  and  later  it  often  contains 
the  tubercle  bacillus. 

The  physical  signs  are  not  distinctive,  being  identical  with  those  met 
with  in  chronic  bronchitis  associated  with  emphysema,  and  followed  by 
those  of  interstitial  pneumonia,  and  sometimes  by  those  of  cavity. 

The  diagnosis  is  to  be  made  both  from  the  history  and  from  a  gross 
or  microscopic  examination  of  the  sputum.  It  may  be  confirmed  by  the 
invariable  presence  of  the  signs  of  bronchitis  and  emphysema,  as  well 
as  by  the  efi'ect  of  removal  to  an  atmosphere  free  from  dust.  In  the 
later  stages  the  detection  of  infallible  evidences  of  phthisis  only  serves 
to  corroborate  the  earlier  diagnosis  of  pneumonokoniosis. 

An  acute  pneumonokoniosis.,  due  to  the  inhalation  of  Thomas  phos- 
phate meal,  has  been  described.     This  dust  causes  a  diff'use  pneumonic 


CARCINOMA   OF  THE  LUNG.  Till 

inflammation  affecting  principally  the  lower  lobes.  The  symptoms  and 
progress  of  the  cases  are  like  tliose  of  lobar  pneumonia. 

The  prognosis  is  favorable  in  hygienic  surroundings  until  the  more 
advanced  stage  is  reached.  The  condition  favors  the  invasion  of  new- 
growths  (lympho-sarcoma,  or  cobalt-miners'  disease;  vide  infra). 

Treatment. — A  change  of  occupation  or  several  hours  of  exercise 
in  the  open  air  daily  for  those  who  are  exposed  to  dust  in  work-rooms 
should  be  advocated.     Dusty  work-rooms  must  be  properly  ventilated. 

The  active  treatment  is  the  same  as  for  chronic  bronchitis  and  em- 
physema from  other  causes,  and  is  to  be  appropriately  modified  when 
pulmonary  tuberculosis  develops. 


NEW  GROWTHS  OF  THE  LUNGS. 

CARCINOMA    OF   THE   LUNG. 

All  varieties  of  carcinoma  have  been  met  with  in  the  lung,  but,  with 
rare  exceptions,  carcinoma  of  this  organ  is  of  secondary  origin.  Ordi- 
narily the  primary  new  growth  involves  a  vein  or  lymph-channel,  and 
the  latter  carries  the  germ  of  the  disease  to  the  lung.  It  is  also  to  be 
recollected  that  it  may  result  from  extension,  or  by  contiguity  from 
neighboring  organs  (as  the  esophagus,  mamma,  pleura,  or  mediastinum). 

Ktiology. — The  causes  of  primary  carcinoma  of  the  lung  must  be, 
in  the  main,  identical  with  those  of  carcinoma  in  general,  and  are  as  yet 
unknown.  Most  cases  occur  in  middle-aged  persons,  and,  while  sex  has 
an  influence  upon  the  appearance  of  the  primary  form  of  the  disease,  it 
occurring  much  oftener  in  males,  especially  those  exposed  to  the  vapors 
of  arsenic,  the  secondary  form  is  more  frequent  in  the  female  than  in  the 
male.  In  the  female,  secondary  carcinoma  of  the  lung  is  often  preceded 
by  carcinoma  of  the  breast.  We  may  also  regard  hereditary  influence 
as  a  potent  predisposing  factor.  Secondary  carcinoma  of  the  lung  is 
most  commonly  consecutive  to  primary  carcinoma  of  the  bones,  and  of 
the  digestive  and  urinary  tracts. 

Pathology. — The  pathologic  varieties  of  the  primary  form  are 
scirrhous,  encephaloid,  and  epithelioma,  and  of  these  the  latter  is  the 
most  common.  Primary  carcinoma  is  usually  unilateral,  the  tumors 
attaining  to  a  massive  size  and  frequently  involving  the  greater  part  of 
one  lung.  Their  favorite  seat  is  in  the  upper  part  of  the  right  lung. 
Henri ci  claims  that  most  cases  have  their  origin  in  the  bronchial  epithe- 
lium. Extension  to  the  pleura  occurs  quite  often.  Less  frequently  there  is 
pleurisy  with  sero-fibrinous  exudate,  which  may  be  hemorrhagic.  Carcin- 
omatous involvement  of  the  cervical,  bronchial,  and  tracheal  lymph-glands 
is  quite  usual,  and  rarely  even  the  inguinal  glands  become  implicated. 
Secondary  carcinomata  are,  as  a  rule,  multiple,  and  may  be  miliary  in 
size.  They  are  disseminated  widely  throughout  both  lungs,  though  in 
the  rarest  instances  they  may  be  unilateral.  In  the  softer  varieties  the 
central  portion  of  the  tumor-mass  may  undergo  fatty  degeneration,  with 
subsequent  discharge  through  adjacent  bronchi. 

Symptoms. — The  symptoms  vary  according  to  the  location  and 
extent  of  the  disease.  Among  the  most  marked  symptoms  belongs  pain. 
particularly  when  the  pleura  is  implicated.  As  a  rule,  for  a  considerable 
period  of  time  the  symptoms  of  bronchitis  obtain,  and  later  the  breathing- 


578  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

space  is  diminislicd  sufficiently  to  excite  dyspnea  and  cyanosis.  With 
the  increase  in  size  of  the  new  growth  compression  of  the  heart,  aorta, 
and  large  veins  may  result,  whereupon  disturbances  of  the  circulation 
will  arise.  The  new  growth  may  exert  pressure  on  the  esophagus,  causing 
dysphagia  ;  or  upon  the  recurrent  laryngeal  nerve,  causing  aphonia  and 
hoarseness  :  or  on  the  tracheii  or  a  main  bronchus,  followed  by  the  symp- 
toms of  stenosis  of  those  organs.  There  are  cow/h  and  expectoration,  the 
latter  frequently  containing  blood-corpuscles  witii  mucus,  and  resembling 
in  appearance  currant-jelly  ;  the  sputa  may  also  rarely  exhibit  a  grass- 
green  color,  due  to  transformation  of  the  blood-pigment.  In  carcinoma- 
tous lungs  putrefactive  changes  sometimes  take  place,  and  if  so  the 
expectoration  and  breath  emit  an  offensive  odor,  while  a  microscopic  ex- 
amination of  the  sputum  frequently  discloses  the  presence  of  carcino- 
matous elements.  A  leukocytosis,  usually  of  moderate  degree,  may  be 
present.      The  well-known  cancerous  cachexia  invariably  develops. 

Physical  Signs. — These  Avill  naturally  depend  upon  the  extent  and 
location  of  the  new  growth.  Inspection. — If  the  lung-tissue  be  exten- 
sively involved,  the  walls  of  the  thorax  become  unduly  prominent  and 
fixed  over  the  seat  of  the  tumor.  Indeed,  the  tumor  may,  though  rarely, 
protrude  between  the  ribs.  The  intercostal  spaces  are  widened,  and  the 
superficial  veins,  in  view  of  the  fact  that  they  cannot  empty  themselves 
into  the  internal  veins,  appear  engorged ;  from  the  same  cause  edema 
afi"ecting  the  thorax,  neck,  face,  and  arms  may  be  noted.  Swelling  of 
the  lymph-glands  in  the  neck  or  axilla  is  an  important  sign.  On 
palpation  the  tactile  fremitus  may  be  diminished  or  absent.  The 
percussion-note  will  be  flat,  since  the  air-vesicles  and  smaller  bronchi 
are  replaced  by  the  solid  growth.  On  auscultation  friction-sounds 
are  the  rule.  The  respiratory  sounds  may  be  greatly  enfeebled  or 
absent ;  but  if  the  carcinomatous  tumor  communicates  with  a  wide- 
mouthed  bronchus,  bronchial  breathing  may  be  audible,  and  the  phys- 
ical signs  of  lung-cavity  may  be  developed.  The  signs  of  general 
bronchitis  are  present  in  most  instances,  especially  in  the  disseminated 
form  of  the  disease ;  in  the  latter  the  lung  may  shrink,  with  retraction 
of  the  chest-walls  on  the  affected  side.  If  secondary  pleurisy  with 
effusion  occurs,  the  detection  of  the  characteristic  cancer-cells  in  the  con- 
tents of  the  pleural  cavity  will  show  the  nature  of  the  thoracic  affection. 

Diagnosis. — The  following  symptom-group  will  pretty  well  establish 
a  diagnosis  :  A  peculiarly  shaped  dull  area  (as  when  it  extends  under  the 
sternum),  perhaps  a  marked  prominence  over  the  site  of  the  tumor, 
enlarged  and  hard  lymphatic  glands  in  the  vicinage,  and  certain  of  the 
compression-symptoms  —  circulatory,  nervous,  bronchial,  or  tracheal. 
Rarely  the  diagnosis  may  be  made  by  the  occurrence  of  metastasis  to  the 
chest-wall.  Again,  the  discovery  of  cancer  tissue  in  masses  accidentally 
detached  gives  reliable  indication  of  the  disease.  An  exact  diagnosis  can 
often  be  made  from  an  examination  of  the  particles  obtained  on  aspiration 
of  the  tumor  and  ])leural  effusion. 

The  differential  diagnosis  between  pulmonary  carcinoma  and  pulmo- 
nary tuberculosis  can  be  made  Avith  positiveness  only  by  a  careful  micro- 
scopic examination  of  the  sputum.  From  fibroid  induration  of  the  lung 
it  is  easily  discriminated,  owing  to  the  history  and  slower  course  of  the 
latter  affection. 


iJYi)ATrr>  (,'YST  OF  Tiii<:  iJJNa.  570 

Prognosis. — This  is  })a(l,  as  deatli  may  occur  suddenly  from  altun- 
dant  hemorrhage  or  more  frequently  from  eitlicr  exhaustion  or  asphyxia. 
The  duration  of  the  affection  varies  from  six  months  to  a  year  or  more. 

Treatment. — The  treatment  must  be  addressed  chiefly  to  the  relief 
of  pain  and  other  subjective  symptoms,  though  the  effect  of  the  x-ray 
should  be  tried. 

SARCOMA   OP    THE    LUNG. 

Primary  sarcoma  of  the  lung  is  rare,  but  in  instances  of  generalized 
sarcomatosis  the  lungs  show  larger  or  smaller  nodules  "in  almost  every 
case  "  (Birch-Hirschfeld),  occurring  in  connection  with  osteo-sarcoma 
of  other  organs  or  in  lympho-sarcoma  of  the  cervical  glands. 

Secondary  sarcoma  of  the  root  of  the  lung  by  sarcomatous  disease  of 
the  post-bronchial  glands,  is  more  common  than  secondary  carcinoma. 
The  diagnosis  is  reached  as  in  carcinoma  {vide  p.  578). 

Neoplasms  occurring  among  the  cobalt-miners  of  Schneeberg  were 
described  by  Hesse  and  Tragner  as  lympho-sarcomata — slowly  growing 
masses  that  attained  to  a  large  size  and  gave  metastasis  to  lymph-glands, 
pleura,  liver,  and  spleen.  In  most  cases  there  was  an  associated  pneu- 
monokoniosis,  which  had  probably  predisposed  to  the  new  growth. 

HYDATID  CYST  OF  THE  LUNG. 

Hydatids  in  the  lungs  may  either  be  primary  or  secondary,  the  former 
variety  being  exceedingly  rare  and  the  latter  somewhat  less  so.  Almost 
invariably  the  echinococci  are  developed  in  other  organs — the  liver  in 
particular — and  find  their  way  to  the  lungs,  either  by  direct  perforation 
through  the  diaphragm  or  by  entering  through  the  blood-current.  The 
lungs  are  involved  in  about  12  per  cent,  of  hydatid  disease. 

For  etiology  and  pathology  see  Hydatid  Cysts  of  the  Liver. 

Symptoms. — The  clinical  manifestations  are  quite  varied,  even 
though  the  cyst  may  entirely  conceal  itself.  It  is  important  to  recollect 
that  similar  involvement  of  the  liver  usually  coexists  ;  and  in  addition 
to  the  symptoms  of  the  latter  affection  there  may  be  pain  in  the  chest, 
dyspnea,  considerable  cough,  and,  rarely,  blood-stained  expectoration. 
General  weakness  and  emaciation  may  attend  the  more  advanced  stages. 

The  physical  signs,  when  present,  are  as  follows  :  Diminished  vocal 
fremitus,  defective  expansion,  dulness  on  percussion  with  an  absence  of 
the  respiratory  murmur — all  signs  pointing  to  pleural  effusion.  The 
cysts  are  more  common  in  the  right  lung  and  frequently  cause  marked 
bulging  over  the  base.  Later  signs  of  cavity-formation  may  appear. 
In  other  cases,  the  signs  of  consolidation  may  preponderate. 

A  positive  diagnosis  of  hydatid  cyst  of  the  lung  can  be  made 
only  when  the  scolices,  pieces  of  membrane,  or  the  booklets  of  the 
echinococcus  are  demonstrable  either  in  the  sputum  or  the  aspirated  fluid. 
Besides  being  evacuated  into  the  bronchi,  the  cysts  may  rupture  into  the 
adjacent  serous  sacs  (pleura,  pericardium),  or  externally,  the  latter  being 
the  most  favorable  termination.  Unless  they  are  discharged  by  ulcera- 
tion into  the  bronchi  or  externally,  they  are  apt  to  excite  inflammation 
of  the  adjacent  lung-tissue  and  tubes,  accompanied  by  an  active  febrile 
movement  and  an  aggravation  of  the  aforementioned  symptoms :  these 


580  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

complications  (pneumonia,  gangrene)  may  assume  a  dangerous  form,  or 
the  patient  may,  if  the  growth  becomes  large,  become  asphyxiated. 
From  (/ang)'c)ie,  pleitrisi/,  and  phthisis  echinococci  are  distinguished  by 
the  sputum-test  or  by  an  examination  of  the  aspirated  fluid. 

Prognosis. — The  affection  is  always  attended  with  great  danger, 
and  is  of  more  serious  import  when  secondary  to  involvement  of  the 
liver  than  when  primary. 

Treatment. — When  it  can  be  shown  that  the  growths  are  situated 
at  the  periphery  of  the  lung  operation  should  be  carefully  considered. 
The  physician  stands  powerless  to  do  more  than  to  relieve  urgent  symp- 
toms in  special  cases  and  to  support  the  vital  functions. 


V.    DISEASES   OF  THE   PLEURA. 
PLEURISY. 

(Pleuritis.) 

Definition. — An  inflammation,  either  local  or  general,  of  one  or 
both  pleural  membranes.  The  disease,  as  shown  by  postmortem  exam- 
inations, is  of  great  frequency. 

Varieties. — Pleurisy  has  been  variously  classified.  Etiologically, 
the  distinction  between  primary  and  secondary  forms  of  the  disease 
should  be  made,  as  well  as  a  division  into  tuberculous,  carcinomatous, 
septic,  etc.  Pathologically^  all  cases  may  be  summarized  under  the 
following  heads  :  Localized  and  generalized  and  dry  (plastic)  pleurisy 
and  pleurisy  with  efiusion  (sero-fibrinous,  purulent,  hemorrhagic).  They 
may  also  be  classified  according  to  their  duration  into  acute,  subacute, 
and  chronic  pleurisies.  I  shall  describe  the  following  forms,  which  are 
based  partly  upon  their  etiology  and  clinical  course,  though  mainly 
upon  their  pathologic  manifestations — viz.  {a)  acute  plastic  pleurisy ;  {h) 
sero-fibrinous  pleurisy;  (c)  purulent  pleurisy  (empyema);  and  (d) 
chronic  adhesive  pleurisy. 

Bacteriology. — In  all  forms  of  the  disease  the  direct  causes  are 
various  micro-organisms  or  their  irritating  chemical  products.  Con- 
spicuous among  these  is  the  bacillus  of  tuberculosis.  Inoculation  of 
guinea-pigs  with  the  latter  by  Eichhorst  gave  positive  results  in  15  out 
of  23  cases,  and  by  La  Damany  in  47  out  of  55  cases.  By  taking  a 
large  amount  of  exudate  either  for  cultures  or  inoculation  of  animals, 
the  bacillus  tuberculosis  can  be  found,  as  a  laile.  Netter.  Prudden,  and 
others  have  found  in  the  exudation  of  fibrino-serous  plemrisy  the  strepto- 
coccus pyogeties,  the  staphylococcus,  the  typhoid  bacillus,  and  the  diplo- 
coccus  of  pneumonia.  The  micro-organisms  most  commonly  present  in 
empyema  are  the  micrococcus  lanceolatus  and  the  streptococcus,  the  for- 
mer especially  in  the  pleurisy  associated  with  pneumonia  (in  two-thirds  of 
the  cases  occurring  in  children — Levy),  and  the  latter  in  those  indepen- 
dent of  pneumonia,  particularly  in  adults.  Amoni:  other  bacteria  that 
have  been  found  rarely  in  the  effusion  are  the  colo7i  bacillus,  the  proteus 


ACUTE  PLASTTC  PLEURISY.  581 

vulgaris,  the  gonoco<;cuH,  the  aineba  coli,  I^Vledlanders  haciUus,  anthrax 
hacillus,  influenza  bacillus,  and  various  saprophytic  bacteria.  Except  in 
the  case  of  the  pleuritic  exudation  in  pneumonia,  in  which  the  diphjcoccus 
is  alone  present  in  about  one-half  of  the  cases,  the  afore-jnentioned  micro- 
organisms are  generally  found  in  association. 

ACUTE    PLASTIC   PLEURISY. 
{Dry,  Fibrinous  Pleuri.ij/.) 

Pathology. — The  lesions  are  usually  circumscribed,  the  part  in- 
flamed being  intensely  injected.  It  has  lost  its  natural  lustre,  and 
instead  has  a  dull,  non-glistening  surface  "like  a  tarnished  mirror," 
due  to  a  slight  fibrinous  exudate.  Minute  ecchymoses  are  seen.  Later 
the  exudate  may  become  more  copious,  when  the  pleura  presents  a  rough, 
shaggy  appearance.  On  account  of  the  friction  between  the  two  pleural 
membranes  in  high  grades  of  dry  plastic  pleurisy,  the  exudate  may  be 
very  thick,  and  its  color-appearance  is  then  yellowish-  or  reddish-gray. 
This  sheeting  of  fibrinous  exudate  entangles  in  its  meshes  numerous  em- 
bryonic round  cells,  out  of  which  blood-vessels  and  connective  tissue  are 
developed.  The  opposing  surfaces  of  the  pleura  adhere.  Occasionally, 
in  the  lighter  grades,  the  disease  does  not  advance  to  firm  adhesion,  and 
in  such  instances  the  products  of  the  exudate  undergo  fatty  degeneration 
and  are  absorbed. 

!]^tiologfy. — The  affection  may  be  (a)  primary  or  (b)  secondary, 
(a)  By  the  primary  form  is  meant  an  inflammation  of  the  pleura  occur- 
ring in  previously  healthy  persons.  It  is  exceedingly  rare;  and  doubt- 
less many  instances  of  true  secondary  pleurisy  are  regarded  as  belong- 
ing to  this  category.  Aschoff"s  studies  of  200  cases  of  pleurisy  showed 
41  to  be  idiopathic.  Of  great  etiologic  prominence  is  exposure  to  cold 
and  wet,  and  next  to  this  stands  mechanical  injury.  It  is  more  com- 
mon in  men  than  in  women,  and  especially  during  the  time  of  active 
life,  on  account  of  the  greater  liability  to  exposure  of  the  former  sex.  In 
almost  all  instances  a  careful  search  will  disclose  the  existence  of  some 
diathesis  (tuberculous,  gout}^  rheumatic)  that  ma,j  be  properly  regarded 
as  the  favoring  cause.  The  changeable  weather  of  the  winter  and  spring 
augments  the  proportion  of  cases  during  these  seasons  as  compared  with 
summer  and  autumn. 

(b)  The  secondary  form  of  dry  plastic  pleurisy  arises  from  extension 
of  acute  and  chronic  inflammatory  affections  of  the  lungs  and  other 
neighboring  organs.  Hence  it  frequently  follows  croupous  pneumonia, 
somewhat  less  frequently  broncho-pneumonia,  and  more  rarely  still 
hemorrhagic  infarct,  abscesses,  and  pulmonary  carcinoma  and  gangrene. 
When  pleurisy  occurs  on  the  right  side  it  must  be  recollected  that  it 
may  have  originated  in  hepatitis.  Plastic  pleurisy  sometimes  arises 
in  acute  articular  rheumatism,  to  which  it  may  essentially  belong. 
It  is  an  almost  constant  accompaniment  of  chronic  pulmonary  tuber- 
culosis, and  may,  though  rarely,  even  constitute  the  primary  lesion 
(primary  tuberculous  pleurisy).  The  disease  may  appear  as  a  com- 
plication in  chronic  alcoholism  and  in  chronic  Bright's  disease.  Finally, 
inflammation  of  other  serous  membranes,  as  of  the  pericardium  and  peri- 
toneum, by  direct  extension  through  the  lymphatics  may  invade  the  pleura. 


582  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Symptoms. — The  affection  may  vary  in  intensity  between  the  ex- 
tremes of  mildness  and  great  severity,  though,  as  a  rule,  well-marked 
local  symptoms  attend  the  onset.  Among  tlie  latter  a  shaiy  '■^stitch" 
in  the  side,  that  is  usually  referred  to  the  nipple,  is  the  most  prominent. 
The  pleural  pain  is  increased  by  inspiration  as  well  as  by  voluntary 
motion  of  the  affected  side,  and  hence  the  patient  assumes  a  fixed  position 
in  which  he  favors  the  affected  side  by  leaning  toward  it.  There  is  a 
drv,  distressing  cough  that  is  restrained  for  obvious  reasons,  and  the 
rcspirafiim  is  someAvliat  hurried,  painful,  and  jerking  in  character  until 
the  exudation  is  poured  out,  when  relief  from  the  latter  symptom  ensues. 

The  general  symptoms  are  not  pronounced,  and,  save  in  compara- 
tively rare  instances,  do  not  correspond  with  the  local  signs.  The  tem- 
perature is  not  typical,  rarely  exceeding  108°  F.  (39.4°  C),  and  more 
often  it  is  below  101°  F.  (38.3°  C).  The  pulse  is  usually  small  and 
tense  or  soft  in  character,  registering  from  90  to  120  beats  per  minute. 
Not  infrequently  the  cases  are  so  mild  as  to  be  attended  by  few,  if  any, 
subjective  symptoms.  The  patient  may  complain  of  ill-defined,  uneasy 
sensations  in  the  affected  side,  but  does  not  discontinue  his  usual  occu- 
pation. On  the  other  hand,  the  worst  cases  of  acute  plastic  pleurisy — 
which,  fortunately,  are  rare — manifest  violent  symptoms :  there  is  a 
distinct  chill,  a  speedy  development  of  high  fever  (104°  F. — 40°  C), 
and  profound  prostration,  and  the  general  and  local  symptoms  are  pro- 
portionately aggravated.     The  illness  then  is  often  a  fatal  one. 

Physical  Signs. — On  inspection  the  movements  of  the  chest-wall  on 
the  affected  side  are  observed  to  be  much  restricted,  particularly  during 
the  first  day  of  the  affection.  Palpation  confirms  the  results  of  inspec- 
tion, while  percussion  yields  a  normal  note.  Auscultation  renders  au- 
dible a  grazing  friction-sound,  most  intense  at  the  end  of  inspiration. 
These  signs  are  not  uncommonly  situated  at  the  apices. 

With  the  occurrence  of  fibrinous  exudation  palpation  detects  over 
the  corresponding  area  a  diminution  of  the  tactile  fremitus.  On  per- 
cussion there  is,  as  a  rule,  a  slight  though  variable  degree  of  dulness  ; 
and  on  auscultation  rubbing  friction-sounds  or  a  rustling  sound  due  to 
fine  rales  are  heard  both  on  inspiration  and  expiration,  being  intensified 
by  deep  breathing.  These  sounds  frequently  persist  for  a  day  or  two 
after  the  other  symptoms  have  disappeared.  Rarely  the  plastic  exuda- 
tion may  be  so  extensive  as  to  cause  compression  of  the  lung,  in  which 
instance  the  breath-sounds  may  become  bronchial  in  character ;  and  such 
cases  have  been  mistaken  for  lobar  pneumonia. 

Diagnosis. — By  exercising  ordinary  care  the  clinician  can  scarcely 
mistake  other  thoraxjic  affections  for  dry  pleurisy,  the  latter  being  diag- 
nosticated to  a  certainty  by  the  presence  of  the  characteristic  friction- 
murmur.  Intercostal  neuralgia  may  present  features  not  unlike  those 
of  acute  pleurisy.  In  both  affections  there  is  frequently  a  history  of 
exposure,  followed  by  severe  chest-pains  that  are  excited  by  coughing 
and  deep  breathing.  "  In  neuralgia,  however,  there  are  painful  pressure- 
points,  and  the  friction-sound  does  not  occur.  Schepelmann  points  out 
that  bending  the  trunk  to  the  side  affected  increases  the  pain  of  inter- 
costal neuralgia,  while  in  pleurisy  this  symptom  is  aggravated  by  bend- 
ing the  trunk  to  the  sound  side.  Pleurodynia  may  also  give  a  history 
very  similar  to  that  of  acute  pleurisy,  but  the  characteristic  physical 
signs  of  pleurisy  are  absent. 


SERO-FIBRTNOUS  PLEURISY.  58?> 

Prognosis. — The  duration  of  the  affection  varies  from  a  few  (Jaya 
to  three  weeks,  and  the  immediate  outcome  i.s  favorable  as  a  rule.  Un- 
doubtedly, however,  a  primary  attack  predisposes  to  subsequent  attacks, 
and  thus,  as  a  result  of  repeated  seizures,  pleural  thickening  and  intra- 
pleural adhesions  often  arise.  Lung-expansion  may  in  this  manner  be 
restricted,  with  the  gradual  development  of  interstitial  pneumonia  as  a 
consequence.  Acute  plastic  pleurisy  is  not  infrequently  a  terminal  con- 
dition in  serious  forms  of  illness  (e.  y.,  septicopyemia  and  chronic  neph- 
ritis). 

Treatment. — The  first  object  in  the  treatment  is  to  relieve  the 
pain,  and  this  can  best  be  accomplished  by  the  hypodermic  use  of  mor- 
phin.  The  inflammatory  process  is  best  controlled  by  absolute  rest  in 
the  recumbent  posture,  or  fixation  of  the  affected  side  by  means  of 
adhesive  plaster.  I  am  also  in  the  habit  of  administering  moderate- 
sized  doses  of  quinin  (gr.  iv — 0.259 — three  times  daily).  After  the 
exudation  has  appeared,  the  iodids  of  iron  and  potassium,  in  com- 
bination, may  be  employed.  Locally,  nothing  is  so  effective  as  cold 
in  the  form  of  the  ice-water  bag  or  Leiter's  coil,  preceded,  in  robust 
patients,  by  the  local  abstraction  of  blood  (.liij  to  vj — 96.0-192.0)  by 
leeches.  At  the  end  of  one  week  the  morphin  may  usually  be  dis- 
continued. During  coiivalescence  the  patient  should  be  instructed 
to  take  deep  inspirations  several  times  in  succession,  not  less  than  a 
dozen  times  each  day,  with  a  view  to  obviating  as  far  as  possible 
pleural  adhesions  and  other  unfavorable  consequences.  Symptomatic 
anemia  may  be  present  at  this  time,  and  should  be  met  by  iron  given 
internally.  At  this  time  iodin  may  be  used  locally  with  great  benefit ; 
I  have  not,  however,  seen  any  favorable  results  from  blisters.  For  the 
pain  which  continues  in  the  side  after  all  detectable  physical  signs  have 
disappeared  the  use  of  the  constant  current  over  the  seat  of  the  pleur- 
isy for  twenty  minutes  at  a  time  gives  almost  instantaneous  relief 
(Loomis). 

SBRO-FIBRINOUS   PLEURISY   (PLEURISY  WITH   EFFUSION,    SUBACUTE 

PLEURISY). 

Pathology. — During  the  first  stage  of  sero-fibrinous  pleurisy  the 
changes  are  the  same  in  character  as  those  met  with  in  dry  pleurisy, 
though  of  severer  grade,  and  usually  involving  the  greater  portion  of 
the  pleura  on  the  side  affected.  There  is  an  abundant  exudation  of 
serum,  and  usually  the  entire  pleura  becomes  coated  with  a  fibrinous 
exudate,  that  varies  greatly  in  thickness  and  arrangement.  The  exudate 
is  thin  and  smooth  in  some  instances,  though  more  frequently  it  forms 
a  thick  layer,  presenting  a  shaggy  surface  on  the  one  hand  or  an 
irregular,  honeycombed  surface  on  the  other.  Lymph  in  the  form 
of  flocculi  is  rather  abundant  in  the  serous  effusion.  The  interlobu- 
lar pleural  surfaces  are  also  invaded  as  a  rule,  in  consequence  of 
which  they  become  adherent.  The  fluid  exudate  varies  greatly  in  quan- 
tity (I  to  8  pints — 4  liters),  is  often  of  a  citron  color,  and  is,  in  the  ma- 
jority of  instances,  clear  or  slightly  turbid.  Rarely  it  is  of  a  dark- 
brown  color. 

Unless  adhesions  between  the  pleural  surfaces  have  previously  existed 
the  effusion  gravitates  to  the  most  dependent  portion  of  the  pleural  cav- 


584  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ity.  Microscopically,  there  are  found  leukocytes,  red  blood-corpuscles, 
endothelial  cells,  threads  of  fibrin,  and,  rarely,  crystals  of  cholesterin 
and  uric  acid.  The  composition  of  the  fluid  is  almost  identical  with  that 
of  blood-serum,  and  on  boiling  it  is  found  to  be  rich  in  albumin.  Spon- 
taneous coagulation  may  take  place  on  standing. 

Changes  in  the  Neighboring  Organs. — So  long  as  the  normal  retrac- 
tility of  the  lung  is  not  overcome  by  the  fluid  that  collects  in  the  pleural 
cavity,  the  latter  does  not  produce  positive  intrathoracic  pressure,  and 
hence  does  not  produce  displacement  of  adjacent  organs.  It  may  be 
assumed  that  until  the  pleural  sac  is  at  least  one-half  filled  with  sero- 
fibrinous exudate  the  natural  contractility  of  the  lung  is  not  destroyed. 
At  this  period  there  may  be  a  slight  displacement  of  the  mediastinum 
toward  the  opposite  side,  due  to  traction  exerted  by  the  normal  retrac- 
tility of  the  sound  lung.  Obviously,  large  eff'usions  must  in  a  mechani- 
cal manner  displace  the  pleural  membranes,  thus  causing  compression 
of  the  pulmonary  structures  lying  above  the  efi"usion.  A  very  copious 
effusion  may  push  the  lung  up  and  back  against  the  vertebral  column 
and  convert  it  into  a  small,  flat,  bloodless,  and  airless  mass  (atelectasis). 
While  a  total  absence  of  air  in  the  collapsed  lung  is  due  chiefly  to  com- 
pression by  the  fluid,  to  some  extent,  however,  the  air  may  be  absorbed 
by  the  vessels  or  even  by  the  effusion  (Strlimpell). 

Together  with  compression  of  the  lung  by  the  effusion,  pressure  is 
also  exerted  by  the  latter  against  the  mediastinum,  causing  displacement 
of  the  heart.  The  mediastinum  also  loses  the  normal  traction-force  of 
the  lung  upon  the  affected  side,  and  hence  the  lung  on  the  sound  side 
draws  the  mediastinum  toward  itself  by  its  own  retractile  energy.  Osier 
shows  that  even  in  the  most  extensive  left-sided  effusion  the  heart's  apex 
is  not  rotated,  but  that  the  normal  relative  position  of  the  apex  and  base 
obtain,  though  the  apex  is  in  some  instances  lifted,  and  in  others  the 
heart  lies  more  transversely.  The  right  chambers  of  the  heart  occupy 
most  of  the  anterior  part  of  the  organ,  showing  that  the  displacement 
of  the  mediastinum  with  the  pericardium  and  its  contents  to  the  right 
involves  no  appreciable  twisting  of  the  heart  itself. 

Downward  displacement  of  the  diaphragm  takes  place  in  extensive 
effusion  on  the  right  side,  depressing  the  liver  to  a  variable  distance  below 
the  inferior  costal  border ;  on  the  left  side  large  effusions  produce 
pressure-displacement  of  the  stomach  and  the  transverse  colon,  and,  to  a 
slighter  extent,  of  the  spleen.  Pre-existing  adhesions  may  prevent  dis- 
placement of  the  adjacent  organs. 

Ktiologfy. — The  causative  factors  are  identical  in  nature  with  those 
producing  dry  plastic  pleurisy.  It  is  highly  probable  that  the  degree  of 
severity  is  dependent  upon  the  previous  condition  of  the  patient,  whether 
he  be  suffering  from  some  other  affection  or  not,  and  upon  the  amount 
of  specific  poison  gaining  access  to  the  pleura. 

The  affection  may  be  primary,  but  is  much  more  often  secondary , 
and  this  fact  may  be  explained  by  reference  to  any  of  the  specific  micro- 
organisms producing  the  affection. 

Direct  Causes. — Many  of  the  cases  follow  quickly  upon  exposure  to 
cold  or  wet  or  an  injury  to  the  thorax.  I  thoroughly  agree  with  those 
authors  who  contend  that  about  three-fourths  of  the  cases  of  sero-fibrinous 
pleurisy  are  of  tubercular  origin.     The  tuberculous  process  may  invade 


SERO-FIBRINOm  PLETJIUSY.  585 

the  pleura  primarily,  but  more  often  it  is  secondary  to  tuberculosis  of  the 
lungs  ;  less  frequently,  though  oftener  than  is  generally  supposed,  it  is 
secondary  to  tuberculous  peritonitis.  In  these  instances  the  tubercle 
bacilli  probably  find  their  way  from  the  peritoneum  to  the  pleura  by 
traversing  the  lymphatics  in  the  diaphragm.  A  large  percentage  of  ap- 
parently primary  cases  of  tuberculous  pleurisy  have  their  origin  in  a  cir- 
cumscribed and  more  or  less  latent  tuberculous  focus  in  the  lungs.  It  is 
not  improbable  also  that  tuberculous  processes  in  other  viscera  may  fur- 
nish the  tubercle  bacilli  for  secondary  pleural  infection.  Moreover,  tlie 
fact  that  many  cases  of  sero-fibrinous  pleurisy  recover  does  not  disprove 
their  tuberculous  nature. 

The  aifection  is  not  infrequently  secondary  to  acute  articular  rheu- 
matism, which  is  itself  most  probably  a  microbic  affection.  It  also 
arises  as  a  complicating  condition  in  the  course  of  various  acute  and 
chronic  affections  of  the  chest,  as  pericarditis  and  catarrhal  pneumonia, 
and  may  develop  in  acute  infectious  diseases,  as  typhoid  fever  or  lobar 
pneumonia.  The  typhoid  bacillus  of  Eberth  has  also  been  known  to 
provoke  pleurisy  (Bozzolo,  Fernet,  and  others).^  It  may  occur  as  a  com- 
plication in  the  chronic  affections  of  various  viscera  (chronic  nephritis, 
cirrhosis  and  carcinoma  of  the  liver).  The  predisposing  causes  are  the 
same  as  for  the  dry  plastic  form. 

Symptoms. — The  description  here  refers  particularly  to  primary 
sero-fibrinous  pleurisy,  and  it  is  important  to  recollect  that  when  second- 
ary to  other  acute  and  chronic  affections  characterized  by  great  bodily 
weakness  the  pleuritic  symptoms  may  be  in  abeyance. 

With  few  exceptions  the  onset  is  insidious,  the  symptoms  being 
quite  mild ;  but  rarely  there  is  a  sudden  onset  with  active  symptoms 
(rigor,  high  fever).  In  the  majority  of  instances  the  patient  first 
complains  of  a  stitch-like  pain  in  the  side ;  this  is  rarely  pronounced, 
but  is  aggravated  upon  deep  breathing  and  upon  any  muscular  exertion. 
Dyspnea  soon  arises  and  gradually  increases  in  intensity.  Cough  may 
be  present  or  absent,  and  in  some  instances  is  attended  by  a  scanty 
mucoid  expectoration  that  may  rarely  be  blood-streaked. 

The  constitutional  symptoms  are  of  correspondingly  slow  and  gradual 
development.  From  the  commencement  of  the  attack  a  moderate  febrile 
movement  at  night  may  be  observed,  and  the  pulse  will  be  found  to  be 
frequent,  small,  and  compressible,  or,  more  rarely,  tense.  At  the  time 
of  the  patient's  first  visit  to  his  physician  he  may  give  a  history  of  having 
gradually  lost  flesh  and  strength  for  a  period  of  weeks  together,  though 
he  may  not  have  been  obliged  to  abandon  his  vocation.  He  looks  pale, 
his  countenance  wears  an  anxious  expression,  and  he  is  without  appetite. 
These  cases  frequently  drag  on  from  two  to  four  weeks  before  con- 
sulting a  physician,  the  local  symptoms  going  unnoticed. 

Sometimes  the  period  of  invasion  develops  acutely  and  after  lasting  a 
few  days  the  symptoms  exhibit  a  decided  remission  ;  subsequently  there 
may  be  a  sudden  recurrence  of  the  local  and  general  phenomena,  and  par- 
ticularly of  the  dyspnea.  The  pleural  cavity,  which  may  have  been  one- 
half  or  two-thirds  full,  now  becomes  completely  filled. 

Special  Symptoms. — Pain. — Chest-pain  is  an  almost  constant  but  not 
highly  characteristic  symptom,  and,  though  usually  among  the  earliest 
symptoms,  it  may  not  be  present  until  a  few  hours  or  a  day  after  the 
'  Annual  of  the  Universal  Medical  Sciences,  vol.  ii.,  p.  12. 


586  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

commencement  of  the  affection.  It  may  be  described  as  a  sharp,  shoot- 
ing pain,  and  is  popularly  termed  a  "stitch  in  the  side."  It  may,  how- 
ever, be  tearing  or  dragging  in  character.  Its  intensity  is  not  a  safe  in- 
dication of  the  severity  of  the  disease.  It  is  usually  referred  to  a  small 
spot  below  the  nipple  or  to  the  mid-axillary  region  ;  exceptionally,  hoAv- 
ever,  it  is  more  diffuse,  and  in  my  experience  it  has  not  infrequently 
been  retrosternal  or  referred  to  limited  areas  below  the  inferior  costal 
border.  When  absent  it  may  be  excited  by  coughing,  sneezing,  deep 
inspiration,  and  stooping.  With  the  appearance  of  the  effusion  the  pain 
diminishes,  and,  as  a  rule,  soon  disappears. 

Dyspnea. — The  breathing  is  shallow,  "  catching,"  inspiration  being 
made  up  of  a  series  of  gasps,  and  it  is  hurried  in  consequence  of  the 
severe  pleural  pain ;  in  copious  effusions,  that  render  one  lung  function- 
less,  the  dyspnea  may  become  intense,  even  attaining  to  orthopnea.  It 
reaches  its  most  pronounced  form  in  previously  robust  subjects,  and  in 
those  in  whom  the  effusion  has  developed  rapidly.  On  the  other  hand, 
Avhen  the  pleural  sac  fills  slowly  dyspnea  may  be  absent  except  on  exer- 
tion. Following  marked  disturbances  in  the  respiration,  cyanosis  appears 
and  may  become  quite  marked. 

Cough  and  Expectoration. — Little  need  be  added  to  what  has  already 
been  stated.  When  there  is  present  much  expectoration  it  is  not  uncom- 
monly due  to  associated  bronchitis  or  to  pulmonary  tuberculosis  ;  there 
may,  however,  be  a  total  absence  of  expectoration,  and  in  such  instances 
the  exciting  cause  of  the  cough  is  probably  the  pleuritis.  Both  the 
cough  and  expectoration  are  apt  to  be  increased  during  the  process  of 
resorption  of  the  exudate  as  the  result  of  a  catarrhal  bronchitis  that  is 
prone  to  develop  in  the  re-expanding  lung. 

Fever. — The  rise  of  temperature  is  not  rapid  as  a  rule,  nor  does  it 
reach  a  high  point  (101.5°  to  103°  F.— 38.6°-39.4°  C).  At  the  end 
of  a  variable  period — usually  one  to  three  weeks — the  temperature  falls 
by  lysis,  and  soon  touches  the  normal.  The  temperature  may  be  of  the 
continued  type  in  many  acute  cases.  In  subacute  forms  the  temperature 
rarely  rises  above  101°  F.  (38.3°  C),  or  the  fever  may,  finally,  become 
hectic.  The  surface-temperature  of  the  affected  side  is  from  one-half 
to  two  degrees  (0.4°-1.6°  C.)  higher  than  that  of  the  normal  side. 

Pulse. — The  pulse  is  quickened,  beating  100  or  more  per  minute,  and 
its  volume  and  tension  are  diminished.  Irregularity  both  of  the  volume 
and  rhythm  of  the  pulse  may  also  be  observed.  These  pulse-character- 
istics are  to  be  attributed  to  the  pressure  of  the  effusion  upon  the  heart 
and  great  vessels.  There  is  a  leukocytosis  in  non-tuberculous  pleuritis, 
although  the  increase  in  the  white  cells  is  moderate. 

G astro-intestinal  Symptoms. — Loss  of  appetite  is  commonly  present, 
and  more  rarely  nausea  and  occasional  vomiting  may  arise  at  the  outset. 
Constipation  is  the  rule.  Sweating  is  a  common  symptom  in  the  more 
protracted  cases. 

Renal  Symptoms. — The  amount  of  urine  is  diminished  both  during 
exudation  and  while  the  exudate  remains  at  its  maximum  level.  The  daily 
quantity  may  not  exceed  eight  or  ten  ounces,  but  the  specific  gravity  is 
increased,  ranging  from  1018  to  1028.  Rarely,  the  quantity  is  increased 
with  existing  effusion.  An  increase  in  the  daily  amount  of  urine  ex- 
creted is  frequently  the  first  sign  of  commencing  absorption  of  the 
exudate,   and  the  rapid  resorption  of  the  copious  effusion  may  greatly 


SERO-FIBRINOUS  PLEURISY.  587 

augment  the  flow  of  urine  to  80  or  100  ounces  (2.5  to  3  liters)  daily 
(Striimpell).  The  cause  of  the  diminished  secretion  of  urine  is,  in  the 
main,  diminished  arterial  pressure. 

Physical  Signs. — The  physical  signs  of  sero-fibrinous  pleurisy  differ 
with  the  stage  of  the  aifection  :  those  of  the  first  stage  are  identical  with 
the  signs  pointed  out  in  connection  with  dry  plastic  pleurisy,  and  need 
not  be  restated  here.  We  will  note  the  physical  signs  (1)  during  the 
stage  of  effusion,  as  well  as  (2)  those  presented  when  absorption  of  the 
effusion  has  taken  place. 

(1)  Stage  of  Effusion. — When  the  pleural  sac  is  only  partly  filled 
there  is  noted,  on  inspection.,  but  little  change  in  the  thoracic  contour. 
The  respiratory  movements  are,  however,  restricted,  owing  to  mechani- 
cal hindrance  to  the  lung-expansion.  In  the  majority  of  instances  the 
effusion  increases  until  positive  intrathoracic  pressure  and  noticeable 
bulging  in  the  middle  and  lower  third  of  the  chest-wall  on  the  affected 
side  take  place ;  the  intercostal  spaces  below  are  shallow,  widened,  and 
sometimes  even  effaced.  The  apex-beat  of  the  heart  is  displaced,  being 
visible  in  right-sided  pleurisy  to  the  left  of  the  vertical  mammary  line 
in  the  fourth  and  fifth  interspaces,  and  in  left-sided  pleurisy  to  the  right 
of  the  right  mammary  line  in  the  third  and  fourth  interspaces.  The 
apex  of  the  heart  may  take  a  position  behind  the  sternum,  when  no  im- 
pulse will  be  visible.  In  moderate  effusions  rhythmic  lateral  displace- 
ment of  the  heart  (which  approaches  the  affected  side  during  inspiration 
and  moves  outward  in  expiration)  occurs  (C  L.  Greene).  Litten's  phe- 
nomenon, or  the  shadow  of  the  diaphragm,  is  absent  in  this  disease. 

Palpation. — The  limited  range  of  expansion  is  readily  appreci- 
ated on  palpation,  and  in  large  effusions  the  chest-wall  is  practically 
fixed.  The  separation  of  the  ribs  and  the  obliteration  of  the  intercostal 
spaces  are  easily  made  out  in  the  same  manner.  Edema  of  the  chest- 
wall  is  rarely  present,  and  fluctuation  almost  never.  An  important 
and  early  physical  sign  is  the  diminished  tactile  fremitus,  which  is 
soon  abolished,  except  in  infants,  in  whom  it  may  be  excited  on  crying. 
This  is  a  less  valuable  sign  in  women  than  in  men,  owing  to  the  differ- 
ences in  the  vocal  vibrations  in  the  two  sexes.  In  copious  effusions  tac- 
tile fremitus  may  sometimes  be  obtained  when  bands  of  adhesion,  which 
serve  as  a  medium  for  the  transmission  of  vocal  fremitus,  connect  the 
pulmonary  with  the  costal  pleura.  The  apical  impulse  can  also  be 
readily  located  by  palpation.  The  displaced  spleen  or  liver  can  be  felt 
through  the  abdominal  wall,  and  must  not  be  mistaken  for  an  actual 
enlargement  of  these  organs. 

Mensuration. — In  right-handed  adults  the  right  side  is,  normally, 
slightly  larger  than  the  left ;  and  it  is  only  after  the  efiusion  is  consider- 
able that  the  cyrtometer  shows  any  alteration  in  the  thoracic  contour. 
The  tape,  however,  exhibits  the  difference  in  expansive  motion  of  the 
two  sides  early.  At  the  end  of  expiration  the  circumference  of  the 
affected  side  will  be  found  to  be  one  or  two  inches  greater  than  that  of 
the  unaffected  side,  while  at  the  end  of  inspiration  the  difference  will  be 
but  slight.  The  cyrtometric  tracing  also  shows  a  discrepancy  between 
the  horizontal  outlines  of  the  two  sides. 

Percussion. — At  first  the  percussion-note  is  impaired,  either  poste- 
riorly or  in  the  infra-axillary  region,  and  a  little  later  there  is  dul- 
ness,  tending  toward  flatness  (deadness),  the  upper  level  of  which  rises 


588  DISEASES  OF  THE  RESPIEATORY  SYSTE^L 

from  day  to  day  with  increasing  effusion.  Over  the  exudate  the  note 
has  a  wooden  quality  (flat)  and  there  is  great  resistance.  When  the 
effusion  rises  to  the  fourth  rib  anteriorly  there  is  dulness  over  the  fluid 
above  and  absolute  flatness  below.  Since  both  the  flatness  and  dulness 
are  due  to  the  free  fluid,  it  is  obvious  that  the  line  of  demarcation  must 
change  with  the  posture  of  the  patient ;  hence  the  limit  of  dulness  will 
be  higher  in  the  sitting  than  in  the  recumbent  position.  When  the 
pleural  sac  is  filled  or  when  the  effusion  is  confined  by  adhesions,  movable 
dulness  is  not  obtainable.  When  the  exudate  rises  to  the  lower  bor- 
der of  the  third  rib.  the  percussion-note  above  the  line  of  dulness  is 
tympanitic  or  vesiculo-tympanitic  [Skoda's  resonance)  ;  this  holds  also 
in  more  moderate  effusions,  and  is  attributable  to  mediate  relaxation  of 
the  lung.  In  copious  exudations  the  cracked-pot  sound  may  be  elicited 
immediately  below  the  clavicle,  and  "  WiUiams's  tracheal  tone"  may 
sometimes  be  obtained.  This  may  also  be  obtained  at  a  point  correspond- 
ing to  the  seat  of  the  compressed  lung.  When  the  patient  is  sitting  or 
in  the  erect  posture  the  upper  limit  of  dulness  in  large  efi"usions 
is  not  a  horizontal  line,  but  is  highest  at  the  spine  and  falls  as 
we  proceed  to  the  front,  which  is  its  lowest  point.  The  upper  line 
of  dulness  in  moderate  effusions  begins  ''relatively  low  down  in  the 
back,  passes  upward  fi-om  the  vertebral  column,  and  soon  turns  upward 
and  proceeds  obliquely  across  the  back  to  the  axillary  region,  where  it 
reaches  its  highest  point ;  thence  it  advances  in  a  straight  line,  but  with 
a  slight  descent,  to  the  sternum"  (Ellis).  This  curved  line  resembles 
the  italic  letter  S  (Garland).  Grocco's  sign  (a  triangular  area  of  dulness 
over  the  back  on  the  opposite  side  in  unilateral  pleurisy,  which  dulness  dis- 
appears when  the  patient  lies  on  the  side  of  the  efiusion)  is  confirmatory, 
although  it  is  not  invariably  present.  On  the  right  side  the  flatness  is 
continuous  with  that  of  the  displaced  liver  ;  on  the  left  it  passes  into  and 
may  obliterate  Traube  s  semilunar  space. 

Auscultation — The  signs  of  the  first  stage  have  already  been  de- 
scribed {I'ide  Plastic  Pleurisy).  With  the  appearance  of  the  efiusion 
the  breath-sounds  become  weak,  distant,  and  have  a  bronchial  quality. 
Soon  the  respiratory  sounds  over  the  affected  side  will  be  entirely  ab- 
sent, except  near  the  upper  level  of  the  fluid  posteriorly,  where  distant 
bronchial  breathing  is  audible.  The  latter  sounds  may  exhibit  a  metallic 
or  amphoric  quality,  and  may  be  accompanied  by  rales  (pseudo-cavernous 
aigns).  The  latter  are  more  frequently  met  in  children  than  in  adults, 
and  often  give  rise  to  a  false  diagnosis.  Above  the  level  of  the  fluid 
there  is  broncho-vesicular  breathing,  and  on  the  opposite  side  intensified 
breath-sounds  may  usually  be  noted.  In  pneumonia  with  pleural  effusion 
there  may  be  loud  and  persistent  bronchial  respiration  over  the  exudate. 
The  vocal  resonance  is  diminished  and  may  manifest  a  nasal  qual- 
ity, simulating  somewhat  the  bleating  of  a  goat  (Laemiec's  egophoni/). 
This  is  best  obtained  near  the  upper  level  of  the  fluid  in  large  effusions, 
and  at  or  above  the  angle  of  the  scapula  when  the  effusion  is  moderate. 

(2)  Stage  of  Resorption. — With  resorption  of  the  fluid  there  is  a  de- 
crease in  the  size  of  the  aff"ected  side,  together  with  a  return  of  the  nor- 
mal appearance  of  the  intercostal  spaces  and  the  respiratory  movements. 
In  many  instances  there  is  positive  retraction,  leading  to  thoracic  defor- 
aaity  with  displacement  of  neighboring  organs  toward  the  affected  side ; 
and  this  retraction  may  be  either  general  or  circumscribed.      The  infe- 


SERO-FIBRINOVS  PLEURISY.  589 

rior  intercostal  spaces  are  more  or  less  narrowed  ;  the  Hlioulder  droops ; 
the  nipple  approaches  the  median  line ;  the  spine  may  he  curved,  the 
convexity  being  directed  toward  the  sound  side  (quite  rarely  toward  the 
affected  side);  and  the  scapula  projects  from  the  chest-wall  on  the  af- 
fected side.  In  children,  and  even  in  adults,  the  lungs  and  thorax  grad- 
ually expand  in  order  to  overcome  this  chronic  deformity. 

Palpation. — The  tactile  fremitus  closely  follows  the  fluid  as  it  sub- 
sides from  above  downward  without  any  extreme  degree  of  thickening 
of  the  pleural  membranes,  though  cohesion  of  their  surfaces  may  pre- 
vent its  return  over  the  lower  segment.  The  inspiratory  movement  of 
the  chest-wall  gradually  returns,  but  not  to  its  former  limit. 

Mensuration  shows  a  steady  diminution  in  the  size  of  the  side  in- 
volved, which  finally  becomes  smaller  than  its  fellow. 

Percussion. — The  dull  or  flat  note  gives  way  to  normal  percussion- 
resonance,  proceeding  from  above  downward  in  a  gradual  manner;  but 
the  latter  is  not  renewed  over  the  lower  portion  of  the  pleural  cavity  for 
a  long  period  after  the  exudation  has  disappeared.  The  abnormal  areas  of 
flatness  due  to  displacement  of  organs  (liver,  spleen,  heart)  also  disappear. 

Auscultation  discloses  most  important  signs  during  the  stage  of  ab- 
sorption. The  breath-sounds  reappear  at  first  above,  and  then  lower 
down,  until  the  base  is  reached.  With  commencing  subsidence  of  the 
fluid  the  respiratory  sounds  are  feeble  and  distant,  but  later  they  resume 
their  natural  distinctness ;  and  partly  as  a  result  of  the  revival  of  the 
natural  muscular  tonicity,  and  partly  in  consequence  of  the  disappear- 
ance of  the  fluid,  the  two  roughened  pleural  surfaces  come  in  contact 
and  play  upon  one  another,  giving  rise  to  a  rubbing,  creaking  friction- 
sound  on  auscultation.  These  friction-murmurs  may  persist  for  months 
after  the  effusion  has  been  absorbed.  Occasionally  the  lower  portion  of 
the  compressed  lung  remains  permanently  inexpansile  ;  the  upper  portion 
of  the  lung  is  now  the  seat  of  compensatory  emphysema.  The  heart- 
sounds  return  to  their  normal  position. 

X.-rays. — Williams  ^  states  when  the  efiusion  is  large  no  more  rays 
pass  through  it  than  through  the  liver,  and  the  outlines  of  the  dia- 
phragm, ribs,  and  heart  are  obliterated  on  the  side  of  the  effusion.  The 
fluoroscope  also  shows  the  direction  and  extent  of  cardiac  displacements 
due  to  pleural  effusions.  Williams  afiirms  that  displacement  of  the 
heart  to  the  right  may  not  be  recognized  by  percussion,  even  when  it 
has  been  pushed  much  beyond  its  normal  place.  Displacement  of  the 
pleuritic  fluid  w^hen  the  patient's  position  is  changed  and  also  with  the 
movements  of  the  diaphragm  has  been  noted  with  the  fluoroscope  (Ber- 
gone  and  Carriere). 

Special  Clinical  Forms  of  Acute  Sero-fibrinous  Pleurisy. — 
(1)  Tuberculous  Pleurisy. — This  is,  in  the  majority  of  instances,  second- 
ary to  pulmonary  tuberculosis.  On  the  other  hand,  the  primary  lesions 
may  be  situated  in  the  pleural  sac  and  give  rise  to  [a)  Acute  sero-fihri7iovs 
pleurisy  (with  the  usual  course) ;  (h)  Subacute  pleurisy  (with  insidious 
course),  leading  to  tuberculous  invasion  of  the  lungs  ;  and  (c)  Chronic 
adhesive  pleurisy,  in  which  the  course  and  physical  signs  correspond 
with  those  to  be  depicted  in  a  special  section  on  Chronic  Pleurisy. 

The  morbid  lesions  are  similar  to  those  met  with  in  other  forms,  plua 
the   specific    tubercles,  which   may   be    exceedingly   numerous  (miliary 
^  Philadelphia  Medical  Journal,  January  6,  1900. 


590  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

tubercles)  on  the  one  band,  or  confined  to  a  few  circumscribed  areas  on 
the  other.  This  variety  has  no  special  etiologic  connection  -with  empy- 
ema, and  the  effusion  is  usually  sero-fibrinous  and  often  blood-stained. 

It  should  be  pointed  out  that  tuberculous  pleurisy  is  sometimes  fol- 
lowed by  tuberculous  pericarditis  or  peritonitis,  or  both.  The  two  latter 
affections  have  been  considered  elsewhere  (vide  p.  279).  We  must 
grant  that  tuberculous  pleurisy  may  proceed  favorably  with  apparent 
recovery,  though  too  often,  after  a  variable  interval  of  time,  tuberculous 
symptoms  are  manifested.  R.  C  Cabot  obtained  the  subsequent  histories 
in  221  cases  of  pleural  effusion  in  the  Massachusetts  Hospital ;  he  fol- 
lowed them  five  years  until  phthisis  or  death  took  place  in  117  ;  at  the 
end  of  five  years  96  had  recovered.  It  is  found  that  about  30  per  cent, 
become  tuberculous. 

(2)  Diaphragmatic  Pleurisy. — This  term  is  applied  to  those  instances  in 
Avhich  the  diaphragmatic  portion  of  the  pleura  is  involved,  either  alone 
or  in  part.  There  occurs  an  exudate  that  may  be  either  plastic  or  sero- 
fibrinous, though  rarely  large  in  amount.  The  symptoms  are  acute,  and 
the  pain,  which  is  lancinating  in  character  and  situated  in  the  epigastric 
region,  is  the  most  prominent  feature.  Geuneau  de  Mussy  ^  holds  that 
pain  along  the  tenth  rib,  extending  from  the  anterior  extremity  to  the 
sternum  and  xiphoid  cartilage,  is  pathognomonic.  It  is  increased  by 
deep  inspiration  and  by  pressure  over  the  insertion  of  the  diaphragm  at 
the  tenth  rib,  and  often  abates  when  effusion  takes  place.  Dyspnea  is 
a  marked  symptom  in  most  cases,  and  the  patient  may  be  forced  to 
assume  a  stooping  or  sitting  posture,  the  respirations  being  superficial, 
purely  thoracic,  and  "catching."  Cough,  nausea,  and  even  vomiting, 
may  occur.  In  a  case  under  my  own  care  vomiting,  due  most  probably 
to  associated  peritonitis,  was  a  troublesome  symptom. 

The  constitutional  features  are  quite  pronounced,  particularly  the 
fever,  Avhich  exceeds  that  met  with  in  other  forms  of  pleurisy.  The 
patient's  anxiety  is  extreme.  The  effusion  may  be  purulent,  and  if  so 
bulging  of  the  lower  intercostal  spaces,  followed  by  edema,  may  occur. 

The  physical  signs  are  for  the  most  part  negative. 

(3)  Encysted  Pleurisy. — This  term  has  reference  to  effusions  that  are 
circumscribed  in  consequence  of  adhesions  between  the  pleural  mem- 
branes. There  may  be  two  or  more  pouches,  with  or  without  communi- 
cation. This  so-called  encapsulated  pleurisy  may  occupy  any  part  of 
the  chest,  and  is  exceedingly  variable  in  extent.  The  symptoms  and 
physical  signs  are  rarely  trustworthy  for  diagnosis,  but  should  usually 
afford  ground  for  suspicion,  and  lead  to  an  exploratory  puncture. 

(4)  Interlobar  Pleurisy. — This  variety  is  usually  secondary  to,  or 
associated  with,  the  ordinary  type  of  acute  sero-fibrinous  pleurisy. 
The  serous  surfaces  between  the  lobes  are  involved  in  the  inflammatory 
process,  and  the  fluid  becomes  encapsulated  in  this  position  in  conse- 
quence of  interlobar  pleural  adhesions.  It  is  more  frequent  on  the  right 
than  on  the  left  side,  and  its  favorite  seat  is  near  the  root  of  the  lung, 
between  the  upper  and  middle  lobes.  Osier  ^  met  with  a  case  following 
pneumonia  in  which  there  was  between  the  lower  and  upper  and  middle 
lobes  of  the  right  side  an  enormous  purulent  collection  that  looked  at  first 
like  a  large  abscess  of  the  lung.  Fistulous  connection  with  a  bronchus 
often  occurs,  and  the  purulent  expectoration  that  follows  may  be  the  first 

*  Arch,  (jen  de  Med.,  1853,  vol.  xi.,  quoted  by  Fox.         *  Practice  of  Medicine,  p.  567. 


SERO-FIBRJNO  US  PLEUJihSY. 


m 


symptom  to  attract  attention  to  the  process  of  suppuration  in  the  thorax. 
Prior  to  the  occurrence  of  this  accident  the  patient  presents  indefinite 
symptoms.  The  patient  may  or  may  not  give  a  clear  Jiistory  of  antece- 
dent pleurisy.  These  cysts  contain,  as  a  rule,  but  a  small  amount  of 
fluid,  and  cause  little  bul<:^in,t^  of  the  intercostal  spaces.  Indeed  in  a  case 
of  my  own  at  the  Philadelphia  Hospital  there  was  actual  retraction, 
though  the  aspirating  needle  showed  the  presence  of  effusion.^ 

(5)  Hemorrhagic  Pleurisy. — By  this  term  is  meant  an  admixture  of 


Fig.  48.— Illustrating  pleurisy  with  effusion :  1,  compressed  lung-tissue,  giving  dull  tympany  on  per- 
cussion ;  2,  fluid  exudation  obliterating  intercostal  spaces  ;  3,  depressed  liver ;  4,  displaced  heart. 


blood  with  the  exudate  in  acute  sero-fibrinous  pleurisy,  in  quantities  suf- 
ficient to  be  detectable  by  the  unaided  eye.  The  condition  must  be  sep- 
arated from  heynotliorax.  The  causes  of  hemorrhagic  pleurisy  are — (1)  Tu- 
berculous infection,  either  of  the  miliary  or  the  chronic  (circumscribed) 
form,  following  tuberculous  disease  of  the  lung ;  (2)  Carcinoma  of  the 
pleura ;  (3)  Bright's  disease  and  cirrhosis  of  the  liver;  (4)  Adynamic  states 

^  International  Clinics  (1894),  vol.  i.,  p.  39. 


592 


DISEASES  OF  THE  RESPIRATORY  SYSTEAf. 


of  the  system  associated  with  malignant  forms  of  acute  infectious  dis- 
eases (pneumonia),     (o)  Advanced  age  and  alcoholism. 

The  fact  that  it  may  be  engendered  by  an  accidental  wound  of  the 
lung  during  thoracentesis  must  be  remembered. 

Diagnosis. — In  diagnosticating  pleurisy  our  attention  must  be 
directed  chietly  to  the  physcial  signs.  Unfortunately,  the  rational 
syniptoms  are  often  too  slight  to  call  attention  to  the  chest.  The  diagno- 
sis should  embrace  the  particular  etiologic  variety  [e.  y.,  tuberculous 
pleurisy,  streptococcus,  or  pneumococcus  pleurisy),  by  a  bacteriologic 
examination  of  the  exudate.  The  chief  difficulties  are  encountered  in 
distinguishing  this  affection  from  conditions  in  which  the  lung  is  either 
consolidated,  retracted,  or  compressed  by  solid  new  growths  or  a  serous 
transudate.  Chief  among  the  former  is  croupous  pneumonia  (especially 
in  pleuritic  exudates  of  moderate  degree),  and  I  have  tal)ulated  below  the 
most  important  distinctions  between  it  and  pleurisy.  The  reader  will  be 
further  aided  by  comparing  Fig.  48  with  Fig.  12,  on  page  122,  since 
these  show  the  physical  conditions  in  the  two  diseases. 

Pleurisy  with  Effusion.  Primarv  Lobar  Pneumonia. 

Rational  SympUwis. 

Onset  acute,  rigor,  lasting  one  hour. 


Onset  marked  by  chilliness,  persisting  for 
a  few  days. 

The  pain  is  sharp,  "  stitch-like,"  and 
strictly  localized. 

Cough  irritating ;  no  expectoration,  or 
catarrhal. 

Sputum  rarely  shows  tubercle  bacillus. 

Moderate  fever  of  continuous  type  ;  de- 
cline by  lysis. 

Systemic  prostration  (moderate). 

Countenance  pale  and  anxious. 

Herpes  does  not  appear. 
Leukocytosis  absent  or  slight. 

Physical 

Inspection. 
Distention  of  the  thorax. 

Palpation. 
Diminished  or  absent  tactile  fremitus. 

Percussion. 

Flatness,  with  great  resistance  to  the 
pleximeter-finger. 

Shows  displacement  of  neighboring  or- 
gans.    Grocco's  sign  usually  present. 

If  the  sac  be  partly  filled,  line  of  flatness 
changes  on  varying  the  position. 
Aiuicultation. 

Diminished  or  absent  breath-sounds, 
bronchial  breathing  frequent,  but  dif- 
fused and  distant  and  unaccompanied 
by  rales,  as  a  rule. 

Vocal  resonance  diminished  or  absent; 
egophony. 

Friction-sound  in  early  and  late  stages. 

Aspiration. 
Yields  serum. 


Acute  pain  (similar),  but  soreness  inore 

diffused. 
Cough  more  marked  and  accompanied  by 

rusty  or  bloody  expectoration. 
Shows  presence  of  pneumococcus. 
Intense  fever  ;  decline  by  crisis  from  the 

fifth  to  the  ninth  day. 
Prostration  marked. 
Countenance  congested  :  mahogany  flush 

on  the  cheeks. 
Herpes  quite  common. 
Leukocytosis  usually  marked. 

Si(/ns. 

None. 

Marked   tactile    fremitus    (absent    only 
when  a  bronchus  is  plugged). 

Dulness  leas  wooden,  less  resistance, 
and  sometimes  a  tympanitic  note. 

No    displacement    of  neighboring   organs, 
if  \mconiplicated.     Grocco's  sign  absent. 

Absent. 


Harsh  bronchial  breathing  and  presence 
of  rales  in  first  and  third  stages,  unless 
a  bronchus  be  plugged. 

Bronchophony  (loud),  unless  a  bronchus 

be  blocked. 
No  friction-sound,  except  crepitant  rfiles 

in  the  first  stage. 

Yields  a  few  drops  of  thick  blood. 


SERO-FIBRINOUS  PLEURISY.  593 

Consolidation  of  the  lunr/,  duo  to  tuberculous  infection,  may  bo  dif- 
ferentiated by  means  of  the  pliysical  signs  contrasted  in  the  foregoing 
table,  the  history  of  the  case,  and  by  the  discovery  of  the  tubercle 
bacillus  in  the  sputum. 

Hydrothorax  presents  physical  signs  that  simulate  strongly  those  of 
pleural  eifusion.  Hydrothorax,  however,  gives  the  history  of  cardiac 
or  renal  disease,  is  oftener  bilateral,  and  is  unassociated  with  a  rise  in 
temperature  or  with  the  pain  or  friction-sounds  peculiar  to  pleurisy.  In 
hydrothorax  the  withdrawn  fluid  has  a  specific  gravity  below  lOlo, 
while  that  of  the  pleural  exudate  is  above  1017.  Iodine  or  its  salts, 
administered  by  the  mouth,  are  recoverable  in  large  quantities,  and 
within  a  short  time  in  the  transudate ;  whereas  in  the  exudate  only  a 
trace  is  found  (Rosenbach  and  Pohl's  test). 

Tumors  and  cysts  of  the  thorax  will  give  complete  dulness,  will  dis- 
place the  heart,  and  compress  the  lung  on  the  affected  side,  thus  caus- 
ing an  absence  of  the  respiratory  murmur,  etc.  But  the  history  of  the 
case,  the  situation  of  the  dulness  (usually  over  the  upper  or  middle  parts 
of  the  lung),  and  the  absence  of  uniform  distention  extending  to  the 
base,  will  serve  to  distinguish  these  affections  from  pleurisy  with  effusion. 

JEehinococcus  cyst  of  the  liver,  or  abscess  of  this  organ,  pushing  up- 
ward, will  cause  retraction  or  even  compression  of  the  lung,  and  produce 
most  of  the  physical  signs  of  pleurisy  with  effusion.  The  former  affections 
can  be  discriminated  only  by  a  correct  appreciation  of  the  history,  by  the 
presence  not  infrequently  of  a  friction-sound  on  auscultation,  of  Litten's 
sign,  and  by  an  immovably  fixed  upper  convex  boundary  of  dulness.  If 
doubt  remains,  an  exploratory  puncture  should  be  made,  and  the  fluid 
withdrawn  should  be  subjected  to  a  chemical,  microscopic,  and  bacteri- 
ologic  investigation. 

An  enormous  pericardial  effusion  may  be  mistaken  for  a  pleural  effu- 
sion on  the  left  side.  In  the  former,  however,  there  is  commonly  a  his- 
tory of  rheumatism,  and  dyspnea  is  an  urgent  symptom,  while  the  heart- 
sounds  are  greatly  enfeebled ;  moreover,  the  heart  is  not  displaced  to 
the  right  as  in  pleura!  effusion.  Again,  flat  tympany  is  obtained  in  the 
posterior  portion  of  the  axilla  and  good  pulmonary  resonance  at  the  base 
in  the  postero-lateral  region  of  the  chest  in  pericarditis. 

For  practical  purposes  it  is  desirable  to  distinguish  the  tuberculous 
from  the  rarer  forms  of  pleurisy.  This  is  possible  by  paying  due  regard 
to  the  previous  history  of  the  patient,  including  hereditary  taint,  by 
noting  certain  clinical  peculiarities  (such  as  associated  disease  of  other 
serous  membranes  and  of  the  lung),  and  by  the  results  of  an  examina- 
tion of  the  exudate.  A  high  proportion  (65-95  per  cent.)  of  lympho- 
cytes in  the  cells  found  in  the  effusion  is  indicative  of  tuberculous  origin. 
Leukocytosis  is  absent  in  tuberculous  pleuritis.  The  tuberculin  reaction 
may  be  elicited  in  cases  presenting  but  little  fever.  Inoscopy — i.  e.,  the 
digestion  and  centrifugalization  of  the  previously  coagulated  exudate, 
often  shows  tubercle  bacilli.  In  a  dubious  case  the  guinea-pig  should 
be  inoculated  with  the  exudate,  and  if  the  patient  be  tuberculous  posi- 
tive results  may  be  confidently  expected. 

Duration  and  Prognosis. — This  depends  largely  upon  the  cause. 
The  course  of  acute  sero-fibrinous  pleurisy  is  not  definite,  but  is  made  up 
of  two  parts — the  febrile  followed  by  the  non-febrile  stage.  The  fever  lasts 
from  one  to  three  weeks ;  it  corresponds  to  the  period  when  the  effusion 

38 


594  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

occurs,  and  the  appearance  of  a  non-febrile  period  indicates  the  subsidence 
of  the  inriauiuiation.  The  exudate  may  be  poured  out  rapidly,  and  may  be 
absorbed  not  less  rapidly ;  more  commonly,  however,  the  effusion  takes 
place  rather  gradually,  and  the  same  is  true  of  resolution.  The  continued 
absence  of  bacteria  in  the  pus  speaks  for  tuberculosis.  In  individual 
cases  the  prognosis  depends  chiefly  upon  the  bacteriologic  cause  (the 
outlook  being  especially  bad  in  streptococcic  pleuritis)  or  the  gravity  of 
the  basal  disease.  Simple  serofibrinous  pleurisy,  including  the  hemor- 
rhagic variety,  unless  it  appears  as  a  complication  in  the  later  stages  of 
some  other  grave  disease,  has  a  comparatively  favorable  prognosis.  Death 
rarely  ensues  suddenly  without  adequate  lesions  to  explain  its  occurrence. 
Moreover,  the  appearance  of  empyema  renders  the  prognosis  far  less  hope- 
ful. Again,  the  crippling  influence  upon  the  lung-tissue  of  previous  attacks, 
owins  to  resultintr  adliesions,  must  be  borne  in  mind,  since  chronic  bron- 
chitis,  emphysema,  fibroid  induration,  and  phthisis  often  supervene.  Con- 
trast between  the  temperature  and  physical  signs  is  an  unfavorable  sign. 

Treatment. — In  the  first  stage  the  treatment  is  the  same  as  for  dry 
or  plastic  pleurisy.  During  the  second  stage,  that  of  efliision,  the  objects 
of  treatment  are  threefold  :  (1)  To  limit  the  extent  and  intensity  of  the 
inflammatory  process ;  (2)  to  accomplish  the  removal  of  the  effusion ; 
and  (3)  to  support  the  strength  of  the  patient. 

(1)  To  Limit  the  Extent  and  Intensity  of  the  Inflammatory  Process. — 
To  this  end  two  classes  of  agents  are  employed — namely,  (a)  Internal, 
and  (5)  External. 

Among  the  latter  are  counter-irritants,  as  sinapisms  and  iodin,  by 
means  of  which  constant  counter-irritation  is  to  be  maintained.  Another 
agent  of  great  worth  is  cold,  applied  by  means  of  the  ice-bag  or  ice-water 
bag,  and  if  the  temperature  rises  to  102°  F.  (38.8°  C.)  cool  spongings  of 
the  surface  of  the  body,  together  with  the  use  of  the  ice-cap,  are  useful. 
Roberts  recommended  keeping  the  affected  structures  at  complete  rest  to 
relieve  the  pain  by  mechanical  fixation  of  the  side  affected.  For  this 
purpose  strips  of  adhesive  plaster  must  be  firmly  and  evenly  applied  to 
the  chest;  they  should  be  removed  during  the  stage  of  effusion. 

The  internal  remedies  embrace  quinin,  the  salicylates,  and  opium. 
Opium  and  quinin  are  potent  in  controlling  inflammation  of  serous 
membranes ;  the  former  being  given  preferably  either  in  the  form  of 
suppositories  or  hypodermically,  and  the  latter  in  divided  doses,  in  cap- 
sule, followed  by  a  few  drops  of  mineral  acid,  administering  gr.  xyj  to 
XX  (1.036-1.296)  daily. ^  I  have  observed  good  results  from  the  salicy- 
lates (3J-ij — 4.0-8.0,  daily),  which  have  been  warmly  advocated  by 
Fiedler,  Koester,^  and  others,  as  valuable  in  mitigating  or  even  aborting 
the  inflammation  of  the  pleurae,  and  thus  in  limiting  the  amount  of 
effusion.  It  must  not  be  forgotten  that  the  effusion  is  due  to  an  inflam- 
mation, and  not  to  a  simple  transudation.  The  use  of  mild  diaphoretics 
and  diuretics,  coupled  with  repeated  small  doses  of  salines,  also  aids  in 
reducing  the  inflammation  in  the  pleura.  With  a  subsidence  of  the 
inflammatory  process  the  temperature  falls,  and  then  our  efforts  should 
be  directed  toward  the  fulfilment  of  the  second  leading  indication,  (2)  the 
removal  of  the  effusion. 

Little  is  to  be  accomplished  b}^  local  means,  though  iodin,  persistently 
employed,  sometimes  does  good.    The  following  ointment  may  also  be  tried : 

1  IrUernat.  Clin.  (1892),  vol.  i.,  2(1  series.       ="  Ann.  of  Univ.  Med.  Sci.  (1893),  vol.  i.  ( A-31 ). 


SERO-FJBRINOUS  PJ.EURIHY  595 

'S/,.   Ung.  ichthyol.  (12  per  cent.), 

Ung.  iodi  cornp.,  da.  3vj  f24.0); 

Ung.  belladonnse,  q.  s.  ad  ^ij  (64.0). — M. 

Sig.  Apply  twice  daily. 

Blisters  are  not  admissible. 

Mild  hydragogue  cathartics,  and  especially  the  salines,  after  the 
Matthew  Hay  method  {L  e.  3ij  to  5ss — 8.0-16.0,  in  the  smallest  possible 
amount  of  water,  on  rising  in  the  morning),  stimulate  absorption  from 
the  pleural  cavities  by  draining  the  blood  of  a  certain  amount  of  serum. 
TJnirritating  diuretics  may  also  be  employed,  but  I  have  found  no  appre- 
ciable advantage  from  their  use.  Free  diaphoresis  (from  the  use  of  pilo- 
carpin)  sometimes  assists  in  the  absorption  of  the  exudate,  but  it  should 
not  be  employed  in  the  presence  of  feeble  heart-action  or  marked  dis- 
placement of  the  organ.  Among  measures  to  promote  absorption,  the 
best,  in  my  own  experience,  is  the  following  combination : 

'Sf.  Potassii  iodidi,  3J   (4.0); 

Syr.  ferri  iodidi,  3ij(8.0); 

Syr.  sarsap.  comp.,  Ij    (32.0); 

Ess.  pepsini,  q.  s.  ad  iij  (64.0). — M. 

Sig.  3j  (4.0)  every  four  hours,  diluted;  the  dose  to  be  doubled  at 
the  end  of  four  days  if  well  borne  by  the  stomach.^ 

Diuretin  is  sometimes  of  service  in  causing  absorption  of  rheumatic 
effusions. 

The  patient  should  be  put  upon  a  dry  diet  in  order  to  increase  the 
plasticity  of  the  blood,  which  is  thus  induced  to  absorb  the  liquid  exu- 
date from  the  pleural  cavity.  The  modus  operandi  of  this  treatment  is 
different,  but  the  effect  aimed  at  is  the  same  as  when  saline  purgatives 
are  given.  Gilbert  and  Fede  advocate  autoserotherapy  to  stimulate 
absorption,  the  method  consisting  in  removing  1  c.c.  of  the  exudate  and 
reinjecting  it  into  the  subcutaneous  tissue.  The  exudation,  however, 
defies  all  efforts  at  removal  in  about  33  per  cent,  of  the  cases,  and  in 
such  the  withdrawal  of  the  liquid  by  aspiration  (thoracentesis)  must  be 
practised.  The  indications  for  thoracentesis  arise  at  two  different  periods 
in  the  course  of  pleurisy  with  effusion  : 

(1)  During  the  febrile  stage,  in  order  to  avert  imminent  danger  to  life, 
and  not  mei'ely  to  remove  the  fluid.  The  conditions  demanding  imme- 
diate thoracentesis  are — (a)  when  one  pleural  sac  is  completely  filled  or 
when  Skoda's  resonance  extends  from  the  clavicle  downward  no  farther 
than  the  second  interspace ;  (&)  in  double  pleurisies,  when  both  sides  are 
half  filled,  since  death  may  occur  from  rapid  filling  of  one  or  the  other 
side ;  (c)  in  cases  of  copious  effusions,  upon  the  first  signs  of  involve- 
ment of  the  unaffected  side,  such  as  moist  rales,  broncho-vesicular 
breathing,  and  impaired  resonance ;  ((i)  the  appearance  of  serious 
symptoms,  such  as  orthopnea  or  syncopal  attacks  with  cyanosis;  {e) 
marked  displacement  of  the  heart,  especially  if  one  or  more  murmurs 
develop  in  the  organ. 

(2)  The  indications  for  aspiration  during  the  second  or  afebrile 
period,  when  the  main  object  is  to  remove  the  exudate,  are — (a)  if  no 

^  The  author  has  employed  this  formula  in  more  than  60  cases  with  very  good  results. 


596  DISEASES  OF  THE  EESPIRATORY  SYSTEM. 

diminution  in  tlio  (i[u:uitity  of  liquid  effusion  has  taken  piiicc  one  week 
after  the  temperature  has  reached  the  normal ;  (6)  in  subacute  cases,  in 
which  there  is  little,  if  any,  temperature  from  the  beginning  ;  aspiration 
should  not  then  be  withheld  longer  than  two  weeks. 

The  operation  is  free  from  danger  if  carried  out  under  antiseptic  pre- 
cautions and  if  a  modern  aspirator  is  employed.  The  instrument  should 
always  be  tested  before  it  is  used.  The  patient  rests  in  bed  in  the  serai-re- 
cumbent posture,  the  arm  of  the  affected  side  being  brought  forward  with 
the  hand  placed  on  the  opposite  shoulder,  so  as  to  separate  the  ribs  from 
one  another.  The  point  of  puncture  is  in  the  sixth  interspace  on  the 
right  side  and  the  seventh  interspace  on  the  left,  in  the  mid-axilla,  or 
just  below  the  outer  angle  of  the  scapula  in  the  seventh  right  and  eighth 
left  interspaces,  respectively.  An  assistant  draws  up  the  skin  from  the 
interspace,  while  the  operator  uses  the  forefinger  of  his  free  hand  as  a 
director.  The  needle  should  be  introduced  with  a  quick  thrust,  hug- 
ging the  rib  below  the  interspace,  but  endeavoring  to  avoid  striking  its 
periosteal  covering.  The  fluid  may  not  be  obtained  at  the  first  o])eration, 
and  the  reasons  for  this  failure  are  several.  The  costal  pleura  may  be 
excessively  thickened,  or  we  may  meet  with  a  much-thickened  fibrous  band. 
Again,  the  fiuid  may  be  encapsulated  ;  and,  lastly,  the  needle  may  become 
blocked.  Under  these  circumstances  repeated  trials  should  be  made.  In- 
aspirable  effusion,  or  blocked  pleurisy  (Mosny  and  Stern),  is  ascribed  to 
abnormal  rigidity  of  the  sac  containing  the  fluid.  Two  needles  may  now 
be  introduced,  one  of  which  is  the  means  of  injecting  sterilized  air. 

The  amount  of  fluid  withdrawn  at  one  time  should  never  be  large 
(5xij  to  xxiv — 384.0-768.0),  though  a  relatively  larger  quantity  may 
be  taken  during  the  febrile  stage  than  during  the  afebrile,  since  in  the 
latter  instance  the  lung  has  been  compressed  for  a  longer  period  of  time. 
The  fluid  is  allowed  to  drain  away  slowly,  a  small  needle  being  used,  so 
as  to  invite  the  lung  to  expand  in  a  gradual  manner.  If  this  precaution 
be  not  taken,  the  paretic  pulmonary  capillaries  are  apt  to  become  the 
seat  of  sudden  fresh  congestion,  followed  by  edema,  and  often  by  a 
speedily  fatal  termination.  Thoracentesis  is  to  be  repeated  at  intervals 
of  several  days  if  nature  does  not  take  up  the  work  of  absorption,  fol- 
lowing the  first  operations.  If  during  the  operation  incessant  cough, 
dyspnea,  a  tendency  to  syncope,  marked  thoracic  constriction,  or  sudden 
intense  pain  be  developed,  the  needle  must  be  withdrawn  instantly. 

Thoracentesis  should  not  be  resorted  to  in  cases  in  which  croupous 
pneumonia  is  associated,  and  never  in  very  aged  and  excessively  feeble 
persons.  In  tuberculous  and  cancerous  pleurisy,  Achard  and  others 
advise  insufflation  of  unfiltered  air  as  a  harmless  means  of  allowing  a 
pleural  effusion  to  be  evacuated.  Achard  uses  an  ordinary  bicycle  or 
other  vacuum  pump  for  this  purpose. 

Holmgren  ^  recommends  blowing  out,  instead  of  aspirating,  pleural 
effusions.  Air  is  pumped  in  at  an  opening  above  to  take  the  place  of  the 
effusion  as  it  is  forced  out  below  by  the  pressure  of  the  instreaming  air. 
Davies^  has  used  oxygen  instead  of  air  for  the  replacement  of  the  fluid 
because  of  the  fact  that  it  is  absorbed  more  quickly  than  the  latter. 

(3)  To  Support  the  Strength  of  the  Patient. — The  powers  of  the  sys- 
tem are  to  be  maintained  by  a  nutritious  diet,  bodily  rest,  and  other 

'  Mitfeihmgen  aus  den  Grenzc/ebieten  rler  Med.  uxid  C'hii.,  Jena,  xxii.,  No.  2,  p.  173. 
2  Lancet,  London,  December  28,  1912. 


EMPYEMA.  597 

hygienic  measures.  The  lighter  forms  of  solid  food  may  be  allowed 
whenever  they  are  found  to  agree,  and  it  is  important  to  promote  the 
digestive  power,  if  weak,  by  the  administration  of  suitable  remedies. 
During  the  stage  of  convalescence,  therefore,  tonics  (strychnin,  quinin, 
and  arsenic)  arc  to  be  administered.  The  dietary  should  be  liberal, 
though  composed  of  wholesome  articles.  Gentle  exercise  in  the  open 
air  is  to  be  encouraged,  and  massage  of  the  muscles  of  the  affected  side 
tends  to  re-establish  their  usual  vigor.  To  bring  about  the  best  possible 
chest-expansion  nothing  is  so  good  as  light  gymnastic  exercises,  ttjgether 
with  the  methodical  practice  of  deep  inspirations  for  a  minute  or  two  at 
intervals  of  three  or  four  hours.  The  management  of  the  third  stage,  or 
that  of  convalescence,  is  similar  to  that  of  tuberculosis. 

EMPYEMA    (purulent   PLEURITIS). 

Definition. — A  suppurative  inflammation  of  the  pleura. 

Pathology. — On  opening  the  pleural  sac  after  death  we  may  find  a 
thick,  creamy  pus,  though  oftener  it  is  seropurulent  and  separated  into 
two  layers — an  upper,  clear,  greenish-yellow  serous,  and  a  lower,  thick, 
purulent  layer.  In  a  smaller  proportion  of  cases  the  exudate  is  fibrino- 
purulent.  The  odor  emitted  from  the  purulent  collection  is  either 
sweetish  or  fetid  (e.  g.,  when  due  to  wounds),  and,  when  the  condition  is 
associated  with  gangrene  of  the  lung  or  pleura,  horribly  oifensive. 
3IicrosGopically  the  inflammatory  products  are  identical  with  those  of 
purulent  inflammation  in  general.  The  pleural  membranes  are  the  seat 
of  a  more  intense  inflammation  than  in  acute  serofibrinous  pleurisy,  and 
are  greatly  thickened  (1  to  2  mm.).  They  present  a  granular  suppurating 
surface,  and  both  visceral  and  costal  pleurae  may  exhibit  perforations, 
and  the  latter,  often  erosions. 

Histologically,  the  altered  membranes  consist  of  new  connective  tis- 
sue, new  blood-vessels,  and  numerous  leukocytes. 

!]^iology. — The  following  are  the  chief  circumstances  under  which 
empyema  arises :  (1)  As  a  sequel  of  the  acute,  sero-fibrinous  variety. 
However  clear  the  effusion  may  be,  it  always  contains  corpuscular  ele- 
ments, which  in  the  further  progress  of  certain  cases  undergo  coincident 
increase  in  numbers  until  the  eff"usion  presents  a  milky  aspect,  when  it 
is  said  to  be  purulent.  Thoracentesis  may  be  responsible  for  this 
change,  though  never  if  performed  under  rigid  aseptic  precautions. 

(2)  In  children  the  eff'usion  early  becomes  purulent  in  many  instances. 

(3)  Secondary  to  the  acute  and  chronic  infectious  diseases — blood 
metastasis — (pyemia,  scarlatina,  pneumonia,  tuberculosis,  and  dysentery 
most  frequently  ;  typhoid  fever,  measles,  whooping-cough  rarely). 

(4)  Secondary  to  malignant  aff"ections  of  contiguous  organs  (lungs, 
esophagus),  or  tuberculous  cavities  which  perforate  the  pleura.  Rarely, 
carious  ribs  and  vertebrae  may  cause  empyema. 

(5)  Lymphatic  metastasis  is  probably  an  important  means  by  which 
bacteria  reach  the  pleura  from  neighboring  but  not  contiguous  tissues 
(McFarland). 

(6)  Injuries  to  the  chest  may  set  up  empyema  (fracture  of  the  ribs, 
stab  or  other  penetrating  wounds). 

Bacteriologic  investigation  has  shown  that  the  organisms  most  fre- 
quently present  are  the  micrococcus  lanceolatus  (ineta-pneumonia).  strep- 
tococcus, staphylococcus,  and  tubercle  bacillus.     The  cases  due  to  pneu- 


698  DISEASES  OF  THE  EESPIEATORY  SYSTEM. 

mococci  usually  pursue  a  favorable  course.     The  leptothrix  pulmonalis 
is  often  found  in  putrid  effusions. 

Clinical  History. — The  symptoms  vary  with  the  cause.  The  on- 
si't  may  be  characterized  by  acute  symptoms  (<'.  g.,  Streptococcus  Em- 
pyema), such  as  rigor,  followed  by  high  temperature  and  signal  prostra- 
tion, and  in  the  affected  side  there  may  be  severe  pains,  aggravated  by 
deep  breathing  and  bodily  movements. 

If  the  exudate  becomes  gangrenous,  a  typlioid  state  develops  early, 
and  the  case  is  apt  to  prove  fatal  in  the  course  of  a  few  weeks.  It  is 
quite  a  common  event  for  the  acute  symptoms  that  characterize  the  in- 
vasion to  be  replaced  at  the  end  of  a  week  or  more  by  the  more  obscure 
rational  symptoms  of  chronic  empyema.  The  latter,  however,  may  de- 
velop very  insidiously  as  a  secondary  affection.  The  rational  symptoms 
in  a  well-marked  case  should  always  excite  a  suspicion  of  the  presence 
of  the  affection,  but  cannot  settle  the  diagnosis.  The  local  symptoms 
(pain,  cough,  and  expectoration)  are  of  a  mild  character ;  dyspnea 
may  be  more  or  less  intense.  I  have  on  more  than  one  occasion 
found  an  utter  absence  of  these  symptoms.  The  general  symptoms 
are  those  of  septic  infection — diurnal  chills  occurring  at  irregular  in- 
tervals, followed  by  intense  paroxysms  of  fever  and  profuse  sweating — 
and  such  patients  lose  flesh  and  grow  pale  and  weak.  The  temperature 
is  higher  than  in  pleurisy  with  effusion  ami  is  intermittently,  though 
irregularly,  elevated. 

Peptonuria  is  a  symptom  of  purulent  pleurisy  that  is  not  without 
diagnostic  value.  It,  however,  also  occurs  in  suppuration  associated 
with  the  third  stage  of  pulmonary  tuberculosis,  and  in  suppuration  due 
to  other  causes.  While  not  indicative  of  empyema,  it  nevertheless  serves 
sometimes  to  eliminate  sero-fibrinous  pleurisy.  The  urine  also  contains 
indiean  in  excess  in  the  various  suppurations,  at  least  from  time  to  time, 
if  not  constantly.  Blood  examination  invariably  shows  leukocytosis, 
often  of  high  degree. 

If  the  pus  is  not  removed  artificially,  it  frequently  breaks  into  the 
lung,  penetrates  it,  and  finally  discharges  through  a  bronchus.  Pneu- 
mothorax now  tends  to  supervene.  Traube  contends  that  necrosis  of 
the  pulmonary  pleura  may  allow  of  the  soaking  of  the  pus  through  the 
spongy  lung-tissue  into  the  bronchi,  without  the  establishment  of  a  fis- 
tulous connection  between  the  latter  and  the  pleural  sac,  hence  without 
the  formation  of  pneumothorax.  E.  Smith's  figures  give  2<S  cases  of 
empyema,  of  which  3,  or  10.7  per  cent.,  showed  pleural  vomicae,  while 
James,  of  Edinburgh,  found  them  present  in  44.18  per  cent.  In  these, 
perforation  into  a  bronchus  has  occurred  with  expectoration  of  pus.  Lord 
states  that  it  is  a  complication  often  overlooked.  Besides  rupture  into  the 
lung  and  external  rupture,  empyema  may  perforate  neighboring  organs 
(esophagus,  pericardium,  stomach,  peritoneum).  In  rare  instances  the  pus 
burrows  along  the  spine  behind  the  peritoneum  and  the  psoas  muscle, 
reaching,  finally,  the  iliac  fossa  and  simulating  psoas  or  lumbar  abscess. 

Physical  Signs. — These  are,  for  the  greater  part,  identical  with  those 
of  pleurisy  with  effusion.  Attention  will  thei*efore  be  called  only  to 
such  as  are  more  or  less  distinctive  of  the  affection.  Slight  edema  of 
the  chest-Avall  over  the  seat  of  effusion,  especially  in  children,  is  often 
present,  and  if  the  pleural  sac  be  not  aspirated,  the  abscess  may  point 


EMPYEMA.  599 

externally  and  evacuate  itself  spontaneously.  In  the  latter  event  a  pro- 
trusion between  the  ribs  shows  itself:  this  may  be  the  seat  of  iiuctua- 
tion,  and  present  an  inflammatory  appearance  prior  to  its  rupture,  with 
subsequent  discharge  of  its  contents.  The  opening  ia  usually  found  in 
the  fifth  interspace  in  front,  and  less  frequently  in  the  third  and  fourth 
interspaces  or  below  the  angle  of  the  scapula  behind.  The  upper  level 
of  the  fluid  does  not  change  so  readily  on  varying  the  posture  of  the 
patient,  requiring  a  longer  period  of  time  than  in  serous  effusion. 

BacGellis  sign,  or  the  transmission  through  a  serous  exudate  of  the 
whispered  voice,  is  sometimes  an  aid  in  the  discrimination  of  pleurisy 
with  effusion  from  empyema.  According  to  my  own  observation,  though 
it  is  not  invariably  propagated  by  large  serous  exudations  of  the  pleura, 
it  is  yet  detectable  in  a  large  majority  of  instances,  while  I  have  never 
observed  it  in  empyema. 

Certain  writers  have  recently  emphasized  the  importance  of  recog- 
nizing small  collections  of  pus  in  the  pleural  cavity,  either  as  complica- 
tions or  sequelae  of  pneumonia,  scarlatina,  typhoid  fever,  and  other  infec- 
tions. Invasion  is  accompanied  by  a  rigor  only  in  cases  in  which  the 
infecting  organism  is  the  streptococcus.  The  temperature  is  irregularly 
elevated  or  distinctly  septic  in  character.  The  leukocyte  curve  rises 
promptly  as  a  rule.  Of  local  symptoms,  circumscribed  tendeiness  "  elicited 
by  pressure  of  the  finger,  and  at  first  deeply  seated,  suggests  both  the  fact 
of  abscess  and  its  location  "  (Musser).  The  physical  signs  of  circum- 
scribed effusion  are  to  be  sought  along  the  fissures  of  the  lobes  and  at 
the  bases.     A  friction-rub  is  usually  audible  in  the  earlier  stages. 

Pulsating  Pleurisy. — Pulsation  synchronous  with  the  cardiac  beat  in 
pleural  effusion  has  received  various  designations  (pulsating  empyema, 
empyema  necessitatis,  pulsating  'pleurisy).  The  latter  term  is  the  most 
appropriate  one,  in  view  of  the  fact  that  it  occurs  not  only  in  empyema 
necessitatis  but  also  in  empyema,  which  manifests  no  tendency  to  point 
externally  and  rarely  in  sero-fibrinous  pleurisy. 

Its  etiology  is  imperfectly  known.  The  principal  causes,  howev.er, 
seem  to  be — (1)  a  copious  effusion  ;  (2)  paresis  of  the  intercostal  muscles, 
inducing  relaxation  of  the  thoracic  wall ;  (3)  a  somewhat  forcible  heart- 
beat (Henry).  The  rational  symptoms  of  empyema  are  present.  The 
physical  signs  are  also  identical  with  those  of  the  latter  affection,  with 
the  pulsation  superadded.  There  are  instances  in  which  palpation  alone 
detects  the  systolic  pulse  in  the  pleural  effusion.  With  rare  exceptions 
the  effusion  occupies  the  left  pleural  sac.  The  pulsation  may  be  limited 
to  two  or  three  interspaces,  or  it  may  be  visible  over  the  entire  antero- 
lateral aspect  of  the  chest ;   pulsation  at  the  back,  however,  is  rare. 

DiflFerential  Diagnosis. — An  absolute  distinction  between  empy- 
ema and  pleurisy  with  effusion  rests  solely  upon  the  results  of  an  aseptic 
exploratory  puncture.  For  this  purpose  the  needle  attached  to  the  ordi- 
nary hypodermic  syringe,  or,  preferably,  the  surgeon's  exploring-needle, 
may  be  employed,  withdrawing  but  a  very  small  quantity  of  the  fluid, 
which,  if  purulent  in  character,  should  be  examined  bacteriologically. 

Pulsating  pleural  effusion  simulates  closely  aneurysm  of  the  thoracic 
aorta.  When  pulsation  occurs  in  empyema,  however,  it  is  seen  to  be  to 
the  left  of  the  normal  course  of  the  aorta :  the  rational  symptoms  and 
usual  physical  signs  of  purulent  pleural  effusion  are  usually  present  also. 


600  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

while  the  vascular  symptoms  and  signs  of  aneurysm  of  the  aorta  (thrill, 
bruit)  are  absent. 

Progrnosis. — Empyema  is  a  serious  disease,  but,  obviously,  the  out- 
look will  be  modified  by  the  special  etiology.  Spontaneous  absorption 
may  occur,  though  it  is  extremely  rare.  Rupture  into  the  bronchial 
tubes  is  a  comparatively  favorable  event,  some  cases  in  which  this  occurs 
recovering,  while  in  others  death  follows  in  consequence  of  the  sudden 
inundation  of  the  bronchi.  An  empyema  may,  in  rarer  cases,  empty 
itself  externally  with  favorable  issue  {empyema  necessitatis).  Evacu- 
ation of  the  pleural  cavity  is  often  followed  by  a  continuous  discharge 
of  pus  for  an  indefinite  period.  As  a  result  of  the  long-continued  sup- 
purative process,  death  may  take  place  by  slow  asthenia.  It  must  not 
be  forgotten,  however,  that  an  unfiivorable  termination  may  be,  in  part 
at  least,  ascribable  to  certain  associated  afi"ections  (phthisis,  pericarditis). 
Double  empyema,  fortunately  a  rare  condition,  is  exceedingly  grave. 

Among  children  the  outlook  is  much  more  favorable  than  among 
adults.  The  prognosis  has  been  rendered  less  serious  by  the  applica- 
tion of  surgical  principles  in  the  treatment  of  the  disease.  In  all  cases 
of  recovery  there  is  a  progressive  obliteration  of  the  pleural  cavity, 
owing  to  adhesions,  which  finally  become  universal  and  lead  to  marked 
retraction  of  the  affected  side  {pleuritis  retrahens). 

Treatment. — The  treatment  of  empyema  is  chiefly  surgical.  In 
a  child,  especially  in  empyema  following  pneumonia,  recovery  may 
follow  one  or  more  tappings.  In  the  vast  majority  of  cases,  how- 
ever, free  drainage  should  be  provided  at  the  earliest  possible  moment. 
The  pleural  sac  should  be  opened  in  the  fifth  or  sixth  interspace  in 
the  mid-axillary  line,  the  incision  being  from  2  to  3  cm.  in  length, 
and  if  this  affords  good  drainage,  nothing  more  is  needed.  Resection 
of  a  rib  (Estlander's  operation)  may  be  employed  in  long-standing  cases 
or  in  those  in  which  close  approximation  of  the  ribs  prevents  free 
drainage.  Opinions  are  divided  as  regards  the  value  of  irrigation  of 
the  pleural  cavity.  When  the  pus  emits  an  offensive  odor  irrigation  with 
a  disinfecting  solution  is  imperative.  Carbolic  acid  should,  however,  not 
be  used.  In  rare  instances  accidents  arise  during  irrigation  (sudden  col- 
lapse, convulsions),  and  I  have  observed  a  dangerous,  and  in  one  instance 
a  fatal,  collapse  as  the  result  of  irrigation  in  a  child.  For  further  details 
in  the  operative  treatment  of  empyema  the  reader  is  referred  to  text- 
books on  surgery.  Every  effort  should  be  made  to  favor  obliteration  of 
the  cavity  during  post-operative  treatment.  The  indication  is  to  bring 
about  the  best  possible  degree  of  re-expansion  of  the  compressed  lung, 
and  in  order  to  accomplish  this  the  method  advised  by  Ralston  James 
has  been  practised  with  great  success  in  the  surgical  wards  of  the  Johns 
Hopkins  Hospital.  The  patient  daily  for  a  certain  length  of  time,  in- 
creasing gradually  with  the  increase  of  his  strength,  transfers  water  by 
air-pressure  from  one  bottle  to  another.  The  bottles  should  be  large, 
holding  at  least  a  gallon  each,  and  by  an  arrangement  of  tubes,  as  in 
the  Wolff  bottle,  an  expiratory  effort  of  the  patient  forces  the  water 
from  one  bottle  into  the  other.  In  this  way  expansion  of  the  com- 
pressed lung  is  systematically  practised.  The  abscess-cavity  is  gradu- 
ally closed,  partly  by  the  falling  in  of  the  chest-Avall  and  partly  by  the 
expansion  of  the  lung.i  In  long-standing  cases,  in  which  the  lung  cannot 
'  Osier's  Text-book  of  Medicine,  p.  605. 


CHRONIC  PLKIJRISY.  601 

expand  on  account  of  thick  bands  of  adhesion,  the  pleural  layers  can- 
not be  brought  into  juxtaposition  without  more  or  less  sinking  in  of 
the  chest-wall.  De  Lorme's  operation  (stripping  the  pseudo-membrane 
from  the  compressed  lung)  may  be  advisable.  This  retraction  of  the 
thorax  is  probably  hastened  by  timely  resection  of  one  or  more  ribs,  the 
amount  of  bone  to  be  removed  depending  upon  the  "  expansive  power 
of  the  lung  and  elasticity  of  the  thorax."  The  small  collections  (pleural 
or  interlobar)  described  above  demand  prompt  drainage. 

The  duration  of  empyema  is  longer  than  in  pleurisy  with  effusion, 
and  the  former  affection  tends  to  exhaust  to  a  greater  degree  the  powers 
of  the  system  than  the  latter;  hence  the  physician's  attention  should  be 
directed  to  the  support  of  the  vital  forces  by  all  possible  agencies, 
modified  to  some  extent  by  the  special  etiology  of  the  case. 

CHRONIC   PLEURISY    (ADHESIVE   PLEURISY). 

Definition. — Chronic  inflammation  of  the  pleural  layers  — (a)  with 
effusion,  and  [b)  without  effusion. 

(a)  Chronic  Pleurisy  with  Effusion. — This  subvariety  may  follow  acute 
sero-fibrinous  pleurisy,  and  less  frequently  it  has  an  insidious  develop- 
ment. The  morbid  lesions,  including  the  character  of  the  exudate,  may 
also  be  identical  with  those  of  the  acute  or  subacute  forms  of  the  affec- 
tion. Fibrin  and  serum  are  present  in  varying  relative  proportions,  the 
latter,  however,  in  nearly  all  of  the  cases  preponderating  when  compared 
with  the  composition  of  the  exudate  in  acute  pleurisy.  The  secondary 
consequences  of  copious  acute  effusions  also  are  met  with — ^.  e.  displace- 
ment of  adjacent  organs  (liver,  spleen,  heart)  and  unilateral  dilata- 
tion of  the  chest.  When  the  fluid  is  either  absorbed  or  removed  and 
the  case  ends  in  recovery,  marked  contraction  of  the  affected  side  re- 
sults, since  the  lung,  which  is  covered  by  thick,  organized  bands  of 
adhesion,  cannot  re-expand.  Symptoms. — But  for  slight  dyspnea  upon 
muscular  exercise  the  subjective  symptoms  are  frequently  wanting.  The 
pulse  is  compressible  and  accelerated,  as  a  rule,  and  there  is  a  trifling 
rise  of  temperature  in  the  evening  hours.  If  the  effusion  becomes 
purulent,  hectic  fever  develops,  leading  to  asthenia,  and  the  latter  con- 
dition eventually  terminates  life.  Death  may  also  be  due  to  secondary 
suppurations  (abscess  of  brain,  etc.).  In  most  cases  occurring  in  chil- 
dren the  effusion  early  changes  to  pus.  The  physical  signs  do  not  differ 
from  those  in  acute  sero-fibrinous  pleurisy.  The  duration  of  the  cases 
yaries  from  three  months  to  several  years,  or  intercurrent  pulmonary 
tuberculosis  may  shorten  the  course  of  the  affection. 

(5)  Chronic  Dry  or  Adhesive  Pleurisy. — (1)  This  may  succeed  to  the 
acute  or  chronic  sero-fibrinous  pleurisy.  If  the  liquid  portion  of  the 
exudate  is  absorbed,  the  pleural  membranes  come  into  more  or  less  close 
apposition,  being  separated  only  by  fibrinous  elements  that  become 
organized  into  a  layer  of  firm  connective  tissue.  Hence  the  two  layers 
of  the  pleura,  that  are  greatly  thickened,  cannot  be  separated,  owing  to 
the  firmness  of  the  adhesions.  In  most  cases  the  autopsy  shows  the 
latter  condition  to  be  most  pronounced  at  the  base,  while  the  lung  is 
found  to  be  compressed  and  the  seat  of  fibroid  change.  If  it  follows 
the  acute   form,  the   extent  of  retraction  is  slight,  since   there   are  no 


602  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

dense  fibrous  bands  to  prevent  a  fair  degree  of  lung-expansion;  if  it 
succeed  the  chronic  form,  however,  or  empyema,  the  extent  of  retraction 
and  flattening  will  be  quite  marked.  The  exudate  may  undergo  cal- 
careous degeneration,  and  occasionally  little  pouches  of  fluid  may  be 
found  between  the  false  bands. 

There  is  a  large  class  of  cases  that  are  dry  from  the  onset  {idio- 
pathic dry  chronic  pleurisj/),  and  this  variety  may  either  be  a  sequel 
of  acute  plastic  pleurisy  or  primarily  tuberculous.  The  condition  is 
very  commonly  met  with  at  autopsy  in  subjects  who  during  life  had 
never  presented  symptoms  of  pleurisy  with  effusion.  The  plastic  exu- 
date, however  slight,  invariably  tends  to  become  organized,  with  result- 
ing fibrinous  adhesion  of  the  two  layers  of  the  pleura.  Most  generally 
the  adliesions  are  circumscribed,  and  if  tuberculous  in  origin  are  most 
frequently  apical  and  often  bilateral.  Under  these  circumstances  small 
caseous  masses  and  little  tubercles  may  be  found  embodied  in  the  some- 
what thickened  pleura.  General  synechia  is,  however,  not  rare,  par- 
ticularly unilateral. 

Sjimptoms. — Definite  rational  symptoms  are  rarely  present,  and  the 
physical  signs  lack  uniformity  or  may  be  entirely  negative.  In  other 
cases  of  a  mild  grade  the  main  characteri&f les  are  restrained  mobility  of 
the  affected  side  and  feebleness  of  the  respiratory  murmur.  In  rarer 
cases  the  weakness  of  the  breath-sounds  is  out  of  all  proportion  to  the 
expansive  motion  of  the  chest.  In  still  another  category — composed  of 
a  considerable  number  of  instances — certain  physical  signs  are  quite 
pronounced.  Inspection  reveals  decided  contraction,  with  immobility 
of  the  aff"ected  side  and  a  compensatory  distention  of  the  healthy 
side.  The  heart  is  displaced,  and  the  apex-beat  may  be  missing 
{e.  g.  when  the  heart  is  drawn  or  pushed  behind  the  sternum,  or  over- 
lapped by  the  emphysematous  lung).  The  spinal  column  is  curved,  the 
scapula  dislocated,  the  shoulder  ill-shapen  and  drooping,  and  the  lower 
part  of  the  thorax  shrunken,  Avhile  the  ribs  are  obliquely  placed  and 
closely  approximated,  or  even  overlap  one  another.  The  tactile  fremitus 
is  decreased  or  absent  over  the  lower  portion  of  the  chest,  and  there  is 
impaired  percussion-resonance  or  dulness  over  this  area.  The  breath- 
sounds  on  auscultation  are  exceedingly  feeble,  and  in  some  cases  an  occa- 
sional dry,  leathery,  or  creaking  friction-sound  is  audible. 

Rarely,  and  particularly  if  the  case  be  tuberculous,  vasomotor  symp- 
toms arise  in  chronic  pleurisy,  such  as  unilateral  flushing  or  sweating  of 
the  face,  or  dilatation  of  the  pupil. 

Doubtless  some  instances  of  chronic  pleurisy  merge  into  the  pleuro- 
genous  type  of  cirrhosis  of  the  lung,  and  fatal  complicating  conditions 
may  arise  in  connection  with  the  general  circulation.  Thus,  I  have  ob- 
served in  one  instance  enlargement  followed  by  dilatation  of  the  right 
ventricle,  and  in  turn  by  general  dropsy,  with  fatal  result. 

Treatment. — In  the  treatment  of  this  aff'ection  two  objects  must 
receive  especial  attention  :  (1)  the  removal  of  any  eff'usion  that  may  be 
present ;  and  (2)  the  improvement  of  the  nutrition  of  the  patient.  The 
first  indication  is  presented  only  by  a  limited  number  of  the  cases,  and 
the  rules  for  meeting  it  have  been  stated  in  the  treatment  of  sero-fibrin- 
ous  pleurisy  and  empyema  ;  the  second  indication  is  presented  by  all 
cases.      Careful  regulation  of  the  diet  is  of  the  utmost  importance :  it 


PNE  UMO  TJIORA  X.  603 

must  be  generous,  with  modifications  to  suit  special  diatliesos  (as  the 
gouty  or  tuberculous),  if  they  be  present.  Lunf.^-gyrnriastics  are  most 
useful  if  methodically  pur;sued.  The  method  of  llalston  James  (pre- 
viously described)  richly  deserves  a  trial  in  suitable  cases.  It  is  to  be 
borne  in  mind,  however,  that  in  old  cases  efforts  at  overcoming  the 
lung-pressure  will  be  unsuccessful.  Climato-therapy  is  advantageous, 
particularly  if  a  tendency  toward  tuberculosis  exists  ;  and  in  my  own  ex- 
perience low,  mountainous  elevations  combined  with  purity  of  atmosphere 
have  given  the  best  results.  Of  medicines  little  need  be  said.  It  is 
especially  important  to  promote  the  digestive  power  of  the  patient  to  the 
greatest  possible  extent.  In  cases  in  which  the  digestive  function  has 
been  feeble  I  have  observed  excellent  results  from  a  brief  stay  at  any 
well-regulated  seaside  resort  or  in  the  country.  We  may  also  use,  with  a 
probability  that  the  effect  will  be  beneficial,  small  doses  (.5J — 4.0j  of  cod- 
liver  oil,  three  times  daily  after  food,  or  the  following  formula  : 

i^.  Acidi  hydrochlorici  dil.,  sijss  (10.0); 

Pepsini  pur.,  3ij     (8.0) ; 

Tinct.  nucis  vom.,  3iss   (6.0) ; 

Glycerini,  3iss  (46.0); 

Aquae,  q.  s.  ad  lij    (64.0).— M. 

Sig.  3j  (4.0),  well  diluted,  ten  minutes  after  each  meal. 

Intercurrent  catarrh  of  the  stomach  may  sooner  or  later  become  a 
troublesome  feature,  and  in  combating  it  lavage  is  frequently  our  most 
effective  measure. 


PNEUMOTHORAX. 

( Sero-pneumothorax  ;  Pyo-pneumothorax.) 

Definition. — A  collection  of  air  in  the  pleural  cavity.  Since  the 
latter,  as  a  rule,  contains  at  the  same  time  serum  or  pus,  the  terms  sero- 
and  pyo-pneumothorax  are  frequently  employed  to  describe  the  same 
condition.     It  is  an  uncommon  condition. 

Pathology. — When  the  pleural  sac  is  punctured  air  usually  escapes, 
accompanied  sometimes  by  an  audible  hissing  sound.  The  pleural  sac 
in  pure  pneumothorax  is  greatly  distended,  and  the  lung  is  impacted 
against  the  spinal  column.  Other  organs  (spleen,  heart)  are  also  dis- 
placed, owing  to  positive  intrathoracic  pressure.  The  heart  is  not  ro- 
tated, however,  and  the  relation  of  its  parts  is  maintained  much  as  in 
the  normal  condition  (Osier).  The  air  may  occupy  but  a  portion  of  the 
pleural  cavity,  on  account  of  previous  firm  adhesions  {circumscribed 
pneumothorax).  The  point  of  perforation,  as  a  rule,  can  be  easily 
found,  and  frequently  corresponds  to  the  seat  of  rupture  of  the  tuber- 
culous cavity  or  superficial  caseous  mass.  In  other  instances  the  cause 
of  pneumothorax  cannot  be  discovered.  Inflation  of  the  lung  under 
water  may  reveal  the  aperture,  which  is  usually  small,  by  the  escape  of 
air-bubbles  at  the  seat  of  puncture.  Occasionally  a  fistulous  connection 
between  the  pleural  sac  and  the  bronchi  can  be  traced. 


604  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Simple  pneionotltorax  is.  however,  of  rare  occurrence.  The  air  thai 
gains  admission  into  the  pleural  sac  is  laden  with  micro-organisms  {vide 
Bacteriology,  p.  580),  which  set  up  various  forms  of  inflammation,  ac- 
companied by  equally  various  exudations.  Hence  the  cavity  is  usually 
filled,  in  part,  with  an  eft'usion  that  is  purulent  or  sero-purulent,  as  a  rule, 
and  rarely  serous  or  sero-fibrinous.  The  gas  in  cases  of  pneumothorax 
may  be  of  bacterial  origin ;  this  contains  substances  not  found  in  air, 
such  as  H.  H2S,  or  marsh-gas. 

Htiolog"y. — Tlu'  jirc disposing  influences  are — (a)  ac/e — the  condi- 
tion occurring  in  adults,  as  a  rule,  though  instances  are  also  observed 
in  young  children  :  (b)  scr — males  suffer  more  than  females ;  (f)  the 
left  side  is  affected  nearly  twice  as  often  as  the  right;  (d)  em- 
physema^ in  which  the  superficial  air-sacs  are  dilated  and  atro- 
phied, and  80  rendered  liable  to  rupture  from  excessive  muscular 
exertion. 

The  exciting  causes  are — (1)  Perforation  of  the  lung  and  pulmo- 
nary pleura  (the  most  frequent  cause),  arising  in  one  or  other  of  three 
ways  :  (a)  From  the  rupture  of  a  tuberculous  cavity  into  the  pleural  cav- 
ity. This  accident  rarely  occurs  at  the  apex  of  the  lung,  but  commonly 
near  the  upper  border  of  the  lower  or  middle  lobe ;  less  frequently  near 
the  lower  border  of  the  upper  lobe.  A  caseous  focus  immediately  be- 
neath the  pleura  may  also,  during  the  process  of  softening,  puncture 
the  pleural  sac  and  invite  the  entrance  of  air  during  the  early  stages. 
It  cannot  occur,  however,  except  in  cases  in  which  previous  adhesions 
have  failed  to  form  at  the  point  of  perforation.  At  least  70  per  cent,  of 
the  cases  of  pneumothorax  are  tubercular  (Morse )}  (b)  As  the 
result  of  necrotic  processes,  in  connection  with  certain  other  lung- 
affections,  as  gangrene,  broncho-pneumonia,  suppurating  bronchial 
glands,  abscess,  and  echinococcus  cysts,  (c)  From  rupture  of  the  normal 
air-sacs  in  consequence  of  severe  muscular  effort  (S.  West,  DeH.  Hall). 
This  accident  is  sometimes  ascribable  to  the  violent  paroxysms  of  cough 
in  pertussis. 

(2)  Some  cases  of  empyema,  by  perforating  the  visceral  pleura,  the 
lungs,  and  bronchi. 

(3)  Perforations  of  the  pleura  in  malignant  disease  and  abscess  of  the 
esophagus. 

(4)  A  peripheral  bronchiectasis  may  open  the  pleural  space. 

(5)  Pyo-pneumothorax  may  be  of  subdiaphragmatic  origin,  consec- 
utive to  perforation  by  malignant  disease  or  ulcer  of  the  stomach  or 
colon. 

(6)  Pneumothorax  may  be  occasioned  by  gases  resulting  from  the 
action  of  a  gas-forming  bacterium  on  the  pleural  exudate. 

(7)  Wounds  causing  direct  or  indirect  perforative  lesions  of  the 
lungs.  Fractures  of  the  ribs  may  produce  laceration  of  the  visceral 
pleura,  and  allow  the  air  to  enter  the  pleui-al  sac. 

Symptoms. — The  earliest  symptoms  vary  according  to  the  cause  or 
causes  that  produce  the  condition.  When  it  develops,  as  it  does  so 
often,  in  the  course  of  pulmonary  tuberculosis,  the  onset  is  sudden, 
marked  by  agonizing  pain  in  the  side,  by  intense  dyspnea,  and  frequently 
cyanosis.  The  dyspnea  is  often  accompanied  by  a  sense  of  impending 
^American  Journal  of  Medical  Sciencefi,  May,  1900. 


PNE  UMOTHORA  X. 


m 


suffocation.  The  severity  of  the  pain  and  the  degree  of  oppression 
depend  largely,  however,  upon  the  amount  of  air  that  gains  entrance 
into  the  pleural  sac  or  is  formed  from  the  exudate,  tlie  rapidity  with 
which  it  enters,  and  the  presence  or  absence  of  previous  pl(;uritio  ad- 
hesions. If  the  orifice  be  large  and  valvular,  the  air  cannot  escape,  but 
rapidly  accumulates  and  forces  all  the  air  out  of  the  lung  by  compression  ; 
the  patient  then  sinks  rapidly  into  collapse  from  shock,  and  sudden  death 
ensues.     Fortunately,   the    open   form   is  commoner,   especially  in  non- 


FiG.  49.-1.  Air  in  the  pleural  sac;  2,  fluid  exudate  at  base  of  pleural  sac;  3,  compressed  portion 
/     of  lung;  4,  displaced  heart;  5,  depressed  spleen;  6,  mediastinum  pushed  toward  the  right. 

tuberculous  pulmonary  affections.  The  respirations  are  frequent :  the 
pulse  is  also  frequent  and  feeble,  sometimes  reduced  to  a  thread ; 
and  cold  sweats  are  not  uncommon.  The  temperature  at  first  is  apt 
to  fall  one  or  two  degrees  below  the  normal,  owing  to  sudden  collapse  : 
fever^  however,  follows  almost  invariably,  and  frequently  is  of  the 
hectic  type.  Its  cause  is  pleuritis,  often  purulent,  and  if  this  be  the 
case,  the  dyspnea  may  be  due  in  part  to  the  increasing  effusion.  The 
patient  now  also  suffers  from  the  grave  symptoms  of  empyema  above 
described.     Edema  of  the  hand  of  the  affected  side  is  sometimes  present 


606  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

as  an  early  manifestation  :  it  rapidly  <lisappears  (Weil).  When  pneumo- 
thorax develops  in  the  last  stages  of  phthisis  acute  symptoms  may  be 
entirely  absent. 

Physical  Signs. — These  are  marked  (see  Fiij.  49),  although  rarely  they 
may  be  in  abeyance  for  several  days  (masked  pneumothorax).  Inspection 
shows  marked  distention  and  immobility  of  the  afi'ected  side ;  also  some 
degree  of  distention  Avith  unnatural  mobility  of  the  healthy  side. 

JRaJpation  shows  the  tactile  fremitus  to  be  diminished  above  and 
greatly  diminished  or  -wholly  absent  over  the  effusion  below.  Edema  of 
the  chest-wall  can  frequently  be  made  out.  The  impulse-beat  of  the 
heart  is  found  to  be  feeble  and  displaced. 

On  percussion  a  deep  and  full,  or  modified  tympanitic  note  {hcU-tym- 
pant/)  can  usually  be  elicited  over  the  area  corresponding  tc  the  contained 
air,  and  the  excessive  tension  in  the  pleural  sac,  due  to  the  enormous 
amount  of  air  it  contains,  may  cause  an  elevation  in  the  pitch  of  the 
note  even  to  dulness.  The  "  cracked-pot "  sound  is  audible  when  the 
air  in  the  pleural  cavity  freely  communicates  with  the  external  air. 
Wintrich's  sign,  or  a  change  in  the  pitch  of  the  percussion-sound  when 
the  mouth  is  open  or  closed  (being  lowered  when  the  mouth  is  closed  and 
raised  when  open),  may  also  be  observed.  In  pyo-pneumothorax  a  flat 
note  is  elicited  from  the  base  upward  as  far  as  the  fluid  extends,  and 
change  of  posture  causes  a  more  marked  temporary  variation  in  the  upper 
level  of  flatness  than  occurs  in  pleurisy.  Modifications  in  the  pitch  of  the 
percussion-sound  result  from  an  alteration  in  the  form  as  well  as  in  the 
dimensions  of  the  air-space.  Owing  to  displacement  of  the  heart,  there 
is,  as  a  rule,  resonance  over  the  normal  cardiac  region,  and  particularly 
■when  the  patient  assumes  a  recumbent  posture.  The  liver  and  spleen, 
according  to  the  side  affected,  are  displaced  downward  to  a  greater 
degree  than  in  simple  pleuritic  exudates. 

Auscultation  discloses  a  greatly  weakened  or  altogether  suppressed 
respiratory  murmur  when  collapse  of  the  lung  is  incomplete.  Amphoric 
breathing  is  audible  in  cases  of  open  pneumothorax,  and  bronchial  rales 
possessing  a  metallic  quality  are  sometimes  heard,  as  well  as  metallic 
tinkling  on  deep  inspiration  or  on  coughing.  Th.e  metallic  tinkling  is 
caused  frequently  by  drops  of  fluid  falling  from  above  upon  the  surface 
of  the  effusion  ;  less  frequently  by  a  re-echoing  of  vibrations  of  moist 
bronchial  rales  communicated  to  the  air  in  the  pleural  chamber.  The 
vocal  resonance  is  enfeebled,  as  a  rule,  and  evinces  the  same  metallic 
quality.  The  so-called  coin-test  is  a  pathognomonic  sign,  and  is  elicited 
in  the  following  manner :  An  assistant  places  one  coin  on  the  front  of 
the  chest  and  taps  it  with  another  while  the  ear  of  the  examiner  is 
placed  on  the  thorax  posteriorly,  where  will  be  heard  the  intensified  echo 
of  the  coin-sound  thus  produced.  Another  most  characteristic  sign  is 
the  so-called  Hippocratic  succussion,  which  is  elicited  by  placing  one 
ear  upon  the  patient's  chest  while  the  latters  body  is  shaken,  when  a  dis- 
tinct splashing  sound  is  heard. 

Diagnosis. — When  the  attack  is  of  ordinary  severity,  pneumo- 
thorax is  diagnosticated  by  the  history  of  one  or  other  of  the  causal 
factors,  together  with  certain  physical  signs  that  do  not  belong  to  any 
other  affection  {coin-sound,  succussion -splash).  The  sputum  test  and  also 
bacteriologic  study  of  the  aspirated  purulent  exudate  with  a  view  to  deter- 


PNEUMOTHORAX.  607 

mining  the  special  etiologic  variety  present  in  a  given  case  is  of  the 
greatest  importance.  It  is  only  when  the  air  and  fluid  in  the  pleural  sac 
are  encapsulated  that  it  may  become  difficult  to  eliminate  (a)  a  large  pul- 
monary cavity ;  (Jj)  excessive  gaseous  distention  of  the  stomach ;  (cj  an 
abscess  below  the  diaphragm  into  which  air  has  entered  {f)yopnei.irno- 
tlwrax  suhphrenicus)  ;  [d)  a  diaphragmatic  hernia;  {e)  emphysema;  and 
(/)  pleurisy  with  effusion. 

(a)  A  Large  Pulmonary  Cavity. — The  "cracked-pot  sound"  and 
Wintrich's  sign  are  more  frequent  in  cavity  than  in  pneumothorax, 
and  the  former  condition  does  not  tend  to  dislocate  the  adjacent 
organs.  There  is  an  absence  of  the  succussion-splash,  and,  except  in 
rare  instances  of  the  coin  test,  these  signs  are  often  present,  even  in  cir- 
cumscribed pyopneumothorax.  Tabulated,  these  points  of  difference 
are — 

Pyo-pneumothorax.  Largk  Pulmonary  Cavity. 

Immobility   and    bulging   of    the   inter-       Immobility,  flattening  of  the  chest,  and 
spaces.     The  apex-beat  is  usually  dis-  depression  of  the  interspaces.     Apex- 

placed,  beat  not  displaced. 

Diminished  vocal  fremitus.  Fremitus  usually  increased. 

Percussion-note  deep  and  full.    The  effu-       Percussion  gives  tympany  or  a  "cracked- 
sion  sinks  to  the  base,  and  yields  fliat-  pot  sound,"  and  Wintrich's  change  of 

ness,  the  outline  of  which  changes  with  sound  as  a  rule. 

the  posture  of  the  patient. 
Respiratory  murmur  and  vocal  resonance       Bronchial   breathing   is   heard,  and  the 
usually  absent.     Amphoric  breathing  vocal  resonance  is  increased.     Crack- 

may  be  heard  if  the   opening  in  the  ling,  gurgling  rales,  cavernous  or  am- 

lung  is  patulous.     The  coin-sound  and  phoricbreathing,and  pectoriloquy  may 

Hippocratic     succussion  -  splash      are  be  present.     Absence  of  bell-tympany 

noted.  (generally)  and  succussion-splash. 

(h)  Excessive  gaseous  distention  of  the  stomach  is  to  be  eliminated  by 
the  history  of  the  case  and  by  the  results  of  the  application  of  the  thera- 
peutic test,  evacuation  of  the  stomach  and  bowels. 

(t-)  Subphrenic  Abscess  Containing  Air. — This  is  exceedingly  rare, 
and  occurs  relatively  oftener  on  the  right  than  on  the  left  side  (Leyden). 
Its  leading  causes  are  ulcers  of  the  stomach  or  duodenum,  followed  by 
circumscribed  peritonitis,  perforation,  and  abscess,  the  latter  occupying 
a  position  immediately  beneath  the  diaphragm  and  above  the  liver.  The 
gases  that  gain  admission  to  the  abscess-sac  from  the  intestines  force 
the  diaphragm  upward,  and  thus  cause  retraction  or  even  compression 
of  the  lung.  The  symptoms  are  now  identical  with  those  of  circum- 
scribed pyo-pneumothorax,  limited  to  the  base.  A  knowledge  of  the 
steps  in  the  production  of  subphrenic  abscess ;  the  absence  of  cough 
and  expectoration,  and  of  marked  displacement  of  the  heart;  and  the 
presence  of  bulging  of  the  hypochondrium,  of  striking  depression  of  the 
liver,  and  of  Pfuhl's  sign  {q.  v.\  are  indications  favoring  subphrenic 
abscess. 

{d)  Diaphragmatic  Hernia. — This  either  results  from  a  severe  injury 
or  is  congenital,  and  the  most  valuable  point  of  difference  between  hernia 
of  the  diaphragm  and  pneumothorax  is  the  peculiar  cause  of  the  former. 
The  next  most  valuable  point  is  the  fact  that  the  hernial  protrusion  may 
return  suddenly  to  its  normal  position,  whereupon  the  patient  will  be  re- 
lieved ;  the  condition  may  then  reappear  not  less  suddenly.     The  third 


608  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

distinctive  feature  is  the  presence  of  rumbling  sounds  in  the  protruded 
bo^vel.  All  other  signs  and  symptoms  of  one  affection  may  have  their 
counterparts  in  those  of  the  other. 

(f)  Pneumothorax  may  be  confounded  with  emphyseiita  by  the  care- 
less observer ;  but  the  latter  affection  is  slow  in  onset,  free  from  serious 
shock,  is  bilateral  as  a  rule,  and  does  not  exhibit  the  distinctive  physical 
signs  of  pneumothorax  (metallic  tinkling,  coin-sound,  succussion-splash). 
In  pleurisi/  'nth  effu.v'on  hyper-resonance  may  be  noted  above  the  fluid, 
but  it  lacks  the  bell-like  tympany  of  pneumothorax.  Over  the  same 
area  there  is  diffuse,  distant,  bronchial  breathing  (at  times  slightly  am- 
phoric). Avhilst  the  metallic  tinkling,  coin-sound,  and  succussion-splash 
are  totally  wanting. 

Prognosis. — This  depends  largely  upon  the  cause.  The  cases  at- 
tributed to  advanced  phthisis  usually  reach  a  fatal  issue  in  the  course 
of  one,  two,  or  more  weeks,  and  rarely  they  run  a  very  rapid  and  fatal 
course.  On  the  other  hand,  the  pulmonary  condition  is  at  times  favor- 
ably influenced  by  its  occurrence.  Following  empyema,  or  when  due  to 
trauma  or  abscess  of  lung,  pneumothorax  sometimes  takes  a  favorable 
course.  It  is  fraught  with  especial  danger  when  it  is  the  resultant  con- 
dition of  some  acute  lung  disease  (gangrene,  broncho-pneumonia).  The 
prognosis  is  worse  in  right-sided  pneumothorax. 

Treatment. — The  leading  indication  is  the  alleviation  of  the  pa- 
tient's sufferings  by  a  prompt  resort  to  morphin,  and  it  often  becomes 
necessary  to  administer  it  hypodermically.  If  the  patient's  previous 
strength  has  been  moderately  good,  the  question  of  operative  interven- 
tion should  be  seriously  considered,  the  nature  of  the  surgical  proced- 
ure then  depending  upon  the  character  of  the  effusion.  If  this  be  sero- 
fibrinous, aspiration,  as  in  simple  pleurisy,  must  be  performed  to  relieve 
the  urgent  dyspnea ;  if  purulent,  permanent  drainage  should  be  pro- 
cured for  the  same  indication.  A  costal  resection  may  be  advis- 
able. When  pneumothorax  develops  late  in  phthisis  radical  measures 
are  not  to  be  thought  of,  and  the  physician  must  rely  upon  aspira- 
tion (when  necessary)  to  relieve  urgent  symptoms.  We  may  also  tap 
the  air-chamber  above  the  fluid  with  a  fine  needle,  with  a  view  to  lessen- 
ing the  excessive  tension.  Unverricht  has  recently  reported  good  results 
from  a  somewhat  novel  mode  of  treatment.  When  there  is  a  pulmonary 
fistula  present,  he  inserts  a  tube  into  the  pleural  sac.  This  allows  free 
entrance  of  air,  the  lung  collapses  completely,  and  the  fistula  has  a 
chance  to  heal.  For  the  dyspnea,  atropin  administered  hypodermically 
is  valuable ;  for  the  feeble  cardiac  action,  alcoholic  stimulants,  aromatic 
spirits  of  ammonia,  strychnin,  ether,  and  other  cardiac  stimulants  should 
be  employed.  Locally,  cutaneous  irritants  may  be  applied  (turpentine 
stupes,  mustard  pastes). 


HYDROTHORAX. 

{Dropsy  of  the  Pleura;   Thoracic  Dropsy.) 

Definition. — A  collection  of  transuded  serum  in  the  pleural  cavity. 

Pathology. — Hydrothorax  is  generally  a  bilateral  condition.  The 
transudate  is  a  clear,  amber-colored  liquid  that  is  free  from  fibrin,  but 
may  contain  cholesterin  and  a  few  endothelial  cells.     It  has  an  alkaline 


NEW  OROWTJIS   OF  THE  PLEURA.  609 

reaction,  a  comparatively  low  specific  gravity  (1009  to  1012),  iirid  is  non- 
inflammatory. The  pleural  surfaces  are  usually  smooth,  though  some- 
times decidedly  pale  and  edematous.  The  mechanical  effects  of  hydro- 
thorax  upon  the  lungs  and  other  thoracic  and  abdominal  viscera  are 
similar  to  those  of  the  exudiites  that  accompany  inflammation  of  the 
pleura,  though  they  are  rarely  so  marked  as  in  sero-fibrinous  pleurisy. 

il^tiology. — Hydrothorax  is  a  secondary  affection,  and  is  usually 
connected  with  one  or  other  of  the  various  forms  of  general  dropsy 
(hemic,  renal,  cardiac).  The  cases  that  are  due  to  blood-impoverish- 
ment are  more  numerous  than  is  generally  indicated  by  writers  upon  the 
subject,  and  not  infrequently  is  hydrothorax  secondary  to  either  chronic 
dysentery,  chronic  diarrhea,  leukemia,  pernicious  anemia,  carcinoma, 
malaria,  syphilis,  or  scurvy.  Strictly  local  causes  may  also  induce  it,  as 
carcinoma  of  the  pleura,  or  the  compression  of  the  superior  vena  cava  or 
of  the  thoracic  duct  by  a  tumor.  Fetterolf  and  Landis  have  demon- 
strated that  the  fluid  comes  from  the  visceral,  and  not  the  parietal, 
pleura,  including  the  azygos  veins. 

Sytnptoms. — The  subjective  symptoms  are  attributed  to  the  mechan- 
ical effects  of  the  fluid,  and  may  be  quite  in  common  with  those  of  the 
causal  affection ;  these  are  dyspnea  (often  culminating  in  orthopnea), 
cyanosis,  asthmatic  seizures.,  irritative  coughs  and  a  feeble  circulation. 
The  general  symptoms  arise  from  the  primary  affection. 

Physical  Signs. — The  physical  signs  are  much  the  same  as  in  pleu- 
risy with  effusion — with  this  difference,  that  they  are  more  often 
bilateral.  Hydrothorax  is  often  unilateral,  however,  and  an  enlarged 
right  auricle  may  be  the  cause  of  this  condition  in  some  instances. 
The  right  side  is  the  one  usually  affected.  I  have  also  observed  that 
quite  frequently  the  two  sides  of  the  chest  exhibit  great  variations  as 
to  the  relative  amount  of  fluid  contained.^ 

Prognosis. — This  depends  upon  the  nature  of  the  primary  disorder 
that  causes  the  dropsical  transudation. 

Treatment. — The  treatment  of  hydrothorax  has  intimate  relations 
with  the  indications  presented  by  the  underlying  affection.  If  the 
measures  directed  toward  the  removal  of  the  general  dropsy  (anasarca), 
of  which  hydrothorax  is  a  part,  are  unsuccessful,  and  the  amount  of 
transudation  in  the  pleural  sac  interferes  with  the  functions  of  the  heart 
and  lungs,  then  aspiration  must  not  be  too  long  delayed,  and  must  be 
repeated  as  often  as  occasion  demands. 


NEW  GROWTHS  OF  THE  PLEURA. 

Almost  all  instances  of  new  growths  developing  in  the  pleura  are 
secondary  to  primary  carcinoma  of  the  lung,  the  pleura  being  invaded 
by  the  direct  extension  of  the  neoplasm.  It  may  also  arise  by  meta- 
stasis from  carcinoma  of  the  lung,  mammary  glands,  etc.  The  pleura 
presents  circumscribed  areas  of  thickening,  or  the  growth  takes  the  form 
of  papular  projections  from  its  surface,  becoming  pedunculated  as  they 
enlarge.  Their  size  varies  from  that  of  a  pea  to  that  of  an  orange.  The 
adjacent  pleura  is  inflamed,  often  adherent,  and  much  thickened,  and  an 
effusion  into  the  pleural  cavity  is  often  observed. 

^  For  the  differential  diagnosis  between  pleurisy  and  hydrothorax,  see  Pleurisy,  p.  593. 
39 


010  DISEASES  OF  THE  RESPIEATORY  SYSTEM. 

Primary  carcinoma  9f  the  pleura  is  very  rare  indeed,  and  E.  War- 
ner, "vvho  first  described  it,  called  it  endothelial  carcinoma.  Most  pa- 
tbolosfists  of  to-day.  however,  look  upon  endothelioma  as  a  variety  of 
sarcoma.  It  owes  its  orgin  to  a  proliferation  of  the  endothelial  cells  of 
the  connective  tissue  and  the  lymph-apparatus  of  the  pleura.  This  in- 
variably assumes  the  diffuse  form,  and  by  metastasis  we  have  involve- 
ment of  the  other  organs  (lungs,  lymphatics,  liver). 

Spindle-cell  sarcoma  of  the  pleura,  as  well  as  the  round-cell  variety, 
is  occasionally  met  with. 

Symptoms. — The  subjective  symptoms  are  slight  in  cases  in  which 
there  is  a  single  circumscribed  carcinomatous  mass  in  the  pleura;  but 
they  are  quite  severe  in  the  diffuse  form,  particularly  when,  as  com- 
monly occurs,  it  is  of  a  secondary  nature.  The  symptoms  are  now 
those  of  plastic  or  sero-fibrinous  pleurisy,  in  addition  to  those  of  pri- 
mary carcinoma  of  the  lung,  and  the  former  may  oftentimes  more  or 
less  completely  overshadow  the  latter. 

Diagnosis. — The  circumstances  under  which  the  condition  arises 
often  throw  the  strongest  light  upon  its  nature.  The  symptoms  of 
slowly  developing  pleurisy,  either  plastic  or  sero-fibrinous,  following 
carcinoma  of  the  lung  or  the  breast,  and  accompanied  by  the  cancerous 
cachexia,  would  point  strongly  to  the  existence  of  carcinoma  of  the 
pleura.  Characteristic  cancerous  elements  may  also  be  found  by  micro- 
scopic examination  of  the  usually  hemorrhagic  fluid  obtained  on  aspira- 
tion. The  exudate  contains  fiitty  endothelial  cells.  Mitotic  figures  in 
cells  of  serous  exudates  are  of  confirmatory  diagnostic  value. 

The  difficulties  surrounding  the  diagnosis  of  primary  carcinoma  of 
the  pleura  are  great  and  usually  insurmountable.  The  cases  are  very 
similar  in  their  clinical  manifestations  to  chronic  pleurisy  with  or  without 
effusion.  Pain  is  always  a  more  prominent  symptom,  however,  than  in 
simple  chronic  pleurisy,  and  this  fact,  when  combined  with  evidences  of 
a  cancerous  cachexia,  should  excite  strong  suspicions. 

The  prognosis  is  wholly  unfavorable,  and  the  treatment  merely 
palliative. 


DISEASES  OF  THE  MEDIASTINUM. 

The  affections  of  the  mediastinum  may  be  divided  into  three  classes : 
((/)  Inflammation,  {b)  Tumors,  and  (e)  Mediastinal  hemorrhage. 

(a)  Inflammation. — ^his  may  affect  (1)  the  glands  or  (2)  the  connec- 
tive tissue.  Lymphadenitis  of  moderate  grade  is  found  in  association 
with  broncho-pneumonia  and  the  various  forms  of  bronchitis.  The  con- 
dition appears  in  its  most  pronounced  form  in  the  bronchitis  of  measles, 
influenza,  and  whooping-cough,  and  De  Mussy  held  that  enlargement 
of  the  glands  in  the  posterior  mediastinum  is  potent  in  exciting  parox- 
ysms of  whooping-cough.  According  to  De  Mussy  and  Guitdras,  these 
glands  when  greatly  enlarged  give  rise  to  dulness  in  the  upper  part  of 
the  interscapular  region  or  down  to  the  fourth  dorsal  vertebra  in  cases 
of  influenza  and  Avhooping-cough.  I  have,  moreover,  been  able  to  con- 
firm this  dictum   in  cases  of  influenza,  though  aware  of  the  fact  that 


DISEASES  OF  THE  MEDIASTINUM.  611 

many  authorities  consider  it  questionable.  Tuberculous  lymphadenitis 
is  elsewhere  described  {vide  Tuberculosis,  page  248j.  'J^he  mediastinal 
lymph-glands  may  undergo  suppuration  in  consequence  of  local  specific 
infection,  and  though  not  recognizable  during  life,  the  condition  may 
lead  to  perforation  into  either  the  esophagus  or  a  bronchus,  with  serious 
results.  In  other  instances  spontaneous  absorption  occurs,  leaving  behind 
inspissated  contents  that  undergo  calcareous  change. 

Abscess  of  the  Mediastinum. — This  is  of  rare  occurrence,  its  most 
frequent  seat  being  the  anterior  mediastinum.  Of  the  commoner  causes 
may  be  mentioned  traumatism  and  the  infectious  diseases — erysipelas, 
rheumatism,  measles,  and  small-pox  in  particular.  It  may  also  be  the 
result  of  an  extension  of  a  suppurative  process  from  neighboring  struc- 
tures. Pulmonary  tuberculosis  is  the  most  potent  factor  in  producing 
chronic  abscess  in  this  situation. 

Symptoms. — Acute  Abscess. — Pain  and  tenderness  in  the  sternum 
are  the  most  prominent  features,  the  pain  being  acute  and  often  of  a 
throbbing  character.  Cough  and  dyspnea  are  usually  present.  The 
general  features  are  fever,  frequently  accompanied  by  rigors,  profuse 
sweats,  and  prostration.  The  chief  physical  sign  is  dulness  upon  per- 
Gussion,  usually  found  anteriorly  and  increasing  gradually  with  the 
development  of  the  abscess.  Later,  the  tumor  may  reach  the  sur- 
face of  the  body,  and  rarely  the  sternum  is  eroded.  Palpation  now 
detects  pulsation  and  fluctuation.  The  abscess  may  either  find  its 
way  downward  into  the  abdomen,  or  it  may  perforate  the  trachea  or 
the  esophagus. 

In  chronic  abscess  the  symptoms  bear  a  closer  similarity  to  those 
of  solid  tumors  than  do  those  in  the  acute  form.  Fortunately, 
chronic  abscess  quite  often  results  in  spontaneous  cure,  in  which 
case  it  is  in  part  absorbed,  and  the  remainder  of  its  contents  become 
inspissated. 

Diagnosis. — Acute  abscess  must  be  differentiated  from  solid  medias- 
tinal tumors  and  aneurysm.  The  more  acute  onset  and  general  symptoms 
of  the  suppurative  process  (hectic  type  of  fever,  chills,  sweats)  and 
the  more  rapid  course  will  serve  to  distinguish  abscess  from  aneurysm 
on  the  one  hand,  and  solid  tumors  on  the  other.  Further,  the  absence 
of  strong  expansile  pulsation,  diastolic  shock,  and  the  aneurysmal  bruit 
aid  materially  in  eliminating  aneurysm  of  the  arch.  In  obscure  cases  an 
exploratory  puncture  with  a  small  needle  may  be  safely  practised,  and, 
as  a  rule,  with  definite  results. 

The  treatment  is  mainly  surgical. 

{b)  Tumors  of  the  Mediastinum. — Two  forms  only  demand  practical 
consideration — carcinoma  and  sarcoma.  Hare's  analysis  of  520  cases 
gave  the  following  ratio :  of  carcinoma,  134 ;  sarcoma,  98 ;  lymphoma, 
21 ;  fibroma,  7  ;  dermoid  cyst,  11 ;  hydatid  cyst,  8 ;  and  fewer  cases  of 
ecchondroma,  lipoma,  and  gumma.  In  48  of  the  cases  of  carcinoma  and 
in  33  of  sarcoma  the  tumor  occupied  only  the  anterior  mediastinum.  It 
is  quite  probable,  however,  that  sarcoma,  and  not  carcinoma,  is  the  com- 
moner neoplasm  of  this  region.  The  clinical  term  "  cancer  "  was  formerly 
used  promiscuously  by  many  authors,  and  the  pathologic  diagnosis  was 
then  difficult,  so  that  statistics  are  scarcely  trustworthy.  Upon  inves- 
tigating 25  of  the  older  reports  of  "  cancer,"  Pepper  and  Stengel  found 


612  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

in  13  uiKiuostionable  evidence  that  tbe  growth  was  sarcoma,  while  in 
the  remaining  12  they  couhi  not,  for  the  greater  part,  decide  to  which 
form  tlie  disease  belonged.  ]*rimarv  sarcoma  may  spring  from  the  rem- 
nant of  the  thymns  gland,  from  the  lymphatic  glands,  the  pleura,  or 
lungs,  or  from  the  fibrous  tissues  of  the  mediastinum.  Primary 
carcinoma  may  originate  in  the  esophagus,  bronchi,  lungs,  or  rarely 
in  the  thymus  gland.  Secondary  mediastinal  tumors  are  most  apt 
to  have  their  seat  in  the  lymphatic  glands.  Carcinoma  is  less  fre- 
quently primary  than  sarcoma.  Among  predisposing  causes  are  sex 
and  age — males  being  more  prone  to  the  affection  than  females, 
and  the  period  of  chief  liability  is  between  the  thirtieth  and  fortieth 
years. 

Symptoms. — The  earlier  symptoms  are  vague  (slight  substernal 
pains,  dyspnea,  general  languor).  Later,  pressure-symptoms  gradually 
supervene. 

The  pain  may  or  may  not  be  severe,  but  is  invariably  accompanied 
by  a  feeling  of  oppression.  Its  chief  seat  is  in  the  upper  sternal  region, 
but  it  may  radiate  to  the  sides  of  the  chest  and  even  down  the  arms  (in 
which  case  it  is  due  to  pressure  on  the  brachial  plexus).  Dyspnea 
appears  early,  is  constant,  and  may  become  intense.  It  is  caused  by 
pressure  either  upon  the  trachea,  upon  a  primary  bronchus,  or  upon  a 
recurrent  laryngeal  nerve.  Asthmatic  seizures  may  occur  before  there 
is  constant  dyspnea  and  before  the  tumor  has  reached  notable  size. 
There  is  cough,  Nvhich  may  be  paroxysmal  and  of  a  brazen  char- 
acter. Aphonia  may  be  present.  There  may  be  dysphagia  from 
pressure  upon  the  esophagus,  though  this  is  rare.  If  there  is  an 
inflammation  of  the  vagus  or  sympathetic  nerve,  the  rate  of  the 
pulse  may  be  either  slowed  or  markedly  quickened.  Owing  to  im- 
plication of  the  sympathetic  there  maj  be  local  hyperemias  and  pupil- 
lary inequalities. 

Compression  of  the  superior  vena  cava  or  of  the  subclavian  vein  may 
be  followed  by  cyanosis  and  edema  of  the  parts  drained  by  these  vessels, 
and  the  early  occurrence  of  venous  occlusion  and  marked  dilatation  of 
the  superficial  veins  is  quite  characteristic.  Collateral  circulation  may 
be  rarely  established.  Less  frequently  the  inferior  cava  may  also  be 
compressed. 

Physical  Signs. — Inspection. — In  advanced  cases  a  swelling,  usually 
somewhat  irregular  and  often  diffuse,  appears  in  the  sternal  region. 
The  tumor  may  cause  erosion  of  the  sternum,  and  a  little  later  occupy 
a  position  immediately  beneath  the  skin,  Osier  ^  being  of  the  opinion 
that  the  rapidly-growing  lymphoid  tumors,  more  commonly  than  others, 
perforate  the  chest-wall.  I  saw  a  case  in  which  the  perforation  occurred 
at  the  right  edge  of  the  sternum,  precisely  at  the  point  at  which  aneur- 
ysms of  the  ascending  arch  most  frequently  appear.  In  the  early  stages, 
however,  this  prominence  is  not  present.  Palpation. — When  a  tumor  is 
present  it  may  pulsate  distinctly,  and  the  heart's  apical  impulse  may  be 
detected  in  various  abnormal  positions.  Tactile  fremitus  is  feeble  or 
absent  over  the  seat  of  the  growth. 

On  percussion  dulness  is  noted,  and  this  is  true  even  in  many  instances 
that  do  not  present  a  visible  swelling.      The  dull  area  varies  in  outline 

*  Practice  of  Medicine,  p.  579. 


DISEASES  OF  THE  MEDfASTfNUM.  613 

witli  tlie  size  and  position  of  the  tumor.  Ausenltatum  usually  reveals 
no  sounds  over  the  dull  area,  except  a  bruit  in  rare  instances.  The 
heart-sounds  are  inaudible  over  the  tumor-site  as  a  rule,  and  the  breath- 
sounds  and  vocal  resonance  are  feeble  or  absent.  To  the  above  pliysical 
signs  are  frequently  added  those  of  pleural  effusion. 

The  diagnosis  of  mediastinal  growths  is  made,  if  at  all,  principally 
by  exclusion. 

Aneurynm  is  differentiated  from  solid  mediastinal  tumors  with  only 
slight  success  in  many  instances.  It  is  most  valuable  to  note  carefully 
the  length  of  time  the  condition  has  lasted,  since  aneurysm  runs  a 
longer  course,  on  the  average,  than  mediastinal  tumor.  The  tumor 
■when  due  to  aneurysm  communicates  a  strong,  heaving,  expansile  pul- 
sation— a  characteristic  that  is  absent  or  only  feebly  manifested  in  the 
case  of  solid  mediastinal  growths.  The  severe  diastolic  shock,  noted 
on  both  palpation  and  auscultation  in  cases  of  aneurysm,  is  also  absent 
in  solid  tumor.  Kassabian  has  shown  that  new  growths  can  be  early 
recognized  by  an  a;-ray  examination.  On  the  other  hand,  shadows  sit- 
uated in  the  anterior  portion  of  the  chest  and  to  the  right  of  the 
median  line  are  generally  produced  by  aneurysms. 

The  duration  of  the  disease  varies  from  six  to  eighteen  months. 

The  prognosis  is  absolutely  hopeless,  except  in  the  case  of  benign 
tumors,  which  may  be  removed  in  some  instances. 

The  treatment  is  directed  toward  the  relief  of  the  most  urgent 
symptoms.  Anodynes  are  required  sooner  or  later,  and  should  not  be 
withheld  if  indicated.  As  a  routine  the  preparations  of  iodin  and  mer- 
cury are  employed ;  but,  as  these  are  useless,  they  are  unwarranted. 
Arsenic  has  sometimes  seemed  to  influence  sarcomatous  and  lymphade- 
nomatous  growths  favorably,  though  only  temporarily. 

(c)  Mediastinal  Hemorrhage. — This  term  signifies  hemorrhage  into  the 
mediastinal  connective  tissue.  It  oftenest  results  from  the  rupture  of 
aneurysms  of  the  arch  or  of  the  large  vessels  within  the  thorax.  It  may 
be  of  traumatic  origin  (wounds,  fractures). 


PART  VI. 

DISEASES    OF   THE   CIRCULATORY 
SYSTEM. 


I.   DISEASES  OF  THE  PERICARDIUM. 


PERICARDITIS. 


Definition. — An  inflammation  of  the  serous  covering  of  the  heart. 

Varieties. — (a)  Plastic,  or  fibrinous ;  (b)  sero-fibrinous,  or  subacute ; 
(c)  purulent ;  (d)  hemorrhagic  ;  (e)  adhesive.  There  is  also  a  tuberculous 
pericarditis  which  has  been  described  (vide  Tuberculosis,  page  279). 

Bacteriology. — Rudini's  experiments  have  shown  that  the  staphylo- 
coccus aureus  may  be  a  cause  of  pericarditis ;  but  they  have  not  con- 
clusively demonstrated  that  it  is  the  specific  cause,  as  is  evidenced  by 
the  fact  that  the  disease  is  sometimes  caused  by  other  organisms. 
Moreover,  staphylococci  have  not  been  encountered  without  demon- 
strable cause.  Among  other  organisms,  the  pneumococcus,  streptococ- 
cus, the  bacillus  coli,  the  tubercle  bacillus,  and  probably  also  a  variety 
of  the  bacillus  pyocyaneus  and  the  gonococcus  may  be  named.  Micro- 
organisms are  not  always  found  in  pericarditic  exudates. 

ACUTE   PLASTIC    OR   FIBRINOUS   PERICARDITIS. 

Pathology. — The  morbid  changes  are  frequently  localized,  and  less 
frequently  are  general.  At  the  onset  the  membrane  is  smooth,  swollen, 
and  injected,  and  punctate  ecchymotic  spots  maybe  visible;  soon  it 
presents  a  grayish,  roughened  appearance  from  the  deposit  of  a  thin 
layer  of  fibrin.  In  the  severer  types  the  fibrinous  deposit  increases  in 
thickness  for  a  time,  and  the  natural  movements  of  the  pericardial  sur- 
faces upon  one  another  sometimes  cause  the  exudate  to  assume  a  honey- 
combed appearance.  Most  examples  that  I  have  seen,  however,  have 
resembled  the  roughened  surfaces  produced  by  separating  two  slices  of 
thickly-buttered  bread ;  the  surfaces  are  grayish-yellow  in  color.  In  the 
later  stages  the  exudation  becomes  partly  organized,  and,  as  the  result  of 
friction  produced  between  the  opposed  surfaces  by  the  incessant  action 
of  the  heart,  may  present  a  villous  appearance;  hence  the  term  "hairy 
heart  "  of  the  ancient  authors.  For  like  reasons  we  may  see  the  exudate 
arranged  in  the  form  of  little  ridges,  forming  a  ''tripe-like  membrane.  ' 

615 


610  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Though  invariably  present,  the  amount  of  serous  effusion,  as  the  terra 
Avouki  indicate,  is  never  hirge  in  dry  or  plastic  pericarditis.  Myocarditis 
may  freijiiently  be  found  as  an  associated  condition. 

Ktiology. — In  each  variety  of  pericarditis  there  are  special  contrib- 
uting factors,  so  that  it  is  desirable  to  give  its  etiology  separatelj^,  except 
in  the  sero-fibrinous  and  acute  plastic  types,  which  have  practically  the 
same  etiology.  The  two  latter  are  the  more  common  forms  of  the  disease. 
Acute  plastic  pericarditis  most  frequently  occurs  in  young  and  middle- 
aged  males.  It  may  be  primary  or  secondary.  It  often  occurs  in  acute 
articular  rheumatism  (in  more  than  ono-half  the  cases),  chorea,  lobar 
pneumonia,  chronic  nephritis,  and,  rarely,  in  other  acute  infectious  dis- 
eases. In  this  form  the  infective  agents  are  transmitted  to  the  peri- 
cardium by  means  of  the  circulation.  It  may  be  caused  also  by  direct 
extension  of  inflammation  from  adjacent  structures  (secondary  pericar- 
ditis), as  in  simple  pleurisy  ;  more  commonly  the  extension  occurs  from  a 
pneumonia  or  tuberculous  pleurisy,  or  the  condition  may  complicate 
new  growths  and  inflammatory  conditions  affecting  the  esophagus  and 
bronchial  glands.  It  may  also  be  secondary  to  chronic  disease  of  the 
aortic  valve,  the  pericardium  becoming  involved  by  extension  through 
the  walls  of  the  aorta.  Finally,  it  may  be  the  result  of  traumatism,  and 
this  may  cause  any  of  the  other  forms  of  pericarditis. 

Clinical  History. — Owing  to  the  fact  that  acute  plastic  pericarditis 
is  usually  a  secondary  aff"ection,  the  symptoms  that  enable  one  to  recog- 
nize it  are  obscured  by  those  of  the  primary  disease.  This  is  particu- 
larly true  of  that  large  class  of  cases  that  develop  in  acute  articular 
rheumatism,  in  which  subjective  symptoms  are  often  entirely  wanting. 
Only  in  the  severest  types  of  this  sort  are  the  symptoms  referable 
to  the  heart  well  enough  marked  to  arrest  the  attention.  There  may 
be  a  feeling  of  distress  or  constriction  with  or  without  slight  pain  in  the 
precordium.  During  the  first  stage  or  prior  to  the  pouring  out  of  the 
effusion  the  pain  is  most  marked,  extending  sometimes  into  the  left  arm 
or  the  back,  and  at  others  to  the  ensiform  cartilage  or  even  to  the  abdo- 
men. This  pain  is,  rarely,  increased  by  pressure  over  the  precordia. 
Palpitation  and  dyspnea  may  be  present,  and  the  pulse  is  increased  in 
frequency  and  strength,  as  a  rule,  except  in  the  later  period,  when  it 
may  be  weak  and  slightly  irregular,  particularly  if  the  muscular  tissue 
of  the  heart  be  involved.  There  is  some  fever,  but  the  degree  of  ele- 
vation of  temperature  perhaps  never  exceeds  102°  F.  (38.8°  C).  In 
this  class  of  cases  the  urinary  features  depend  largely  upon  the  charac- 
ter of  the  leading  etiologic  factors ;  though  in  many  instances  the  urine 
is  scanty,  high-colored,  and  acid  in  reaction. 

Physical  Signs. — Inspection  discloses  increased  vigor  of  the  apex- 
beat.  Friction-fremitus  (due  to  rubbing  of  the  altered  pericardial 
layers  upon  one  another)  may  sometimes  be  felt  during  the  earlier  and 
later  courses  of  the  disease  or  when  the  membrane  is  comparatively  dry, 
and  is  usually  most  intense  near  the  base,  just  to  the  left  of  the  sternum. 
Percussion  gives  negative  results.  Auscultation  usually  reveals  a  double 
friction-sound,  sometimes  quadruple  (locomotive  murmur) — the  most  im- 
portant sign  for  a  positive  diagnosis.  The  friction-rub  is  caused  partly 
by  the  exudate  and  partly  by  the  dry  state  of  the  membrane.  Its  usual 
seat  of  maximum  intensity  is  in  the  fourth  and  fifth  interspaces  and  the 


ACUTE  PLASTIC  OR  FIBRINOUS  Pl<:i.,I<JAItI>ITIS.  fil7 

adjacent  portions  of  tlie  sternum — i.  g.,  where  the  pericardial  surfaces 
can  be  but  slightly  separated  from  one  another.  Anotlier  favorite 
point  is  the  cardio-aortic  jumttion.  it  is  usual  to  hear  the  rub  over 
small  areas,  though  occsisionally  it  is  audible  over  the  whole  pre- 
cordia,  and  its  distinguishing  feature  is  its  superficiality,  seeming  closer 
to  the  ear  than  endocardial  murmurs.  Pressure  with  the  stethoscope, 
which  approximates  the  layers,  increases  its  intensity  ;  though,  if  too 
much  force  be  exerted,  the  murmur  may  disappear  entirely.  In  like 
manner  the  friction-sound  is  influenced  by  respiration,  losing  in  distinct- 
ness on  deep  inspiration.  The  quality  of  the  sounds,  like  their  position, 
exhibits  great  variability.  They  are  sometimes  soft;  but  quite  com- 
monly they  are  grating  or  rubbing,  and  in  the  later  stages  I  have  noticed 
that  they  may  have  a  loud  creaking  quality.  Though  with  few  exceptions 
they  are  double,  and  are  primarily  produced  by  the  rhythmic  movements 
of  the  heart,  they  do  not  always  occur  synchronously  with  the  heart- 
sounds,  and  usually  exceed  the  latter  in  duration — facts  that  go  to  show 
that  the  quality,  location,  or  superficial  area  of  a  given  murmur  does  not 
indicate  the  extent  of  the  lesion.  When  the  exudate  is  soft  and  the 
heart's  action  weak,  the  characteristic  murmur  may  be  absent. 

Complications. — There  may  be  an  extension  of  the  inflammatory 
process  to  the  external  surface  of  the  pericardium,  either  from  the  deeper 
pericardial  structures  or  from  the  pleura,  particularly  the  left.  This  is  a 
complicating  condition  termed  "  external  pleural  pey^carditis  "  or  "  medi- 
astino-per {carditis,"  in  which  the  mediastinal  connective  tissue  is  also,  as 
a  rule,  involved.  It  is  most  frequently  secondary  to  tuberculous  pleurisy 
(tuberculo-mediastino-pericarditis),  sometimes  also  to  pleuro-pneumonia, 
and  rarely  to  simple  pleurisy  or  plastic  pericarditis.  The  recognition  of 
these  combined  lesions  rests  chiefly  upon  the  detection  of  a  friction-mur- 
mur that  is  partly  dependent  upon  the  cardiac  and  partly  upon  the  respi- 
ratory movements.  These  sounds  are  most  distinctly  heard  along  the 
left  edge  of  the  heart.  Momentary  arrest  of  breathing  suppresses  the 
pleuritic  friction-sound,  there  remaining  merely  the  sounds  produced  by 
the  rhythmic  cardiac  action,  and  even  these  may  be  absent.  On  the 
other  hand,  during  forced  respiration  nothing  is  audible,  as  a  rule,  except 
the  strong  pleural  rub.  In  normal  respiration  the  inspiratory  movements 
decrease  while  expiratory  movements  increase  the  intensity  of  the  sounds. 
During  inspiration  the  pulse  may  become  small  and  slow,  owing  to  the 
partial  occlusion  of  the  aorta,  brought  about  by  the  traction  of  fibrous 
bands  of  adhesions  which  pass  over  the  vessel,  being  at  the  same  time 
connected  with  the  pleura.  When  these  bands  pass  from  the  exterior  of 
the  heart-muscle  or  pleura,  they  may  cause,  as  first  pointed  out  by 
Riegel,  an  absence  of  the  apex-beat  during  expiration.  Instances  of  this 
sort  are  not  uncommon. 

Diagnosis. — Although  the  presence  of  a  to-and-fro  friction-sound  is, 
as  a  rule,  indicative  of  plastic  pericarditis,  it  is  an  error  to  regard  it  as 
an  infallible  sign,  since  complete  calcification  of  the  coronary  arteries,  as 
well  as  excessive  dryness  of  the  pericardial  surfaces,  may  rarely  produce 
friction-murmurs.     The  etiologic  factors  are  important  diagnostically. 

Differential  Diagnosis. — The  harsh  double  murmurs  due  to  chronic  val- 
vular lesions  can  be  eliminated  if  it  be  recollected  that  they  are  more 
constant,  more  distant,  and  that  each  has  an  area  of  transmission  beyond 


618  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  limits  of  the  precordia.  The  sitting  posture,  leaning  forward,  or 
moderate  pressure  with  the  stethoscope,  all  fail  to  produce  or  to  increase 
endocardial  murmurs,  whether  acute  or  chronic.  A  double  aortic  mur- 
mur is  associated  with  cardiac  hypertrophy,  the  Corrigan  pulse,  and  sys- 
tolic flushing  of  the  capillaries. 

Prognosis. — The  termination  is  always  favorable  as  to  life.  Com- 
plete resolution  does  not  often  occur,  but  tlie  exudate  becomes  connective 
tissue,  and  agglutinates  the  two  layers  of  the  pericardial  sac.  The  acute 
may  merge  into  the  chronic  form,  and  dry,  plastic  pericarditis  often  con- 
stitutes the  first  stage  of  sero-fibrinous  and  purulent  pericarditis. 

Treatment. — Absolute  quiet  in  the  recumbent  position  should  be 
enjoined.  The  diet  should  be  composed  chiefly  of  light,  easily  digested 
solids,  and  allowing  little  drink,  thus  endeavoring  to  avoid  an  overfilling 
of  the  vessels.  With  the  same  object  in  view,  if  the  patients  strength 
be  good,  a  half-dozen  leeches  should  be  applied  over  the  heart,  followed 
by  the  use  of  the  ice-bag ;  the  bowels  are  to  be  kept  soluble  by  using 
stewed  fruits  or  saline  laxatives.  Calomel  in  doses  ranging  from  gr.  ^ 
to  \  (0.016-0.032)  every  hour  or  two,  combined  with  a  little  opium  to 
prevent  purgation,  is  serviceable.  At  the  beginning  veratrum  viride 
may  also  be  cautiously  administered,  with  a  view  to  dilating  the  arte- 
rioles throughout  the  rest  of  the  body,  and  thus  virtually  "  bleeding  the 
patient  into  his  own  vessels."  The  salicylates  are  indicated  in  cases  of 
rheumatic  origin.  Later,  the  iodids  of  potassium  and  iron  should  be 
substituted  for  the  purpose  of  absorbing  the  effused  material.  Tonics 
and  a  change  of  air  may  be  required  during  convalescence. 

SERO-FIBRINOUS    PERICARDITIS. 

Pathology. — The  anatomic  changes  may  be  grouped  into  three 
stages — tke  first  being  characterized  by  a  plastic  exudation  (correspond- 
ing with  the  lesions  in  dry,  plastic  pericarditis,  though  more  pronounced) ; 
the  second  stage,  by  a  variable  amount  of  effusion  composed  largely  of 
serum.  The  exudation  usually  begins  about  the  origin  of  the  great  ves- 
sels at  base  of  the  heart,  and  ultimately  forms  a  thick  covering  of  fibrin, 
especially  on  the  visceral  layer.  The  quantity  of  serous  effusion  may  be 
from  2  to  10  ounces  (64.0-320.0),  but  occasionally  it  is  as  much  as  3 
pints  (1 J  liters).  The  admixture  of  a  small  number  of  red  blood-corpus- 
cles or  leukocytes  sometimes  occurs  in  this  form  of  the  complaint.  The 
third  is  the  stage  of  absorption  in  the  most  favorable  cases.  Perfect 
resolution  rarely  takes  place,  but,  instead,  the  liquid  effusion  is  alone 
absorbed,  and  the  lymph  causes  firm  adhesions  of  the  visceral  and  pari- 
etal membranes.  If,  as  sometimes  happens,  the  serum  remains,  the  acute 
passes  into  a  chronic  condition.  The  myocardium  may  become  involved 
by  an  extension  of  inflammation  from  the  visceral  layer ;  it  is  always 
the  seat  of  more  or  less  collateral  edema.  The  grade  of  the  myo- 
cardial inflammation  will  depend  much  upon  the  extent  and  duration 
of  the  pericarditis,  though  usually  it  is  moderate  in  the  fibrino-serous 
variety. 

Ktiology. — The  disease  is  most  frequently  observed  to  be  associated 
with  acute  rheumatism,  Bright's  disease,  and  pulmonary  tuberculosis. 
Sears  collected  100  cases  of  pericarditis,  of  which  51  were  due  to  acute 


SERO-FWRINOUS  PERICARDITIS.  619 

rheumatism  ;  and,  accordintf  to  Baumgarten,  tlic  former  disease  arises  as  a 
complication  of  the  latter  in  about  one-tliird  of  the  cases.  I  believe 
that  exceptionally  both  serofibrinous  and  plastic  pericarditis  may  occur 
in  the  course  of  rheumatic  dyscrasia  without  the  slightest  evidence  of 
arthritis.  The  disease  also  occurs  in  the  course  of  the  eruptive  fevers 
and  lobar  pneumonia,  and  from  extension  of  inflammation  from 
neighboring  parts.  Of  QQ  instances  of  pericarditis  in  children,  24 
were  caused  by  rheumatism.  Next  in  frequency  were  tuberculosis 
and    pleuro-pneumonia  (Baginsky).     (See  also  Bacteriology,  p.  615j. 

Clinical  History. — When,  as  rarely  occurs,  a,  primary  pericarditis 
develops,  the  initial  symptoms  common  to  inflammation  of  other  serous 
membranes  manifest  themselves,  as  anorexia,  sometimes  nausea  and  vom- 
iting, ehills,  fever,  increased  respiratioji  and  pulse-rate,  together  Avith 
local  pain.  The  pain  is  usually  of  a  dull,  aching  character,  and  less  fre- 
quently merely  a  slight  soreness,  or  it  may  be  absent  altogether.  Acute 
pain  is  experienced  only  when  the  pleura  is  implicated. 

When  pericarditis  is  secondary  there  are,  in  many  cases,  no  subject- 
ive symptoms  to  indicate  its  presence.  In  other  instances  there  may  be 
precordial  oppression  with  or  without  slight  pain  or  a  feeling  of  sore- 
ness. Hence  in  affections  in  which  pericarditis  is  likely  to  arise  physical 
examinations  of  the  heart  should  be  systematically  conducted.  Import- 
ant symptoms  are  due  to  the  intrapericardial  pressure  of  the  exudate. 

Dyspnea  comes  on  simultaneously  with  the  appearance  of  the  effusion 
and  may  lead  to  actual  orthopnea.  Pressure  is  exerted  upon  the  left 
lung  if  the  exudate  be  large — a  fact  that  explains  in  part  the  presence 
of  dyspnea.  The  cardiac  muscle,  especially  the  right  ventricle,  is  also 
pressed  upon  by  the  effusion,  thus  impeding  the  cardiac  diastole.  Under 
these  circumstances  the  veins  fail  to  empty  themselves  into  the  heart, 
the  arterial  system  is  incompletely  filled  and  the  blood-pressure  falls  as 
the  result.  Prior  to  the  occurrence  of  the  effusion  the  circulation  is  too 
actively  carried  on,  the  pulse  being  full  and  strong.  It  is  clear  from  the 
above  explanation  that  during  the  second  stage  the  pulse  is  small,  feeble, 
and  irregular.  When  the  exudate  is  small,  the  heart-action  may  be  ap- 
parently feeble,  while  the  pulse  remains  strong — a  valuable  rational  sign. 
On  the  other  hand,  an  excessive  amount  of  fluid  may  cause  the  radial 
pulse  to  disappear  during  inspiration  (the  pulsus  paradoxus).  Fever  is 
present,  as  a  rule ;  the  temperature  is  irregularly  elevated,  ranging  from 
101°  to  103°  F.  (38.3°-39.4°  C).  In  fevorable  cases  defervescence 
takes  place  by  lysis,  Nervous  symptoms,  as  headache  and  mild  delirium. 
often  appear,  and  sometimes  give  place  to  stupor  or  even  coma.  Acute 
mania  is  rarely  observed.  The  urine  is  decreased  in  amount,  and  occa- 
sionally general  dropsy  occurs. 

Physical  Signs. — Inspection. — The  skin-surface  and  mucous  mem- 
branes are  observed  to  be  pale  and  more  or  less  cyanotic.  The  neck- 
veins  are  prominent,  and  sometimes  exhibit  undulatory  movements  or 
pulsations.  The  expression  is  anxious ;  the  respirations  are  increased, 
labored,  and  at  times  irregular.  The  decubitus  is  dorsal :  the  head 
and  shoulders  are  elevated,  and  the  patient  may  be  forced  to  assume 
the  sitting  posture.  In  young  subjects  precordial  prominence,  with  efface- 
ment  or  even  bulging  of  the  intercostal  spaces,  may  result  from  the  pres- 


620  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ence  of  a  moderate  effusion.  In  adults,  however,  a  large  collection  is 
indispensable  for  the  production  of  this  effect.  If  the  lung  be  shrunken 
or  if  there  are  pleuritic  adhesions,  expansion  of  the  pericardium  and, 
hence,  also  bulging  will  be  prevented.  The  distended  pericardium  may 
depress  the  diaphragm.  Elevation  of  the  left  nipple  in  consequence  of 
marked  anterior  expansive  bulging  has  been  observed.  In  the  first 
stage  the  apical  beat  is  exaggerated,  but  as  the  exudate  increases  (forcing 
the  heart  backward  and  upward)  it  is  displaced  in  an  upward  and  outward 
direction,  at  the  same  time  becoming  weaker  as  well  as  more  dif!used, 
since  with  expansion  of  the  sac  comes  greater  mobility  of  the  organ. 
Wiien  the  pericardial  sac  becomes  filled  the  impulse-beat  disappears,  the 
fluid  now  completely  surrounding  the  heart. 

Palpation  confirms  the  results  of  inspection.  The  apical  beat  is 
diffused  and  feeble  or  lost.  When  detectable  it  is  found  to  be  displaced 
upward  and  to  the  left.  Altering  the  patients  posture  changes  the  seat 
of  the  apex-beat  (Oppolzer),  and  if  the  shock  has  been  lost,  turning  the 
patient  on  his  left  side  or  bending  his  body  forward  may  cause  its  return. 
The  cardiac  impulse  disappears  earlier  when,  on  account  of  myocarditis, 
the  svstole  is  greatly  enfeebled.  On  the  other  hand,  old  adhesions  and 
marked  hypertrophy  of  the  heart  may  retain  the  apex-beat  in  contact 
with  the  chest-wall,  despite  the  presence  of  a  large  accumulation.  A 
friction-rub  can  be  felt  occasionally  over  the  base  of  the  heart  even  in 
the  stage  of  effusion,  and,  if  absorption  takes  place,  the  friction  fremitus 
becomes  more  marked.  Fluctuation  is  rarely  detected.  In  large 
effusions  the  liver  is  depressed  and  easily  jialpahle. 

Percussion. — The  area  of  cardiac  dulness  is  increased,  and  assumes 
a  characteristic  triangular  outline  with  the  base  downward  and  the  apex 
extending  up  to  the  third  or  even  second  interspace  to  the  left  of,  though 
near,  the  sternum.  The  lateral  border-lines  of  dulness  obviously  diverge 
from  above  downward,  the  right  passing  to  a  point  corresponding  with 
the  right  edge  of  the  sternum,  along  which  it  runs  to  the  hepatic  flatness  ; 
the  other  to  the  left,  finally  intersecting  the  base-line,  and  extending  to 
splenic  flatness,  or  the  lower  limit  of  pulmonary  resonance.  Flatness 
may  be  met  in  the  axillary  region,  even  obliterating  Traube's  semilunar 
space.  Rotch  points  out  that  even  in  moderate  effusions  there  is  flatness 
in  the  fifth  interspace  to  the  right  of  the  sternum  (cardio-hepatic  triangle 
— Ebstein).  Broadbent,  however,  has  found  several  instances  in  which 
dulness  in  this  area  was  present,  but  at  necropsy,  dilatation  without 
effusion  was  found.  The  margins  of  the  lungs  surrounding  the  heart 
may  be  retracted  and  the  heart  carried  forward  or  dilated  ;  the  dull  space 
will  then  appear  larger  than  is  justified  by  the  amount  of  fluid.  Retrac- 
tion or  moderate  compression  of  the  lung  may  give  rise  to  a  modified 
tympanitic  resonance  to  the  left  of  the  flat  area.  Occasionally  the  lung 
is  attached  anteriorly,  and  the  heart  is  crowded  backward  by  the  effusion, 
while  the  area  of  flatness  on  percussion  is  relatively  diminished.  The 
triangular  shape  of  the  flat  space,  noted  when  the  patient  is  in  the  sitting 
posture,  is  lost  and  its  area  diminished  when  he  lies  down,  the  effusion 
obeying  the  laws  of  gravitation.  Sibson's  notch,  or  narrowness  of  the 
dull  area  at  the  third  costal  cartilage  in  the  transverse  diameter,  with 
reflection  of  the  dulness  to  the  left  below  this  level,  thus  forming  an 


8ER0-FIBRIN0US  PERIGARDITIS.  621 

oT)tuse  angle,  obtains  in  medium-sized  effusions.  The  feeble  impulse  can 
be  at  times  felt  within  the  dull  area  and  not  at  its  boundary. 

Auscultation. — The  characteristic  friction-rub  of  the  first  stage  has 
already  been  described.  It  may,  however,  also  be  audilde  over  the  base 
during  the  stage  of  effusion,  and  always  returns,  after  absorption  of  the 
fluid,  for  a  brief  period.  The  heart-sounds  grow  more  and  mr)re  distant, 
faint,  and  muffled,  though  tiie  second  sound,  as  heard  over  the  extreme 
base  of  the  organ,  may  remain  clear.  Over  the  area  of  dull  tympany 
corresponding  to  the  lower  antero-lateral  portion  of  the  left  lung  (which 
is  more  or  less  compressed)  may  be  heard  broncho-vesicular  breathing. 

Course  and  Duration.— It  will  appear  obvious  tluit  the  course 
must  vary  in  individual  cases  with  the  cause  and  severity  of  tlie  infection. 
Observation  has  shown  that  in  one  class  of  cases  the  three  stages  are 
passed  through  in  rapid  succession,  while  in  another  class  each  stage  is 
proportionately  lengthened.  The  latter  form  has  been  termed  "chronic" 
by  some  and  "subacute"  by  others.  The  acute  may  be  followed  by  the 
chronic  variety.  Usually  sero-fibrinous  effusions  complicating  rheumatism 
are  absorbed  with  rapidity  once  the  process  has  begun,  seldom  requiring 
more  than  two  weeks.  When  recovery  is  about  to  occur,  the  temperature 
falls  by  lyais  ;  the  dyspnea  gradually  disappears,  and  with  it  the  effusion 
is  gradually  absorbed.  Convalescence  is  further  indicated  by  a  return 
of  the  appteite,  normal  heat  of  the  skin,  and  a  more  infrequent,  full,  and 
regular  pulse.  In  cases  that  tend  to  a  fatal  termination  either  the  fever 
continues  or  there  is  suddenly  developed  hijperpijrexia,  as  may  happen 
when  pericarditis  occurs  in  the  course  of  acute  rheumatism  ;  in  such 
cases  the  dyspnea  is  urgent  and  cyanosis  is  often  marked,  with  signs  of 
failing  circulation.  Nervous  symptoms.,  as  extreme  restlessness,  insomnia, 
and  active  delirium,  may  be  present.  Under  these  circumstances  death 
usually  ensues  at  the  end  of  a  week  or  ten  days.  In  a  fatal  case  of 
acute  articular  rheumatism  that  I  saw,  complicated  by  pericarditis,  with 
hyperpyrexia,  death  occurred  on  the  sixth  day. 

Complications. — Copious  effusion  may,  by  causing  pressure  upon  the 
recurrent  laryngeal  nerve,  produce  paralysis  of  the  vocal  apparatus,  or, 
it  may  press  upon  the  esophagus,  causing  dysphagia.  Rarely  acute 
pleuritis  is  a  complication ;  it  lengthens  the  course  of  the  pericarditis 
and  renders  the  outcome  uncertain.  When  there  coexists  extensive  myocar- 
ditis syncopal  attacks  often  endanger  the  life  of  the  patient.  Associated 
endocarditis  and  a  complicating  pneumonia  may  be  observed. 

Prognosis. — In  sero-fibrinous  pericarditis  recovery  is  the  rule  un-der 
favorable  conditions.  The  outlook,  however,  becomes  gloomy  when  the 
above-mentioned  complications  arise,  and  particularly  when  there  is  hyper- 
pyrexia in  connection  with  acute  rheumatism.  Occurring  as  a  secondary 
event  in  serious  acute  diseases,  as  pneumonia,  or  in  chronic  diseases,  as 
Bright's,  or  organic  affections  of  the  heart,  the  pericarditis  often  precip- 
itates a  fatal  termination.  The  strong  possibility  that  these  cases  may 
only  partially  recover  or  assume  a  chronic  form  must  be  recollected. 

Diagnosis. — The  disease  is  often  overlooked,  because  unsuspected. 
Ordinarily  the  recognition  of  pericarditis  by  the  characteristic  triangular 
area  of  percussion-dulness  and  by  the  friction-sound  is  not  difficult.  The 
causative  factors,  and  the  symptoms  dependent  on  the  mechanical  pressure 
of   the  exudate,  are  of  considerable  diagnostic  importance.     Atypical 


622  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

cases  or  those  first  seen  during  the  stage  of  effusion  can  only  be  correctly 
diagnosticated  by  exclusion. 

Differential  Diagnosis. — Acute  pleun'si/  of  the  left  side  may  simulate 
pericarditis  with  copious  effusion,  and,  as  before  stated,  these  diseases 
may  coexist.  Acute  pain,  however,  belongs  to  pleurisy  alone.  In  peri- 
carditis the  characteristic  physical  signs  are  elicited  over  the  precordia : 
in  pleurisy  they  are  apt  to  occupy  not  only  the  anterior  but  also  the 
axillary  and  posterior  aspects  of  the  chest ;  hence  the  percussion-flatness 
in  pleurisy  extends  to  the  left,  far  beyond  the  boundary-line  of  the  per- 
cussion-flatness in  pericarditis.  The  pericardial  friction-sound  has  a  dif- 
ferent situation  usually  from  the  pleuritic,  and  the  latter  is  heard  syn- 
chronously with  the  respiratory  movements,  while  the  former  is  intimately 
related  to  the  time  of  the  cardiac  movements.  The  friction-murmur  of 
pleurisy  ceases  if  the  breathing  be  momentarily  suspended.  Encapsulated 
pleural  eff'usious  limited  to  the  antero-lateral  portion  of  the  chest  are 
exceedingly  difficult  of  elimination,  and  especially  in  the  absence  of 
pleuritic  friction.  In  the  latter  complaint,  however,  the  heart-sounds 
are  clear  and  the  apex-beat  often  pushed  to  the  right ;  on  the  other 
hand,  in  pericarditis  the  general  disturbance  is  usually  greater,  while  a 
friction-rub  may  be  detectable  over  the  base.  The  heart-sounds  are 
distant  and  muffled.  The  diagnosis  is  often  aided  by  the  bearing  of  any 
facts  in  the  previous  history  upon  the  known  etiology  of  these  afi'ections. 
We  encounter  formidable  difficulties  in  attempting  to  exclude  cardiac 
dilatation^  though  the  following  brief  table  will  render  assistance : 

Pericarditis  with  Effusion.  Cardiac  Dilatation. 

( Clinical  History.) 

Recent  history  of  gout,  acute  rheumatism,  Usual  history  of  chronic  valvular  disease 

acute  infectious  or  septic  disease,  scurvy,  of  the  heart. 

chronic  nephritis,  or  tuberculosis. 

Fever  and  slight  pain  often  associated.  No  fever  or  pain,  as  a  rule. 

Nervous  symptoms  are  often  present.  Absent. 

{Physical  Signs.) 

Inspection   often   reveals  bulging   (more  Apex-beat    usually   visible,    wavy,    and 

marked    in   the    young).      Apex-beat  diffused, 
pushed  up,  is  feeble,  and  later  absent. 

Heart's  impulse  usually  absent  or  occu-  Though  feeble,  the  impulse  is  palpable. 
pies  center    of    dull    area.      Friction- 
fremitus  may  be  present  over  the  base. 

Percussion  shows  a  triangular  flat  area,  Dull  area  varies  with  chambers  dilated  ; 

and  the  boundary-line  above  changes  it  is  coextensive  with  a  wavy  impulse, 

on  altering  the  posture.    There  is  dull  does  not  extend  so  high  (except  in  mi- 

lynipany  in    the   axillary    region.     Eb-  tral  stenosis),  and  does  not  vary  with 

stein's  angle  obtuse.  change  of  position.     No  dull  tympany. 

Auscultation  shows  the  first  sound  distant  First  sound  clear,  short,  and  sharp.     No 

and  muffled  ;  a  double  friction-rub  is  friction-murmur  present,  but  an  endo- 

often  present  over  the  base.  cardial  murmur  may  appear. 

Xray  shows  triangular,  movable  shadow.  Upper  level  of  shadow   (quadrangular) 

fixed. 

Resistance  gymnastics  negative  in  their  Resistance  gymnastics  decrease  dull  area 

effects.     ""  (Schott). 

Digitalis  has  slight  influence.  Digitalis  diminishes  the  field  of  dulness. 

Treatment. — The  management  of  the  first  (or  dry)  stage  is  identical 
with  that  detailed  in  discussing  the  plastic  variety.  During  the  stage  of 
effusion  the  patient  should  be  kept  at  absolute  rest  in  the  recumbent  pos- 


PURULENT  PERICARDITIS.  f523 

ture,  and  mental  excitants  should  be  prohibited  with  a  view  to  minimizing 
the  labor  of  the  heart.  The  diet  is  to  consist  mainly  of  easily  digested 
albuminous  articles;  fluids  are  not  to  be  given  in  large  amounts,  since 
this  tends  to  increase  the  arterial  tension  and  delays  absorption. 

Local  Measures. — Flannel  should  be  kept  over  the  precordia,  so  as  to 
avoid  exposure  and  undue  chilling.  The  ice-bag  or  Leiter's  coils  (to  be  used 
in  the  first  stage)  should  be  cautiously  employed  during  the  second  stage, 
until  the  temperature  has  defervesced  considerably,  thus  indicating  a  sub- 
sidence of  inflammation  in  the  pericardium.^  Subsequently,  if  absorption 
does  not  proceed,  blisters  may  be  applied  over  the  precordia ;  but  should 
the  patient's  general  condition  be  bad,  an  absorbifacient  containing  iodine, 
lanolin,  and  ichthyol  may  be  substituted  with  advantage. 

The  therapeutic  measures  must  be  chosen  with  sole  reference  to  the 
primary  disease,  which  the  physician  must  continue  to  treat  while  he 
attempts  by  other  means  to  relieve  certain  symptoms  and  promote  absorp- 
tion. For  example,  if  the  pericarditis  be  due  to  rheumatism,  the  use 
of  the  salicylates  must  be  persevered  in,  and  opium  may  be  added  to 
quiet  restlessness  and  procure  relief  from  pain.  In  my  oAvn  experience 
absorption  has  been  best  promoted  by  the  use  of  the  double  iodid  of 
potassium  and  iron,  or  of  iron  and  manganese.  These  agents  are  seldom 
contraindicated  unless  they  are  badly  borne  by  the  stomach.  Diuretics 
and  saline  purgatives  are  not  without  value,  but  do  good  only  in  the 
later  stages.  Depressing  measures  of  whatever  sort  are  not  to  be  re- 
sorted to  unless  the  circulation  be  good.  If  the  pulse  be  small,  weak, 
and  rapid,  with  marked  cyanosis,  stimulants  are  indicated  and  are  to  be 
given  in  moderate  quantity.  Strychnin  and  the  salts  of  ammonium  are 
useful.  Digitalis  and  strophanthus  are  not  to  be  thought  of  when  myo- 
carditis is  associated  ;  at  other  times  they  often  improve  the  peripheral 
circulation  and  increase  the  urinary  secretion.  When  the  breathing  be- 
comes greatly  embarrassed  and  the  circulation  fails,  as  shown  by  the  feeble, 
broken,  rapid  pulse  and  cyanosis,  cardiocentesis  is  indicated,  and  has,  in 
recent  years,  given  good  results  if  not  too  long  delayed.  A  preliminary 
puncture  with  a  hypodermic  needle  should  be  made.  In  cases  where  the 
apex  cannot  be  localized,  the  sixth  space  at  about  the  mamillary  line  is 
the  point  of  greatest  advantage  for  paracentesis.  "If  it  be  definitely 
determined  that  the  dilated  heart  extends  beyond  the  mamillary  line,  one 
would  then  seek  a  point  a  little,  outside  of  the  supposed  position  of  the 
apex  "  (Thayer).  In  a  case  of  extreme  dilatation  of  the  heart  and  marked 
excitement  of  the  patient,  Curschmann  punctures  through  the  eighth 
interspace  from  the  rear.  The  operation  must  be  performed  with  the 
strictest  asepsis,  and  the  amount  of  liquid  withdrawn  at  any  one  time 
should  not  exceed  6  ounces.  Of  60  cases  of  paracentesis  for  pericarditis 
of  different  varieties,  collected  by  Roberts,  24  terminated  in  recovery. 

PURULENT   PERICARDITIS. 

( Empyema  of  the  Pericardium. ) 

Pathology  and  etiology. — The  condition  may,  rarely,  follow  the 
sero-fibrinous  form.      Septic  and  tuberculous  processes  involving  theperi- 

^  If  the  pericarditis  be  secondary  to  an  acute  febrile  disease,  this  fact  must  modifv 
the  method  here  recommended  accordingly. 


624  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

cardium  are  apt  to  cause  purulent  effusion  from  the  start,  and  many  of 
the  cases  that  arise  in  the  course  of  the  acute  infectious  diseases  belong 
to  this  category.  The  pueumococcus  has  been  found  in  the  pus  (Shattuck 
and  Porter).  The  membrane  is  much  thickened  and  jiresents  a  gra\', 
granular  surface,  and  the  myocardium  underlying  the  visceral  layer  is 
softened,  fragile,  and  pale  looking  (fatty). 

Clinical  History. — The  local  subjective  symptoms  and  physical 
signs  are  the  same  in  kind  as  in  the  former  variety,  but  tlie  amount  of 
exudation  is  frcfjuently  less.  At  the  onset  riij/ors  often  occur,  and  may 
be  repeated  at  varying  intervals.  The  temperature-curve  is  of  the  sup- 
purative type;  X\xe  pnhe  is  small,  rapid,  and  irregular;  smd  j^hT/sical 
prostration  is  pronounced.  Purulent  pericarditis  runs  a  comparatively 
rapid  and  an  almost  uniformly  unfiivorable  course. 

DiagtlOSis. — The  chief  clinical  features  are  often  referable  to  the 
primary  or  causal  disease ;  hence  in  every  instance  in  which  purulent 
pericarditis  is  apt  to  arise  a  physical  exploration  of  the  chest  is  impera- 
tive. The  purulent  character  of  the  effusion  cannot  readily  be  ascer- 
tained, as  a  rule ;  but  the  history  of  an  affection  having  etiologic  impor- 
tance, the  observance  of  rigors,  a  leukocytosis  showing  relative  increase 
in  the  polynuclear  forms,  and  the  presence  of  the  fever-curve  peculiar 
to  suppuration,  would  all  point  strongly  to  purulent  effusion,  and  should 
lead  to  aspiration  with  the  hypodermic  needle — a  harmless  procedure  if 
carefully  performed,  and  one  that  almost  constantly  gives  reliable  results. 

Treatment. — It  is  within  the  physician's  province  to  treat  the  pri- 
mary disease  assiduously,  but  not  pericardial  empyema.  Incision  (after 
preliminary  resection  of  a  rib — Brentano)  and  drainage  of  the  sac  are 
advisable  and  feasible  measures. 

HEMORRHAGIC    PERICARDITIS. 

In  purulent  pericarditis  the  effusion  may  be  hemorrhagic,  and  par- 
ticularly when  it  is  of  tuberculous  origin.  In  non-purulent  tuberculous 
pericarditis  also  the  exudation  is  apt  to  be  hemorrhagic.  In  the  non- 
purulent instances  that  are  due  to  chronic  Bright's  disease  or  that  occur 
in  the  aged  the  effusion  is  sometimes  blood-stained ;  and  future  observa- 
tion may  show  that  this  variety  is  of  more  frequent  occurrence  than  has 
hitherto  been  supposed.  In  ordinary  serous  pericarditis  there  is  apt  to  be 
present  more  blood  than  in  serous  pleuritis.  M.  T.  Terrier  has  found  5 
examples  in  9  collections.  Sears  found  a  pure  growth  of  pneumococci  in 
the  exudate  from  a  case  of  hemorrhagic  pericarditis.  This  etiologic 
variety  scarcely  calls  for  separate  clinical  consideration. 

ADHESIVE   PERICARDITIS. 

( Chronic  Pericai'dili.s.) 

Pathology  and  Htiology. — Chronic  pericarditis  follows  the  acute 
forms,  and,  as  in  the  case  of  the  latter,  it  may  be  partial  or  general. 
The  effusion  may  rarely  remain  as  a  permanent  condition,  but  not  in- 
frequently a  clear  history  of  the  preceding  acute  attack  is  wanting.  In 
most  instances  the  opposed  surfaces  of  the  membrane  are  either  univer- 
sally or  over  a  limited  area  firmly  adherent.  The  amount  of  new  con- 
nective tissue  present  or  the  degree  of  thickening  of  the  layers  varies 
greatly,  and  is  dependent  upon  the  type  of  the  primary  acute  attack. 


ADHESIVE  PERIOARDITLS.  625 

If  the  latter  is  of  mild  grade — a-fj-',  the  sero-fibrinous  rheumatic  form,  not 
much  thickening  is  encountered  in  the  resulting  ciironic  form. 

Qhronic  tuberculous  pericarditis  is  not  uncommon,  and  is  usually 
secondary.  The  disease  may  be  chronic  from  the  time  of  onset.  The 
layers  become  enormously  thickened,  with  obliteration  of  the  sac. 

In  the  dense  exudate  that  remains  after  complete  absorption  of  a  peri- 
cardial effusion  calcareous  depositions  occur,  forming  a  bony  casing, 
which  either  partially  or  totally  encircles  the  organ.  The  external 
surface  of  the  pericardium  may  become  united  with  adjacent  tissues 
(spinal  column,  anterior  thoracic  wall,  aorta,  sinus  pleurae).  The  myo- 
cardium is  the  seat  of  atrophic  and  degenerative  changes. 

Ktiology. — The  principal  etiologic  factors  are  tuberculosis  and  rheu- 
matism. Pilt*  analyzed  40U  cases  of  acute  pericarditis,  of  which  70  per 
cent,  were  due  to  rheumatism,  about  50  or  60  per  cent,  died,  and  from 
30  to  40  per  cent,  left  the  hospital  with  an  adherent  pericardium. 

Symptoms. — Autopsies  frequently  discover  an  unsuspected  adhesive 
pericarditis.  Hypertrophic  dilatation  of  the  chambers  usually  develops 
sooner  or  later,  and  is  due  to  adhesions  that  interfere  with  the  free  action 
of  the  organ  as  well  as  with  its  systole.  When  present  the  subjective 
symptoms  point  to  a  giving  way  of  the  right  ventricle,  as  shown  by  the 
presence  of  venous  stasis  and  dropsy.  The  pulse  is  rapid,  of  low  tension, 
and  irregular,  and,  though  not  diagnostic,  the  pulsus  paradoxus  is  noted. 

Pericarditis  Callosa  (Galvagni  ^). — A  form  of  chronic  fibrous  pericar- 
ditis which  comes  on  insidiously  during  childhood  and  is  exceedingly 
difficult  of  diagnosis  {vide  infra).  Pericarditis  callosa  is  characterized 
principally  by  facial  cyanosis,  slight  edema,  full  and  tortuous  jugular 
veins  without  pulsation.  The  typical  physical  signs  of  pericarditis  are 
wanting  also.  On  the  other  hand,  a  congestive  cirrhosis  of  the  liver 
may  supervene  and  lead  to  ascites. 

Physical  Signs. — Inspection. — Depression  or  pitting  of  the  intercostal 
space,  in  place  of  the  apex-beat,  may  be  noticed.  Synchronous  with 
the  systole  there  is  also  a  retraction  of  the  chest-wall  in  the  apical 
area,  and  less  frequently  over  the  whole  precordia,  the  latter  being  an 
unerring  sign  of  universal  adhesions.  The  degree  of  systolic  recession 
is  slightly  influenced  by  the  respiration,  inspiration  increasing  it,  except 
adhesions  exist  between  the  pericardium  and  the  adjoining  pleura. 
It  is  best  appreciated  on  palpation.  When  the  apex-beat  is  not  palpable, 
the  systolic  pitting  over  its  site  may  be  due  to  atmospheric  pressure. 
During  the  diastole  the  heart  forcibly  rebounds,  causing  the  so-called 
diastolic  shock,  which  is  of  great  diagnostic  importance  when  associated 
with  marked  systolic  retraction.  Though  not  always  visible,  it  can  be 
readily  felt  on  palpation.  Friedreich's  sign  (the  sudden  collapse  of  the 
jugulars  during  diastole)  may  frequently  be  observed.  Prior  to  the  onset 
of  dilatation  the  apex-beat  may  be  forcible  and  visible  oyer  an  increased 
area,  indicating  hypertrophy  ;  but  after  the  myocardium  is  weakened 
(from  interference  with  its  nutrition)  and  dilatation  comes  on,  the 
impulse-beat  is  faint  or  Avanting,  and  in  marked  systolic  retraction  may 
be  vibratory.  The  fixed  position  of  the  apex-beat  when  the  patient  is 
turned  over  upon  his  left  side  is  a  strong  confirmatory  sign. 

^  Practitioner  (London),  Aug.,  1912. 
40 


626  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Percussion. — The  area  of  cardiac  dulness  is  increased,  especially  up- 
ward and  to  the  left,  owing  to  the  associated  hypertrophy  and  pleuro- 
pericardial  adhesions,  and,  since  the  latter  do  not  allow  the  lungs  to 
overlap  the  heart  during  inspiration,  the  upper  and  left  lines  of  dulness 
remain  fixed  (0.  J.  B.  Williams).  The  most  trustworthy  symptom  is  the 
unchanging  shape  of  the  area  of  precordial  dulness  during  inspiration 
and  expiration  (Davis). 

Auscultation. — In  many  cases  no  murmurs  are  detectable.  Loud  mur- 
murs, quite  independent  of  any  value  as  regards  cardiac  lesions,  however, 
may  be  audible  ;  these  may  be  due  to  the  vertiginous  movements  in  the 
endocardial  blood-current  occasioned  by  the  jogging  cardiac  action.  The 
murmur  of  tricuspid  regurgitation,  from  a  breakdown  of  the  right  ven- 
tricle without  apparent  exciting  cause,  is  most  significant. 

Differential  Diagnosis. — The  condition  is  apt  to  be  confounded 
with  chronic  myocarditis  and  simple  hypertrophic  dilatation. 

As  before  stated,  chronic  pericarditis  may  be  associated  with  effusion, 
and  it  is  important  to  distinguish  such  instances  from  the  adhesive 
form,  if  we  Avould  institute  a  proper  treatment.  In  chronic  pericarditis 
with  moderate  effusion  the  seat  of  the  apex-beat  is  higher  and  less  un- 
dulatory,  and  Avhen  the  amount  of  effusion  is  large  the  impulse  is  absent 
and  there  is  bulging.  Adhesive  pericarditis  with  hypertrophy  causes 
bulging  in  young  subjects,  but  the  apical  beat  is  retained.  There  is  no  for- 
ward elevation  of  the  chest  during  inspiration  (Wenckebach).  In  pericar- 
ditis with  effusion  the  upper  and  left  limits  of  dulness  are  not  stationary, 
and  there  is  an  absence  of  systolic  retraction  and  diastolic  concussion. 

Course  and  Prognosis. — The  hypertrophy  that  comes  on  early  in 
consequence  of  the  obstruction  offered  to  cardiac  action  is  compensatory, 
and  this  harmonious  balance  may  be  maintained  for  a  long  period  of  time 
with  apparent  comfort.  After  myocardial  degeneration,  followed  by 
atrophy  or  dilatation,  has  occurred,  the  condition  becomes  quite  serious, 
and  death  usually  ensues  amid  signs  of  extreme  cardiac  dilatation. 

The  treatment  must  be  ordered  chiefly  with  reference  to  the  nutri- 
tion of  the  heart-muscle,  following  the  principles  noted  in  dealing  with 
the  management  of  valvular  affections  of  the  heart.  Precordial  thora- 
cectomy  is  advocated  by  Brauer  and  others.^  If  chronic  effusion  be  pres- 
ent, early  operative  measures  are  to  be  warmly  advocated. 


HYDROPERICARDIUM. 

{Dropsy  of  the  Pericardium.) 

Definition. — A  condition  in  Avhich  the  pericardium  contains  a  serous 
transudation,  but  shows  no  signs  of  inflammation. 

Etiology. — (a)  Hydropericardium  is  usually  associated  with  general 
cardiac  or  renal  dropsy,  of  which  it  forms  a  component  part.  Under 
these  circumstances  it  develops  late,  and  frequently  follows  hydrothorax, 
on  account  of  which  condition  it  is  liable  to  be  overlooked.  It  may  also 
occur  suddenly  in  chronic  nephritis,  and  particularly  in  the  scarlatinal 
variety,  {h)  It  may  arise  from  local  mechanical  causes,  as  the  pressure 
of  mediastinal  tumors,  aneurysm,  or  thrombosis  of  the  cardiac  veins. 
1  Semaine  Medicale,  Sept.  7,  1910. 


HEMOPERIOABDIUM— PNEUMOPERICARDIUM.  G27 

Symptoms. — No  subjective  symptoms  arc  present,  save  perhaps 
dyspnea,  and  the  diagnosis  rests  upon  the  history  and  the  physical  signs. 
None  of  the  latter,  however,  arc  distinctive.  They  point  to  the  presence 
of  fluid  in  the  pericardial  sac,  and  the  area  of  percussiori-diilness  as- 
sumes the  same  form  and  exhibits  even  greater  change,  with  alteration 
of  the  patient's  posture,  tlian  in  pericarditis.  No  friction-murmurs  are 
heard  on  auscultation  and  no  bulging  of  the  pericardium  is  observed. 
Again,  there  is  neither  a  history  of  infectious  disease  nor  inflam- 
mation of  adjacent  organs,  as  in  pericarditis.  It  is  rare  indeed  to 
see  an  excessive  amount  of  serum  in  the  pericardium  at  the  post-mortem 
The  symptoms  and  signs  of  hydrothorax  generally  precede  and  accompany 
hydropericardium,  and  the  latter  condition  tends  to  intensify  the  effect  of 
the  former.  Osier  remarks  :  "  Naturally  there  are  in  the  pericardial  sac 
a  few  cubic  centimeters  of  clear,  citron-colored  fluid,  which  probably  rep- 
resents a  post-mortem  transudate."  In  rare  instances  the  transudate  has 
a  milky  appearance  {chylo-pericardium). 

The  treatment  suitable  for  cases  of  general  dropsy,  as  a  rule,  affords 
relief.     In  large  serous  accumulations  aspiration  should  be  practised. 


HEMOPERIOARDIUM. 

By  the  term  "  hemopericardium  "  is  meant  hemorrhage  into  the  peri- 
cardial pouch — a  rare  event.  Among  the  causes  are — (a)  perforation  by 
aneurysms  of  the  aorta  and  the  coronary  arteries  into  the  sac ;  (5)  rupture 
of  the  heart,  due  to  injuries  or  cardiac  aneurysms  and  fibrous  formations 
from  myocarditis;  (c)  direct  injuries,  especially  stab-  and  bullet-wounds. 
The  symptoms  and  course  depend  greatly  upon  the  nature  of  the  exciting 
cause.  The  most  frequent  factor,  rupture  of  an  aneurysm,  proves  quickly 
fatal  from  overcrowding  of  the  heart.  In  rupture  of  the  heart-muscle 
there  is  sometimes  a  slow  outpouring  of  blood,  with  a  correspondingly 
slow  course,  varying  from  a  few  hours  to  a  couple  of  days  in  duration. 
The  physical  signs  of  pericardial  effusion  come  on  with  dyspnea  and  fail- 
ing circulation,  which  lead  to  cardiac  exhaustion  and  death.  The  blood- 
stained effusions,  occurring  in  certain  forms  of  pericarditis  {vide  supra),  are 
not  to  be  regarded  as  instances  of  hemopericardium.  Unconsciousness 
appears  early,  to  be  quickly  relieved  when  the  pressure  is  removed. 


PNEUMOPERICARDIUM. 

{Air  in  the  Pericai'diuin.) 


In  this  complaint,  besides  air  or  gas,  there  is  usually  present  pus,  and 
less  frequently  blood  ;  hence  an  appropriate  term  in  most  instances  would 
be  pyo-pneumopericardium.  The  causes  are  the  following :  (a)  wounds  ; 
(6)  a  fistulous  connection  between  the  adjacent  air-containing  organs  and 
the  pericardium  as  the  result  of  diseased  processes,  such  as  pulmonary 
tuberculosis  or  empyema ;  (c)  rarely  decomposition  of  liquid  pericardial 
efi'usions,  or  the  development  of  gas-producing  bacteria.      The  symptcms 


628  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

are  equivocal.  In  the  main  they  do  not  diflFer  from  those  of  pericarditis 
uith  eff.ision,  exceptinix  that  dyspnea  is  more  intense  than  in  the  latter 
affection.  The  physical  signs,  however,  are  different.  In  pneumoperi- 
cardium there  is  tympanitic  percussion-resonance  over  the  precordia, 
though  the  fluid,,  when  present,  gives  rise  to  a  boundary-line  of  dulness. 
The  change  of  the  patient's  posture  decidedly  alters  the  area  of  the  tym- 
panitic note.  On  auscultation  may  be  heard  loud,  rasping,  friction- 
sounds  having  a  metallic  quality,  intermingled  with  churning,  splashing 
noises,  or  the  so-called  "water-wheel  sounds."  Pneumothorax  when 
encysted  in  close  pro.xiinity  to  the  heart,  displacing  the  hitter  organ,  must 
be  eliminated.  The  latter  complaint  gives  cardiac  dulness  in  an  abnormal 
position  and  a  metallic  auscultatory  sound  synchronous  with  the  respira- 
tory movements — two  diagnostic  points  of  pneumothorax  that  are  absent 
in  pneumopericardium.  The  jwognods  is  grave,  death  coming  on  most 
commonly  in  a  day  or  two.  The  admission  of  air  alone  might  result  in  a 
spontaneous  cure,  as  occurs  rarely  in  pneumothorax.  The  treatment  is 
the  same  as  has  been  recommended  for  purulent  pericarditis. 


II.  DISEASES  OF  THE  HEART. 

ENDOCARDITIS. 

.  Definition. — Inflammation  of  the  lining  membrane  of  the  heart. 
The  process  is  usually  confined  to  the  valves,  though  the  cardiac  layer 
may  also   be  affected. 

Varieties. — {a)  Simple  acute  endocarditis;  {h)  ulcerative  endocarditis ; 
(c)  chronic  endocarditis.  The  pathologic  processes  involved  in  the  first 
two,  the  acute  forms,  are  identical  in  nature,  though  they  differ  in  severity. 
I  have  met  with  two  instances  that  apparently  occupied  a  middle  ground. 

SIMPLE   ACUTE    ENDOCARDITIS. 
{Endocarditis    Verrucosa.) 

Pathology. — The  disease  is  characterized  by  the  formation  of  small 
vegetations  on  the  segments,  varying  in  size  from  excrescences  that  are 
scarcely  visible  to  those  the  size  of  a  pea.  They  are  found  chiefly  on 
surfaces  that  are  opposed  to  the  blood-current,  near  the  margin  of  the 
valve,  and  '•forming  a  row  of  bead-like  outgrowths."  Their  seat  corre- 
sponds to  the  point  of  maximum  contact  (Sibson),  but  the  mitral  valve 
is  much  more  commonly  affected  than  the  aortic.  With  the  segments  the 
chordae  tendinese  are  sometimes  affected,  and  very  rarely  the  latter  are 
alone  involved.  The  left  side  of  the  heart  is  much  more  frequently  the 
seat  of  acute  endocarditis  than  the  right,  except  during  fetal  life,  when 
the  right  side  is  almost  exclusively  involved.  To  account  for  the  greater 
frequency  of  occurrence  on  the  left  side  after  birth,  it  has  been  suggested 
that  freshly  oxygenated  blood  affords  the  most  favorable  condition  for 
the  multiplication  of  the  micro-organisms  principally  concerned  in  the 


SIMPLE  ACUTE  ENDOCARDITIS.  629 

inflammatory  process.  Corroborating  this  view  is  the  fact  that  during 
fetal  life  the  blood  in  the  right  chamber  is  the  more  completely  oxygen- 
ated. It  has  also  been  pointed  out  that  before  birth  the  right  side,  and 
after  birth  the  left  side,  is  the  more  active,  and  that  the  active  side  is  apt 
to  suffer  on  account  of  higher  pressure.  Obviously,  the  vegetations  form 
an  obstruction  to  the  current  of  the  circulation  as  it  flows  through  the 
valvular  opening.  In  the  early  stage  the  membrane  in  the  vicinity  of 
these  excrescences  shows  a  bright-red  color,  which  has  usually  disappeared 
in  fatal  cases  before  they  come  to  autopsy.  The  hiHtologic  changes  con- 
sist in  a  proliferation  of  the  subendothelial  tissue  (small-celled  infiltra- 
tion), which  forms  the  principal  component  part  of  the  vegetation.  On 
this  basal  mass  of  granulation  tissue  there  is  deposited  fibrin  from  the 
blood,  the  latter  being  separable  from  the  former  in  acute  forms  of  the 
complaint.  Micro-organisms  have  repeatedly  been  found  in  the  fibrinous 
depositions,  but  the  specific  causal  irritant  has  not  as  yet  been  discovered. 
In  favorable  cases  either  the  vegetation  is  ultimately  absorbed  or  there 
remains  a  small  indurated  mass.  When  the  vegetations  are  of  consider- 
able size  emboli  may  become  detached  by  the  force  of  the  blood-current, 
and  be  carried  to  the  vessels  of  the  extremities  and  to  the  various  viscera, 
particularly  the  brain,  spleen,  and  kidneys,  giving  rise  to  embolic  infarcts. 
The  latter  event  is  frequently  observed  in  cases  in  which  acute  endocar- 
ditis is  engrafted  upon  chronic  valvulitis. 

Simple  acute  endocarditis  may  end  in  the  more  serious  or  ul- 
cerative  variety  {vide  infra).  More  commonly,  however,  does  the  simple 
form  terminate  in  chronic  valvulitis  with  deformity. 

Ktiology. — The  most  frequent  cause  of  acute  endocarditis  is  acute 
articular  rheumatism,  which  induces  the  disease  in  not  less  than  40 
per  cent,  of  the  cases.  In  young  rheumatic  subjects  the  liability 
to  the  complaint  is  particularly  pronounced.  The  severity  or  mild- 
ness of  the  rheumatic  attack  does  not,  however,  influence  the  ap- 
pearance of  the  cardiac  complication.  Cases  of  acute  endocarditis  of 
rheumatic  origin  are  met  with  in  which  the  arthritic  phenomena  are 
secondary.  It  may  complicate  tonsillitis  when  the  latter  is  due  to  or  asso- 
ciated with  rheumatism.  In  specific  fevers  it  is  also  encountered,  and  is 
common  in  scarlet  fever,  but  rare  in  typhoid  fever,  diphtheria,  measles, 
erysipelas,  variola,  and  varicella.  It  is  not  uncommon  as  a  complication 
in  pneumonia.  Osier,  as  the  result  of  100  autopsies  in  cases  of  pneu- 
monia, found  it  present  in  5  instances.  TuherGulosis  is  not  infre- 
quently the  basal  disease.  Of  11,000  records  of  autopsies  in  cases  of 
tuberculosis,  151  instances  of  endocarditis  were  found  (G.  W.  Norri.s). 
It  has  frequently  developed  in  the  more  serious  forms  of  cliorca.,  and  inter- 
current acute  endocarditis  may  result  from  chronic  diseases  attended  with 
emaciation  and  general  weakness  or  suppuration,  such  as  ulcerative  car- 
cinoma, gleet,  gout,  chronic  Bright's  disease,  and  diabetes.  Lastly, 
acute  endocarditis  may  occur  as  a  secondary  event  in  pre-existing  scle- 
rotic endocarditis,  Avhen  it  is  termed  acute  recurrent  endocarditis.  In 
chronic  endocarditis  the  liability  to  the  acute  form  is  greatly  increased 
by  the  puerperal  state,  and,  to  a  lesser  extent,  by  pregnancy. 

Bacteriology. — All  cases  of  acute  endocarditis  are  microorganismal 
in  character.     The  disease,  however,  is  the  result  of  various  microorgan- 


630  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

isms  or  their  toxins,  Avliose  action  is  assisted  by  tlie  friction  between  the 
blood  current  and  the  surfaces  of  the  valves.  Frank  el  and  Sanger 
affirm  that  tlie  sta])hylococcus  pyogenes  aureus  is  the  chief  specific  or- 
ganism. The  diplococcus  pneumonia^  the  streptococcus  pyogenes,  and, 
less  commonly,  the  Bacillus  coli  communis,  the  gonococcus,  the  Bacillus 
(liphtheri;Te.  the  bacillus  ofEberth,  that  of  Pfeiffer,  and  the  micrococcus 
endocarditis  capsulatus  and  rugatus  are  found. 

Clinical  History. — It  is  only  occasionally  that  definite  subjective 
symptoms,  as  precordial  vain  (sometimes  extending  down  the  left  arm), 
dyspnea,  and  cardiac  palpitation,  are  complained  of  by  the  patient.  If 
fever  have  been  present,  as  is  common,  the  temperature  usually  rises 
rather  abruptly.  In  the  vast  majority  of  instances  the  condition  is  discov- 
ered accidentally.  This  being  true,  its  frequent  occurrence  in  acute  artic- 
ular rheumatism,  and  its  occurrence  in  the  other  diseases  mentioned  under 
'*  Etiology,"  should  be  kept  in  remembrance.  The  symptoms  of  embolism 
are  rarely  observed.     F.  Billings  reports  a  case  with  multiple  emboli. 

The  physical  signs  by  which  acute  endocarditis  is  recognizable  are 
dependent  upon  the  valvular  insufficiencies  caused  by  the  morbid  lesions 
previously  described.  In  some  cases,  including  tliose  in  which  the  valves 
are  not  affected,  distinct  physical  signs  are  absent. 

On  inspection  the  area  of  visible  impulse  may  be  seen  to  be  increased, 
to  the  left  in  most  cases.  The  impulse  is  sometimes  forcible  and  often 
irregular  during  the  initial  period,  but  later  it  becomes  less  distinct  and 
more  feeble.  Palpation  confirms  the  result  of  inspection.  I  have  found 
the  impulse  to  vary  at  each  visit,  with  a  general  tendency  to  lessen  in 
intensity  in  the  later  period  of  the  disease.  A  very  weak  impulse  is  in- 
dicative of  associated  myocarditis  or  of  the  poisonous  effect  of  a  severe 
type  of  primary  infection.  In  recurrent  endocarditis  the  apical  impulse 
is  often  heaving,  on  account  of  pre-existing  compensatory  hypertrophy, 
and  its  area  is  exceedingly  variable.     A  systolic  thrill  is  sometimes  felt. 

On  percussion  the  cardiac  area  of  dulness  is  found  to  be  either  normal, 
or,  more  commonly,  enlarged  in  the  transverse  diameter,  especially  to 
the  left ;  this  results  from  the  increased  diastolic  tension  in  the  left  ven- 
tricle. While  the  right  ventricle  meets  with  greater  resistance,  it  rarely 
dilates,  owing  to  its  power  of  accommodation  during  the  course  of  acute 
endocarditis.  In  recurrent  acute  endocarditis  the  area  of  dulness  cor- 
responds to  the  increased  area  of  the  apical  beat. 

Auscultation. — Acute  endocarditis  is  usually  attended  with  a  soft 
blowing,  systolic  murmur,  which,  since  the  mitral  segments  are  the 
favored  seat  of  the  disease,  is  heard  much  more  frequently  at  the  apex 
than  at  the  base.  The  point  of  maximum  intensity  of  this  murmur  is 
often  movable,  but  its  area  of  transmission  is  limited.  In  rheumatic 
endocarditis  this  murmur  is  preceded  by  a  prolongation  of  the  first  sound. 
It  is  associated  with  accentuation  of  the  second  pulmonic  sound.  The 
murmur  is  sometimes  heralded  by  a  dull  first  sound  and  delayed  radial 
pulse,  with  apparent  intensification  of  the  second,  suggesting  ventricular 
dilatation  as  the  cause  of  the  murmur.  The  characteristic  presystolic 
murmur,  indicating  mitral  stenosis,  may  be,  in  exceptional  cases,  asso- 
ciated. In  acute  endocarditis  affecting  the  mitral  valves  aortic  murmurs 
may  coexist,  but  their  true  nature  is  more  than  doubtful.  There  is  also 
a  short,  low-toned,  and  double  systolic  murmur  over  the  tricuspid  orifice 


SIMPLE  ACUTE  ENDOCARDITIS.  631 

in  a  small  proportion  of  the  cases ;  this  is  due  most  probably  to  a  relative 
incompetency.  When  acute  endocarditis  arises  in  connection  with  chronic 
valvular  disease,  the  auscultatory  signs  of  the  latter  are  but  little  changed, 
and  hence  an  assured  diagnosis  is  not  possible. 

Cotnplications. — There  may  be  developed  by  direct  extension  sec- 
ondary myocarditis  [vide  p.  690)  and  pericarditis. 

The  diagnosis  is  based  principally  on  the  physical  signs,  though 
these  are  by  no  means  trustworthy.  The  points  gained  by  careful 
inspection  and  palpation  are  of  especial  diagnostic  importance,  as  is  also 
the  previous  history  of  the  patient.  Leube  ^  points  out  that  if  the  dul- 
ness  is  slightly  increased  to  the  left  and  there  is  fever — in  fact,  if  there 
is  infectious  disease  present — a  diagnosis  must  be  made  of  acute  insuffi- 
ciency of  the  ostium  mitralis  occurring  in  the  course  of  acute  endo- 
carditis. Rosenau  states  that  blood-cultures  should  be  made  for  the 
identification  and  study  of  the  infecting  organism  as  well  as  for  prognostic 
reasons. 

Differential  Diagnosis. — The  soft  bellows  murmur  is  often  present  in 
acute  febrile  diseases  in  which  the  autopsy  fails  to  reveal  the  lesions  of 
acute  endocarditis.  The  functional  murmurs  that  arise  in  the  specific 
fevers,  however,  are  principally  heard  over  the  aortic  and  pulmonary  areas, 
while  those  occurring  in  endocarditis  are  commonly  heard  over  the  mitral 
area.  The  murmurs  present  must  be  called  accidental  (functional)  if  the  area 
of  cardiac  dulness  is  normal,  the  second  pulmonary  sound  not  accentuated, 
and  if  the  murmur  be  heard  only  at  the  pulmonary  cartilage,  or  at  this 
point  and  at  the  apex,  and,  at  any  rate,  more  distinctly  at  the  pulmonary 
cartilage  (Leube  ^).  The  distinction  between  simple  acute  endocarditis 
and  pericarditis  should  be  categorical,  in  view  of  the  manifold  differences 
between  their  signs.  But  the  fact  that  these  two  affections  may  be 
associated,  more  especially  when  they  are  of  rheumatic  origin,  must  be 
steadily  borne  in  mind,  and  also  that  when  combined  the  pericardial 
friction-sound  and  the  later  effusion  obscure  the  signs  belonging  to  the 
endocarditis.  I  have  found,  however,  that,  fortunately,  endocarditis 
precedes  pericarditis  in  the  majority  of  the  cases.  The  elimination  of 
old  endocarditis  or  chronic  valvular  disease — a  matter  of  importance — 
may  be  accomplished  by  attention  to  the  character  of  the  murmur  in 
acute  endocarditis,  as  well  as  to  its  limited  area  of  diffusion,  and  by  the 
absence  of  the  signs  of  hypertrophy  and  of  marked  accentuation  of  the 
second  pulmonary  sound. 

A  relative  insufficieiicy  distinguishes  itself  by  a  pure  systolic  murmur, 
loud  and  not  invariably  uniform,  by  a  weak  cardiac  impulse,  a  slight  ac- 
centuation of  the  second  pulmonary  sound,  and  a  comparatively  small  and 
often  irregular  pulse.  It  is  met  with  in  excessive  dilatation  of  the  left 
ventricle,  in  anemia,  "  and  particularly  in  certain  changes  of  the  valvular 
muscles,  due  to  myocarditis  "  (Leube). 

Prognosis. — The  immediate  dangers  are  few,  and  depend  largely 
upon  the  primary  disease.  In  many  instances,  however,  acute  endocar- 
ditis initiates  permanent  lesions  of  the  valves. 

Treatment. — Prophylaxis. — The  prevention  of  acute  endocarditis  in 
rheumatism  has  been  dealt  with  in  discussing  the  latter  disease.  No  known 
direct  measures  can  prevent  the  development  of  this  condition  in  the  course 
»  Deutsch.  Archiv  f.  klin.  Med.,  Nov.  5,  1896.  ^  Loc.  cit. 


632  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  tlie  specific  fevers,  though  absolute  rest  in  bed  and  protection  of  the 
body  against  ''  coM  "  may  diminish  somewhat  the  tendency  to  it. 

The  Attack. — The  sick-room  should  be  free  from  draughts,  though 
well  ventilated,  and  flannel  is  to  be  applied  to  the  chest.  The  diet 
may  be  liberal,  but  should  be  composed  chiefly  of  milk  and  other  light 
nutritious  substances.  Stimulants  are  required  in  most  instances,  and 
in  abundance  should  the  heart  be  failing.  Digitalis  is  to  be  employed 
cautiously  if  at  all.  When  the  myocardium  is  involved,  its  use  is 
not  without  danger ;  under  these  circumstances  the  drug  increases  the 
suff'erings  of  the  patient  by  throwing  the  inflamed  and  weakened  car- 
diac muscle  into  firm  contractions.  The  salts  of  ammonium,  particu- 
larly the  carbonate,  should  be  given  continuously  with  a  view  to  obvi- 
atino-  intracardial  coagulation  of  blood ;  and  should  the  latter  accident 
occur  despite  all  efforts  to  prevent  it,  the  carbonate,  together  with  strych- 
nin and  alcoholic  stimulants,  should  be  freely  administered.  I  am  con- 
vinced that  in  endocarditis  due  to  acute  articular  rheumatism  it  is  wise  to 
continue  the  exhibition  of  the  salicylates,  though  in  moderate  doses,  pro- 
vided that  the  heart  is  guarded  by  the  use  of  stimulants.  During  con- 
valescence from  an  acute  endocarditis  the  patient  should  be  kept  at  rest, 
so  as  to  minimize  the  strain  upon  the  affected  valves ;  even  after  he  has 
apparently  recovered,  and  particularly  should  the  murmur  still  be  present, 
perfect  quiet  is  to  be  enjoined  for  a  period  of  several  weeks. 

ULCERATIVE   ENDOCARDITIS. 
{Malignant  or  Infectious  Endocarditis.) 

Malignant  endocarditis  is  variously  characterized,  though  usually 
either  by  perforative  ulceration,  by  suppuration  of  the  valves,  or  by  both, 
giving  rise  to  the  physical  signs  of  acute  endocarditis.  These  develop 
amid  the  symptoms  of  a  severe  primary  infectious  or  septic  disease. 
There  is  at  hand  enough  clinical  evidence  to  warrant  the  assumption  that 
ulcerative  endocarditis  also  occurs,  though  rarely,  as  a  primary  aff'ection. 

Pathology. — {a)  Valvular  Endocarditis. — In  its  early  development 
the  valves  are  the  seat  of  vegetations  (such  as  are  met  with  in  simple 
acute  endocarditis)  which  later  undergo  necrosis.  The  latter  process 
tends  to  spread,  destroying  more  or  less  of  the  endocardium.  In  the 
interior  of  the  vegetations  suppuration  not  infrequently  takes  place,  and 
the  abscesses  thus  formed  rupture  and  produce  various  lesions  according 
to  their  size  and  situation.  The  vegetations  take  on  a  grayish-  or  yellow- 
ish-green appearance.  Histologically,  they  are  composed  of  granulation 
tissue,  veiled  by  granular  and  fibrillated  fibrin,  containing  numerous  micro- 
organisms. At  the  base  there  is  usually  developed  more  or  less  reaction- 
ary inflammation.  After  rupture  the  blood-current  may  enter  the  abscess- 
cavity,  and,  if  there  be  no  complete  perforation,  the  endocardium  will  be 
pouched  out,  and  an  aneurysmal  dilatation  of  the  valve  will  result. 
Ulcerative  lesions  are  most  frequently  observed.  They  may  be  mere 
erosions  of  the  endocardium,  but,  as  a  rule,  are  penetrating  and  often  re- 
sult in  complete  perforation.  I  have  seen  repeated  instances  in  which  the 
three  classes  of  lesions  above  depicted  were  all  present.  Osier,  in  an  analysis 
of  209  cases  examined  by  him  with  a  view  to  ascertaining  approximately 
the  relative  frequency  with  which  the  diff'erent  parts  of  the  heart  were 


ULCERATIVE  ENDOCARDITIS.  633 

affected,  obtained  this  result:  Aortic  and  mitral  valves  tofretlier,  41; 
aortic  valves  alone,  53;  mitral  valves  alone,  77;  tricuspid  in  19,  pul- 
monary valves  in  15,  and  the  heart-wall  in  83  instances.  In  9  instances 
the  right  heart  alone  was  involved.^ 

(b)  Malignant  mural  endocarditis  gives  the  same  set  of  changes  as 
the  valvular  form ;  indeed,  the  two  may  be  combined  throughout.  It  is 
a  comparatively  rare  condition,  as  is  shown  by  the  foregoing  figures  of 
Osier.  The  ulcerative  process  may  invade  the  chordae  tendinae  and  the 
valves,  and  may  perforate  the  septum  or  even  the  ventricular  wall  itself. 
The  vegetations  are  detached  in  small  or  large  masses,  and  are  conveyed 
by  the  blood  to  various  organs,  especially  to  the  spleen  and  kidneys,  less 
frequently  the  intestines,  meninges  of  the  brain,  and  the  skin.  Their 
site  is  determined  largely  by  their  size,  and  they  may  be  so  large  as  to 
plug  vessels  of  the  caliber  of  the  external  iliac.  When  found  in  the 
lungs  they  may  originate  in  endocarditis  affecting  the  right  heart.  These 
emboli,  containing,  as  they  do,  the  agents  of  inflammation,  form  suppu- 
rative infarcts  that  may  be  either  white  or  red  in  color.  The  detached 
vegetations  are  sometimes  so  laden  with  irritants  as  to  cause  rapid 
softening  of  the  coats  of  the  vessel  at  the  point  where  they  become 
arrested,  with  consequent  aneurysmal  dilatation  directly  opposite  their 
seat.  The  number  of  infarcts  varies  greatly  in  different  cases;  thus  there 
may  be  only  one  or  two,  as  in  a  case  in  my  own  knowledge  in  which  the 
spleen  alone  contained  two  small  infarcts,  or  there  may  be  more  than  a 
thousand  minute  abscesses  widely  scattered  throughout  the  body. 

etiology. — It  is  to  be  kept  in  remembrance  that  the  condition  is, 
with  few  exceptions,  most  probably  a  secondary  one.  This  explains 
why  the  lesions  peculiar  to  simple  acute  endocarditis  usually  precede 
and  accompany  those  of  the  ulcerative  form. 

Bacteriology. — The  specific  irritant  is  usually  the  streptococcus  pyog- 
enes (Frankel  and  Sanger) ;  hence  the  diseases  in  which  ulcerative  en- 
docarditis occurs  as  a  complication  merely  furnish  the  opportunity  for 
the  invasion  of  the  streptococcus.  The  bacillus  diphtherise,  however, 
as  well  as  the  staphylococcus,  the  bacillus  coli,  the  bacillus  anthracis, 
the  pneumococcus,  the  gonococcus,  and  other  organisms,  have  been  found 
in  some  cases  in  the  absence  of  the  streptococcus. 

In  purely  septic  diseases  the  cardiac  element  serves  to  facilitate  tlie 
generation  and  rapid  diffusion  of  the  poison  ;  and,  since  the  latter  is 
prone  to  attack  the  valve-segments,  the  morbid  lesions  within  the  heart 
not  rarely  constitute  the  chief  pathologic  factor  in  septicopyemia. 

Predisposing  Affections. — The  malignant  form  occurs,  in  connection 
\vith  acute  articular  rheumatism,  in  about  10  per  cent,  of  the  cases  in 
which  acute  endocarditis  appears.  In  lobar  pneumonia  the  ulcerative 
type  is  common,  occurring  almost  as  frequently  as  the  simple  variety, 
and  was  found  by  Osier  in  11  out  of  23  cases.  The  septic  processes 
that  arise  from  the  puerperal  state  or  from  gonorrheal  infection  may  also 
be  complicated  with  ulcerative  endocarditis.  Among  many  other  diseases 
that  furnish  occasional  instances  of  this  serious  complication  are  measles, 
scarlet  fever,  typhoid  fever,  erysipelas,  small-pox,  chorea,  tuberculosis, 
and  chronic  nephritis. 

*  Text-hook  of  3fedicine,  p.  631. 


634  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Clinical  History. — That  form  of  ulcerative  endocarditis  which  is  a 
more  or  less  promiuent  factor  in  septic  diseases  has  been  considered  in 
connection  with  septicemia.  Malignant  endocarditis  being  usually  a 
secondary  event,  its  clinical  features  must  not  be  confounded  with  those 
of  the  primary  affection.  It  is,  however,  often  impossible  clearly  to 
separate  the  symptoms  of  the  former  from  those  of  the  intercurrent 
affection.     I  shall  describe  first  the  common  typhoid  form. 

Local  syynptoms  are  often  entirely  wanting,  or,  when  present,  consist 
merely  in  slight  precordial  pain  and  oppression,  and  are  not  sufficiently 
well  pronounced  to  arrest  attention.  Subjective  symptoms  are,  however, 
connected  with  other  organs  than  tlie  heart,  and  are  due  to  the  irritating 
effects  of  emboli  that  occupy  the  various  organs  of  the  body.  Grasiro-intes- 
tinal  disturbance,  as  shown  by  the  occurrence  of  vomiting  and  diarrhea, 
is  common.  Pain  ascribable  to  local  peritonitis  over  the  spleen,  and 
sometimes  also  over  the  liver,  is  observed.  Hematuria  and  dim,ne»s  of 
vision  are  also  frequent  concomitants,  and  are  due  to  renal  and  retinal 
hemorrhages.  The  urine  may  be  scanty  and  albuminous.  The  vhoyq  gen- 
eral features,  that  are  the  result  of  the  local  embolic  processes  or  small 
abscesses,  and,  in  part,  of  the  valvular  lesions,  are  for  the  most  part 
typhoid  in  character.  The  onset  is  usually  signalized  by  a  severe  rigor 
that  may  be  repeated  at  intervals  varying  from  one  to  several  days,  and 
there  is  often  an  irregularly  continued  fever-curve,  often  touching  a  high 
mark  (105°  or  106°  F.— 40.5°  or  41.1°  C).  I  saw  a  case  in  which  the 
febrile  movement  pursued  the  continued  type  for  seven  weeks.  The  pulse 
is  rapid  and  irregular,  though  frequently  becoming  slow  within  a  brief 
period.  The  patient  rapidly  emaciates.,  and  from  the  onset  is  profoundly 
prostrated ;  nervous  symptoms,  as  headache,  mild  delirium,  followed  by 
somnolence,  and  sometimes  even  coma,  appear.  Profuse  sweating  sets  in 
and  persists,  and  as  a  result  the  skin  may  be  covered  by  sudamina.  An 
ecchymotic  eruption  due  to  cutaneous  emboli  is  also  common,  often  asso- 
ciated with  a  papular  or  a  diffused  roseolar  rash.  At  times  arthritis  may 
occur.     Micro-organisms  may  be  discovered  in  the  blood. 

Physical  Signs. — These  may  be  negative  as  regards  the  heart.  In  the 
majority  of  instances,  however,  a  systolic  murmur  is  present,  which, 
when  associated  with  other  clinical  indications  of  this  affection,  is  valu- 
able for  diagnosis,  and  especially  so  if  developed  while  the  patient  is 
under  treatment  for  the  primary  attack.  The  second  sound  is  some- 
times accentuated  even  when  no  organic  lesions  have  previously  existed. 
The  physical  signs  of  pneumonia  and  pleuritis  (particularly  the  latter) 
may  not  infrequently  be  noted.  Cases  occur  in  which  infarcts  of  the 
right  lung  give  rise  to  signs  of  localized  consolidation  ;  the  spleen  be- 
comes swollen,  easily  palpable,  and  is  quite  tender  as  a  rule ;  the  liver 
is  likewise  moderately  enlarged  and  slightly  sensitive. 

Cerebral  Variety. — In  a  small  though  decisive  percentageof  the  cases 
all  the  clinical  features  of  acute  suppurative  meningitis  are  presented, 
and  sometimes  to  the  almost  total  exclusion  of  symptoms  pointing  to  the 
primary  disease  or  to  the  more  typical  typhoid  form  of  ulcerative  endo- 
carditis. For  a  description  of  the  symptoms  that  characterize  the  cere- 
bral form  the  reader  is  referred  to  the  discussion  of  Purulent  Meningitis. 

Recurrent  Malignant  Endocarditis. — By  this  term  is  meant  an  acute 
ulcerative  endocarditis  coming  on  in  the  course  of  chronic  valvular  dis- 


VLCEEATIVE  ENDOCARDfT/S.  635 

ease.  As  has  been  pointed  out,  simple  acute  recurrent  enrlocarditis  ia 
common,  though  difficult  of  recognition.  The  latter  condition,  as  well 
as  the  lesions  in  chronic  valvular  disease,  predisposes  to  secondary  infec- 
tion by  the  streptococcus  and  other  organisms.  The  onset  is  usually 
abrupt  and  marked  by  a  chill.  The  patient  has  fever,  which  may  be 
quite  high  (104°  F. — 40°  C,  or  over),  and  may  present  either  an  irreg- 
ularly intermittent  or  a  truly  intermittent  curve.  The  latter  is  often  asso- 
ciated with  recurring  chills.  In  either  of  the  above  groujiH  the  course  is 
likely  to  be  acute.  In  some  cases  the  pre-existing  murmur  becomes 
louder  and  more  decidedly  blowing ;  the  character  of  the  super- 
added murmur  is  changeable ;  in  many  other  instances,  however, 
there  is  no  appreciable  alteration.  The  condition  may  arise  sud- 
denly, amid  the  signs  of  failing  compensation,  as  in  a  fatal  case 
reported  by  Dr.  H.  P.  Loomis,^  in  which  the  patient  was  semi-con- 
scious, cyanotic,  and  suiFering  from  intense  dyspnea  and  general  dropsy. 
It  was  impossible  to  diagnosticate  the  cardiac  lesions  by  the  murmur 
present.  Occasionally  these  severe  intercurrent  febrile  attacks  end  in 
recovery,  and  such  cases  probably  belong  to  the  benign  form  of  acute 
endocarditis.  There  is  a  third  group  of  cases  that  run  a  subacute  or  even 
chronic  course,  with  more  moderate  elevations  of  temperature,  or,  as 
rarely  happens,  none  at  all.  Mullin,  of  Hamilton,  has  reported  a  case 
that  lasted  more  than  a  year.  Here  the  other  clinical  phenomena, 
especially  those  referable  to  the  heart,  are  often  scanty  and  indefinite. 

In  a  series  of  14  cases  of  chronic  infectious  endocarditis  reported  by 
F.  Billings  ^  5  were  implanted  on  normal  valves,  while  in  2  previous 
heart  lesions  were  in  doubt. 

Diagnosis. — It  is  of  paramount  importance  to  consider  the  previous 
history  and  all  the  circumstances  under  which  individual  cases  occur. 
These  points,  together  with  the  early  symptoms,  more  particularly  the 
severe  rigor,  early  high  temperature,  and  profound  prostration,  the  sweat- 
ings, the  various  embolic  phenomena,  and  the  presence  of  cardiac  symp- 
toms, are  often  adequate  for  a  certain  diagnosis.  With  a  clear  history 
and  the  presence  of  the  more  characteristic  general  symptoms  (in  partic- 
ular, the  signs  of  embolism),  a  correct  diagnosis  is  possible,  even  though 
cardiac  murmurs  be  absent.  Instances  in  which  no  data  can  be  found  to 
explain  the  occurrence  of  the  disease  are  especially  puzzling,  and  will 
remain  unrecognized  if  the  heart  manifests  no  special  symptoms,  and 
embolic  phenomena  are  absent.  Here  the  existence  of  a  chronic  valvu- 
lar aifection  would  afford  strong  probability  of  the  presence  of  recurrent 
malignant  endocarditis,  especially  if  an  intercurrent  fever  be  present. 
A  blood  culture  should  be  undertaken  in  all  cases. 

Differential  Diagnosis. — The  subjoined  Table  will,  I  feel,  be  found 
valuable  as  an  aid  in  eliminating  enteric  fever  from  the  typhoid  form  of 
malignant  endocarditis : 

Ulcerative  Endocarditis.  Typhoid  Fever. 

Previous  or  associated  disease,  as  acute  Previous   health   good.      History   of  an 

rheumatism  or  pneumonia.  epidemic. 

Very    rarely  a   primary   aflPection.      No  Always    idiopathic,    with    a    prodromal 

prodromes  observable.  stage. 

^  Transactions  of  the  N^eic  York  Pathological  Soeiet)/,  1890. 
2  Archives  of  Internal  Medicine,  Chicago,  November,  1909. 


636  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Ulcerative  Endocarditis.  Typhoid  Fever. 

Ushered   in  suddenly  by  a  severe  rigor.  Invasion    marked    by   slight    recurring 

which  may  recur.  chilly  sensations.      (Severe  chill  very 

rarely.) 

The  fever  rises  rapidly.  More  gradually,  in  step-like  fashion. 

Profound   prostration   as  early    as  third  Profound    prostration    not    earlier    than 

day.  seventh  day. 

The   fever  is   markedly  irregular    from  Less  so,  especially  in  the  first  week. 

time  of  onset,  as  a  rule. 

Embolic  symptoms  (hemiplegia,  etc.)  may  Extremely  rare. 

appear. 

Cardiac  symptoms,   especially  loud  sys-  Sometimes  a  soft  systolic  murmur. 

tolic  murniur,  often  present. 

The  blood  usually  shows  signs  of  septic  The  blood  shows  a  leukopenia. 

leukocytosis. 

Blood  culture  may  show  a  micro-organism  Blood  culture  may  show  the  typhoid  bacil- 

other  than  the  typhoid  bacillus.  lus. 

Widal  reaction  and  characteristic  erup-  Both  symptoms  usually  present  and  diag- 

tion  absent.  nostic' 

When  no  etiologic  factors  are  discoverable,  and  embolic  and  cardiac  phe- 
nomena are  absent,  we  must  rely  upon  the  Gruber-Widal  reaction,  and  other 
laboratory  tests,  to  distinguish  typhoid  fever  from  ulcerative  endocarditis. 

Prognosis. — Most  cases  that  run  an  acute  course  terminate  in  death, 
and  when  supposed  instances  of  malignant  endocarditis  recover  they  are 
usually  to  be  regarded  as  being  of  beniiin  character.  Subacute  or  chronic 
varieties,  however,  such  as  are  most  frequently  met  with  in  connection 
with  organic  heart-disease,  sometimes  end  in  recovery. 

Treatment. — This  is  largely  supportive.  The  feeding  is  to  be 
pushed  vigorously,  and  concentrated  forms  of  liquid  food  should  be  given 
at  regular,  brief  intervals.  Iie8t  and  arterial  stimulants  in  liberal  quan- 
tities are  also  demanded,  and  in  addition,  quinin,  sodium  salicylate,  and 
antiseptics  may  be  tried.  For  the  embolic  symptoms  the  salts  of  am- 
monium give  slight  promise  of  beneficial  results,  and  I  prefer  the  car- 
bonate for  this  purpose.  Potassium  iodide  in  moderate  dosage  is  recom- 
mended for  its  control  over  vascular  metabolism.  Antistreptococcic 
serum  has  proved  eificacious  in  certain  cases  in  which  the  streptococcus 
was  the  causative  agent.  Broadbent  thinks  the  vaccine  treatment  affords 
a  better  chance  of  success  than  the  antistreptococcic  serum.  Moritz 
treated  a  case  with  anti staphylococcic  serum,  with  a  favorable  issue. 

CHRONIC   ENDOCARDITIS. 
{Chronic  Interstitial  EirdomrdUis.) 

Two  clinical  varieties  are  met  with — one  following  the  acute  form,  the 
other  beginning  as  a  chronic  inflammation. 

Pathology. — The  lesions  may  be  limited  to  the  valvular  endocardium 
(their  most  common  seat),  or  the  mural  endocardium  may  also  be  involved. 
In  not  a  few  instances  the  lesions  are  confined  to  the  edges  or  bases  of 
the  segments,  and  when  seen  in  the  early  stages  there  may  frequently  be 
observed  merely  a  slight  thickening  of  the  free  border  of  the  leaflets ; 
in  most  cases  small  prominences  appear  near  their  free  margins.  The 
endocardium  looks  opaque  and  its  normal  elasticity  is  lost  quite  early. 
When  the  auriculo-ventricular  valves  are  aff'ected  the  primary  seat  of 
inflammation  is  the  auricular  face,  but  lesions  of  the  semilunar  valves 

1  The  septic  form  may  simulate  malaria  in  its  general  course.  The  points  of  dissim- 
ilarity may  be  found  in  the  discussion  of  Septicenua. 


CHRONIC  ENDOCARDITIS.  637 

begin  on  the  ventricular  side  and  implicate  the  Aurantian  body.  Exten- 
sion of  the  morbid  process  to  otiier  and  all  parts  of  tlie  valvular  curtain 
is  common,  and  it  is  in  cases  of  this  sort  that  the  greatest  degree  of 
shrinking  and  crumpling  occurs.  The  most  characteristic  lesions  consist 
of  inflammation  and  exudation,  which  produce  cohesion  of  the  segments, 
roughen  the  surfaces,  and  lead  to  the  deposit  of  fibrin  upon  them.  The 
histologic  alterations  consist  for  the  most  part  in  a  proliferation  of  the 
endothelium  and  a  round-cell  infiltration  of  the  subendothelial  connective 
tissue.  Organization  of  these  products  of  inflammation  into  connective 
tissue,  with  resulting  induration  and  contraction,  is  the  necessary  subse- 
quent pathologic  event.  In  old  cases  calcification  of  the  diseased  struc- 
ture is  frequent.  The  fibrinous  deposits  in  acute  endocarditis  may  be- 
come calcareous  "  at  the  same  time  that  the  sclerotic  processes  are  tak- 
ing place  in  the  valve  "  (Stengel).  The  shrinking  shortens  the  curtains 
or  curls  their  free  edges,  and  produces  insufficiency  in  either  case,  since  on 
dropping  into  the  plane  of  the  valvular  orifice  they  fail  to  close  it  perfectly. 
Valves  thus  deformed  may  also  obstruct  the  blood-stream.  Conesion  of 
the  invaded  segments  leading  to  constriction  or  stenosis  may  take  place. 

Involvement  of  the  semilunar  (aortic)  segments  in  the  ways  previously 
described  opposes  an  obstruction  to  the  outflowing  blood-current  on  the 
one  hand,  and,  owing  to  the  inability  of  the  segments  to  effect  perfect 
closure  of  the  aortic  orifice,  allows  on  the  other  hand  a  diastolic  reflux  of 
blood  into  the  left  ventricle.  The  aortic  ring  to  which  the  semilunar 
segments  are  normally  attached  becomes  sclerosed,  and  finally  the  seat  of 
atheromatous  changes,  either  fatty  or  calcareous.  Again,  chronic  inflam- 
mation of  the  intima  of  the  aorta  produces  a  similarly  thickened  condi- 
tion of  this  layer  in  spots,  followed  by  atheroma.  These  changes  are 
most  prone  to  take  place  in  the  course  of  the  ascending  arch  of  the  aorta 
or  just  above  the  aortic  segments.  The  diseased  processes  before  de- 
scribed may  extend  to  the  coronary  arteries.  Hence  sclerotic  and  athero- 
matous alterations  in  the  blood-vessels  are  found  frequently  in  association. 

Much  less  commonly  similar  lesions  are  noted  at  the  orifice  of  the  pul- 
monary artery.  A  similar  involvement  of  the  auriculo-ventricular  valves 
also  causes  regurgitant  and  obstructive  deformities  at  the  mitral  orifice, 
and  in  advanced  cases  the  chordae  tendineae,  and  even  the  papillary 
muscles,  are  almost  invariably  invaded  by  direct  extension  from  the 
valves.  As  these  structures  undergo  marked  thickening  with  subsequent 
contraction,  they  become  shortened  and  rigid,  causing  an  actual  narrowing 
of  the  cardiac  orifice.  In  mitral  stenosis  during  the  early  stages  a  more 
or  less  complete  ring  of  vegetations  encircles  the  mitral  orifice  on  its 
auricular  aspect.  The  margins  of  the  orifice  also  become  hardened  and 
roughened,  with  extension  to  the  valvular  curtains  and  the  chordae 
tendineae.  Under  such  circumstances  the  thickened  valve  could  not, 
during  the  ventricular  diastole,  be  forced  back  against  the  ventricular 
wall,  but  would  occupy  a  nearly  central  position.  Owing  to  cohesion  of 
the  free  edges  of  the  valvular  structures  and  to  contraction  of  the  chordae 
tendineae  drawing  the  leaflets  toward  the  apex  of  the  heart,  the  transition 
from  this  condition  to  the  formation  of  a  hollow  cone  {funnel  mitral)  is 
by  natural,  easy  stages.  Extensive  union  of  the  segments  along  their 
free  margins  may  reduce  the  aperture  to  a  mere  button-hole  slip  (button- 
hole mitral)  as  viewed  from  the  auricular  aspect.  The  last  two  forms  of 
lesions  are  far  less  commonly  met  with  at  the  aortic  orifice,  though  they 


638  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

occur  rarely  in  moderate  degree ;  on  the  other  hand,  curling  of  the  val- 
vular edges  is  far  more  commonly  seen  at  the  aortic  than  at  the  mitral 
orifice,  if  we  except  the  cases  that  occur  in  children.  The  curtains  of 
the  thick,  rigid  valves  may  also  permanently  occupy  the  plane  of  the 
orifice,  presenting  a  small  ring-like  opening  [annular  mitral). 

Fatty  degeneration  leading  to  the  formation  of  necrotic  (atheromatous) 
ulcers  is  common  ;  and  calcareous  deposits  are  frequently  seen  in  old  cases, 
either  in  localized  areas  or  coextensive  with  the  diseased  tissue,  converting 
the  entire  valve  into  a  calcified  mass,  with  loss  of  the  valvular  outlines.  " 

Under  such  conditions  of  the  valves  the  deposit  of  fibrin  would  be 
greatly  favored,  and  the  presence  of  an  ulcerative  surface  or  of  a  fibrous 
deposit  on  the  valves  affords  a  ready  and  satisfactory  explanation  of 
the  occurrence  of  embolism  in  these  cases.  Emboli  may  also  become 
detached  from  cardiac  thrombi  or  from  thrombi  formed  in  the  peripheral 
veins.  For  anatomic  reasons  the  favored  seats  of  embolic  processes  are, 
as  in  acute  endocarditis,  the  spleen,  brain,  and  kidneys,  and  irritants 
that  cause  acute  endocarditis,  find  here  a  tissue-soil  whose  capacity 
for  resistance  to  invasion  is  greatly  lowered.  Chronic  mural  endocarditis^ 
which  exhibits  lesions  in  the  form  of  grayish-white  patches,  and  chronic 
myocarditis  are,  as  a  rule,  due  to  the  extension  of  the  inflammation 
from  the  valves,  though  the  ventricular  endocardium  may  be  invaded 
independently  of  the  valvular  affection.  In  one  instance  of  mitral  sten- 
osis I  observed  an  enormous  calcareous  mass  partly  in  the  subvalvular 
tissue  and  partly  in  the  wall  of  the  ventricle,  the  segments  remaining 
altocrether  intact.  In  advanced  stages  of  most  cases  of  chronic  endocar- 
ditis  myocardial  degeneration  occurs.  It  takes  the  form  of  fibroid  change 
or  fatty  degeneration,  or  both.  Aortic-valve  involvement,  especially 
when  complicated  with  atheromatous  change  in  the  coronary  arteries,  is 
most  prone  to  these  forms  of  myocardial  disease.  Chronic  endocarditis 
may  be  said  to  persist  until  death,  although  Musser  has  reported  tAvo 
cases  in  which  the  murmur  of  this  lesion  disappeared  during  life. 

Sequelae  of  Valvular  Lesions. — The  various  valvular  defects  constantly 
produce  lowering  of  the  blood-pressure  in  the  arterial  system  and  in- 
creased pressure  in  the  veins.  The  variations  in  arterial  and  venous 
pressure  causes  the  blood-current  in  the  capillaries  to  become  slowed,  the 
blood  loses  more  of  its  oxygen  to  the  tissues,  and  as  the  result  of  this 
abnormal  condition  of  the  circulation,  cyanosis  and,  finally,  edema  ensue. 
The  effect  of  valvular  deficiencies  upon  the  several  cardiac  chambers 
will  be  most  advantageously  studied  when  the  individual  lesions  of  the 
segments  are  considered  . 

etiology. — There  can  be  no  doubt  that  most  cases  of  organic  heart- 
disease  occurring  in  children  and  young  adults  are  caused  by  primary  acute 
rheumatic  endocarditis  and  tonsillitis,  and,  although  the  latter  affection 
cannot  in  truth  be  said  to  terminate  invariably  in  chronic  endocarditis,  it 
probably  does  in  most  instances.  This  result,  in  my  opinion,  is  more 
frequent  in  children  suffering  from  acute  endocarditis  than  in  adults.  On 
the  other  hand,  not  a  few  cases  of  chronic  endocai-ditis  originate  in  a  very 
mild  grade  of  acute  valvular  inflammation,  which  may  be,  though  itself 
mute,  reinforced  by  a  rheumatic  diathesis.  Indeed,  acute  endocarditis 
may  be  the  sole  expression  of  rheumatic  disease.  Not  less  than  one-half 
of  all  cases  of  organic  valvular  disease  are  caused  by  rheumatism,  and 


AORTW  INCOMPETENCY.  639 

more  than  one-half  occur  between  tiventy  and  iJdrty  years  of  age.  Acute 
endocarditis  complicating  scarlatina,  measles,  chorea,  pneumonia,  may 
also  be  followed  by  the  chronic  variety,  although  probably  not  so  com- 
monly as  in  the  case  of  acute  endocai-ditis  of  rheumatic  origin. 

The  second  variety,  in  which  slow  interstitial  changes  occur  from  the 
beginning,  is  dependent  upon — (a)  biologic  irritants  (e.  //.  syphilis,  malaria, 
and  chronic  rheumatism) ;  (7>)  chemical  irritants  (uric  acid,  alcohol,  lead) ; 
and  (c)  mechanical  influences.  Doubtless  the  influence  of  repeated  strain- 
ing efforts  is  the  most  potent  cause  of  this  class  of  cases.  Heavy  muscular 
labor  increases  constantly  the  tension  in  the  arterial  system,  and  this  acts 
injuriously  upon  the  valve-segments,  setting  up  a  gradual  sclerotic  change. 
In  like  manner,  arterial  sclerosis  and  Bright' s  disease  may  cause  chronic 
interstitial  endocarditis  by  maintaining  a  persistent  increase  in  the  vas- 
cular tension,  though  the  fact  that  these  aff'ections  may  in  turn  result 
from  the  action  of  some  of  the  leading  causes  of  organic  heart-disease 
must  also  be  recollected.  Trauma  has  produced  in  valves  previously 
healthy  a  sudden,  incontestable  proof  of  valvular  paresis  or  laceration 
that  has  persisted  in  a  few  well-attested  cases.  This  accident  is  more 
frequent  in  cases  in  which  the  valves  have  been  already  diseased  {e.  g., 
ulcerative  processes). 

The  predisposing  causes  of  organic  valvular  disease  may  be  discussed 
briefly.  Hereditary  influence,  as  pointed  out  by  Virchow,  is  especially 
potent  in  persons  in  whom  there  is  hypoplasia  of  the  heart  and  aorta  (e.  g. 
in  chlorosis).  Any  malformation  of  a  valve  is  certain  to  throw  an 
undue  strain  upon  certain  portions,  and  hence  is  likely  to  be  followed 
by  interstitial  change.  Osier,  in  17  cases  of  bicuspid  aortic  valve, 
has  reported  the  segments  to  be  uniformly  sclerosed.  The  cases  of  sup- 
posed hereditary  transmission  are  doubtless,  however,  for  the  most  part, 
due  to  the  causes  mentioned  above,  and  particularly  to  rheumatism.  Age 
exerts  a  predisposing  influence,  its  efi'ects,  however,  varying  with  the 
valve  implicated.  During  fetal  life  this  is  on  the  right  side  of  the  heart 
in  a  vast  majority  of  cases ;  during  childhood,  adolescence,  and  early 
adult  life,  when  the  infectious  diseases  and  rheumatism  are  frequent,  it  is 
the  mitral  valve  in  most  instances ;  and  finally,  during  middle  and  espe- 
cially during  advanced  life  the  aortic  segments  are  especially  involved. 
I  have,  however,  found  aortic  disease  to  be  more  common  in  young  adults 
than  most  writers  are  ready  to  admit,  and  that  it  is  favored  especially  by 
an  occupation  involving  muscular  strain  {e.  g.  blacksmiths,  draymen,  sol- 
diers during  campaigns).  Sex  per  se  has  little  if  any  effect,  though,  owing 
to  the  greater  frequency  of  certain  well-known  causes  of  valvular  disease 
(chorea  and  rheumatism)  in  girls  and  young  women,  females  may  be 
more  frequent  sufferers  than  males. 


AORTIC  INCOMPETENCY. 

{Aortic  Insufficiency ;  Aortic  Regurgitation.) 

Definition. — The  failure  of  the  aortic  valves  to  prevent  a  return  flow 
of  blood  into  the  ventricle,  owing,  as  a  rule,  to  a  diseased  condition  of  the 
aortic  leaflets  (sclerosis)  that  is  followed  by  crumpling  and  attended  with 


640  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

contraction,  shortening,  or  curling  of  the  edges,  and  finally  calcifica- 
tion. 

Pathology. — The  aortic  orifice  may  be  enlarged  (relative  insuf- 
ficiency), and  here  the  normal  cusps  fail  to  effect  complete  closure  when 
they  become  tense.  The  cusps  of  the  diseased  aortic  valves  sometimes 
adhere  to  the  iritima  of  the  aorta,  and  laceration  of  the  semilunar  seg- 
ments, which  are  the  seat  of  diseased  processes  (particularly  ulceration), 
is  sometimes  found  post  vwrtem,  and  may  be  the  chief  factor  in  deter- 
mining the  development  of  the  condition.  This  accident  may,  though 
rarely,  occur  as  a  result  of  a  severe  straining  effbrt  in  the  case  of  valves 
previously  healthy.  Occasionally,  also,  the  principal  factor  in  the  pro- 
duction of  this  valvular  lesion  is  a  congenital  malformation  of  the  seg- 
ments whereby  they  are  rendered  very  prone  to  chronic  endocarditis  in 
consequence  of  the  undue  strain  to  which  they  are  subjected.  At  times 
the  lesions  that  give  rise  to  stenosis  may  coexist  with  simple  aortic 
incompetency. 

Mechanical  Influence  of  the  Lesion. — The  reflux  current  passes  from 
the  aorta  backward  through  the  imperfectly  closed  semilunar  valve  into 
the  left  ventricle  during  the  diastole  of  the  heart  or  while  the  left  ventri- 
cle is  being  filled  by  the  normal  blood-flow  from  the  auricle.  It  is  clear 
that  over-distention  of  the  left  ventricle  must  result  at  once  from  two 
simultaneous  influx  currents  of  blood,  with  a  tendency  to  an  increasing 
dilatation,  especially  since  the  lesion  itself  is  steadily  progressive.  To 
expel  the  increased  amount  of  blood  from  the  left  ventricle  demands 
increased  cardiac  power,  and  the  over-exertion  causes  a  compensa- 
tory hypertro'phy.  Dilatation  and  hypertrophy  of  the  left  ventricle 
develop  pari  passu  until  this  chamber  reaches  enormous  dimensions, 
forming  the  cor  bovinum,  which  weighs  1000  grams  or  more  (30  to 
50  ounces).  Under  these  cii'cumstances  the  arterial  system  is  over- 
filled at  each  ventricular  systole.  In  the  very  early  stage  the  reflux 
of  blood  from  the  aorta  into  the  ventricle  tends  to  lessen  the  volume  of 
the  circulating  medium  in  the  arterial  tree,  but  this  depleting  influence  is 
successfully  counterbalanced  by  the  augmented  column  of  blood  thrown 
from  the  ventricle  during  cardiac  systole.  Hence  the  requirements  for 
bodily  nutrition  are,  for  a  longer  or  shorter  time,  satisfied.  The  abnor- 
mally large  amount  of  blood  that  is  thrown  into  the  arteries  with  undue 
force  subjects  them  to  increased  tension,  and  as  a  result  arterio-scle- 
rosis,  leading  sometimes  to  atheroma,  is  commonly  developed,  and  pre- 
sents its  ulterior  dangers  (aneurysm,  apoplexy).  The  coronary  arteries  are 
similarly  involved,  their  caliber  being  reduced,  and  particularly  at  the 
point  of  origin.  Soon  or  late  the  blood-supply  to  the  heart-muscle  may 
become  inadequate,  and  nutritional  disturbances  now  manifest  themselves 
in  fatty  and  fibroid  degeneration  of  the  cardiac  muscles ;  these  pathologic 
changes  are  attended  with  secondary  dilatation,  which  soon  predominates 
over  the  hypertrophy.  The  imperfect  blood-supply  to  the  ventricular 
tissue  may  be  accounted  for,  in  great  measure,  by  the  narrowed  lumen 
of  the  coronary  vessels,  and  also  in  part  by  the  inelasticity  of  the  walls  of 
the  latter  and  by  the  inefficiency  of  the  aortic  recoil.  In  consequence  of 
the  increased  tension  to  which  they  are  constantly  subjected  the  mitral 
leaflets  may  become  the  seat  of  sclerotic  endocarditis,  and  this  may 
lead  to  mitral  insufficiency  (usually  of  mild  grade) ;  or  there  may  be  a 


AORTIC  INCOMPETENCY.  G41 

displacement  of  the  mitral  segments  in  the  direction  of  the  auricle,  pro- 
ducing a  considerable  degree  of  incompetency.  There  is  also  in  the  ma- 
jority of  cases  a  marked  degree  of  fatty  degeneration,  with  more  or  less 
flattening,  of  the  papillary  muscles.  Again,  secondary  dilatatiori,  com- 
monly produces  relative  insufficiency  at  the  mitral  orifice.  When  incom- 
petency has  been  established  here,  impeded  pulmonary  and  general 
venous  circulation,  together  with  the  secondary  lesions  in  the  left  auricle, 
pulmonary  vessels,  and  right  ventricle  that  are  characteristic  of  mitral 
incompetency,  are  the  necessary  result.  The  blood-current  through  the 
mitral  ring  may  be  retarded,  owing  to  the  simultaneous  influx  into  the 
left  ventricle  from  the  aorta,  thus  causing  pulmonary  congestion  with- 
out either  change  in  the  segment,  or  overdistention  of  the  orifice. 

Special  Etiology. — (1)  Acute  Endocarditis. — Incomplete  resolution  of 
the  acute  form  of  endocarditis  leads  to  progressive  chronic  valvular  dis- 
ease. In  the  young  it  is  caused  with  comparative  frequency  by  rheu- 
matic endocarditis  often  associated  with  involvement  of  the  mitral  secr- 
ments.  Aortic  regurgitation  may  also  arise,  though  rarely,  in  the  course 
of  acute  endocarditis,  attended  with  destructive  ulceration.  Such  in- 
stances usually  terminate  in  speedy  death. 

(2)  Ohronio  Infectious  Irritants. — I  have  found  syphilis  to  be  a  not 
uncommon  factor  (though  rarely  the  sole  cause),  hence  the  disease  is  fre- 
quent in  sailors  and  soldiers.  Syphilis  as  a  causative  agency  is  shown 
by  a  positive  Wassermann  reaction.  It  is  quite  probable  that  chronic 
rheumatism  has  a  similar  influence. 

(3)  Chemical  Irritants. — {a)  Uric  Acid. — In  chronic  and  irregular 
forms  of  gout  the  irritating  qualities  of  uric  acid  give  rise  to  interstitial 
endocarditis  and  arterial  sclerosis.  (5)  Lead. — The  effects  of  lead  may 
be  primary  on  the  cells  of  the  valvular  endocardium,  or  secondary  to 
chronic  degeneration  of  the  kidneys.  ((?)  Alcohol^  by  its  persistent  irri- 
tant action,  may  excite  chronic  valvulitis. 

(4)  Augmented  Aortic  Tension. — The  excessive  functional  activity 
of  the  heart  occasioned  by  the  immoderate  use  of  cardiac  stimulants 
(alcohol)  tends  to  raise  the  blood-pressure  above  the  normal  point,  and 
thus  sclerotic  endocarditis  may  be  developed  very  slowly.  The  eff"ect  of 
occupation  in  causing  this  disease,  by  increasing  the  vascular  tension,  is 
more  notable  than  in  the  case  of  alcohol,  though  both  of  these  factors 
are  found  not  infrequently  to  be  present  in  the  same  case.  It  is  unde- 
niably true  that  strong-bodied  men  in  the  middle  period  of  life  and 
engaged  in  such  occupations  as  entail  strain — "  not  a  sudden,  forcible 
strain,  but  a  persistent  increase  of  the  normal  tension  to  which  the  seg- 
ments are  subject  during  the  diastole  of  the  ventricle  "  (Osier) — are  the 
most  frequent  sufferers  from  aortic  incompetency. 

(5)  From  personal  observation  I  feel  convinced  that  chronic  endo- 
carditis (affecting  the  aortic  valves)  may  be  secondary  to  aortic  end- 
arteritis as  the  result  of  direct  extension.  It  must  be  borne  in  mind,  how- 
ever, that  arterio-sclerosis  is  also  often  secondary  to  chronic  valvulitis. 

(6)  Relative  insufficiency  is  caused,  in  some  instances,  by  pronounced 
dilatation  of  the  root  of  the  aorta,  or  by  an  aneurysm  just  beyond  the 
aortic  orifice.  Incompetency  of  muscular  origin  (e.  g..,  in  marked  dilata- 
tion of  the  left  ventricle)  occurs,  though  rarely. 

Among  the  more  effective  predisposing  factors  are  age  and  sex.     The 

41 


642  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

disease  occurs  much  more  often  in  males  than  in  females,  chiefly  on 
account  of  greater  percentage  of  the  former  engaged  in  occupations  that 
are  causally  related  to  the  disease.  As  to  age,  a  preponderating  pro- 
portion of  the  cases  arise  during  advanced  middle  life,  and  a  compara- 
tively smaller  number  at  an  earlier  period. 

Symptoms. — So  long  as  the  hypertrophy  of  the  left  ventricle  suc- 
cessfully overcomes  the  otherwise  injurious  consequences  of  the  valvular 
defect  the  harmonious  balance  of  forces  is  maintained,  and  there  is  an 
almost  entire  absence  of  symptoms.  I  have  observed,  moreover,  that 
compensation  docs  not  fail  so  early  in  young  subjects  as  in  those  more 
advanced  in  years,  or  at  a  period  of  life  when  aortic  incompetency  is 
often  a  sequel  of  atheroma  combined  with  hypertrophy  and  dilatation 
of  the  left  ventricle.  With  the  development  of  marked  hypertrophy 
severe  muscular  e.xertion  and  strong  mental  excitement  Avill,  by  exciting 
over-action  of  the  powerful  heart,  bring  on  a  train  of  symptoms  as  throh- 
hinfi  headache.,  vertigo.,  and  tinnitus  atirium.  Per  contra,  the  clinical 
manifestations  of  arterial  anemia,  particularly  of  the  brain,  and  also 
those  of  general  arteriosclerosis,  frequently  coexist.  The  patient's 
countenance  exhibits  pallor,  and  he  complains  of  headache,  flashes  of 
light  before  the  eyes,  and  dizziness.  Dilatation  of  the  peripheral  vessels 
often  leads  to  hot  flushes  and  drenching  sweats.  Cases  exhibiting  the 
latter  symptoms  may  be  mistaken  for  phthisis.  Dizziness  is  often  dis- 
tressing, and  is  more  marked  upon  rising  quickly  from  the  recumbent  to 
the  erect  posture.  Dyspnea,  may  come  on  early,  but  this  rarely  happens 
except  upon  inordinate  exertion  or  great  mental  excitement — conditions 
that  cause  strong  cardiac  action  and  prohibit  the  discharge  of  blood 
from  the  left  auricle  into  the  left  ventricle,  thus  causing  pulmonarg 
congestion.  Oppression  in  the  precordial  region  and  cardiac  palpi- 
tation are  commonly  present,  as  is  a  dull  aching  pain,  but  it  radiates  not 
infrequently  to  the  shoulders,  and  thence  down  the  arms,  particularly 
the  left.  Genuine  angina  pectoris  may  be  a  concomitant.  I  have  seen 
instances  of  aortic  regurgitation  in  Avhich  severe  pain  simulating  rheu- 
matism was  located  in  the  left  shoulder-joint. 

Following  immediately  upon  failure  of  compensation  the  cardio-pul- 
monary  circulation  is  retarded,  and  there  is  increased  dgspnea,  the  latter 
symptom  being  greatly  intensified  by  undue  exertion  and  at  night. 
There  may  be  cough,  and  not  rarely  hemoptysis,  though  less  frequently 
than  in  simple  mitral  disease.  Later  on,  general  venous  congestion  of  a 
moderate  grade  follows  pulmonary  congestion,  and  the  dyspnea  now 
becomes  severe.  It  is  nocturnal,  and  often  compels  the  patient  to 
assume  a  semi-erect  posture  in  bed.  In  the  later  stages  the  symp- 
toms, particularly  those  of  venous  stasis  as  shown  by  cyanosis  and 
malleolar  dropsy,  are  due  to  mitral  incompetency,  followed  by  fail- 
ure of  compensation.  Marked  enlargement  of  the  liver  due  to  passive 
congestion  may  now  ensue  and  give  rise  to  the  suspicion  of  a  new 
growth.  Edema  of  the  feet  rarely  goes  on  to  general  anasarca. 
In  aortic  incompetency  a  higher  grade  of  symptomatic  anemia 
is  reached  than  in  any  other  cardiac  lesion — a  recent  blood- 
count  showing  2,800,000  red  corpsucles  to  the  c.mm.  Hence  slight 
edema  of  the  feet  may  be  due  solely  or  in  part  to  anemia.  The  in- 
tercurrence  of  acute  endocarditis,  as  evidenced  by  prostration  and 
irregular  fever,   is  observed,  not  infrequently  as  a  terminal  condition. 


AORTW  INCOMPETENCY.  643 

The  symptoms  of  cerebral,  splenic,  and  renal  ernhoNsm  may  arise.  Prob- 
ably sudden  death  ensues,  as  the  result  of  involv(;ment  of  the  coronary 
arteries,  with  greater  frequency  in  this  than  in  all  other  forms  of  val- 
vular disease  combined  ;  and  yet  this  accident  is  by  no  means  frequent. 
Instances  of  aortic  incompetency,  in  which  nervous  phenomena,  as 
peevishness,  irritability,  delusions,  or  melancholia,  manifest  themselves, 
are  too  common  to  be  looked  upon  as  mere  coincidences.  Many  patients 
are  led  to  commit  suicide  because  of  their  cardiac  lesion  when  otlier  and 
erroneous  explanations  are  given  to  account  for  their  acts. 

Physical  Signs. — Inspection  brings  to  light  an  enlarged  apex-beat ; 
this  is  displaced  downward  and  outward,  being  visible  in  the  sixth  and 
seventh  spaces,  and  most  marked  between  the  mid-clavicular  and  anterior 
axillary  lines.  The  precordial  zone  may  be  arched,  particularly  in 
young  subjects,  and  the  apex-beat  is  usually  markedly  heaving  in  char- 
acter. The  carotids  throb  forcibly,  as  do  the  temporals,  brachials,  and 
radials,  though  less  violently.  These  abnormal  pulsations  are  due 
chiefly  to  the  strong  action  of  the  hypertrophied  ventricle,  though  fre- 
quent factors  of  lesser  influence  are  associated — an  arteriosclerosis  and 
a  regurgitant  blood-stream  from  the  aorta  into  the  left  ventricle.  The 
impulse  becomes  Avidely  diffused  and  wavy  with  the  progressive  enfee- 
blement  of  the  left  ventricle,  and  venous  pulsation  due  to  tricuspid  in- 
sufiiciency  may  be  associated  with  arteriopulsation  later  in  the  aff"ection. 
Epigastric  throbbing  may  be  noticed,  and  on  gently  rubbing  a  spot  upon 
the  forehead  an  alternate  paling  and  blushing  appear  (Quincke' s  capil- 
lary pulse) ;  this  may  also  be  noted  in  the  finger-nails.  It  is  not  pecu- 
liar to  aortic  insufiiciency,  however,  and  may  be  observed  in  cases  of 
decided  neurasthenia  and  in  anemia.  Very  rarely  the  pulse-Avave  is  prop- 
agated from  the  capillaries  to  the  veins  of  the  neck,  hand,  and  back  of 
the  foot,  giving  rise  to  a  visible  venous  pulsation.  L.  Webster  Fox 
informs  me  also  that  the  retinal  vessels  are  often  seen  to  pulsate  in  this 
disease.     The  systolic  and  diastolic  blood-pressures  are  widely  separated. 

On  'palpation  a  forcible  heaving  impulse  is  usually  felt.  When,  how- 
ever, dilatation  predominates  over  hypertrophy,  the  impulse  is  weak  and 
undulating.  A  diastolic  thrill  is  sometimes  felt  over  the  base  of  the 
heart,  and  a  pr,esystolic  thrill  is  also  discoverable,  though  rarely.  The 
arteries  are  lengthened  and  the  pulse  is  characteristic  ;  it  is  quick,  leaping. 
and  full,  but,  upon  striking  the  finger,  recedes  abruptly,  and  is  known 
as  the  Corrigan  or  %oater-har)imer  pulse.  This  sudden  collapse  of 
the  pulse  is  most  decided  Avhen  the  arm  is  held  in  a  vertical  position. 
It  may  lose  its  distinctive  character  after  compensation  is  lost.  Broad- 
bent  has  noted  a  considerable  increase  in  the  interval  between  the  apex- 
beat  and  the  pulse-wave  in  severe  aortic  regurgitation.  A  glance  at  the 
sphygmographic  tracing  will  show  a  sudden  rise  and  fall,  with  absence  or 
delay  of  the  secondary  wave  {vide  Fig.  50).  There  is  marked  excess  in 
the  arterial  pressure  in  the  lower  extremity  over  that  of  the  upper  (Hill). 

Percussion. — Cardiac  dulness  is  coextensive  with  the  impulse,  ex- 
tending in  some  cases  downward  to  the  eighth  rib,  and  to  the  left  from 
one  to  two  inches  without  the  mid-clavicular  line.  Later,  enlargement  of 
the  left  auricle  may  cause  dulness  upward  and  to  the  left  of  the  sternum. 
Enlargement  of  the  right  ventricle  causes  an  increase  of  dulness  to  the 
right.     When  the  dilatation  exceeds  the  hypertrophy  the  area  of  dul- 


644  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ness  will  be  much  extended  transversely  and  slightly  up-vvard,  the  apex 
now  being  more  rounded.^ 

On  auscultation  a  diastolic  murmur  is  audible  with  its  seat  of  greatest 
pronunciation  at,  or  a  little  below  and  to  the  left  of,  the  aortic  cartilage 
and  is  transmitted  down  along  the  left  edge  of  the  sternum ;  this  is  pro- 
duced in  the  left  ventricle.     From  the  xiphoid  it  may  be  transmitted  to 


Fig.  C)0.— Normal  pulse-tracing. 

the  left  as  far  as  the  spinal  column  as  a  mere  diastolic  whisper.  It  may 
be  heard,  at  times,  in  the  vessels  of  the  neck.  A.  Borgherini  affirms  that 
the  special  direction  taken  by  the  regurgitant  current  determines  largely 
the  variable  position  of  the  murmur  and  the  variable  size  of  the  heart. 
The  rhythm  of  the  murmur  can  be  most  readily  determined  by  auscul- 
tating over  the  base,  for  while  the  pulmonic  second  sound  is  usually 


Fig.  51. — Pulse-tracing  in  a  case  of  aortic  regurgitation  (William  Hoffman). 

audible  at  the  apex  (the  murmur  appearing  to  follow  it),  it  is  not  so 
when,  as  sometimes  happens,  the  murmur  is  quite  loud.  The  first  sound 
is  often  dull,  indefinite,  and  widely  diffused,  owing  to  hypertrophy  of  the 
left  ventricle.  In  quality  this  murmur  is  usually  soft,  blowing  (long- 
drawn),  and  frequently  musical ;  sometimes,  however,  it  is  somewhat 
rough  and  loud.  Associated  murmurs. — In  most  instances  a  systolic 
murmur,  brief  and  harsh  in  character  and  transmitted  into  the  vessels 
of  the  neck,  is  also  discovered  over  the  aortic  region  {double  aortic). 
The  presence  of  the  murmur  with  the  first  sound  is  not  diagnostic  of 
actual  aortic  stenosis.  It  is  more  often  due  to  a  mere  roughening  of 
the  semilunar  segments  or  of  the  intima  of  the  aorta.  In  advanced 
cases  a  soft  systolic  murmur  is  commonly  heard  at  the  apex  ;  it  is  readily 
distinguished  from  the  diastolic  murmur  by  its  rhythm,  and  is  occasioned 
usually  by  a  relative  mitral  incompetency.  Still  another  murmur, 
of  rare  occurrence,  is  rolling  in  character,  generally  presystolic  in 
time,  and  may  be  heard  at  the  apex  over  a  limited  surface-area.  This 
may  be  accounted  for  by  the  presence  of  excessive  dilatation  of  the  left 

1 A  dilated  aorta  with  thickened  walls — a  condition  sonietiiues  ass^ociated  with 
aortic  regurgitation — may  give  rise  to  dulness  over  and  to  the  right  of  the  manubrium 
stemi. 


AORTIC  STENOSIS.  Q4cb 

ventricle,  in  consequence  of  wliich  the  mitral  leaflets  must  remain  free 
in  the  blood-stream  during  the  diastole,  and  here  they  set  up  vortiginous 
movements  that  cause  the  presystolic  (Flint)  murmur.  Duroziez  dis- 
covered a  double  murmur  in  the  femoral,  but  this  may  be  noted  occa- 
sionally in  the  absence  of  aortic  regurgitation.  Traube  has  described 
another  arterial  phenomenon — a  systolic  sound  in  the  leg  ("  pistol-shot"), 
probably  due  to  sudden  systolic  distention  of  vessels  that  were  previously 
empty. 

The  diagnosis  demands  the  presence  of  a  diastolic  murmur,  the 
signs  of  left  ventricular  hypertrophy,  the  peculiar  arterial  pulsations, 
and  the  characteristic  water-hammer  or  Corrigan  pulse.  The  secondary 
manifestations  are  usually  confirmatory.  The  diastolic  murmur  may  be 
absent,  in  which  case  a  certain  diagnosis  must  not  be  made.  It  may  be  rarely 
heard  with  the  unaided  ear,  and  not  with  the  stethoscope.  In  rare  cases  a 
diastolic  murmur  has  its  origin  in  the  veins  adjacent  to  the  heart  (e.  ^.,  in 
the  anemias).    For  the  differetitial  diagnosis,  see  Aneurysms  of  the  Arch. 


AORTIO  STENOSIS. 

Definition. — A  narrowing  or  stricture  of  the  aortic  orifice,  due  to 
thickening  or  adhesion  of  the  valve-segments,  and  causing  an  obstruction 
to  the  flow  of  blood  into  the  aorta. 

Simple  aortic  stenosis  may  be  met  with,  though  it  is  a  great  rarity. 
Its  development  is  soon  followed  by  more  or  less  valvular  incompetency. 
It  may  be  secondary  to  aortic  insufficiency ;  but  this  is  rare,  the  latter 
lesion  being  unfavorable  to  the  development  of  the  former. 

Special  l^tiology. — Rarely  rheumatic  endocarditis,  and  still  less 
commonly  other  forms  of  acute  endocarditis,  cause  union  of  the  semi- 
lunar segments,  with  resulting  stenosis.  The  most  common  causative 
factor  is  a  slo^v  sclerosis  of  the  aortic  valve,  accompanied  by  calcareous 
deposits.  The  more  or  less  immobile,  rigid  valves  narrow  the  aortic 
orifice  and  oppose  a  barrier  to  the  outflowing  blood-current  from  the 
left  ventricle.  The  aortic  ring  may  be  the  seat  of  changes  similar  to 
those  just  described,  resulting  in  a  moderate  grade  of  stenosis  with  intact 
leaflets.  The  lesions  are  most  frequently  to  be  regarded  as  a  part  of  a 
general  arterial  sclerosis,  most  marked  in  the  region  of  the  thoracic 
aorta;  sometimes,  as  Peter  contends,  they  are  distinctly  secondary  to 
sclerotic  changes  at  the  root  of  the  aorta.  The  coronary  arteries  may  be 
the  seat  of  sclerotic  changes.  The  condition  is  also  rarely  congenital. 
Males  who  have  reached  advanced  years  are  especially  prone  to  aortic 
stenosis,  atheromatous  processes  belonging  to  that  sex  and  period  of  life. 
Gallavardin  ^  has  described  a  rare  non-congenital  and  non-rheumatic  form 
of  aortic  stenosis  occurring  in  young  subjects;  it  is  characterized  by 
extreme  latency. 

Mechanical  Influence  of  Lesion. — To  propel  the  normal  volume  of 
blood  through  the  constricted  aortic  orifice  requires  increased  strength 
on  the  part  of  the  left  ventricle,  and,  as  a  consequence,  the  latter  hyper- 
trophies. This  hypertrophy  develops  slowly,  is  uncombined  with  exten- 
sive dilatation  unless  incompetency  be  associated,  and  keeps  pace  with 
the  progress  of  the  valvular  lesions.  The  undue  ventricular  tension  some- 
*  Lyon  Med.,  January  31,  1909. 


646  DISEASES   OF  THE  CTECULATORY  SYSTEif. 

times  induces  more  or  less  sclerotic  change  in  the  mitral  valves.  Hyper- 
trophy of  the  left  ventricle  eventually  gives  way  to  extreme  dilatation, 
resulting  in  relative  mitral  incompetency,  with  its  sequeljB,  namely,  pul- 
monary, followed  bv  general  venous,  stasis. 

Symptoms. — The  symptoms  date  from  the  commencement  of 
ftiihire  of  comjiehsation  ofren  many  years  after  the  onset  of  the  disease. 
Their  appearance  will  be  found  to  follow  some  unusual  muscular  effort  or 
the  operation  of  some  depressing  influence,  as  the  too  free  use  of  to- 
bacco or  alcohol.  They  are  due  to  disturbances  of  circulation  arising 
from  a  gradual  secondary  dilatation  of  the  left  ventricle,  which  is  now 
unable  to  propel  the  normal  (juantity  of  blood  into  the  arterial  tree. 
Hence  anemia,  especially  of  the  brain  and  peripheral  parts  of  the  body, 
becomes  pronounced,  and  is  evidenced  by  such  symptoms  as  syncope, 
dizziness,  headache,  and  pallor.  Since  aortic  incompetency  usually  mani- 
fests itself  secondarily,  the  clinical  features  of  both  affections  are  sooner 
or  later  variously  commingled.  In  cases  in  which  mitral  lesions  develop 
they  are  overcome  by  compensatory  enlargement  of  the  right  ventricle: 
the'  latter    chamber  may  at   a  later  period   become   dilated,   in   which 


Fig.  52. — Sphygmogram  of  aortic  stenosis,  from  a  man  aged  sixty  years. 

event  tricuspid  regurgitation  and  the  symptoms  of  general  venoua 
engorgement  appear.  Slight  edema  of  the  feet  is  common  as  a  terminal 
symptom ;  marked  dropsy,  however,  is  uncommon.  From  the  fibrous 
deposits  on  the  segments,  as  well  as  from  any  small  clots  behind  the 
valves,  emboli  are  apt  to  become  dislodged  by  the  forcible  blood-stream 
and  be  conveyed  to  the  brain,  spleen,  kidneys,  or  other  organs. 

Physical  Signs. — Inspection. — The  apex-beat  is  gradually  displaced 
downward  and  to  the  left,  owing  to  left  ventricular  hypertrophy.  It  is, 
as  a  rule,  slow,  forceful,  and  heaving,  but  less  frequently  may  be  lacking 
in  strength.  It  may  be  enfeebled,  diminished  in  area,  or  absent,  owing 
to  associated  emphysema.  Absence  of  the  apex-beat  may  be  occasioned 
by  diminished  contraction  of  the  myocardium,  or  during  vigorous  con- 
traction of  the  heart,  the  ventricle  emptying  itself  from  the  beginning, 
so  that  there  is  "  no  closing  period  and  with  it  no  apex-beat '"  (Leube). 

Palpatio7i  discloses  the  forcible  and  heaving  impulse-beat,  unless 
obscured  or  even  absent  owing  to  emphysema.  A  marked  systolic  thrill, 
with  the  seat  of  greatest  intensity  in  the  aortic  region,  is  quite  gener- 
ally present.  I  have  rarely  felt  this  thrill  in  the  apex  region.  Tiie 
pulse- wave  is  small,  regular,  not  compressible,  and  of  normal  or  slightly 
lessened  frequency  (sbcgi/isJi).  The  estimated  blood-pressure  is  about 
normal.  The  sphygmographic  tracing  shows  slowness  of  the  ascending 
curve  and  a  gradual  formation  of  the  descending  line  (vide  Fig.  52). 

Percussion. — Although  hypertrophy  of  the  left  ventricle  is  present, 


MITRAL  INCOMPETENCY.  647 

the  area  of  cardiac  dulncss  is  largely  dependent  upon  the  degree  of 
emphysema  associated.  In  the  absence  of  this  condition  the  diilnes8 
is  increased  to  the  left  and  downward,  especially  so  when  insufficiency 
coexists. 

Auscultation. — A  systolic  murmur,  harsh  in  quality,  most  audible  at 
the  aortic  cartilage  (the  second  right),  and  transmitted  into  the  carotids, 
is  present  in  typical  aortic  stenosis.  When  non-compensation  is  ad- 
vanced the  murmur  is  neither  so  rough  nor  so  loud,  and  quite  late  it 
may  be  missing  altogether.  The  second  sound  is  faint  or  inaudible  on 
account  of  the  diminished  blood-tension  in  the  aorta  and  the  character 
of  the  valvular  lesion.  As  aortic  incompetency  is  commonly  associated, 
a  regurgitant  or  diastolic  murmur  is  also  heard,  forming  a  double  or  see- 
saw murmur,  the  stenotic  bruit  more  or  less  completely  masking  the 
regurgitant.  A  soft,  blowing  apical  murmur  (with  the  systole)  is  not 
infrequent  after  relative  insufficiency  of  the  mitral  valves  has  appeared. 

The  diagnosis  demands  the  concurrence  of  the  following  signs :  a 
systolic  thrill,  most  marked  at  the  base :  a  tense,  small,  somewhat  slow 
pulse ;  indications  of  left  ventricle  hypertrophy  (unless  emphysema  be 
present)  ;  a  rough,  loud,  systolic  murmur  at  the  aortic  cartilage,  propa- 
gated into  the  vessels  of  the  neck,  and  a  feeble  second  aortic  sound. 

Differential  Diagnosis. — A  calcareous  plate  lying  on  the  intima  of  the 
aorta  and  a  markedly  roughened  condition  of  the  aortic  segments  are 
conditions  frequently  mistaken  for  aortic  stenosis,  since  they  give  rise 
to  a  murmur  possessing  naany  of  the  characteristics  of  the  one  above 
described.  These  murmurs,  however,  are  seldom  musical,  while  the 
murmur  of  aortic  stenosis  is  often  so ;  moreover,  the  second  sound  is 
decidedly. accentuated,  Avhile  in  aortic  stenosis  it  is  faint.  In  chronic 
Bright' s  disease  v\^ith  arterial  sclerosis  and  left  ventricular  hypertrophy 
a  murmur  of  maximum  intensity  may  be  developed  at  the  base ;  but 
here  the  urinary  symptoms,  together  with  intensification  of  the  second 
sound,  are  sufficient  for  a  discrimination.  In  aortic  regurgitation  a  sys- 
tolic murmur  frequently  coexists,  but  it  cannot  be  reckoned  as  indicat- 
ing actual  stenosis  unless  it  has  a  musical  quality  and  a  systolic  thrill 
can  be  felt  on  palpation.  In  combined  aortic  regurgitation  the  charac- 
teristic condition  of  the  pulse  of  stenosis  may  be  missing.  The  basic 
murmurs  of  chlorosis  and  other  forms  of  anemia  are  soft  and  distant, 
and  not  harsh  ;  the  intense  thrill  and  ventricular  hypertrophy  are  absent. 
The  venous  hum  may  also  be  heard  in  the  veins  of  the  neck.  Pulmon- 
ary stenosis  occurs  in  young  subjects,  and  while  it  gives  rise  to  a  harsh 
systolic  murmur,  is  best  heard  to  the  left  of  the  sternum,  is  propagated 
upward  and  to  the  left,  and  the  second  pulmonic  sound  is  weak. 


MITRAL  INCOMPETENCY. 

{Mitral   Regurgitation;   Mitral   Insufficiency.) 

Definition. — Imperfect  closure  of  the  mitral  valve  due  to  rupture 
(rare)  or  contraction  of  the  mitral  leaflets.  It  is  also  caused  by  dilata- 
tion of  the  left  ventricle  and  by  a  diseased  condition  of  the  chordse. 

Pathology. — This  is  the  most  frequent  form  of  organic  disease  of 


648  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  heart.  Thomas  G.  Ashton,^  from  clinical  observation  of  1012  cases 
of  heart-affection,  comprising  all  the  different  varieties,  found  that  54.4 
per  cent,  were  instances  of  mitral  regurgitation.  The  predominating 
lesions  may  be  brought  under  four  heads  :  ((?)  Acute  endocarditis,  lead- 
ing to  contraction  and  deformity,  particularly  curling,  of  the  margins 
of  the  valve ;  (6)  primary  sclerotic  form  ;  (c)  relative  insufficiency  from 
excessive  dilatation  of  the  left  ventricle  (the  segments  being  healthy) ; 
also  from  insufficiency  of  the  valvular  muscles;  and  (d)  adhesion  of  a 
segment  •with  the  walls  of  the  ventricle,  and  also  contraction  and  weaken- 
ing of  the  chord*  tendineie. 

Mechanical  Influence  of  the  Lesion. — The  mitral  leaflets  normally  close, 
and  prevent  the  reflux  of  the  blood  from  the  left  ventricle  into  the  left 
auricle  during  systole.  Hence  incomplete  closure  of  the  mitral  segments 
allows  a  portion  of  the  blood  to  return  into  the  left  auricle  during  the 
systole.  This  regurgitant  wave  meets  and  offers  an  obstacle  to  the 
normal  blood-current  coming  simultaneously  from  the  pulmonary  veins 
into  the  left  auricle.  It  is  clear  that  vertiginous  movements  must  result 
under  these  circumstances  and  give  rise  to  a  murmur.  The  double  blood- 
current,  entering  the  left  auricle  during  the  systole  of  the  left  ventricle, 
causes  over-filling  (hence  dilatation)  of  the  left  auricle,  and  in  a  grad- 
ual manner  induces  compensatory  hypertrophy  of  its  walls  since  its 
labor  has  been  increased.  During  the  next  diastole  the  abnormally 
large  contents  of  the  auricle  stream  under  increased  pressure  into  the 
left  ventricle,  producing  over-distention  (dilatation)  of  that  chamber. 
This  increased  volume  of  blood  in  the  ventricle  is  not  all  expelled  into 
the  aorta,  but  a  portion  of  it  returns  into  the  left  auricle.  Thus  the 
left  ventricle,  in  consequence  of  its  increased  labor,  becomes  hypertro- 
phied  as  well  as  dilated.  Under  these  circumstances  the  volume  of  blood 
that  is  poured  into  the  aorta  remains  about  normal,  and  hence  the 
arterial  tension  for  a  longer  or  shorter  period  is  also  normal.  Soon  the 
cardio-pulmonary  circulation  becomes  impeded.  The  blood  that  returns 
into  the  left  auricle  must,  by  reason  of  pressure,  offer  increased  obstruc- 
tion to  the  outflow  of  blood  from  the  pulmonary  veins,  and  the  pressure 
in  the  latter  must,  in  turn,  be  similarly  increased.  The  current  of  the 
blood  through  the  pulmonary  capillaries  and  branches  of  the  pulmonary 
artery  is  thus  retarded,  owing  to  the  gradual  backward  accumulation. 
The  walls  of  the  lung-vessels  are  the  seat  of  a  sclerotic  process,  and  pre- 
sent an  abnormal  obstacle  to  the  passage  of  the  systolic  wave  from  the 
right  ventricle  to  the  distal  end  of  the  cardio-pulmonary  arc.  As  a 
consequence  of  the  lung  congestion  and  vascular  changes  the  right  ven- 
tricle becomes  dilated  and  hypertrophied.  The  abnormally  increased 
tension  in  the  pulmonary  vessels  is  shown  by  the  accentuated  pulmonic 
second  sound.  Thus  the  right  heart  compensates  the  lesion  in  the  left, 
though  to  supply  an  adequate  amount  of  blood  to  the  peripheral  arteries 
the  left  ventricle  must  maintain  its  proper  degree  of  hypertrophy.  As 
soon  as  this  harmonious  balance  is  disturbed,  either  as  the  result  of  in- 
crease in  the  degree  of  incompetency  or  of  failure  of  muscular  power, 
the  progress  of  the  blood  from  the  right  auricle  to  the  right  ventricle  is 
hindered.  Increased  pressure  in  the  right  auricle  produces  dilatation 
of  its  chamber,  with  subsequent  general  venous  congestion  as  a  natural 
backward  effect  {vide  Tricuspid  Regurgitation).  It  is  now  seen  that 
1  Medical  News,  June  30,  1894. 


MLTRAL  INCOMPETENCY.  649 

when  the  right  heart  fails  a  lessened  amount  of  hlood  reaches  the  left 
ventricle,  and  hence  an  abnormally  small  amount  finds  its  way  into  the 
aorta;  this  fact  explains  the  presence  of  the  low  arterial  tension  late  in 
the  disease.  Hypertrophy  of  the  left  ventricle  in  this  disease  has  also 
been  attributed  in  part  to  the  augmented  tension  in  the  general  capillary 
vessels  that  is  occasioned  by  the  venous  stasis. 

Special  Ktiology. — («)  Rheumatic  endoearditiH  is  the  most  fre- 
quent cause,  though  mitral  regurgitation  also  results  less  frequently 
from  acute  endocarditis  due  to  other  causes.  (6)  It  may  be  a  part  of  a 
general  arteriosclerotic  process.,  caused,  not  rarely,  by  syphilis  and  alco- 
hol, (c)  A  diseased  condition  of  the  columnoi  carnece  or  cltordce  tendineoi., 
if  it  contracts  them  or  weakens  their  structures  so  that  the  free  edges  of 
the  segments  pass  beyond  the  plane  of  the  orifice,  produces  insufficiency. 
id)  It  rarely  arises  in  the  course  of  aortic  valvular  disease  (a  secondary 
mitral  affection),  and  is  then  excited  mainly  by  undue  tension  of  the 
blood  in  the  left  ventricle.  Here  the  lesion  is  of  a  mild  grade,  as  a  rule. 
{e)  It  is  frequently  occasioned  by  enlargement  of  the  l^t  auriculo-ven- 
tricular  ring,  resulting  from  excessive  dilatation  of  the  left  ventricle,  as 
in  aortic  incompetency,  aortic  stenosis,  long-continued  fevers  (toxic  myo- 
carditis), and  the  graver  anemias  (relative  incompetency).  (/)  Ulcera- 
tive endocarditis,  either  by  perforating  or  producing  rupture  of  the  valve- 
curtains  or  by  destroying  the  chordae  tendinege,  may  bring  about  mitral 
incompetency.  Among  predisposing  factors  age  and  sex  are  worthy  of 
special  mention,  the  incompetency  occurring  with  greatest  relative  fre- 
quency in  young  adults  (from  twenty  to  thirty  years  of  age,  according 
to  Ashton's  figures)  and  somewhat  more  commonly  in  males. 

Symptoms. — During  Compensation. — In  healthy  persons  the  com- 
pensatory forces  keep  pace  with  the  valvular  lesions  for  an  indefinite 
and  usually  lengthy  period,  during  which  time  there  may  be  an  entire 
absence  of  symptoms.  When  present  they  are  dependent  upon  dis- 
turbances of  the  cardio-pulmonary  circulation  that  are  occasioned  by  trivial 
causes,  such  as  excitement,  going  up  stairs,  or  other  forms  of  active 
physical  exertion.  Under  these  circumstances  the  force  of  the  regurgi- 
tant current  is  increased  (by  the  hypertrophied  left  ventricle),  thus  pro- 
ducing more  or  less  pulmonary  congestion  that  may  proceed  to  edema 
of  the  lungs  or  hemoptysis.  The  condition  is  usually  a  temporary  one, 
and  is  attended  by  dyspnea,  palpitation  of  the  heart,  a  short,  hacking 
cough,  and  expectoration  of  a  frothy  serum  that  may  be  blood-stained. 
The  relation  existing  between  the  severity  of  the  dyspnea  and  the 
degree  of  active  physical  exertion  is  positive  and  vital.  Shortness  of 
breath  may  be  the  sole  feature  during  a  long  period.  The  rational 
symptoms  rarely  warrant  a  suspicion  of  the  existence  of  mitral  disease 
until  compensation  has  failed,  but  the  patient's  appearance  often  indicates 
heart-disease.  The  face  is  pale  and  the  features  peaked,  the  eyes,  lips, 
and  ears  are  dusky,  and  the  minute  vessels  of  the  cheeks  are  prominent. 
Clubbing  of  the  finger-nails  is  observed  most  frequently  in  the  young. 

After  Failure  of  Compensation. — Failure  of  compensation  implies 
failure  of  the  right  ventricle  to  cope  efficiently  with  the  augmented  ten- 
sion in  the  pulmonary  circulation,  with  accompanying  congestion  of  the 
lungs,  followed  by  engorgement  of  the  systemic  veins.  The  latter  process 
begins  at  the  right  heart  and  proceeds  toward  the  periphery,  involving 


650  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  viscera,  mucous  membranes,  and  extremities  until  it  is  universal. 
The  pulmonic  sijmptoms  above  detailed  are  now  more  marked,  particu- 
hu"ly  the  dyspnea  (-which  may  be  constant),  cough  (with  expectoration 
of  alveolar  epithelium  containing  brown  pigment-granules),  and  cardiac 
palpitation  with  arrhythmia.  Pain  is  rare  unless  stenosis  coexists. 
General  venous  engorgement  manifests  itself  by  an  enlargement  of  the 
liver  and  of  the  spleen,  in  the  features  of  gastro-intestinal  catarrh,  in 
hemorrhoids,  in  marked  cyanosis  of  the  surface,  and  in  tiie  passage  of 
a  scanty  albuminous  urine  containing  tube-casts  and  blood-corpuscles. 
Dropsy  follows,  beginning  in  the  feet  and  progressing  upward,  until 
finally  the  trunk  and  the  serous  sacs  are  involved.  By  stimulation  the 
heart  may  be  reinforced,  and  all  of  the  unfavorable  symptoms  disap- 
pear. I  have  at  present  under  observation  a  case  in  which  not  less 
than  half  a  dozen  instances  of  broken  compensation  have  occurred 
at  intervals  of  six  to  eight  months.^  In  ail  cases,  however,  there 
comes  a  time  when  compensation  cannot  be  restored,  and  the  end  is 
soon  reached. 

Physical  Signs. — In.spectio?!. — The  precordia  is  prominent,  particu- 
larly in  children,  and  the  area  of  the  apex-beat  is  enlarged,  later 
becoming  diffuse  and  wavy.  It  is  carried  to  the  left  and  down- 
ward, sometimes  to  the  sixth  interspace,  corresponding  Avith  the 
degree  of  hypertrophy  of  the  left  ventricle.  A  pulsating  epigas- 
trium is  in  frequent  association,  particularly  after  dilatation  of  the  right 
ventricle  appears.  With  the  failure  of  the  right  heart  also  come 
wavy  pulsations  in  the  cervical  veins,  and  occasionally  a  mild  grade  of 
jaundice. 

Palpation  sometimes  discovers  a  thrill  at  the  seat  of  the  apex-beat, 
synchronous  with  the  first  sound.  The  impulse  during  the  stage  of 
full  compensation  is  forceful  and  heaving,  but  with  the  beginning  of 
failure  of  compensation  it  grows  feeble  and  irregular,  and  late  in  the 
affection  is  excessively  weak  and  arrhythmic.  The  pulse  bears  a  defi- 
nite relation  to  the  apical  impulse ;  it  is  commonly  regular  and  full 
during  the  compensatory  period  (though  at  times  the  tension  is  slightly 
lowered),  but  becomes  small,  easily  compressible,  and  exceedingly  irreg- 
ular during  the  period  of  broken  compensation.  One  meets  with  cases 
in  which  irregularity  appears  during  the  period  of  fair  compensation. 

Percussion. — The  dull  area  is  increased  to  the  left,  extending  fre- 
quently to  the  anterior  axillary  line ;  and  also  to  the  right,  frequently 
from  ^  to  1  inch  (1.2-2.5  cm.)  without  the  right  sternal  margin.  Dila- 
tation of  both  ventricles  exerts  a  widening  influence ;  hence  cardiac 
dulness  is  increased  more  laterally  than  vertically.  The  upper  arc  of 
cardiac  dulness  commences  usually  at  the  third  intercostal  space. 

Auscultation  reveals  a  systolic  murmur,  with  greatest  intensity  at 
the  apex  (see  Fig.  53).  It  is  rarely  loudest  in  the  fourth  or  third 
space  in  the  vertical  nipple  line.  Balthazar  Foster  first  called 
attention  to  the  fact  that  the  murmur  of  mitral  regurgitation  may  be 
loudest  at  the  base  of  the  heart,  and  at  times  audible  only  in  that  situa- 
tion— an  occurrence  that  has  since  been  confirmed.  It  is  sometimes 
audible  in  the  recumbent  posture  and  inaudible  in  the  erect.     From  the 

^  Neglect  of  hygienic  precautions  and  intercurrent  complaints  of  various  sorts  often 
determine  the  occurrence  of  failure  of  compensation. 


MITRAL  INCOMPETENCY. 


651 


apex  it  is  transmitted  to  the  left  as  far  as  the  anf^le  of  the  scapula,  with 
progressively  diminishing  clearness.  It  has  a  blowing  quality,  and  fre- 
quently ends  in  a  musical  tone.  Loudness  implies  strength  of  con- 
traction (Broadbent).  It  is  fair  to  assume  that  on  account  of  the 
defect  in  the  closing  of  the  mitral  valve,  there  is  often  a  decreased 
tone-formation  with  systole.  Over  the  third  left  costal  cartilage,  and  fre- 
quently at  the  apex,  there  is  heard  the  accentuated  pulmonic  second 
sound,  due  to  the  increased  tension  in  the  pulmonary  vessels  en- 
gendered by  the  hypertrophy  of  the  right  ventricle.  Combined  mur- 
murs may  be  heard,  and  not  infrequently  a  rough,  rolling,  or  rum- 
bling presystolic  murmur  is  detected.  A  frequent  late  occurrence  is 
secondary  dilatation  of  the  right  ventricle,  causing  relative  tricuspid 
insufficiency  with  its  characteristic  soft,  low-pitched,  systolic  murmur, 
heard  best  at  the  ensiform  cartilage.     A  spurious  diastolic  murmur  may 


Fig.  53.— 1,  Seat  of  greatest  intensity ;  2,  direction  of  chief  transmission ;  3,  boundary  line  of  rela- 
tive dulness ;  4,  boundary-line  of  absolute  dulness  (modified  from  Sahli). 

be  noted,  though  rarely,  when  the  sounds  are  timed  with  the  pulse. 
This  is  due  to  a  weak  systole  that  fails  to  cause  a  radial  pulse. 

Diagnosis. — In  the  presence  of  the  following  group  of  features  the 
diagnosis  is  set  at  rest :  A  marked  broadening  of  the  area  of  cardiac 
dulness ;  a  systolic,  apical  murmur  that  is  conveyed  to  the  left  axilla 
and  may  be  heard  even  at  the  back ;  and  a  decided  accentuation  of  the 
pulmonary  sound.  Obviously,  the  latter  sound  becomes  feeble  after 
dilatation  of  the  right  ventricle  has  occurred.  A  systolic  thrill  is 
of  the  highest  diagnostic  importance,  but  is  unfortunately  absent   in 


652  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

perhaps  a  majority  of  the  cases.  Free  regurgitation  through  the  mitral 
orifice  may  be  safely  inferred  when  the  following  signs  are  concurrent : 
(a)  An  absence  of  the  sound  of  mitral-valve  tension,  a  murmur  replacing 
the  first  sound ;  {b)  accentuation  of  the  pulmonic  second  sound ;  (c) 
an  enlarged  area  of  the  left  cavity ;  (d)  an  enlarged  area  of  the  right 
cavity  (ISansom). 

Differential  Diagnosis. — There  are  two  organic  lesions  of  the  heart 
that  are  sometimes  mistaken  for  mitral  incompetency,  since  both  are  ac- 
companied by  a  systolic  murmur — the  one  aortic  stenosis,  and  the  other 
tricuspid  regurgitation.  How  to  distinguish  mitral  from  tricuspid  in- 
competency is  a  question  that  will  receive  due  attention  when  the  latter 
disease  is  considered.  Aortic  stenosis  generates  a  systolic  murmur,  but 
it  is  loudest  over  the  base,  and  is  transmitted  through  the  great  vessels 
of  the  neck ;  while  the  mitral  systolic  is  most  intense  over  the  apex  and 
is  transmitted  far  to  the  left.  In  mitral  incompetency  the  pulmonary 
second  sound  is  accentuated ;  in  aortic  stenosis  it  is  not.  In  mitral  in- 
sufficiency both  ventricles  are  enlarged,  as  shown  by  percussion  and 
other  signs ;  in  aortic  stenosis  the  hypertrophy  affects  chiefly  the  left 
ventricle.  In  mitral  incompetency  a  thrill,  most  marked  over  the  apex- 
beat,  may  be  felt;  in  aortic  stenosis  a  thrill,  rough  and  having  its' chief 
seat  at  the  base,  is  present.  Additional  points  of  distinction  are  fur- 
nished by  the  contrasting  factors  of  the  pulse,  the  age  of  the  patient,  and 
other  etiologic  influences. 

Functional  systolic  murmurs  are  often  confounded  with  mitral  insuffi- 
ciency. The  considerations  on  which  the  greatest  dependence  is  to  be 
placed  in  the  diflerentiation  are  given  in  the  subjoined  parallel  tables: 

Mitral  Incompetency.  Functional  and  Harmless  Murmurs. 

History. 

Previous  history  of  rheumatism  or  other      History  of  one  or  other  form  of  anemia, 
disease  causally  related.  of  debility,  or  of  Graves'  disease. 

Frequently  there  is  definite  knowledge  of       No  such  association, 
rheumatism  and  organic  heart-disease, 
in  combination  in  the  same  individual. 

Physical  Signs. 

Inspection. — Dusky  lips,  ears,  etc. ;  later  Pallor  of  skin  and  mucous  surfaces  com- 

wavy  pulsation  in  veins  of  neck.  mon. 

Palpation. — Finger-tips  placed  over  apex-  Finger  not  lifted  by  the  impulse,  which 

beat  forcibly  lifted.  Pulse-tension  some-  often  cannot  be  felt.    Pulse-tension  pro- 

what  lowered  and  not  prolonged.     Im-  longed  and  arterial  pressure  increased 

pulse  displaced.  generally.     Impulse  not  displaced. 

Percussion. — Evidence   of   dilatation   of  Dilatation  of  right  auricle,  but  only  in 

both  ventricles.  about  one-half  of  the  cases,  giving  rise 

to  dulness  above  or  to  the  right  of  the 
right  edge  of  sternum. 

Auscultation. — A   systolic  apex-murmur  Soft  systolic   murmur  at  apex  (variable 

(often  musical), with  characteristic  area  in  intensity,  rarely  transmitted  to  ax- 

of  transmission.    This  murmur  is  often  ilia),  usually   preceded   by  or  associ- 

heard  posteriorly  ;    pulmonary    sound  ated  with  a  basic  systolic  murmur  and 

accentuated.  a  venous  hum  in  the  veins  of  the  neck. 

To  differentiate  relative  from  organic  mitral  incompetency  is  difficult. 
It  rests  upon  two  points  :  (a)  the  character  of  the  murmur,  which  is  softer 


MITRAL  STENOSIS.  653 

and  wshows  greater  changes  in  intensity  (e.  g.,  being  either  less  pronounced 
or  disappearing  if  the  heart  is  "whipped  up"  hy  digitalisj  tlian  that  due 
to  valvular  lesions  ;  and  (h)  the  antecedent  history  of  the  patient.  Thus, 
relative  insufficiency  of  the  mitral  segments  prohably  exists  in  patients 
in  the  middle  period  of  life,  in  whom  the  previous  history  either  furnishes 
such  etiologic  factors  as  chronic  gout,  syphilis,  or  evidences  of  myocar- 
ditis, fatty  heart,  or  anemic  conditions ;  or  in  persons  who  exhibit 
arteriosclerosis  or  organic  disease  of  the  aortic  valve  and  an  apex-systolic 
murmur.  Again,  if  present  in  chronic  renal  disease,  with  concurrent 
symptoms  of  high  arterial  tension  and  of  left  ventricular  hypertrophy — 
accentuation  of  the  second  aortic  sound,  a  mitral  systolic  mu)mur — it  is 
to  be  ascribed  to  relative  insufficiency.  On  the  other  hand,  if  the  signs 
of  mitral  regurgitation  occur  in  a  younger  subject  or  in  one  who  has  been 
afflicted  with  acute  rheumatism,  it  is  highly  probable  that  the  mitral- 
valve  segments  are  the  seat  of  chronic  endocarditis  of  rheumatic  origin. 
Compression  of  the  edge  of  the  left  lung  by  the  ventricular  systole  may 
produce  a  spurious  murmur.  A  rare  sequel  of  mitral  incompetency  is 
mitral  stenosis,  owing  to  the  contraction  of  the  mitral  orifice  or  cohesion 
of  the  free  edges  of  the  cusps. 


MITRAL  STENOSIS. 

Definition. — Constriction  of  the  left  auriculo-ventricular  orifice, 
due  to  either  thickening  or  adhesion  of  the  segments.  In  most  cases, 
adhesions  of  the  free  borders  of  the  valve  or  of  the  chordae  tendinae 
obtain.  Mitral  stenosis  is  generally  combined  with  insufficiency,  and  also 
frequently  associated  with  adhesive  pericarditis. 

Special  Pathology  and  i^tiology. — It  is  to  be  recollected  that 
the  constriction  may  be  almost  inappreciable,  and  yet  an  uneven,  rough- 
ened surface  be  presented,  producing  a  murmur.  A  high  degree  of  con- 
striction, however,  "which  is  more  frequent  than  is  generally  supposed" 
(Elliott),  may  be  encountered.  Thus,  in  the  funnel-shaped  form  of  mitral 
stenosis  the  aperture  may  be  so  small  as  scarcely  to  admit  the  passage  of 
a  goose-quill.  When  moderate  in  degree  the  tip  of  the  index-finger  is 
admissible ;  in  the  hutton-hole  form  the  slit  may  be  so  narrow  as  not  to 
allow  an  object  larger  than  a  shirt-button  to  pass  through  it.  This  form 
is  comparatively  rare  in  children,  while  the  funnel  variety  is  common, 
and  is  occasionally  a  congenital  condition  (possibly  hereditary).  In 
adults,  however,  the  funnel-shaped  constriction  is  rare,  while  the  button- 
hole valve  is  common  ;  in  62  post-mortem  examinations  only  3  showed 
funnel-form  contraction  (Hayden  and  Fagge).  Mitral  stenosis  is,  gener- 
ally, dependent  upon  a  mild  or  limited  endocarditis  of  rheumatic  origin. 
It  is  more  common  in  young  adults  and  in  children  after  the  fifth  year 
than  in  older  persons,  and  a  greater  incidence  is  shown  m  females,  for  the 
reason  that  the  affections  that  are  causally  related  to  endocarditis  are  more 
frequent  in  females  (rheumatism,  chorea,  chlorosis).  The  endocarditis 
of  measles  and  scarlatina  may  also  lead  to  narrowing  of  the  mitral  orifice, 
and  I  quite  agree  with  Osier  in  the  belief  that  Avhooping-cough,  owing  to 
the  great  strain  that  it  imposes  upon  the  heart-valves,  maybe  accountable 
for  certain  cases.     In  adults  arteriosclerosis  and  chronic  nephritis  may 


654  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

act  as  causes.  The  hemorrha«2;ic  cases  may  at  times  be  the  immediate 
effect  of  an  accident.'  In  not  a  fcAv  cases  the  etioloiry  is  obscure,  par- 
ticularly in  adult  women.      Ball-thrombi  have  been  found  in  the  auricle. 

Mechamcal  Influence  of  the  Lesion. — The  task  of  the  left  auricle  is 
oreattT  than  normal,  and  a.s  a  couse(|Uence  its  walls  hypertrophy.  They 
may  be  found  to  be  one-fourth  or  even  one-half  inch  (1.2  cm.)  in  thick- 
ness, the  normal  thickness  being  only  three-twentieths  of  an  inch  (3.7  mm.). 
Dilatation  of  the  auricle  comes  on  early,  since  this  chamber  cannot  take 
on  much  hypertrophy  owing  to  lack  of  muscular  structure,  and  in  the  later 
stages  its  walls  become  extremely  thin.  For  a  varying  period  of  time  the 
increased  power  due  to  hypertrophy  of  the  left  auricle  and  the  increased 
resistance  to  the  circulation  that  is  the  result  of  the  mitral  lesion  are  exactly 
balanced.  At  a  comparatively  early  period,  however,  the  auricle  can  no 
longer  maintain  this  equilibrium;  and  then,  owing  to  retardation  of  the 
current  from  the  pulmonary  veins  to  the  auricle,  the  vascular  tension  in  the 
lungs  and  right  ventricle  is  increased.  The  right  ventricle,  in  seeking  to 
overcome  the  obstruction,  becomes  greatly  hypertrophied  and  dilated,  and 
late  in  the  disease  tricuspid  incompetency  supervenes.  The  hypertrophy 
of  the  latter  chamber  counterbalances  the  lesion  during  the  period  of 
compensation.  For  a  brief  time  the  left  ventricle  exhibits  no  abnormal 
proportions.  Later  and  at  autopsies  its  cavity  is  found  smaller  and  its 
walls  thinner  than  the  normal,  these  conditions  being  due  to  its  abnor- 
mally light  labor.  The  a))ex  of  the  heart  is  formed  almost  exclusively  by 
the  enlarged  right  ventricle.  If  the  left  ventricle  be  hypertrophied,  it  is 
owing  to  co-existence  of  mitral  incompetency. 

Symptoms. — The  subjective  symptoms  are  scanty.  During  the 
period  of  compensation  they  may  be  absent  except  on  going  up  stairs  or  on 
attempting  some  unusual  muscular  effort,  when  dyspnea  appears.  Frag- 
ments of  fibrinous  coagula  dislodged  from  between  the  musculi 
pectinati  of  the  auricle  or  swept  from  the  valves  may  give  rise 
to  the  phenomena  of  cerebral  embolism  (aphasia  and  hemiplegia).  The 
same  conditions  may  arise,  and  in  the  same  way,  from  recurring  endo- 
carditis, to  which  such  patients  are  specially  liable.  The  patient  in 
well-marked  cases  presents  an  anemic  appearance :  a  stitch-like  pain  in 
the  apex-region  is  fre(juently  present,  and  active  exertion,  by  overtax- 
ing the  left  auricle,   induces  cardiac  palpitation  and  dyspnea. 

After  failure  of  compensation  the  symptoms  referable  to  the  pulmo- 
nary system  are  almost  identical  with  those  manifested  in  mitral  incom- 
petency. Owing  to  the  pulmonary  engorgement  the  dyspnea  is  constant, 
and  is  increased  by  exertion.  After  severe  physical  exercise  congestion., 
followed  by  edema  of  the  lungs,  may  supervene,  attended  by  a  copious 
blood-stained,  serous  expectoration.  True  hemoptysis  may  arise  from 
time  to  time.  The  sputum  often  contains  large,  mostly  oval,  nucleated 
cells  showing  yellowish-brown  pigment  ("heart-failure  cells").  Ilie 
increased  tension  in  the  pulmonary  vessels  leads  to  sclerosis,  followed 
by  atheromatous  degeneration  of  their  walls,  and  may  result  in  pul- 
monary apoplexy.  Intercurrent  febrile  attacks  (due  to  recurring  endo- 
carditis) are  common,  partieulavly  in  the  later  stages,  and  are  attended 
with  marked  aggravation  of  the  circulatory  disturbances.      Mitral  steno- 

1  See  also  "Trauma  and  Heart  Disease,"  by  .J.  ('.  AVilson,  Jaur.  Amer.  Med.  Assoc, 
Feb.  10,  191-2,  p.  405. 


MITJiA  L  STENOSIS. 


655 


sis  differs  from  rnitrnl  iricornyxitency  in  that  general  anasarca  is  rare, 
though  marked  enlargement  of  the  liver  and  other  evidences  of  portal 
congestion  (including  ascites)  are  commonly  present.  Boinet,  Osier,  and 
others  state  that  paralysis  of  the  left  recurrent  laryngeal  nerve  may  occur 
either  as  the  result  of  compression  or  traction. 

Physical  Signs. — InHpection. — The  apex-beat  is  diffused,  hut  not  dis- 
placed downward,  unless  there  be  excessive  enlargement  of  the  right 
ventricle  or  associated  hypertrophy  of  the  left.  There  is  usually  ob- 
served pulsation  in  the  second  left  intercostal  space,  and  sometimes  in 
the  third  and  fourth,  occasioned  by  increased  tension  in  the  pulmonary 
artery ;  there  is  also  a  diffuse  impulse  along  the  right  border  of  the  sternum. 
Epigastric  pulsation  is  common.  A  prominence  over  the  fifth  and  sixth 
left  costal  cartilages  and  the  lower  half  of  the  sternum  is  observed,  partic- 
ularly in  children.  After  failure  of  compensation  the  impulse  is  feeble 
and  undulating,  with  engorgement  and  pulsation  of  the  jugular  veins. 

Palpation  discovers  a  presystolic  thrill  in  a  great  proportion  of 
cases.  In  certain  instances  active  physical  exertion  may  render  this 
appreciable,  or  when  in  the  recumbent  posture  on  the  left  side  the  ele- 
vation of  the  arms  may  accomplish  the  same  result.  It  is,  however, 
absent  in  rare  instances  before  failure  of  compensation  occurs,  and  more 
frequently  by  far  after  the  latter  event.  This  fremitus  is  best  felt  over 
the  third  and  fourth  (less  frequently  the  fifth)  interspaces,  just  within 
the  nipple,  and  during  expiration.  It  commences  after  the  second  sound 
(during  the  diastole)  as  a  purring  fremitus,  increasing  steadily  in  volume 
and  intensity,  and  terminates  abruptly  with  the  severe  shock  of  the  new 
impulse.  The  fremitus  and  systolic  shock  are  pathognomonic,  and  may 
be  relied  upon  in  the  absence  of  the  murmur.  The  heart's  impulse  is 
most  forcible  over  the  lower  portion  of  the  sternum  and  along  the  right 
border,  being  due  to  the  enlarged  right  ventricle;  in  a  smaller  propor- 


PiG.  54. -Sphygmograms  in  a  case  of  mitral  stenosis  treated  by  extract  of  convallaria.  and  sub- 
sequently by  digitalis :  A,  before  treatment,  showing  the  interpolated  pulsations :  B,  after  treat- 
ment (Sansom). 


tion  of  cases,  in  the  third,  fourth,  and  fifth  interspaces  to  the  left  of  the  ster- 
num. The  radial  pulse  is  small,  compressible,  and  markedly  irregular 
(disorderly)  as  the  propulsive  power  of  the  right  ventricle  diminishes.  Ar- 
rhythmia often  appears  early,  and  is  due  to  failure  of  contraction  of  the  left 
auricle.  The  sphygmographic  tracing  is  notably  irregular  {vide  Fig.  54). 
Percussion    show^s  an    extension    of  heart-dulness  to   the  right,  fre- 


656  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

quently  5  centimeters  (2  inches)  beyond  the  sternal  margin,  as  a  result 
of  hypertrophy  of  the  right  ventricle,  and  upward  as  high  as  the  sec- 
ond rib  on  either  side  of  the  sternum.  Increase  in  the  cardiac  dulnesB 
to  the  left  also  occurs  not  infrequently,  and  is  attributable  to  excessive 
enlargement  of  the  right  ventricle,  though  more  often  of  the  left  ven- 
tricle in  consequence  of  associated  mitral  insufficiency. 

Auscultation  reveals  a  rough,  presystolic  murmur,  which  may  be 
characterize*!  as  churning  or  rolling,  acquiring  increased  intensity. 
It  occurs  synchronously  with  the  thrill.  Its  point  of  greatest  pronun- 
ciation is  just  above  and  about  one  inch  within  the  normal  apex-beat. 
The  area  of  transmission  does  not  exceed  a  couple  of  inches  in  any 
direction.  Griffith,  however,  has  shown  that  the  murmur  may  be  widely 
transmitted.  This  murmur  sometimes  exhibits  atypical  characters :  it 
mav  be  brief,  low-toned,  and  inconstant.  After  the  right  ventricle  be- 
comes weak,  the  murmur  may  absent  itself  either  temporarily  or  per- 
manently. In  most  cases,  the  clear,  accentuated  first  sound  is  retained, 
even  though  the  murmur  disappears.  Improvement  in  the  muscular 
power  of  the  heart  as  the  result  of  judicious  treatment  may  cause  the 
murmur  to  reappear.  For  purposes  of  diagnosis,  nothing  is  so  vitally 
important  as  the  rhythm  of  the  murmur,  hence  the  observer  must  palpate 
the  heart,  and  not  the  radial  pulse,  while  practising  auscultation.  The 
finger  as  well  as  the  ear  will  thus  become  sensible  of  the  systolic  shock 
Avhich  replaces  the  cardiac  impulse,  and  it  Avill  be  noted  that  the  murmur 
terminates  at  the  same  moment.  In  cases  in  which  the  impulse  cannot 
be  felt,  the  finger  should  be  placed  over  one  or  other  carotid,  since  here 
the  pulse  is  practically  synchronous  with  the  systole.  In  most  cases  the 
murmur  occupies  only  the  latter  half  of  the  diastole.  In  some  cases  it  is 
purely  diastolic,  the  blood  being  driven  under  high  pressure  in  the  lesser 
circulation,  from  the  auricle  into  the  relaxed  ventricle,  at  the  beginning 
of  the  long  pause.  Owing  to  the  presence  of  right  ventricle  hypertrophy 
the  second  pulmonic  sound  is  greatly  accentuated,  being  distinctly 
audible  at  the  apex,  while  the  second  aortic  sound  is  often  absent  or 
feeble.      Reduplication  of  the  second  sound  is  not  rare. 

Secondary  Murimirs. — While  mitral  stenosis  may  rarely  follow  mitral 
incompetency  or  aortic  valve  disease,  in  the  vast  majority  of  instances  it 
is  a  primary  affection.  Secondary  murmurs  are  not  uncommon,  however. 
Among  these  the  bruit  of  mitral  incompetency  is  relatively  frequent. 
After  compensation  is  ruptured  the  murmur  of  tricuspid  ini<ufficiency 
usually  becomes  audible  at  the  lower  end  of  the  sternum  and  persists 
until  the  end.  In  so-called  '•'•relative  mitral  stenosis,''  associated  with 
primary  dilatation  of  the  left  ventricle,  which  holds  the  orifice  open, 
there  occurs  also  a  mitral  regurgitant  murmur. 

Diagnosis. — The  distinctive  features  of  mitral  stenosis  are — (1)  A 
presystolic  thrill  at  the  apex.  (2)  An  increase  in  the  precordial  dul- 
ness  upward  and  to  the  right.  (3)  A  murmur  which  (a)  has  its  seat 
above,  yet  near,  the  normal  apex-beat;  (b)  is  usually  localized;  (c)  is 
presystolic  in  time,  terminating  abruptly  with  the  systolic  shock  (sharp 
impulse):  and  (d)  is  rough  and  vibratory  in  chai'acter.  (4)  A  marked 
accentuation  of  the  second  pulmonic  sound. 

Diflferential  Diagnosis. — When  the  murmur  of  mitral  stenosis  is  very 
brief,  it  is  difficult  to  eliminate  a  mere  roughening  without   valvulitis. 


TRICUSPID  INCOMPETENCY.  g57 

In  the  latter  condition,  however,  there  is  no  increase  in  intensity  of 
the  murmurs  on  exertion  or  when  the  arms  are  uplifted,  they  are 
not  vibratory  in  character,  and  there  is  no  right  ventricular 
hypertrophy.  From  simple  mitral  stenosis  the  lesion  of  mitral  incom- 
petency is  easily  distinguished  by  its  systolic  rhythm,  greater  area  of 
transmission,  and  by  the  soft,  more  blowing  cliaracter  of  its  murmur. 
As  stated,  the  majority  of  the  cases  of  mitral  stenosis  are  associated 
with  mitral  incompetency;  it  is  clinically  important  to  recognize  the 
combined  presence  of  these  two  valvular  lesions,  and  also  which  lesion 
predominates  in  the  individual  case.  The  presence  of  the  systolic 
murmur  is  distinguishable  by  its  synchronism  with  the  impulse  or  carotid 
pulse,  and  by  its  area  of  transmission  to  the  left  as  far  as  the  axilla.  If 
now  the  stethoscope  be  applied  just  above  and  to  the  right  of  the  normal 
apex,  a  limited  superficial  area  will  be  found  where  a  typical  presystolic 
murmur  is  distinctly  heard.  Points  can  also  usually  be  found  where  a 
continuous  bruit,  covering  a  portion  of  the  period  of  diastole  and  the 
systole,  is  audible.  A  rumbling  apical  sound  resembling  a  presystolic 
murmur  may  be  heard  in  pericardial  adhesion.  Its  seat  is  different  and 
it  does  not  end  in  sharp  systolic  shock. 

In  aortic  regurgitation  the  presence  of  a  presystolic  thrill  and  mur- 
mur has  rarely  been  recorded,  and  Fisher,  Phear,  and  others  have  noted 
them  in  simple  dilatation  ("  relative  mitral  stenosis").  "When  a  purely 
diastolic  murmur  is  present  in  the  aortic  area,  indicating  aortic  regurgi- 
tation, the  diagnosis  of  mitral  stenosis  must  be  made  with  due  caution. 


TRICUSPID  INCOMPETENCY. 

{Tricuspid  Regurgitation.) 

Definition. — An  imperfect  closure  of  the  tricuspid  valve,  due  either 
to  a  dilatation  of  the  right  ventricle  that  is  secondary  to  mitral  or  lung- 
disease,  or,  less  frequently,  to  an  inflammatory  shortening  of  the  valves. 

Patliology  and  Htiology. — As  a  primary  disease  tricuspid  in- 
competency is  rare.  It,  however,  is  not  uncommonly  due  to  chronic 
organic  changes,  though  originating  in  fetal  endocarditis.  After  birth 
this  variety  is  most  common  during  childhood,  and  the  frequency  of 
occurrence  is  in  inverse  ratio  to  the  age.  At  any  period  of  life,  how- 
ever, chronic  affections  of  the  lungs  or  organic  disease  of  the  left  side 
of  the  heart  may,  by  augmenting  the  tension  in  the  right  ventricle,  pro- 
duce chronic  interstitial  changes  in  the  tricuspid  segments.  These  are 
usually  of  mild  grade.  In  chronic  bronchitis  associated  with  emphysema, 
and  in  pulmonary  tuberculosis,  extensive  lesions  of  these  valves  are  seen 
rarely,  owing  to  the  fact  that  dilatation  of  the  right  ventricle  is  soon  fol- 
lowed by  relative  insufficiency,  and  thus  the  strain  is  in  great  part  removed 
from  the  valves  themselves.     And  yet,  according  to  Byron  Bramwell,  the 

42 


658  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

tricuspid  valve  is  implicated  in  50  per  cent,  of  all  cases  of  acute  endocar- 
ditis. He  suggests  that  the  acute  form  frequently  results  in  cure  because 
of  the  rehitively  diminished  right  intraventricular  tension.  In  rare  in- 
stances one  of  the  leafiots  has  been  ruptured  by  straining.  The  relative 
tricuspid  insufficiency,  produced  in  a  manner  analogous  to  relative  mitral 
insufficiency,  is  an  exceedingly  common  secondary  condition  in  affections 
of  the  lungs  and  heart  that  cause  hypertrophy  and  dilatation  of  the  right 
ventricle  (mitral  incompetency  and  stenosis,  emphysema,  sclerosis  of  the 
lung). 

Physiologic  Pathology. — In  tricuspid  leakage  every  systole  of  the 
right  ventricle  is  accompanied  by  a  reHux  of  venous  blood  through  the 
imperfectly  closed  tricuspid  orifice  into  the  auricle,  and  thence  into  the 
veins.  This  causes  venous  stasis  and  visible  pulsation,  and  in  this 
manner  the  engorged  pulmonary  circulation  is  somewhat  relieved.  An 
unfavorable  consequence,  however,  of  the  reflux  current  from  the  right 
ventricle  is  the  lessened  blood-supply  to  the  already  engorged  pulmonary 
arteries.  The  hypertrophied  and  ddated  right  heart  now  undergoes 
further  enlargement  in  the  same  manner  as  in  the  hypertrophy  of  the  left 
ventricle  folloAving  mitral  incompetency,  though  to  a  less  extent.  In 
mitral  incompetency  the  right  ventricle  compensates  the  mitral  lesion 
after  failure  of  the  left  auricle,  but  there  can  be  no  such  effective  com- 
pensatory mechanism  after  failure  of  the  right  auricle  in  tricuspid  incom- 
petency, since  the  right  heart  is  not  reinforced  by  a  fellow  as  is  the  left. 
The  blood-stream  flowing  into  the  right  ventricle  during  diastole,  how- 
ever, is  abnormally  large,  owing  to  moderately  increased  venous  tension. 
When  the  right  ventricle  fails  to  maintain  the  pulmonary  circulation, 
progressive  dilatation  of  its  chamber  occurs,  with  a  proportionate  thin- 
ning of  its  walls,  until  its  dimensions  are  enormous. 

Symptoms. — In  most  instances  the  indications  of  the  primary  or 
causal  affection  must  be  noted,  though  these  are  often  more  or  less 
screened  by  the  more  characteristic  features  of  the  disease  under  con- 
sideration. The  symptoms  of  tricuspid  incompetency  point  to  passive 
congestion  of  the  lungs  and  engorgement  of  the  systemic  veins,  and 
have  been  described  in  connection  with  mitral  lesions.  Cardiac  dropsy 
is  common,  though  present  in  by  no  means  all  cases.  It  is  a  prominent 
feature  in  the  cases  that  are  secondary  to  mitral  disease.  Frederick 
Taylor^  contejids  that  ascites  is  absent  frequently,  because  the  liver  acts 
as  a  diverticulum  to  accommodate  the  excess  of  venous  blood. 

Physical  Signs. — Inspection. — Venous  pulsation,  caused  by  the  back- 
ward blood-wave  from  the  right  ventricle  and  auricle,  is  a  pathognomonic 
sign.  It  is  confined  to  the  lower  portion  of  the  jugular  veins  so  long  as 
the  valve  that  lies  above  the  jugularis  remains  closed,  but  soon  this 
yields,  and  then  the  veins  seem  to  pulsate  through  their  entire  course. 
This  is  best  seen  Avhen  the  patient  is  in  the  semi-recumbent  posture,  and 
is  most  marked  in  the  right  side.  The  venous  pulse  is  presystolic-sys- 
tolic  in  time  (Leube).  The  increase  in  the  venous  tension,  and  the 
slowing  of  circulation  in  the  capillaries,  combine  to  produce  a  cyanosis 
that  is  more  noticeable  when  the  breathing  is  discontinued  teqiporarily 
than  in  ordinary  respiration.  Tricuspid  incompetency  may  be  shown 
»  Lamel,  Nov.  22,  1890,  p.  1126. 


TRICUSPID  INCOMPETENCY.  059 

by  pressing  on  the  vein  with  the  finger  rather  firmly,  commencing  just 
above  the  clavicle  and  passing  upward,  thus  emptying  it  of  blood.  If, 
now,  the  right  ventricle  be  capable  of  producing  a  r(!turn  wave  .sufficiently 
powerful  to  overcome  the  valve  in  the  external  jugubxr,  pulsation  is  seen 
in  the  vessel  slowly  and  increasingly  until  the  vein,  as  far  as  the  point 
compressed,  becomes  filled.  The  vein  fills  "by  jets  synchronous  with  the 
heart-beat"  (Sansom).  If  an  impulse  be  communicated  to  the  jugulars 
from  the  underlying  carotid  artery,  the  light  pressure  upon  the  vein  below 
does  not  arrest  the  pulsation  above,  as  is  the  case  in  tricuspid  incom- 
petency. A  feeble  presystolic  venous  pulse,  due  to  the  weaker  contrac- 
tion of  the  right  auricle  as  compared  with  that  of  the  right  ventricle 
{anadichrotic  venous  pulse)  may  occur.  The  area  and  seat  of  the  apex- 
beat  vary  with  the  nature  of  the  primary  aff"ection ;  in  mitral  incompe- 
tency, for  example,  the  beat  is  displaced  to  the  left  and  downward,  while 
in  uncomplicated  mitral  stenosis  no  appreciable  displacement  occurs.  To 
the  right  of  the  sternum  an  undulatory  pulsation  is  seen,  due  to  contrac- 
tion of  the  right  auricle  and  ventricle,  but  this  is  not  characteristic,  since 
it  may  take  place  in  simple  mitral  stenosis  without  tricuspid  regurgita- 
tion.    Epigastric  pulsation  is  almost  invariably  observed. 

Palpation  detects  the  heaving  impulse  of  the  right  ventricle  in  the 
upper  epigastric  region.  Rhythmic  expansile  pulsation  of  the  veins 
of  the  liver  is  quite  diagnostic  and  is  usually  detectable.  To  obtain 
this  sign  the  patient  should  lie  on  the  back  with  the  arms  raised,  and 
the  examiner  should  place  the  palm  of  his  left  hand  over  the  right  mid- 
axillary  region,  and  that  of  the  right  hand  over  the  upper  abdomi- 
nal region.  He  will  thus  be  enabled  to  feel  an  expansile  pulsation  of 
the  liver  synchronous  with  the  ventricular  systole.  This  is  to  be  care- 
fully distinguished  from  mere  systolic  depression  of  the  organ  due  to  the 
impulse  of  an  enlarged  right  ventricle,  transmitted  through  the  diaphragm 
and  left  lobe  of  the  liver  to  the  epigastrium. 

Popolf  and  others  have  noted  an  inequality  in  the  radial  pulses  in 
tricuspid  regurgitation.  This  is  probably  due  to  the  pressure  of  an  en- 
larged auricle.  The  radial  pulse  is  small,  irregular,  and  often  rapid. 
The  blood-pressure  in  the  arterial  tree  is  low. 

Percussion. — The  extent  and  form  of  precordial  dulness  are  variable 
according  to  the  nature  of  the  causative  disease,  but  a  dulness  extending 
far  beyond  the  right  edge  of  the  sternum  is  especially  characteristic. 

Auscultation. — A  systolic  murmur  having  its  seat  of  greatest  inten- 
sity at  the  base  of  the  ensiform  cartilage  {vide  Fig.  55)  is  almost  con- 
stantly audible.  The  area  in  which  it  is  best  heard  varies  according  to 
ihe  intensity  of  the  murmur.  Lowering  the  patient's  head,  while  in  the 
recumbent  posture,  causes  murmurs  to  become  evident  which  were  not 
previously  heard  (Stern's  sign).  It  is  clearly  conveyed  to  the  left  one  inch 
beyond  the  left  sternal  margin,  and  to  the  right  and  upward  for  an  equal 
distance  beyond  the  limit  of  cardiac  dulness.  It  is  soft  in  character, 
short,  and  often  faint.  If  the  heart  be  weak,  it  may  be  absent.  Ad- 
ditional murmurs,  due  to  primary  lesions,  are  often  heard,  and  usually 
at  other  orifices.     The  second  pulmonic  sound  is  not  much  accentuated. 

Diagnosis. — I  believe  that  the  most  valuable  symptom  for  diagnosis 
is  the  venous  pulse,  whether  observed  clearly  in  the  neck  or  determined 
positively  by  bimanual  palpation  of  the  liver.  The  murmur  is  gen- 
erally audible.     Relative  incompetence  distinguishes  itself  from  that  due 


660 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


to  viilvulitis  by  greater  extension  of  dulness  to  the  right,  and  bv  disappear- 
ance of  the  positive  venous  pulse  and  murmur,  with  restoration  of  com- 
pensation. The  differential  diagnosis  between  mitral  and  tricuspid 
regurgitation  is  easy  when  either  exists  alone,  if  it  be  remembered  that 
the  seat  of  greatest  pronunciation,  the  area  of  transmission,  and  the 
acoustic  character  of  the  respective  murmurs  are  widely  different.  But 
it    is  extremely   difficult   to   discern   a  faint   tricuspid  murmur  when  it 


Fig.  55.— 1,  Seat  of  greatest  pronunciation;  2,  chief  direction  of  conveyance;  3,  boundary-line  of 
absolute  dulness;  -1,  boundary-line  of  relative  dulness  (modified  from  Sahli). 

develops  secondarily  to  the  murmur  of  mitral  incompetency.  If  a  care- 
ful observation  of  the  murmur  ftiils  to  establish  the  diagnosis  of  tricuspid 
insufficiency,  absolute  reliance  should,  in  my  opinion,  be  pLiced  upon  the 
venous  pulse  when  present.  On  the  other  hand,  with  characteristic 
symptoms  of  tricuspid  insufficiency,  the  diagnosis  of  simultaneous  mitral 
insufficiency  is  assured  if  the  systolic  murmur  is  heard  dorsally. 


TRICUSPID  STENOSIS. 
This  is  a  rare  condition,  occurring  as  a  congenital  and  an  acquired 
disease  with  about  equal  frequency.  As  a  primary,  independent  dis- 
ease tricuspid  stenosis  is  very  rare,  being  usually  seen  in  association 
with  organic  disease  of  the  left  side  of  the  heart.  The  lesions  of  mitral 
and  tricuspid  stenosis  are  observed  to  be  combined  most  frequently, 


PULMONARY  INCOMPETENCY.  661 

while  those  of  tricuspid  stenosis  and  aortic  insufficicricy  coexist  less 
frequently.  The  morbid  changes  arc  practically  identical  witli  those  of 
mitral  stenosis,  the  right  auricle  becoming  dilated,  and  this  being  fol- 
lowed by  general  venous  stasis.  The  right  ventricle,  however,  is  usually 
hypertrophied,  owing  to  the  obstruction  in  the  pulmonary  circulation  that 
results  from  the  combined  valvular  deficiencies. 

Special  Etiology. — The  fact  that  mitral  and  tricuspid  stenosis  fre- 
quently have  a  common  cause,  acting  concurrently,  can  scarcely  be 
doubted.  Judson  Daland  and  E.  L.  McDaniel,  who  have  collected  186 
cases  of  associated  mitral  and  tricuspid  stenosis,  believe  that  most  of 
them  occur  in  hearts  overdistended  as  the  result  of  attempts  at  compen- 
sation, after  acute  endocarditis  and  simple  mitral  disease.  Bheumatie 
antecedents  are  furnished  by  the  history  in  from  30  to  40  per  cent,  of  the 
cases  of  tricuspid  stenosis.  As  in  mitral  stenosis,  sex  is  a  potent  factor, 
the  statistics  of  Bedford,  Fenwick,  Herrick,  and  of  Leudet  (which  embrace 
a  total  of  160  cases)  showing  a  ratio  of  5  to  1  in  favor  of  the  female  sex. 

Symptoms. — These  are  those  of  the  combined  affections — venous 
stasis,  marked  polycythemia,  and  dropsy,  particularly  hydrothorax. 

Physical  Signs. — Inspection  may  reveal  a  feeble  venous  pulse  in  the 
jugulars,  due  to  right  auricular  systole,  hence  presystolic  in  time.  Pal- 
pation may  detect  a  presystolic  thrill  over  the  body  of  the  right  ven- 
tricle. Percussion  may  reveal  the  enlarged  right  auricle.  Auscultation 
gives  usually  a  presystolic  rolling  murmur,  which  is  best  heard  over  the 
lower  sternum  and  along  its  right  border.  The  above  physical  signs  are 
to  be  relied  upon  in  uyicomhined  cases,  which  are  exceedingly  rare.  On 
the  contrary,  it  is  difficult  in  the  extreme  to  differentiate  the  signs  of  tri- 
cuspid stenosis  from  those  of  the  lesions  with  which  it  is  almost  uniformly 
associated — viz.,  mitral  stenosis  and  aortic  insufficiency. 


PULMONARY   INOOMPETENCY. 

{Pulmonary  Regiirgitation. ) 

This  is  an  exceedingly  rare  complaint  that  results  from  acute  (ma- 
lignant) or  chronic  endocarditis  after  birth ;  it  is  also  rarely  due  to  a 
congenital  malformation.  In  the  latter  form  union  of  two  of  the  seg- 
ments is  often  observed  ;  in  the  former,  the  usual  sclerotic  processes, 
with  the  occasional  adhesion  of  one  or  more  segments  with  the  pulmo- 
nary artery  Avail,  may  be  noted.  The  effect  of  the  lesion  is  to  cause 
hypertrophy  and  dilatation  of  the  right  ventricle.  The  physical  signs 
furnish  no  diagnostic  characteristics.  There  is  developed  a  diastolic 
murmur  which  is  most  audible  in  the  second  left  interspace,  and  is 
transmitted  to  the  lower  sternal  region,  simulating  the  murmur  of  aortic 
regurgitation.  The  water-hammer  pulse  and  marked  hypertrophic  dila- 
tation of  the  left  ventricle  are  present  in  the  latter  complaint,  however, 
and  are  absent  in  pulmonary  regurgitation.  In  pulmonary  insufficiency, 
on  the  other  hand,  hypertrophy  and  dilatation  of  the  right  ventricle  en- 
sue. Preble  reports  a  case  of  relative  insufficiency  of  the  pulmonary 
cusps  (the  so-called  Graham-Steell  murmur) ;  at  the  autopsy  aortic  and 
mitral  insufficiency  were  also  found. 


i](]2  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


PULMONARY   STENOSIS. 

A  QUITE  frequent  form  of  congenital  malformation  of  the  heart  is 
the  narrowing  of  the  pulmonary  orifice.  In  the  rarest  cases  it  is  of 
post-natal  date,  and  may  result  in  induration,  contraction,  and  fusion  of 
the  segments.  In  one  of  Osier's  cases  the  orifice  ""  was  only  two  milli- 
meters in  diameter,  with  vegetations  of  acute  endocarditis  on  the  seg- 
ments." I  saw  one  case  in  which  the  pulmonary  artery  near  the  valve 
was  contracted  to  one-half  its  normal  caliber.  Myocarditis  with  result- 
ing contraction  of  the  conus  arteriosus  may  cause  pulmonary  stenosis, 
and  some  of  the  cases  that  originate  during  adolescence  and  later  in  life 
are  due  to  atheromatous  change,  white  others  possibly  are  the  result  of 
chronic  endocarditis,  direct  violence,  and  ulcerative  endocarditis.  The 
lesion  is  compensated  by  an  hypertrophy  of  the  right  ventricle,  follow- 
ing which  dilatation  and  tricuspid  incompetency  may  appear. 

Symptoms. — Cyanosis  and  distention  of  the  systemic  veins  are 
observed. 

Physical  Signs. — A  systolic  tlirill  may  be  felt  at  times  over  the  base. 
There  is  considerable  enlargement  of  the  right  ventricle,  as  elicited  by 
percussion  and  palpation,  and  a  systolic  inurmur  is  audible,  its  greatest 
distinctness  being,  as  a  rule,  in  the  third  left  space  near  the  sternum.  It 
is  harsh,  superficial,  and  transmitted  a  short  distance  upward  and  to  the 
left.  Occasionally  this  murmur  is  heard  best  at  the  aortic  valve,  but  it 
is  never  conveyed  to  the  vessels  of  the  neck,  and  hence  is  easily  distin- 
guished fi'om  the  aortic  systolic  murmur.  Its  harsh  charactej*  and  loud- 
ness would  serve  to  obviate  confusion  with  functional  or  anemic  murmurs 
that  are  sometimes  heard  here.  The  pulmonic  second  sound  is  weak, 
and,  not  rarely,  there  is  a  diastolic  murmur  of  the  same  character,  indi- 
cating pulmonary  regurgitation.  Broadbent  asserts  that  a  temporary 
systolic  murmur  due  to  severe  exertion  may  be  observed,  and  I  have 
noted  a  .systolic  murmur  in  the  pulmonary  area  in  young  adults  of 
remarkably  vigorous  build  and  unusual  endurance.  A  careful  review 
of  the  literature  indicates  that  stenosis  of  the  pulmonary  artery  predis- 
poses to  luns:  tuberculosis.  The  conditions  are  not  favorable  to  healthy 
nutritive  processes,  especially  of  the  lungs. ^ 


COMBINED  FORMS  OF  CARDIAC  DISEASES. 

It  may  be  asserted  safely  that  in  more  than  one-half  of  all  cases  com- 
bined lesions  or  murmurs  are  exhibited  before  the  fatal  termination.  As 
already  stated,  stenosis  of  an  orifice  when  due  to  valvular  disease  is  asso- 
ciated with  incompetency  of  the  corresponding  valve.  Thus  aortic 
stenosis  is  constantly  combined  with  or  followed  by  aortic  incompetency, 
and  in  like  manner  mitral  stenosis  by  mitral  incompetency.  The  associa- 
tion may  also  have  reference  to  lesions  at  two  or  more  different  valves.  In 
1  The  Amer.  Jour,  of  the  Med.  ScL,  Jan.,  1902,  by  the  writer. 


CHRONIC   VALVULAR   DISEASE.  0G3 

the  table  of  F.  J.  Smith,  the  relative  frequency  of  the  chief  murmurs 
found  in  combination  is  as  follows : 

Aortic  diastolic  and  syHtolic  and  mitral  systolic,  16.55  per  cent. 

Aortic  stenosis  and  mitral  stenosis,  6.12         " 

Aortic  diastolic  and  mitral  systolic  (common  in  children),  5.21         " 

Aortic  diastolic  and  systolic  and  mitral  presystolic  and  systolic,    3.77         " 

When  two  lesions  coexist  at  the  same  valve,  the  one  may  compensate, 
in  part  at  least,  for  the  other,  as,  for  example,  in  the  case  of  aortic  ste- 
nosis in  association  with  aortic  regurgitation.  Here  the  stenotic  deficiency 
lessens  the  reflux  current  from  the  aorta  into  the  left  ventricle  during  the 
diastole ;  hence  the  latter  receives  a  correspondingly  diminished  amount 
of  blood.  During  the  contraction  of  the  ventricle  the  distending  force 
in  the  aorta  is  diminished,  both  on  account  of  the  narrowinf^  at  the 
aortic  orifice  and  the  relatively  lessened  contents  of  the  hypertrophied 
ventricle.  Similarly,  in  dominating  mitral  incompetency  an  associated 
mitral  stenosis  by  lowering  the  strength  of  the  regurgitant  current  ren- 
ders the  conditions  more  favorable.  Relative  insufficiency  at  the  mitral 
valve,  following  aortic  insufficiency,  may  prove  salutary  by  preventing 
over-distention  of  the  left  ventricle,  and  also  the  over-filling  of  the  ar- 
terial tree  and  the  possible  rupture  of  a  blood-vessel.  On  the  other 
hand,  when  mitral  incompetency  is  secondary  to  aortic  stenosis,  the 
latter  defect  may  hasten  the  unfavorable  tendencies  in  the  former. 

Relative  tricuspid  incompetency,  secondary  to  mitral  disease,  usually 
results  in  the  development  of  a  serious  impediment  to  the  systemic 
venous  circulation,  and  if  it  occur  in  the  course  of  diseases  of  the  aortic 
cusps,  an  early  fatal  termination  is  reached.  In  advanced  mitral  disease 
a  slight  leakage  at  the  tricuspid  valve  may  be  the  means  of  obviating 
disastrous  consequences  to  the  right  ventricle  in  case  of  undue  strain. 

Physical  Signs. — These  are  confusing,  but  a  systematic  analysis  often 
leads  to  the  correct  inference.  That  one  of  the  valvular  lesions  pre- 
dominates over  all  others  is  a  fact  of  paramount  importance  for  the  solu- 
tion of  these  cases.  The  chief  lesions  can  usually  be  determined  by 
noting  the  seat,  the  area  of  transmission,  and  the  character  of  the  most 
pronounced  murmur.  More  important  still  is  the  correct  timing  of 
any  murmurs  that  may  be  audible.  When  a  murmur  occupies  both  the 
aortic  and  mitral  arpas  the  student  will  note  two  points  of  maximum  in- 
tensity, and  that  each  grows  weaker  as  the  stethoscope  is  moved  to- 
ward the  mid-prsecordial  region.  The  secondary  alterations  in  the 
heart  frequently  coincide  with  the  predominating  murmur,  and  observers 
should  recollect  that  mitral  murmurs  are  often  secondary  to  aortic,  and 
that  tricuspid  murmurs  point  to  accompanying  mitral  disease.  In 
children,  however,  rheumatic  endocarditis  often  aff"ects  both  valves  on 
the  left  side  of  the  heart.  Unquestionably,  a  single  observation  of  these 
cases,  however  carefully  made,  is  often  profitless. 

Complications  of  Valvular  Disease. — Most  of  these  have 
already  been  spoken  of  at  sufficient  length,  but  to  restate  them  col- 
lectively in  this  connection  may  prove  useful  to  the  student  and  phy- 
sician. They  are — (1)  acute  endocarditis  (including  the  ulcerative 
form)  ;  (2)  acute  pericarditis  ;  (3)  pleurisy  ;  (^4)  pneumonia  ;  (5)  nephritis. 


664  DISEASES  OF  THE  CIIirULATORY  SYSTEM. 

followed  by  uremia :  (6)  local  or  <reneral  arterial  sclerosis;  (7)  chronic 
gastric  or  intestinal  catarrh  with  intercurrent  acute  attacks ;  (8)  embolic 
processes;  (9)  angina  pectoris;  (10)  edema  of  the  lungs;  (11)  hysteria, 
neurasthenia,  epilepsy,  and  insanity  ;  (12)  rupture  of  the  skin  of  the  ex- 
tremities in  consequence  of  excessive  edema,  with  erysipelatous  intlam- 
mation :  (lo)  febrile  paroxysms,  accompanied  not  rarely  bv  synovitis, 
occur  at  varying  intervals  of  time,  and  are  due  to  various  causes,  as 
rheumatism,  simple,  acute,  and  ulcerative  endocarditis,  and  pericarditis. 

Course  and  Duration. — When  valvular  disease  consists  in  ruj^ture 
of  a  segment  the  course  is  brief  and  usually  proves  quickly  fatal.  Apart 
from  these  exceptional  instances  the  duration  is  measured  by  months,  or 
more  often  by  years  or  even  decades.  Statements  applicable  to  all  cases 
cannot  be  made,  however,  owing  to  the  wide  differences  in  difterent 
cases.  Amonc;  the  circumstances  affecting  the  duration  I  would  men- 
tion  in  particular  the  patient's  mode  of  life,  the  hygienic  conditions 
under  which  he  lives,  his  occupation,  mental  condition,  and  the  severity 
of  the  morbid  processes.  Every  experienced  physician  has  doubtless 
met  with  a  small  class  of  cases  that  have  terminated  fatally  in  from  six 
months  to  a  year,  having  developed  in  that  period  all  of  the  serious 
phenomena  and  complications  of  the  more  chronic  forms  of  organic 
heart-disease.  In  the  preponderating  proportion  of  cases,  however,  the 
course  is  exceedingly  slow,  and  often  cases  have  existed  many  years 
before  they  have  finally  been  recognized.  In  numerous  instances  the 
patient  follows  his  usual  vocation,  which  may  even  be  laborious,  for 
years,  and  without  discomfort.  In  other  cases  the  sym[)t<)ms,  as  dysp- 
nea on  exertion,  are  so  slight  as  not  to  excite  suspicion.  Facts  such  as 
these  render  it  obvious  that  while  the  period  of  compensation  is  long,  its 
exact  limits  are  indeterminable. 

The  progress  after  failure  of  compensation  is  more  definitely  known, 
since  frequent  opportunities  for  observation  are  afforded.  At  this  time  the 
cases  also  exhibit  wide  differences  in  duration ;  in  my  own  experience 
they  have  varied  from  two  or  three  months  to  as  many  years  (rarely 
even  longer),  depending  much  on  the  patient's  mode  of  living.  The 
course  may  be  shortened  by  severe  external  injury,  intercurrent  acute  ill- 
ness (especially  febrile  disease),  vicious  habits,  straining  efforts,  and  the  like. 

Prognosis. — The  detection  of  a  cardiac  murmur  should  not  alone 
lead  to  a  gloomy  prognosis.  Says  Osier:  ''With  the  apex-beat  in  the 
normal  situation  and  regular  in  rhythm,  the  auscultatory  phenomena 
may  be  practically  disregarded."  Individual  cases  recjuire  separate  and 
careful  consideration.  It  is  well  not  to  advance  positive  assertions 
until  all  the  circumstances  that  may  influence  the  prognosis  of  any 
given  instance  have  been  well  weighed.  Observation  of  a  case  for 
some  weeks  and  months  enables  the  physician  to  speak  Avith  greater 
confidence  and  knowledge  concerning  the  probable  outcome.  Prior  to 
the  occurrence  of  disturbances  of  compensation  the  prognosis  is  meas- 
urably favorable.  After  this  pivotal  event  the  prognosis  as  to  life 
becomes  wholly  unfavorable  in  direct  proportion  to  the  extent 
of  the  degenerative  changes  of  the  myocardium.  Disturbances  of 
compensation  that  are  attended  with  marked  arythmia,  urgent  dyspnea, 
and  general  dropsy  may  admit  of  complete  relief.  Later,  restoration 
of  the  balance  of  forces  becomes    only  partial,  and  finally  the  above- 


CHRONIC  VALVULAR  DISEASE.  665 

mentioned  symptoms  become  more  pronounced  ;  Cheyne-Stokes'  breath- 
ing may  then  develop,  and  after  a  prolonged  and  distressing  struggle 
for  breath  the  patient  succumbs.  Death  may  also  occur  suddenly  from 
cardiac  paralysis.  Among  ominous  and  yet  common  cowplieationn  and 
intercurrent  affections  may  be  cited  again  extensive  edema  of  the  lungs, 
pneumonia,  marked  arteriosclerosis,  embolic  processes,  ulcerative  endo- 
carditis, acute  endocarditis,  obstinate  gastritis,  and  nephritis.  On  the 
coxxtvdir J ,  favorable  indicatioriH  are  sound  general  health,  good  external 
conditions  (absence  of  poverty,  hunger,  etc.),  strong  and  regular  action 
of  the  heart,  absence  of  arteriosclerosis,  of  excessive  hypertrophy,  of 
syphilis  (unless  recognized  early),  and  of  rheumatic  antecedents,  as  Avell 
as  any  vices  of  life.  Age  influences  the  prognosis  to  some  extent.  In 
children  under  ten  years  the  lesions  are  usually  somewhat  more  rapidly 
progressive  than  in  adults,  and  the  compensatory  hypertrophy  is  devel- 
oped with  corresponding  rapidity ;  hence  the  period  of  failing  com- 
pensation is  reached  earlier.  This  may  be  said  to  be  a  broad  general 
rule,  and  I  have  found  that  it  is  one  to  which  there  are  many  exceptions. 
Among  other  reasons  for  the  more  gloomy  prospect  when  heart  disease 
occurs  in  young  children  are  the  following  :  the  mitral  valve  is  generally 
implicated,  the  liability  to  rheumatic  intercurrences  is  great,  and  there 
is  a  greater  tendency  to  overtax  the  reserve  cardiac  power  by  violent 
forms  of  exercise.  After  the  twelfth  year  the  prognosis  becomes  more 
favorable.  Sex  is  also  a  modifying  prognostic  factor,  women  bearing 
valvular  lesions  better  than  men,  apart  from  the  influence  of  childbear- 
ing,  though  even  this  is  an  influence  the  significance  of  which  has  been 
greatly  magnified  by  many  writers.  To  explain  the  more  favorable 
outlook  in  women  we  have  two  main  facts — viz.,  a  less  laborious  as  well 
as  a  more  quiet  life,  and  a  diminished  liability  to  arteriosclerosis  and 
involvement  of  the  coronary  vessels.  The  particular  valve  involved  has 
some  influence  on  the  prognosis. 

Aortic  regurgitation  gives  a  fairly  good  prognosis  in  those  cases  that 
begin  in  early  adult  life,  and  in  which  the  second  sound  in  the  neck  is 
not  abolished,  granting  that  the  patient  regulates  wisely  his  manner  of 
living.  A  long,  loud  murmur  indicates  a  strong  heart  with  slight  leak- 
age. When  the  lesion  is  due  to  acute  endocarditis,  the  prospect  of  life 
is  better  than  when  it  originates  in  degenerative  changes.  A  chief 
danger  arises  from  associated  arterio-sclerosis — a  frequent  occurrence, 
particularly  in  advanced  life — and  from  implication  of  the  coronary 
arteries.  Much  depends  upon  the  condition  of  the  latter  vessels. 
When  their  lumen  is  narrowed,  starvation  of  the  heart-muscle  quickly 
ensues,  followed  by  myositic  degeneration.  Blocking  of  one  of  the 
branches  of  the  coronary  artery  is  the  most  frequent  cause  of  sud- 
den death  in  this  affection.  After  failure  of  compensation,  the  prog- 
nosis is  less  satisfactory  by  far  in  aortic  regurgitation  than  in  mitral 
regurgitation,  since  restoration  of  compensation  is  not  as  readily  accom- 
plished in  the  former  as  in  the  latter  variety.  Aortic  regurgitation 
stands  first  among  valvular  affections  in  the  order  of  gravity  (Broad- 
bent).  In  aortic  stenosis  favorable  predictions  are  warrantable  when 
the  disease  is  uncomplicated.  When  the  left  ventricle  gives  way.  the 
condition  is  serious.  Osier  states  that  the  rheumatic  form  of  early  life  is 
more   serious  than   the  late   sclerotic   variety.     The  size  of  the  radial 


GQQ  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

artery  is  proportionate  to  the  size  of  the  blood-stream,  hence  indicative 
of  the  dei^ree  of  stenosis. 

Mitral  regurijitatioiu  when  a  primary  lesion,  is  propitious,  except  in 
the  very  young,  and  not  infrequently  the  progress  of  the  morbid  process 
is  apparently  arrested.  In  a  considerable  proportion  of  cases  the  dis- 
ease does  not  materially  shorten  the  life  of  the  sufl'crer.  In  a  larger 
percentage,  liowever,  there  is  special  liability  to  a  renewal  of  the  causa- 
tive affections  {e.  g.,  rheumatism)  and  to  pulmonary'  conditions  of  serious 
import,  producing  exacerbations  and  ])ermanent  aggravations  of  the 
disease.  The  gravity  of  these  intercurrent  complaints  is  also  increased 
by  the  existence  of  the  cardiac  lesion.  If  a  good  first  sound. is  audible 
as  well  as  the  murmur,  it  is  of  good  prognostic  significance.  Failure 
of  compensation  at  once  renders  the  prognosis  decidedly  unfavorable.  In 
mitral  stenoftis  compensation  of  the  right  heart  fails  somewhat  earlier  than 
in  mitral  insulhciency,  and  hence  the  accidents  and  conditions  referable  to 
the  lung  (diffuse  pulmonary  apoplexy,  edema)  are  not  so  long  delayed 
as  in  the  latter  disease.  In  my  experience  mitral  stenosis  is  better  borne 
by  women  than  by  men,  and  better  during  adolescence  and  early  adult 
life  than  during  more  advanced  years.  The  congenital  forms  are  com- 
paratively benign.  Mitral  stenosis  causes  sudden  death  more  frequently 
than  any  other  form  of  organic  disease  of  the  heart  except  aortic  regurgi- 
tation. Tricuspid  incovipetency,  whether  secondary  to  disease  of  the 
lung  or  of  the  left  side  of  the  heart,  is  grave ;  it  is  extremely  serious 
when  it  arises  in  the  course  of  aortic  incompetency.  It  is  usually  indica- 
tive of  dilatation  following  hypertrophy  of  the  right  ventricle.  Com- 
pensatory hypertrophy,  however,  can  be  re-established  repeatedly. 

Treatment. — This  falls  naturally  into  three  subdivisions :  (1)  Pro- 
phylaxis ;  (2)  management  during  the  stage  of  compensation  ;  (3)  ti'eat- 
ment  of  the  stage  of  non-compensation. 

(1)  Prophylaxis. — The  statistics  of  Sibson  show  that  complete  rest  and 
protection  of  the  surface  during  an  attack  of  acute  articular  rheumatism 
lessen  the  average  percentage  of  cases  in  which  acute  endocarditis 
develops.  When  the  latter  complication  occurs  in  acute  rheumatism  the 
patient  should  keep  to  his  bed  for  some  time  after  all  rheumatic  symp- 
toms have  disappeared  (two  to  six  weeks)  or  until  the  improvement  in  the 
cardiac  condition  has  ceased  absolutely.  This  precautionary  measure 
will  often  lessen  the  extent  of  the  ensuing  chronic  endocarditis,  and  also 
increase  the  proportion  of  perfect  recoveries.  When  the  physician  is 
cognizant  of  hereditary  predisposition  to  organic  heart  disease,  or  has 
to  deal  with  the  arthritic  diathesis  (gouty  or  rheumatic)  or  the  alcoholic 
habit,  he  can  frequently,  by  timely  advice  and  hygienic  suggestions, 
direct  his  patient  to  adopt  measures  that  will  obviate  the  occurrence  of 
valvular  disease.  Systematic  treatment  of  syphilis  would  greatly  lessen 
the  incidence  of  valve  disease.  All  persons  predisposed  by  heredity  or 
otherwise  should  be  told  of  the  probable  effect  of  muscular  strain  {e.g., 
competitive  sports),  alcohol,  and  other  exciting  factors ;  too  often, 
however,  when  he  first  sees  his  patient  the  physician  is  confronted  by  an 
incurable  malady. 

(2)  Management  During  the  Stage  of  Compensation. — Three  main 
objects  are  to  be  accomplished :  {a)  The  avoidance  of  every  agency  that 
tends  to  aggravate  or  maintain  the  lesion  or  lesions.     Under  this  head 


CHRONIC  VALVULAR  DISEASE.  007 

the  detection  and  removal  of  all  causal  factors  is  imperative.  Thus,  if 
the  patient's  vocation  entails  undue  muscular  effort,  it  must  be  aban- 
doned ;  violent  exercise,  as  running  up  flights  of  stairs,  heavy  lifting, 
or  straining  at  stool,  is  dangerous  and  must  be  prohibited.  If  alcohol 
has  been  a  factor,  it  must  be  discontinued;  if  syphilis,  it  must  be  treated 
specifically.  A  rheumatic  or  gouty  taint  must  be  overcome  as  far  as  pos- 
sible by  special  measures.  Fatigue  and  exposure  must  be  avoided,  par- 
ticularly if  the  patient  be  young.  Emotional  excitement  and  mental 
overexertion  injuriously  affect  the  cardiac  lesion ;  therefore  tranquillity 
of  mind  should  be  insisted  upon,  though  moderate  and  systematic  mental 
exercise  has  no  risks  for  the  patient.  In  the  case  of  children  at  school 
careful  supervision  of  their  studies  as  well  as  of  their  recreative  exercises 
is  essential.  Fright  and  sudden  emotion  must  be  avoided  if  possible. 
The  use  of  tea,  coffee,  and  tobacco  should  be  rigidly  prohibited.  In 
mitral  disease,  bronchitis  is  to  be  especially  guarded  against. 

(h)  The  diet  of  the  patient  demands  careful  regulation.  Only  a  mod- 
erate amount  of  food,  composed  for  the  most  part  of  readily  digested 
albuminous  articles  (milk,  eggs,  light  forms  of  meats),  green  vegetables 
and  stewed  fruits,  is  to  be  taken,  since  overloading  the  stomach  will  dis- 
turb the  action  of  the  heart ;  particularly  is  this  true  at  night.  The 
carbohydrates  may  be  allowed,  but  only  in  limited  quantities,  since  they 
are  apt  to  decompose  and  form  gases  that  distend  the  stomach  and  intes- 
tines. The  coarser  and  more  indigestible  food-stuffs  should  also  be 
avoided.  The  amount  of  liquids  taken  should  not  exceed  the  actual  re- 
quirements of  the  patient,  inasmuch  as  overfilling  of  the  blood-vessel 
system  increases  the  work  of  the  already  overburdened  cardiac  forces. 
Alcoholic  beverages  should  not  be  used,  as  a  rule ;  but  if  the  patient  has 
been  moderate  in  the  use  of  alcohol,  and  particularly  if  he  be  advanced 
in  years,  light  wines  may  be  allowed  in  small  quantities  to  aid  diges- 
tion. 

(c)  Carefully  regulated  exercise  is  beneficial,  but  it  must  be  gentle 
and  should  be  taken  out-of-doors.  A  good  general  muscular  develop- 
ment is  an  aid  of  no  mean  value  to  the  conservative  powers  of  the  heart. 
Oertel,  with  a  view  to  assisting  the  compensatory  forces  of  the  heart,  has 
recommended  graduated  physical  exercise ;  he  advises  that  patients  be 
instructed  first  to  ascend  low  elevations,  and  with  increased  endurance, 
mountains  of  a  considerable  height,  the  object  being  to  bring  about  full 
compensation.  This  method,  however,  has  been  found  to  be  inapplicable 
to  a  large  percentage  of  cases.  Cardiac  distress,  palpitation,  and  dyspnea 
are  complained  of  by  this  large  group  of  patients  if  other  than  the  gen- 
tlest forms  of  exercise  be  undertaken.  With  respect  to  exercise,  then, 
the  sensations  and  experiences  of  each  patient  must  be  consulted  before 
the  physician  can  advise  judiciously.  Woolens  should  be  worn  next  to 
the  skin  during  both  the  warm  and  cold  seasons.  The  skin  should  be 
kept  clean  by  daily  sponge-baths,  followed  by  friction  of  the  surface. 
Thus  the  nutrition  will  be  improved  and  the  liability  to  intercurrent  at- 
tacks of  bronchitis  lessened.  The  bowels  should  be  moved  each  day,  and 
usually  the  use  of  stewed  fruits  suffices  to  accomplish  this  end ;  if  not, 
salines,  as  Rochelle  or  Carlsbad  salts,  and  the  bitter  waters  (Friedrichs- 
hall,  Hunyadi-Janos)  must  be  brought  into  requisition.  In  winter  a 
warm  climate  may  prove  advantageous,  though  long  journeys  are  often 


668  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

illy  borne,  owing  to  the  fatigue  induced  thereby.  If  the  patient  be 
anemic  or  his  nutrition  is  notably  impaired,  a  suitable  change  of  air,^  or 
the  use  of  hematinics,  arsenic,  small  doses  of  mercury,  and  cod-liver  oil, 
is  to  be  recommended.  Digitalis  should  not  be  employed  when  compen- 
sation can  be  preserved  in  other  ways.  We  sliould  train  the  heart  up  to 
the  amount  of  work  re(iuii(Ml  ot'  it  ( linintnii). 

(3)  Treatment  of  the  Stage  of  Non-compensation. — The  principal  object 
to  be  kept  in  view  in  this  stage  is  the  reinvigoration  of  tlie  exhausted 
cardiac  muscle,  and  thus  to  relieve  the  impeded  circulation.  Sudden 
death  may,  though  rarely,  occur  from  the  blocking  of  a  branch  of  the 
coronary  artery  or  from  acute  dilatation.  Failure  of  compensation, 
however,  begins  gradually  as  a  rule,  the  condition  often  existing  without 
marked  or  characteristic  symptoms ;  but  its  early  recognition  is  import- 
ant from  the  stand-point  of  therapy.  Increased  dyspnea  on  exertion, 
and  nocturnal  seizures  of  shortness  of  breath  and  irregular  action  of  the 
heart  {arrhj/thmid),  are  among  the  earliest  clinical  features.  The  latter 
symptom  may  have  been  present  before,  particularly  during  active 
exercise  in  mitral  disease,  but  is  now  more  marked,  and  may  be  con- 
stant. The  patient's  nutrition  often  suffers,  and  he  is  pale  and  rather 
feeble.  Absolute  quiet,  liberal  feeding  with  suitable  food,  and  iron 
may  in  a  little  while  restore  the  impaired  cardiac  tone.  If  this  treat- 
ment fails,  by  the  end  of  a  fortnight  a  small  dose  of  digitalis  should 
be  exhibited  (5  minims — 0.3o3 — of  the  tincture  tliree  times  daily) ; 
this  should  be  promptly  withdrawn  upon  the  disappearance  of  the 
symptoms.  Derided  indications  of  lost  compensation  are  marked  dys- 
pnea and  arrhythmia ;  the  canter  rhythm  ;  an  irregular,  small,  compres- 
sible pulse ;  and  cyanosis,  with  or  without  the  presence  of  dropsy.  The 
object  now  is  the  maintenance  of  the  blood-pressure  at  an  adequate  height 
by  the  following  means :  {a)  Absolute  rest  in  bed  This  diminishes 
greatly  the  work  of  the  heart,  and  thus  enables  it  to  regain  largely  its 
former  vigor.  Rest  joined  with  massage,  careful  yet  liberal  feeding 
and  attention  to  the  bowels  will  often  restore  disturbed  compensation 
in  from  one  to  two  weeks.  In  a  considerable  number  of  cases 
treated  at  the  Medico-Chirurgical  Hospital  this  method  succeeded  ad- 
mirably. 

(b)  Cardiac  stimulants  and  tonics.  Of  these  the  most  important  is 
digitalis.  By  stimulating  the  pneumogastric,  by  increasing  the  blood- 
supply  to  the  heart-muscle,  by  causing  the  systole  to  be  more  complete 
and  the  period  of  diastole  to  be  lengthened,  digitalis  becomes  an  invalu- 
able aid  to  the  nutrition  of  the  cardiac  muscles.  In  addition,  the  heart 
contracts  more  regularly  and  the  blood-pressure  is  raised.  As  a  result  of 
the  use  of  this  drug  the  tissue  calls  upon  the  cardiac  forces  from  the  out- 
lying portions  of  the  body  are  satisfied  and  the  reserve  energies  of  the 
heart-muscles  are  maintained. 

In  mitral  disease  the  influence  of  digitalis  is  most  beneficial,  the  pulse 
becoming  slower,  of  better  tension  and  more  regular,  while  the  urine 
increases  in  amount.     In  mitral  incompetency  its  good  effects  are  ascrib- 

'  Observation  and  experienfe  have  confirmed  my  belief  that  sea-air  during  the  warm 
season  and  high  altitudes  at  ail  times  are  injurious  in  their  effects  in  valvular  disease  of 
the  heart. 


CHRONIC    VALVULAR   DISEASE.  V>V>[) 

able  in  part  to  the  powerful  contractions  of  tlic  left  ventricle,  whereby 
the  blood-stream  from  the  ventricle  to  the  aorta  is  greatly  increased. 
On  the  contrary,  the  patient's  condition  is  occasionally  aggravated 
by  the  drug,  because  "  the  h;ak  is  inc^reased  as  mucli  as  the  normal 
flow  "  (Hare).  Digitalis  exercises  its  most  beneficial  influence  by  ren- 
dering the  systole  of  the  right  ventricle  more  energetic,  the  blood-press- 
ure being  raised  in  the  pulmonary  circuit  and  left  auricle;  this  fills  the 
left  ventricle  better  during  diastole  and  "  resists  refiux  through  the  mi- 
tral orifice  in  the  systole  "  (Broadbent).  In  mitral  stenosis  digitalis,  by 
lengthening  the  period  of  diastole,  allows  time  for  the  blood  to  pass  from 
the  auricle  through  the  narrowed  mitral  orifice  into  the  ventricle.  Slight 
toxic  effects  may  sometimes  result  from  digitalis,  the  pulse  becoming 
thread-like  and  irregular,  and  the  urine  scanty.  Under  these  circum- 
stances the  drug  should  be  discontinued. 

In  aortic  regurgitation  digitalis  exercises  a  beneficial  efl"ect  in  cases 
dependent  on  chronic  valvulitis :  the  theoretic  view,  however,  that  by 
prolonging  the  diastole  digitalis  causes  overfilling  of  the  left  ventricle 
rests  on  too  slender  a  foundation  to  be  regarded  as  a  valid  objection  to 
its  use.  It  may.  however,  produce  excessive  hypertrophy,  in  which  case 
it  should  be  withheld.  When  atheroma  is  associated,  and  especially  if 
relative  insufficiency  at  the  mitral  orifice  has  not  as  yet  supervened,  digi- 
talis produces  harmful  effects.  After  secondary  mitral  insufficiency  is 
developed,  this  drug  may  be  employed,  but  it  should  be  guarded  by  nitro- 
glycerin when  marked  arterio-sclerosis  coexists,  to  counteract  the  musculo- 
arterial  contraction  caused  by  the  digitalis,  and  thus  diminish  arterial 
resistance.  Digitalis  is  also  powerless  and  probably  harmful  in  propor- 
tion to  the  extent  of  fatty  and  fibroid  degeneration  of  the  myocardium. 
In  aortic  regurgitation,  nausea  and  vomiting  sometimes  follow  the  admin- 
istration of  digitalis ;  when  this  is  the  case  it  should  be  stopped.  When 
secondary  dilatation  comes  on  in  aortic  stenosis,  digitalis  is  needed  to  in- 
crease left  ventricular  power.  The  dose  is  to  be  calculated  according  to 
the  degree  of  cardiac  exhaustion.  When  tricuspid  incompetency  is  sec- 
ondary to  mitral  disease,  striking  results  are  obtained  from  the  use  of 
digitalis  {supra)  ;  but  when  it  exists  alone — e.  g.,  following  emphysema 
or  cirrhosis  of  the  lung — digitalis  often  fails.  The  cardiac  contractions, 
if  they  have  previously  been  irregular,  may  become  somewhat  more  regu- 
lar, but  the  precordial  distress  will  often  be  increased,  while  the  circu- 
latory disturbance,  as  evidenced  by  the  objective  signs,  will  remain  unre- 
lieved. If  dropsy  he  slight  or  absent,  2  to  3  drams  (8.0-12.0)  of  the 
freshly  prepared  infusion,  three  or  four  times  daily,  will  suflSce.  If 
symptoms  of  decidedly  unfavorable  import  be  present,  including  marked 
dropsy,  the  dose  should  then  be  larger  (of  the  infusion,  sss — 16.0.  every 
two  or  three  hours)  for  two  or  three  days,  when  the  dose  must  be  dim- 
inished or  given  at  longer  intervals.  Quantitative  estimations  of  the 
urine  should  be  made  during  the  use  of  the  drug,  and  if  the  eff"ect  be 
good,  the  daily  amount  will  often  be  greatly  increased ;  if  bad,  there  will 
be  a  diminution  rather  than  an  increase  in  the  amount.  There  are  not 
a  few  patients  in  whom  the  symptoms  of  commencing  failure  of  compen- 
sation recur  as  soon  as  the  drug  is  discontinued.  To  such,  digitalis  may 
be  administered  continuously  or  until  toxic  symptoms  are  manifested. 


670  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

I  believe  that  the  solid  preparations  (powdered  leaves  and  extract)  can 
be  taken  for  longer  periods  than  the  liquid  forms  without  exciting  unto- 
ward symptoms.  This  suggestion  should  be  followed,  particularly  in  cases 
that  are  seen  at  long  and  irregular  intervals  of  time.  With  this  excep- 
tion, it  should  be  a  cardinal  rule  to  discontinue  the  digitalis  when  the 
symptoms  of  disturbed  circulation  have  vanished.  When  it  fails  of  its 
eftect  or  is  not  well  borne,  and  when,  as  often  happens,  the  arrhythmia  is 
not  favorably  influenced  by  it,  the  physician  is  compelled  to  resort  to 
other  cardiac  stimulants.  These  are  numerous,  and.  whilst  their  effects  are 
not  comparable  to  those  of  digitalis  in  every  respect,  some  of  them  seem  to 
meet  certain  indications  that  are  not  met  by  this  drug.  Among  the  more 
important  are  nitroglycerin,  strophanthus,  convallaria,  strychnin,  cocain, 
spartein,  and  caftein.  Nitroglycerin  in  small  doses  is  at  the  same  time  a 
cardiac  stimulant  and  an  arterial  relaxant,  and  hence  is  more  often  useful 
in  aortic  than  in  mitral  valvular  disease.  In  larger  doses,  when  left  ven- 
tricular hypertrophy  is  excessive,  as  may  occur  when  general  arterio- 
sclerosis is  associated  with  aortic  regurgitation  and  also  (though  rarely) 
aortic  stenosis,  it  is  highly  useful,  Avidening  the  blood-paths,  and  causing 
less  powerful  contractions  of  the  heart.  Strophanthus  should  be  em- 
ployed in  instances  in  which  digitalis  must  be  interrupted,  since  the 
action  of  these  two  remedies  upon  the  heart-walls  is  very  similar.  The 
tincture  is  usually  employed,  the  dose  (varying  with  the  indications  of 
each  case)  being  from  4  to  10  minims  (0.266-0.666)  every  three  or  four 
hours,  and  in  controlling  the  irregularity  or  intermittency  of  cardiac 
action  it  is  sometimes  better  in  its  influence  than  digitalis.  Many  cases 
of  marked  arrhythmia  will  not  yield  to  either  when  but  one  is  given  ;  and 
in  such  I  have  occasionally  obtained  good  results  from  digitalis  and  stro- 
phanthus in  combination.  Another  drug  which  is  an  excellent  stomachic 
tonic,  and  one  that  may  be  employed  as  a  substitute  for  digitalis,  is  con- 
vallaria. It  should  be  stated  that,  rarely,  strophanthus,  like  digitalis, 
does  harm  rather  than  good,  being  sometimes  badly  borne  by  the  stomach- 
Under  these  circumstances  I  have  employed  the  following  combination : 

:^.   Caff'ein.  citrat.,  3ss      (2.0): 

Strychninse  sulphat.^  gr.  ^(0.021); 

Spartein.  sulphat.,  gr.  iij  (0.193). 

Ft.  capsulse  No.  xii. 
Siof.  One  every  three  or  four  hours. 

The  above  prescription  is  not  only  a  good  heart  stimulant,  but  also  a  good 
diuretic.  Caftein  citrate  is  superior  as  a  diuretic.  Spartein  is  a  potent 
diuretic  and  heart  stimulant  in  doses  of  gr.  ^  to  ^  (0.01-0.032)  every 
four  to  six  hours,  and  is  especially  serviceable  when  dropsy  as  a  symptom 
and  nephritis  as  a  complication  exist.  Strychnin,  given  hypodermically 
in  full  dose,  gr.  4-^  to  ^^  (0.002-0.004), 'is  the  most  efficient  cardiac 
stimulant  known  "to  meuical  science.  It  should  be  employed  in  this 
manner  in  sudden  fiulure  of  heart  power.  Given  in  doses  of  average 
size,  its  eff"ects  in  chronic  valvular  disease  are  not  striking.  Atropin 
may  be  advantageously  combined  with  it. 

When  the  indications  are  urgent  and  the  above  agents  are  not  avail- 
able, diflTusible  stimulants,  as  ether  or  ammonium,  may  be  used  until  more 


CHRONIC  VALVULAR   DISEASE.  671 

suitable  remedies  can  take  effect.  Cocain  .simulates  strychnin  in  its 
action.  The  dose  is  gr.  |  (0.016)  every  four  hours,  and  the  drug  may 
be  given  with  digitalis  in  pill-form.  Later,  systemic  tonics  are  often  de- 
manded by  the  anemia  and  other  constitutional  indications,  and  here  iron 
and  quinin  should  be  joined  with  strychnin.  Unquestionably,  tlie  value 
of  iron  in  full  doses  as  an  aid  in  the  completion  of  the  work  of  restor- 
ing broken  compensation  has  been  and  is  still  scarcely  appreciated  by  the 
profession  at  large.  When  iron  disagrees,  arsenic  may  be  given  instead. 
In  many  cases  of  failure  of  compensation  the  restoration  of  the  balance  of 
the  cardio-systemic  circulation  can  be  greatly  assisted  by  depleting  the 
over-filled  venous  system.     There  are  two  ways  of  attaining  this  end  : 

(a)  Venesection. — When  the  right  heart  is  over-distended,  as  shown 
by  its  very  feeble  efforts  at  contraction,  and  the  whole  venous  system  is 
intensely  engorged,  as  shown  by  marked  cyanosis  and  orthopnea,  bleeding 
directly  from  a  vein  is  not  only  warrantable,  but  often  imperatively  de- 
manded in  order  to  save  life.  From  16  to  30  ounces  (473.0-887.0)  may 
be  removed  safely,  and  the  heart's  action  will  almost  immediately  be 
observed  to  grow  stronger  and  more  regular,  and  the  pulse  fuller  and  of 
better  tension.  As  before  intimated,  the  form  of  dilatation  of  the  right 
ventricle  that  follows  emphysema  is  disinclined  to  yield  to  digitalis.  In 
such  instances,  following  the  suggestion  of  Osler,^  I  have  obtained  bril- 
liant results  from  free  bleedings. 

(h)  Depletion  hy  purgation  affords  less  pronounced  relief  to  the  heart, 
though  it  is  of  the  greatest  value  in  cases  in  which  a  moderate  grade  of 
cyanosis  and  dropsy  exist.  As  in  the  case  of  venesection,  a  feeble, 
irregular  pulse  is  not  a  contraindication  to  the  use  of  purgatives,  since  the 
latter  remove  directly  a  considerable  portion  of  the  heart's  burden.  The 
purgative  to  be  used  will  vary  with  different  cases.  I  select  at  the  outset 
Rochelle  or  Epsom  salts,  employing  them  after  the  method  of  Matthew- 
Hay — i.  e.  from  1  to  2  ounces  (32.0-64.0)  of  Rochelle  or  1  to  1^  ounces 
(32.0-48.0)  of  Epsom  salts,  in  concentrated  solution,  to  be  given  from  a 
half  to  one  hour  before  breakfast.  Watery  evacuations  (three  to  six  in 
number  daily)  usually  follow  the  administration  of  the  saline  ;  but,  unfor- 
tunately, one  meets  with  many  patients  in  whom  it  produces  symptoms 
of  marked  catarrhal  irritation.  Next  to  salines,  the  most  satisfactory 
results  have  been  obtained  from  the  use  of  elaterium  ;  I  often  combine 
this  with  podophyllin  and  belladonna.  I  have  never  seen  good  results 
from  the  use  of  mercurials  when  the  object  has  been  to  procure  venous  de- 
pletion, but  they  are  of  service  in  dropsy,  and  particularly  in  ascites. 

Schott  of  Nauheim  has  introduced  a  special  treatment  by  baths  and 
resistance  movements  that  is  applicable  to  most  forms  of  valvular  disease, 
simple  dilatation,  and  nervous  affections  of  the  organ.  The  beneficial 
effects  are  principally  attributable  to  the  salt  and  the  carbon  dioxid. 
which  act  as  cutaneous  stimulants.  Greene^  regards  the  warmth  and 
moisture  as  the  important  features.  Twenty-one  baths  are  given  in  one 
month,  dropping  one  every  fifth,  fourth,  third,  and  second  days.  The 
water  contains  sodium  chlorid,  calcium  chlorid,  and  carbon  dioxid, 
and  the  temperature  ranges  from  82°-95°  F.  (27.7°-35°  C).  The 
first    bath    lasts   seven   or   eight   minutes ;    the   time   is   then   gradually 

1  For  illustrative  cases  from  Prof.  Osier's  wards,  see  article  bv  Leufler,  Medical  Xews, 
July,  1891.  2  Jour.  Amer.  Med.  Assoc,  Oct.  15,  1898. 


672  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

lengthened,  the  temperature  lowered,  and  the  carbon  dioxid  increased. 
After  the  bath  the  patient  is  rubbed  and  allowed  to  rest  for  an  hour. 

Artificial  Nauheim  baths  are  successfully  employed  in  certain  Ameri- 
can iiospitals  at  the  present  time.  They  are  prej)are(l  as  follows  :  Five 
pounds  of  sodium  chlorid  and  eight  ounces  of  calcium  chlorid  are  dissolved 
in  one  half  bath  (80  gals. — 114  liters),  the  temperature  of  the  water  being 
95°  F.  (35°  C).  In  a  few  days  the  bath  is  charged  with  carbon  dioxid 
by  adding  sodium  bicarbonate  (1  lb. — 153.6)  and  HCl  {}y  lb. — 226.8),  the 
latter  just  before  the  bath  is  taken.  The  effects  are  to  lower  the  pulse- 
rate,  to  decrease  the  size  of  the  heart,  to  stimulate  the  nerves,  and,  indi- 
rectly, the  cardiac  nutrition.  There  is  also  a  tendency  toward  improve- 
ment of  the  nutritive  processes  and  an  increase  of  the  urine. 

Gentle  resistance  exercises  (consisting  of  all  the  more  reasonable  move- 
ments that  a  person  naturally  makes,  and  resisted  by  an  attendant)  form 
an  important  element  of  the  treatment,  since  they  tend  to  stimulate  the 
muscles  and  nerves  and  propel  the  blood  from  the  congested  veins.  The 
Nauheim  treatment  is  not  suitable  in  aortic  regurgitation,  aneurysm, 
advanced  arteriosclerosis,  marked  dropsy,  or  fatty  degeneration  of  the 
heart,  although  the  movements  alone  are  beneficial  in  these  conditions 
and  may  be  employed  without  the  baths. 

Individual  symptoms  frequently  demand  special  treatment. 

(1)  I)i/sj)iH'(i  and  OrfJioj)/n'(t. — When  these  jilicnoiiiena  are  caused  by 
engorgement  of  the  pulmonary  vessels,  the  cardiac  stimulants  above 
detailed  usually  afford  relief.  Frequently  the  patient  cannot  lie  down, 
in  which  case  a  suitable  bed-rest  often  gives  immediate  comfort  and 
support.  For  the  severe  attacks  of  nocturnal  dyspnea  (amounting  some- 
times to  orthopnea),  particularly  when  accompanied  by  cardiac  palpita- 
tion, the  subjoined  formula  has  proved  itself  of  great  benefit : 

I5«.   Sodii  bromidi,  gr.  xv    (0.972); 

Tr.  opii  deed.,  m^-xv  (0.666-0.999).— M. 

Sig.  To  be  taken  in  one  dose  at  bed-time. 

In  the  late  stages  of  heart-disease  morphin,  given  hypodermically,  is  to  be 
preferred  in  combating  this  symptom,  and  is  entirely  free  from  the  usual 
objections  to  the  habitual  use  of  the  remedy.  Its  influence  for  good  is 
inestimable.  Dyspnea  may  also  be  produced  by  associated  bronchitis, 
edema,  emphysema,  and  hydrothora.\ — conditions  that  must  be  treated 
according  to  the  customary  rules.  Frequent  physical  explorations  of 
the  chest  should  not  be  omitted.  Hydrothorax  demands  aspiration,  and 
this  repeatedl}"  in  some  instances. 

In  valvular  disease  (particularly  aortic),  owing  probably  to  coronary 
arterio-sclerosis,  paroxysms  of  severe  dyspnea  {catdiac  asthma)  are  apt 
to  arise.  These  are  best  overcome  by  nitroglycerin  in  ascending  dosage 
in  combination  with  sodium  bromid  at  bed-time,  to  be  repeated  as  needful. 
His  lauds  the  Karcll  "milk  cure,"  which  is  a  strict  diet  of  800  to 
1000  c.c.  of  milk  per  day  for  a  period  of  five  or  six  days ;  it  should  be 
carried  out  only  in  bed  patients. 

(2)  Coui/h. —  Cough  IS  common  after  failure  of  compensation,  and  is 
due  to  bronchitis  resulting  from  stasis  in  the  pulmonary  vessels.  In 
mitral  disease  it  may  come  on  before  the  rupture  occurs.  Beyond  the 
treatment  directed  to  the  causal  condition  (the  cardiac  failure)  nothing 


CHBONia   VALVULAR  ULSEASE.  fj73 

is  needed  to  relieve  the  cougli.  These  subjects,  however,  are  prone  to 
suffer  from  catarrhal  bronchitis  due  to  cold,  and  this  impairs  the  com- 
pensatory mechanism.  J.  Weiss  extols  heroin  in  cases  not  relieved  by 
the  ordinary  remedies. 

(3)  Hemorrhage  may  take  place,  and  generally  from  the  lungs,  though 
it  may  also  proceed  from  the  nose,  stomach,  bowels,  or  uterus.  In  a 
recent  case  of  double  aortic  disease  and  relative  mitral  insufficiency  hem- 
orrhages occurred  from  the  bowel  with  apparent  relief  to  the  patient.  The 
hemoptysis,  which  is  an  accompaniment  of  mitral  lesions,  is  rarely  ex- 
cessive, and  is  probably  always  beneficial.  I  would  advise  against  active 
treatment  unless  the  hemorrhage  is  actually  copious  in  amount. 

(4)  Palpitation  may  be  due  to  different  causes,  the  recognition  of 
which  in  each  case  is  important.  At  times  undue  hypertrophy  maintains 
a  constant  throbbing  and  distress  in  the  precordial  region,  the  condition 
being  distinguished  by  the  strength  of  the  impulse  and  by  the  full,  tense 
pulse  at  the  Avrist.  Palpitation  is  best  met  by  the  use  of  the  tincture 
of  aconite,  HTLj-iv  (0.066-0.266)  every  four  hours.  With  the  aconite  I 
frequently  associate  the  bromid  with  excellent  effect.  An  ice-bag  to 
the  precordia  is  worthy  of  recommendation.  Unless  the  patient's  dis- 
comfort is  significant,  however,  this  symptom  does  not  call  for  active 
treatment.  The  administration  of  a  saline  purge  not  infrequently  serves 
to  quiet  the  heart.  The  patient  may  suffer  from  pure  nervous  palpitation, 
in  which  case  the  diet  and  the  condition  of  the  stomach  must  be  care- 
fully looked  to,  while  for  the  throbbing  the  bromids  of  ammonium  and 
sodium,  together  with  preparations  of  valerian,  are  the  most  reliable. 

(5)  Anginose  Pains. — These  are  seen  in  aortic  incompetenc}'^  accom- 
panied by  sclerotic  vessels,  and  also  in  mitral  stenosis.  When  dependent 
upon  rigid  blood-vessel  walls  nitroglycerin  should  be  tried ;  if  the 
attacks  be  severe,  amyl  nitrite  by  inhalation  deserves  a  trial,  this 
failing,  morphin  and  atropin  may  be  employed  hypodermically.  Local 
measures  alone  are  sometimes  sufficient  when  the  pain  is  only  moderatelv 
intense,  and  the  ice-bag  or  Leiter's  coils  may  be  tried.  The  sedative 
effect  of  a  blister  (4  by  6  in. — 10  by  15  cm.)  has  more  often  proved 
effectual  in  my  experience,  though  its  use  should  be  limited  to  patients 
whose  general  strength  is  not  materially  impaired. 

(6)  Pain  referred  to  the  stomach,  and  less  frequently  to  the  abdomen 
also,  occasionally  assumes  prominence  and  is  relieved  with  great  diffi- 
culty. It  is  dependent,  in  part  at  least,  upon  obstinate  subacute  gas- 
tritis, and  I  have  quite  recently  seen  an  instance  of  the  sort  verified  by 
autopsy.  Among  many  drugs  tested  in  this  case,  opium  alone  gave 
relief.  Should  this  fail,  however,  carminatives  in  combination  with  some 
antiseptic  agent,  as  salol  or  guaiacol  carbonate,  should  be  used. 

(7)  G-astrie  Symptoms. — Soon  after  compensation  is  broken  the  ap- 
pearance of  mild  symptoms  of  catarrh  of  the  stomach  may  be  said  to 
be  the  rule,  and  these  yield  to  simple  measures  in  addition  to  the  cardiac 
stimulants  and  laxatives  already  indicated.  But  there  are  not  a  few 
instances  in  which  such  symptoms  as  gastric  distress  and  uneasiness, 
constant  nausea  with  frequent  vomiting,  particularly  after  food,  occur, 
and  assume  a  distressing  phase.     In  such  cases  digipuratum  deserves  a 

43 


674  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

trial.  The.^e  patients  sometimes  do  ^vell  on  the  capsules  before  adduced 
composed  of  strychnin,  spartein,  and  caftein.  When  the  ahove  remedies 
cannot  be  borne  I  em])loy  hypodermically  digitalin  and  strychnin  or 
caftein  citrate,  the  .latter  being  made  soluble  by  the  addition  of  sodium 
benzoate  in  solution.  Cases  of  this  class  reach  an  early  fatal  termination, 
as  a  rule.  The  symptoms  may  be  partly  due  to  gastric  catarrh,  and 
partly  to  uremic  intoxication. 

(S)  Xerrous  Si/ni/tfonis. — Insomnia  and  restlessness  are  almost  con- 
stantly present  at  some  period  in  tiie  course  of  heart  disease,  and  notably 
in  the  more  advanced  stages.  The  restiveness  is  rendered  more  dis- 
tressing on  account  of  hideous  dreams  and  cardiac  palpitation  on  awakino-. 
For  these  phenomena  stimulation  often  answers  a  better  jnirpose  than 
sedation,  lloff'inan's  anodyne  (.^j — 4.0,  well  diluted),  spirits  of  chloro- 
form (TTLx'v— 0.099),  or  ether  (.^ss— 2.0),  taken  in  whisky  (3J— .32.0)  are 
serviceable.  The  elixir  of  ammonium  valerianate  is  also  of  value. 
Recently,  trional  (gr.  xv.)  in  combination  with  sodium  bromid  (gr.  xx) 
has  given  satisfaction.  Paraldehyd,  veronal,  medinal.  and  chloralamid 
are  among  the  remedies  of  choice  in  the  treatment  of  this  symptom,  but 
I  have  had  no  experience  with  their  emplovment. 

In  the  later  stages  there  is  no  objection  to  the  use  of  morphin  hypo- 
dermically. Headache  due  to  uremia  may  frequently  be  a  troublesome 
symptom  in  connection  with  sleeplessness,  and  in  such  cases  morphin  is 
the  remedy  par  excellence  :  it  is  to  be  supplemented  by  free  purgation 
and  cardiac  stimulants.  Should  the  right  heart  be  found  flagging, 
venesection   may  be  practised. 

(9)  Drops!/. — As  above  pointed  out,  rest  with  attention  to  the  diet 
and  the  judicious  use  of  hydrogogue  cathartics  will  often  restore  broken 
compensation.  In  the  severe  grades  of  failure  of  the  balancing  forces, 
complete  rest,  purgatives,  and  a  cautious  employment  of  morphin  hypo- 
dermically, often  suffice  to  remove  the  dropsy.  If  this  method  of  treat- 
ment proves  unsuccessful,  then  the  therapeutic  indications,  so  far  as  the 
dropsy  is  concerned,  are  for  the  use  of  cardiac  stimulants,  diuretics,  and 
purgatives.  Diaphoretics,  particularly  the  hot-air  and  vapor  baths,  are 
not  to  be  thought  of,  since  they  tend  to  depress  the  already  weakened 
heart.  While  describing  the  action  of  digitalis  as  a  cardiac  stimulant, 
incidental  allusion  was  also  made  to  its  action  as  a  diuretic.  In  view 
of  the  fact  that  it  raises  the  blood-pressure  in  the  peripheral  vessels  and 
capillaries  by  contracting  their  walls,  and  because  of  its  stimulating 
effect  on  the  heart,  digitalis  in  large  doses  becomes  a  most  efficient  diu- 
retic in  cardiac  dropsy.  When  it  fails,  I  have  freijuently  found  that  a 
combination  of  strychnin,  spartein,  and  caffein  (vide  supra)  will  excite 
free  diuresis.  Acet-theocin  sodium  may  be  tried  in  doses  of  0.2  gm. 
(gr.  iij)  dissolved  in  water  twice  daily,  to  be  increased  to  three  or  four 
times  if  necessary  ;  it  demands  a  kidney  which  is  tolera])ly  intact.*  Nitro- 
glycerin may  also  be  prescribed,  especially  in  cases  presenting  evidences 
of  advanced  arteriosclerosis.  Diurctin  has  acted  well  in  recent  cases  as 
a  diuretic.  AVhen  digitalis  fails,  Fraenkel  uses  strophanthin  intraven- 
ously, giving  as  the  initial  dose  0.5  milligram  and  repeating  only  when 
the  favorable  effect  is  no  longer  apparent.  An  unirritating  yet  highly 
effective  diuretic  mixture  in  these  cases  is  the  following: 
1  Internalional  Clinics,  vol.  ii.,  20tli  Series,  p.  9. 


CHRONIC   VALVULAR  DLSKASK.  675 

!^,   Potassii  acetatis,  z]    (4.0); 

Inf.  digitalis,  .?*ij  (64.0).— M. 

Sig.  .Iss  (16.0)  every  three  hours. 
Purgatives  are  of  the  utmost  value.  Frcfjuently,  after  a  few  copious 
watery  evacuations  as  the  result  of  the  action  of  hydragogue  cathartics, 
a  free  discharge  of  urine  can  be  established,  when  before  the  latter  event 
it  has  been  impossible.  Salines  and  elaterium,  Avith  podophyllin  and 
belladonna,  are  agents  that  have  been  already  recommended  as  purga- 
tives (to  deplete  the  venous  system),  and  these  should  be  first  employed 
in  the  order  named.  Compound  jalap  powder  may  also  be  combined 
with  the  elaterium.  A  course  of  calomel,  followed  by  salines  until  free 
catharsis  is  set  up,  is  valuable  from  time  to  time.  Mercury  is  especially 
applicable  when  the  liver  is  much  enlarged  and  ascites  is  a  marked  fea- 
ture, or  when  the  history  of  syphilitic  infection  is  obtainable.  It  may 
be  combined  with  cardiac  stimulants  and  other  diuretics  as  follows: 

I|i.   Pulv.  digitalis  foL, 

Pulv.  scillge,  aa  gr.  xij      (0.777); 

Mass.  hydrargyri,  gr.  xxiv  (1.555); 

Ext.  belladonnje,  gr.  ss       (0.0324). 

M.  et  ft.  pil.  No.  xii. 
Sig.   One  every  three  or  four  hours. 

When  efforts  at  relieving  the  dropsy  by  means  of  medicines  fail,  then 
the  most  dependent  parts  of  the  body,  or  those  most  swollen,  should  be 
scarified  under  strict  aseptic  precautions.  Fine  silver  trocars  with 
rubber  tubes  attached  (Southey's  tubes)  may  be  inserted  and  the  liquid 
allowed  to  drain  off  in  a  gradual  manner. 

Means  to  Prevent  Recurrence  of  Broken  Compensation. — When  the 
compensation  has  been  successfully  re-established,  the  after-treatment 
must  be  prosecuted  with  vigor  for  at  least  a  year.  The  cause  of  the  rupt- 
ure of  compensation  is  most  probably  fibroid  and  fatty  degeneration  of 
the  cardiac  muscle,  and  hence  the  mere  restoration  of  the  compensatory 
power  of  the  heart  does  not  imply  a  complete  cure  of  the  impaired  mus- 
cular structure  of  that  organ.  Much  can  be  done,  however,  to  overcome 
the  tendency  to  degeneration  by  the  peristent  use  of  hematinics  and 
other  tonics,  as  cod-liver  oil  and  mercuric  chlorid,  the  latter  in  small 
doses.  I  have  obtained  excellent  results  from  the  use  of  the  following 
prescription  in  these  cases  : 

•  ^.  Liq.  arsenici  chlor.,  ITLxlviij  (3.186); 

Tinct.  ferri  chlor.,  Sss  (16.0); 

Hydrarg.  chloridi  cor.,  gr.  ss      (0.0324); 

Elixir  digestivi  comp.,  q.  s.  ad  fgiij         (96.0). — M. 
Sig.  3j  (4.0)  after  each  meal,  well  diluted. 

This  preparation  may  be  taken  indefinitely  with  occasional  brief  inter- 
ruptions. The  patient  should  lead  a  very  quiet  life,  and  follow  rigidly 
all  hygienic  rules  that  tend  to  prevent  the  production  of  valvular  disease. 
Appropriate  diet,  it  should  be  emphasized,  is  not  inferior  to  appropriate 
medication  in  its  salutary  effect.  Should  the  faintest  evidence  of  failure 
of  the  right  ventricle  manifest  itself,  the  patient  must  be  put  to  bed 


070  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

and  the  foregoing  treatment  carried  our.  I  am  inclined  to  the  view  that 
the  planJierein  advocated  not  only  renders  the  course  of  recurring  attacks 
of  failing  compensation  milder,  but  that,  in  a  considerable  proportion  of 
the  cases,  the  much-dreaded  recurrence  is  thus  prevented. 


CARDIAC  THROMBOSIS. 

Pathology. — True  cardiac  thrombi  are  seen  most  frequently  on  the 
right  side  of  the  heart,  in  the  auricular  appendices,  and,  less  commonly, 
in  the  right  ventricle  near  the  apex.  They  are  of  firm  consistence,  and 
are  tightly  adherent  to  the  endocardium,  considerable  force  being  re- 
(juired  to  dislodge  them.  The  color,  while  generally  grayish-brown  or 
red,  varies  with  the  age  of  the  thrombus,  being  more  colorless  as  it  be- 
comes older.  Cardiac  thrombi  may  be  pedunculated  or  sessile,  and  their 
contour  is,  as  a  rule,  more  or  less  rounded.  Recklinghausen  and  others 
have  observed  globular  masses,  the  so-called  ''  ball-thrombi,  "  in  the  auri- 
cles, without  the  slightest  endocardial  attachment.  They  vary  greatly 
in  size,  from  a  mustard-seed  to  a  hen's  egg,  and  sometimes  exhibit  cal- 
careous degeneration.  Cardiac  thrombi  may  occur  singly  or  in  groups 
of  considerable  numbers.  From  the  cavity  in  which  they  have  their 
primary  seat  they  may  project  into  other  chambers  of  the  heart,  or  from 
the  left  ventricle  into  the  aorta  for  a  considerable  distance.  It  is  evi- 
dent that  fragments  detached  by  the  blood-stream  from  these  cardiac 
blood-concretions  will  tend  to  lodge  in  various  viscera  and  in  the  per- 
ipheral tissues,  and  set  up  embolic  processes.  The  microscope  shows 
degenerated  round  cells  and  detritus,  but  no  pus-cells.  Secondary  degen- 
erative changes,  and  later  softening,  may  take  place  in  the  central  portions 
of  a  thrombus,  and  these  areas  may  contain  a  reddish-brown  liquid. 

Ktiology. — The  causes  of  cardiac  thrombosis  are  to  be  found  chiefly 
in  som^  previously  diseased  or  injured  condition  of  the  endocardium, 
though  sometimes  alterations  of  the  blood  constitute  a  factor  of  consid- 
erable importance.  The  condition  may  occur  in  the  course  of  both 
acute  and  chronic  diseases,  in  which  the  intracardiac  conditions  favor 
the  formation  of  a  blood-clot.  Hence  it  is  seen  in  connection  with 
organic  diseases  of  the  heart  in  which  the  valvular  and  often  the  mural 
endocardium  are  roughened,  and  the  obstructive  and  regurgitant  lesions 
at  the  various  valves  cause  retardation  in  the  blood-current.  '  Chronic 
obstruction  in  the  lungs  may  contribute  to  the  result  by  slowing  the  cir- 
culation in  the  heart.  Cardiac  thrombosis  has  been  observed  in  many 
of  the  acute  affections,  and  almost  invariably  there  is  a  loss  of  endocar- 
dium, due  to  inflammatory  action  (endocarditis)  at  some  point  in  the 
cavities  of  the  heart.  T'his  becomes  the  seat  of  the  fibrinous  deposit 
which  is  subsequently  imperfectly  organized.  Among  the  most  import- 
ant of  these  acute  primary  diseases  are  rheumatism,  diphtheria,  lobar 
pneumonia,  and  p7/e7nic  and  puerperal  conditions.  It  may  be  questioned 
whether,  given  a  healthy  endocardium,  as  contended. by  some  writers, 


HYPERTROPHY  OF  THE  HEART.  .     077 

the  slowing  of  the  circulation  alone  suffices  to  cause  true  cardiac 
thrombi. 

Symptoms. — These  will  depend  very  much  upon  the  rapidity  with 
which  the  thrombus  is  formed,  as  well  as  upon  its  seat  and  dimensions. 
Thrombi  invariably  lack  definiteness,  and,  as  their  effects  are  lar^rely 
mechanical,  signs  of  obstruction  to  the  cardiac  circulation  and  failure 
of  the  cardiac  muscle  are  developed.  The  piihe  becomes  weak,  lapid, 
and  irregular;  dyspnea,  vertigo,  and  attacks  of  nyncope  are  frequent; 
and  later  cyanosis  may  appear.  It  is  probable  that  at  times  the  liquefied 
products  of  a  clot  may  be  absorbed,  producing  blood-poisoning.  When 
the  thrombus  is  formed  rapidly  the  symptoms  are  suddenly  developed 
and  the  course  is  rapid.  Rarely  a  valvular  orifice,  an  efferent  vessel,  or 
the  coronary  artery  may  become  blocked  and  instant  deatli  follow.  Since 
the  right  heart  is  the  most  frequent  seat  of  these  thrombi,  pulmonary 
embolism  with  its  usual  symptoms  is  a  common  event.  When  portions 
of  a  clot  are  broken  oft'  and  swept  into  the  systemic  circulation,  the 
clinical  phenomena  of  cerebral,  splenic,  or  renal  emholism  are  exhibited. 
A  localized  gangrene  of  the  foot  has  been  described. 

The  physical  signs  consist  of  a  feeble  impulse  with  marked  arrhythmia ; 
the  area  of  dulness  is  somewhat  increased  to  the  right,  and  often  upward ; 
and  the  heart-sounds  are  greatly  enfeebled  and  quite  irregular,  with 
marked  change  in  any  murmurs  that  may  previously  have  been  audible. 
A  presystolic  murmur  may  be  engendered. 

Differential  Diagnosis. — It  is  important  to  distinguish  true  car- 
diac thrombi,  such  as  are  above  described,  from  the  less  dense  and  usu- 
ally darker  clots  that  are  formed  either  immediately  before  or  after 
death.  The  latter  may  seldom  show  an  attempt  at  a  very  low  grade  of 
organization,  and  may  present  a  somewhat  decolorized  appearance,  but 
they  do  not  adhere  firmly  to  the  endocardium.  Moreover,  antemorteni 
and  postmortem  clots,  as  the  latter  may  be  appropriately  termed,  have  a 
different  causation  from  true  thrombi.  For  instance,  they  are  apt  to 
form  in  diseases  in  which  the  fibrin-factors  of  the  blood  are  greatly 
increased,  as  in  pneumonia.  Perhaps  a  more  potent  causal  element  is 
the  progressive  weakening  of  the  heart-muscle,  resulting  in  partial  ex- 
pulsion of  the  contents  of  the  right  ventricle;  the  blood  that  remains 
in  the  chamber  is  merely  whipped  up,  and  the  deposition  of  its  fibrin 
must  thus  be  greatly  favored.  Such  heart-clots  may  be  generated  if  the 
endocardium  be  healthy,  and  cannot  be  separated  positively  from  true 
cardiac  thrombi  by  clinical  observation. 

The  prognosis  is  uniformly  bad  and  sudden  death  may  be  expected. 

Treatment. — Beyond  measures  calculated  to  meet  the  symptomatic 
indications  nothing  can  be  suffgested. 


HYPERTROPHY  OF  THE  HEART. 

( Hypertrophia  Cordis. ) 

Definition. — Hypertrophy  is  an  increase  in  the  muscular  structure 
of  the  heart,  evidenced  usually  by  an  increased  thickness  of  its  walls. 
It  is  almost  invariably  associated  with  dilatation   of  the  chambers. 


678    •  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Pathology. — When  the  two  processes — hypertrophy  ami  dilatation 
— coexist,  they  cause  groat  enlargement  of  the  organ.  To  this  condition 
the  term  '"eccentric  /ii/pertrophj/"  has  heen  given.  Hypertrophy  with- 
out dilatation  receives  the  name  "^  sitnple  /ri/pertro/>hi^."  and  hypertrophy 
with  diminution  in  the  size  of  the  cavities  was  formerly  described  as 
'"concentric  hiipertrophy,"  but  this  term  should  now  be  regarded  as  ob- 
solete, inasmuch  as  the  condition  is  due  to  postmortem  contraction  of 
the  ventricles. 

The  increase  in  size  may  affect  the  whole  heart,  one  chamber  on 
either  side,  one  whole  side,  or  but  a  single  cavity  (general  and  partial 
hi/pertroplii/).  The  process  may  also  be  limited  to  a  minute  division  of 
the  heart  {circamscribed  hypertrophy).  Owing  to  its  important  physio- 
logic function  the  left  ventx'icle  is  more  frequently  enlarged  than  the 
right,  while  the  right  auricle  is  more  frequently  involved  than  the  left. 
The  weight  of  the  normal  heart  in  a  man  of  average  size  is  approximately 
9  ounces  (255.0) ;  in  a  woman  it  is  8  ounces  (226.0).  In  bilateral  hyper- 
trophy, however,  the  weight  of  the  heart  may  be  greatly  increased ; 
hearts  weighing  from  15  to  25  ounces  (425.0—710.0)  are  seen  in  mod- 
erate grades  of  hypertrophy,  and  those  from  40  to  50  ounces  (1134.0— 
1420.0)  in  extreme  cases  (ear  bovinum).  Measurements  showing  the 
thickness  of  the  walls  also  indicate  the  degree  of  hypertrophy  ^  and  the 
exact  seat  of  the  enlargement  when  not  general.  The  normal  diameter 
of  the  left  ventricular  wall  is  from  8  to  12  mm.  (^ — 1-  in.);  that  of  the 
right  ventricle,  from  5  to  7  mm.  (^— ^  in.) :  that  of  the  left  auricle,  about 
3  ("^  in.),  and  of  the  right  2  mm.  [-^  in.).  In  cardiac  hypertrophy  the 
normal  thickness  of  the  various  cavity-walls  is  usually  doubled,  not  in- 
frequently trebled,  and.  rarely,  even  quadrupled.  In  cases  in  which 
there  is  a  concomitant  dilatation  the  walls  may  appear  thinned,  while 
the  measurement  will  show  them  to  be  in  reality  thickened. 

The  shape  of  the  heart  is  also  altered  according  to  the  seat  and  ex- 
tent of  the  hypertrophy.  If  both  ventricles  are  enlarged,  the  apex  is 
widened  and  appears  flattened  ;  if  only  the  left  ventricle  is  involved, 
the  apex  is  lengthened  and  is  more  or  less  pear-shaped  :  and  if  the 
right  ventricle  alone  is  h3'pertrophied  (as  in  mitral  stenosis),  it  may  form 
the  largest  part  of  the  apex,  which  Avill  be  less  conical  than  in  health. 

The  papillary  muscles  and  columuce  carneoe  are  greatly  thickened, 
and,  particularly  in  the  eccentric  form  of  hypertrophy,  they  are  often 
decidedly  flattened.  In  this  form  the  septum  frequently  shows  increased 
thickness — a  condition  that  I  have  never  observed  in  simple  hypertrophy. 
The  muscular  trabecuhe  generally  assume  greater  prominence  on  the 
right  than  on  the  left  side.  The  muscular  structure  is  usually  of  a 
deeper  red  color  and  also  firmer  than  normally.  The  hypertrophied  left 
ventricle  can,  as  a  rule,  be  lacerated  readily,  while  the  right,  as  first 
pointed  out  by  Rokitansky,  may  be  tough  and  leathery.  As  the  heart 
continues  to  enlarge  it  sinks  lower  in  the  chest-cavity,  owing  to  an  in- 
crease in  weight  as  well  as  in  size.  In  hypertrophy  of  the  heart  there  is 
a  multiplication  of  muscular  fibers,  to  which  alone  the  enlargement  of  its 
walls  is  attributable. 

Htiology. — Hypertrophy  of  the  left  ventricle   (sometimes    termed 

'  Measurements  should  not  be  attempted  until  the  rigor  mortis  has  been  overcome  by 
soaking  the  organ  in  water. 


HYPEllTllOrilY  OF  TU1<:  HEART.  fj79 

ifeneral  hypertroph/ij)  results  from  obstructions  to  the  arterial  eircula- 
tion  of  whatever  sort.  These  may  be  classified,  accordin^^  to  their  seat, 
into — (1)  Lesions  of  the  Heart. — (a)  Aortic  incompetency  and  aortic 
stenosis ;  {b)  Mitral  insuiliciency  ;  (c)  The  fibroid  form  of  myocarditis ; 
(d)  Pericardial  adhesions,  particularly  in  the  young.  In  such  cases  the 
adherent  pericardium  exerts  a  counter-traction  force  during  the  systole, 
and  thus  the  work  is  increased  beyond  the  capacity  of  the  normal  heart, 
with  consequent  hypertrophy.  Late  in  life  the  heart  may  become  atro- 
phied. 

(2)  Abnormal  Conditions  of  the  Blood-vessels. — (a)  Narrowing  of  the 
aorta — e.  g.  congenital  stenosis,  external  pressure,  and  the  development 
of  an  aneurysm  ;  (6)  General  arterio-sclerosis,  by  raising  the  pressure  ;  {<:) 
Increased  arterial  pressure,  due  to  contraction  of  the  peripheral  vessels 
in  consequence  of  the  local  action  of  certain  chemical  and  biologic  irri- 
tants (lead,  Bright's  disease,  gout,  syphilis).  Hassenfeld  '  has  recently 
shown  that  hypertrophy  of  the  left  ventricle  occurs  only  when  the  vis- 
ceral arteries  exhibit  an  extreme  degree  of  sclerosis,  or  when  the 
thoracic  aorta  is  sclerotic.  In  cases  of  pure  contracted  kidney  all  the 
chambers  of  the  heart  are  hypertrophied  ;  but  when  extreme  arterio- 
sclerosis is  present  also  the  left  ventricle  is  disproportionately  enlarged. 
In  all  of  these  cases,  whether  the  blood-pressure  is  raised  in  larger  or 
smaller  vessels,  increased  cardiac  action  is  essential  to  meet  the  demands 
of  the  system-circulation. 

Attention  should  be  called  to  the  causes  of  the  so-called  "  primary  idio- 
pathic hypertrophy."  The  main  causal  conditions  are — (1)  Prolonged  physi- 
cal exertion,  as  in  certain  occupations  (blacksmiths,  locksmiths,  dray- 
men, and  athletes).  Excessive  bicycling  causes  hypertrophy,  particularly 
if  arterio-sclerosis  exists.  (2)  Constant  over-distention  of  blood-vessels, 
as  in  the  case  of  excessive  beer-drinkers  [heer-heart).  Here  the  direct 
action  of  the  alcohol  upon  the  heart-muscle  must  also  be  taken  into 
account.  (3)  Functional  disturbances  (neuroses),  constant  over-action 
of  the  heart,  and  even  paroxysmal  tachycardia,  tea,  coffee,  tobacco,  and 
alcohol  may  give  rise  to  primary  and  general  hypertrophy.  Idiopathic 
hypei'trophy  of  the  heai-t  is  undoubtedly  due  to  increased  activity, 
which  is  dependent  on  a  variety  of  irritating  influences  acting  upon 
the  heart  muscle  (De  Domenicis^).  Primary  coyigenital  hypertrophy  of 
the  heart  is  attributable  either  to  circulatory  disturbance  (Simmonds^) 
or,  as  Virchow  holds,  to  a  diifuse  myomatous  neoplasia  of  congenital 
origin. 

Hypertrophy  of  the  right  ventricle  develops  secondarily  to  any  condi- 
tion that  ofiers  obstruction  to  the  pulmonary  circulation  or  to  the  blood- 
current  through  the  right  ventricle.  Among  them  may  be  mentioned — 
(1)  mitral  incompetency  and  stenosis ;  (2)  emphysema,  chronic  bronchitis, 
collapse  of  a  portion  of  the  lung,  contraction  of  a  lung  from  pleural  ad- 
hesions, and  cirrhosis  of  the  lung  ;  (3)  right-sided  valvular  lesions,  par- 
ticularly obstruction  at  the  pulmonary  orifice  ;  (4)  it  is  doubtful  whether. 
on  account  of  the  normal  situation  of  the  right  ventricle,  pericardial 
adhesions  induce  hypertrophy  of  this  chamber. 

Hypertrophy  of  the  Auricles. — Hypertrophy  with  dominant  dilatation 

1  Deutsch.  Arch.f.  klin.  Med.,  Dec.  9,  1897  ;  Phila.  Med.  Jour.,  Jan.  22,  1898. 

2  WieTuklin.  Wocli.,  May  22,  1897.  ^  Mimchene)-  med.  Woch.,  1899,  No  4,  S.  108. 


680  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  the  left  auricle  occurs  in  mitral  disease,  and  especially  in  mitral  ste- 
nosis. The  right  auricle  hypertrophies,  though  not  invariably,  when  the 
blood-pressure  in  the  pulmonary  vessels  is  pronounced  from  any  cause. 
Stenosis  of  the  tricuspid  orifice  is  occasionally  the  sole  cause  of  thicken- 
ing of  the  right  auricular  wall,  which  also  becomes  hypertrophied  in  tri- 
cuspid incompetency. 

Symptoms. — There  is  usually  an  entire  absence  of  subjective  symp- 
toms when  compensation  is  efhcient.  When  present,  their  intensity 
varies  with  the  degree  of  the  hypertrophy,  whicii  is  then  pronounced, 
as  a  rule,  and  often  already  attended  by  incipient  dilatation.  They 
may  be  local  entirely,  though  frecjuently  general  as  well.  Of  the  former, 
precordial  discomfort  and  uneasiness  from  the  violence  of  the  impulse 
occur.  They  are  most  annoying  when  tlie  patient  is  in  the  recumbent 
posture  on  the  left  side  and  when  the  hypertrophy  is  dependent  upon 
nervous  causes.  J^ain  and  palpitation  are  seldom  complained  of  except 
by  neurasthenics  and  patients  suffering  from  enlargement  due  to  tobacco 
or  excessive  muscular  exertion.  Decided  aggravations  of  the  local  mani- 
festations may  follow  undue  mental  emotion  or  excitement,  physical 
exhaustion,  active  bodily  exercise,  and  gourmandizing. 

The  general  symptoms,  when  present,  may  fluctuate  or  even  intermit. 
Those  most  frequently  observed  are  fulness  in  the  head,  often  amounting 
to  actual  headache,  tinnitus  aurium,  carotid  pulsations,  flushing  of  the 
face.  Hashing  of  light  before  the  eyes,  and  often  prominent  eyeballs.  These 
symptoms  are  attributable  to  the  increased  vigor  of  the  cerebral  circulation. 

Remote  Effects. — General  or  total  hypertrophy  promotes  high  ten- 
sion throughout  the  arterial  tree.  Endarteritis  and  arterio-sclerosis  are, 
as  a  consequence,  frequent  simultaneous  developments  in  advanced 
cases,  especially  when  the  cause  of  the  enlargement  has  been  increased 
tension  in  the  peripheral  vessels,  as  in  Bright's  disease.  With  a  circu- 
lation too  forcibly  carried  on,  as  in  hypertrophy,  the  sclerotic  vessels 
are  overstrained,  and  are  apt  to  rupture.  The  break  often  occurs  in  the 
brain  (apoplexy)  or  in  the  lung  {^pulmomary  apoplexy),  and  hemorrhage 
from  the  lung  (hemoptysis),  due  to  left  ventricular  hypertrophy,  is  more 
common,  I  believe,  than  is  supposed.  The  blood-pressure  is  high, 
although  the  records  vary  with  the  dominating  cause.  Some  of  the 
symptoms  are  due  to  the  cause  or  causes  of  the  hypertrophy. 

Physical  Signs  in  Left-sided  Hypertrophy. — Inspect ioyi. — In  females 
and  in  children  with  soft,  yielding  ribs  there  is  visible  arching.  The 
intercostal  spaces  are  much  broadened  and  the  apex-beat  covers  an  in- 
creased area,  the  extension  being  downward  and  to  the  left.  The  whole 
body  of  the  patient,  and  even  the  bed  on  which  he  may  be  lying,  may 
share  visibly  in  the  cardiac  impulse. 

Palpation. — In  pronounced  grades  the  impulse  may  be  felt  as  low 
down  as  the  seventh  interspace  and  as  far  to  the  left  as  the  axilla.  In 
simple  hypertrophy  it  is  carried  downward  to  the  sixth  intercostal  space 
and  outward  to  a  point  near  the  anterior  axillary  line.  The  impulse  is 
slow,  forcible,  and  heaving,  the  "thrust"  lifting  the  fingers  of  the  ex- 
aminer. In  eccentric  hypertrophy  (hypertrophy  with  dilatation),  though 
heaving  and  forcible,  it  is  somewhat  more  abrupt,  as  in  cardiac  dilata- 
tion. Over  the  aortic  orifice  a  short  diastolic  impulse  may  also  be  felt 
occasionally  (double  impulse).     Pressing  the  fingers  into  the  second  and 


HYPERTROPHY  OF  THE  UK  A  JIT.  fj81 

third  right  spaces  will  detect  an  impulse  if  the  aorta  be  dilated.  The 
pulse  in  pure  hypertrophy  is  full,  strong,  regular,  and  of  normal  rate ; 
it  is  also  prolonged,  owing  to  increased  tension.  In  eccentric  hyper- 
trophy it  is  more  abrupt,  soft,  full,  and  somewhat  accelerated. 

Percussion. — This  defines  <jnly  approximately  the  degree  of  enlarge- 
ment, as  the  hypertrophy  may  take  a  backward  direction  or  there  may 
be  more  than  the  usual  overlapping  of  the  heart  by  the  lung.  Traced 
upward,  dulness  may  terminate  in  the  second  interspace,  whilst  to  the 
loft  it  may  extend  1  or  2  inches  (2.5-5  cm.)  beyond  the  mid-clavicular 
line.  When  hypertrophy  is  of  moderate  extent  the  left  limit  of  dulness 
corresponds  with  the  results  of  palpation  and  inspection ;  but  when  it 
is  of  immoderate  extent  the  extension  of  dulness  does  not  keep  pace 
with  the  systolic  impulse,  which  is  diffused  to  points  without  the  limits 
of  contact  of  the  heart  with  the  thoracic  wall.  If  concomitant  hyper- 
trophy of  the  right  ventricle  be  present,  dulness  will  also  extend  to  the 
right  {vide  infra). 

Auscultation. — The  sounds  vary  with  the  grade  of  the  morbid  proc- 
ess and  the  variety.  In  simple  hypertrophy  of  marked  type  a  pro- 
longation of  the  first  sound  is  always  appreciable,  and  usually  it  is 
duller  than  the  normal.  The  second  sound  (aortic)  is  intensified,  clear,  and 
often  ringing.  The  degree  of  accentuation  depends  partly  upon  the 
vigor  of  the  left  ventricle,  though  chiefly  upon  the  condition  of  the 
blood-vessels.  Reduplication  of  the  second  sound,  due  to  high  tension, 
is  common  [e.  g.  in  Bright's  disease).  The  first  sound  may  also  be  du- 
plicated. In  dilated  hypertrophy  the  first  sound  is  clearer  and  more 
abrupt,  while  the  second  is  less  marked  or  even  faint.  Modification  of 
these  sounds  occurs  when  hypertrophy  is  due  to  chronic  valvular  disease. 

Hypertrophy  of  the  Right  Ventricle. — One  or  more  of  the  causal  fac- 
tors that  produce  augmented  tension  in  the  pulmonary  vessels  are  pres- 
ent, and,  if  properly  appreciated,  will  throw  light  upon  the  condition. 
There  may  be  an  absence  of  all  symptoms  if  the  hypertrophy  exactly 
balances  the  result  of  the  obstructive  forces,  and  this  state  may  be  main- 
tained for  a  long  period  of  time.  Undue  exertion,  however,  soon  leads 
to  temporary  dyspnea  in  many  cases.  When  secondary  to  emphysema 
or  cirrhosis  of  the  lung  the  symptoms  occasioned  by  the  latter  diseases, 
such  as  cough  and  dyspnea,  may  completely  veil  any  symptoms  that 
may  be  due  to  the  hypertrophy.  Discomfort  in  the  cardiac  region 
should,  however,  arouse  suspicions  of  the  existence  of  the  latter  con- 
dition. When  dilatation  of  the  ventricle  supervenes,  as  is  usual,  and 
the  clinical  evidences  of  tricuspid  incompetency  develop,  then  pulmo- 
nary symptoms,  due  to  venous  congestion,  are  prominent ;  these  are 
bronchial  catarrh,  shortness  of  breath,  and  the  like.  Later,  general 
cyanosis  and  edema  appear.  As  pointed  out  in  the  discussion  of  Mitral 
Stenosis  with  permanently  heightened  tension  and  overgrowth  of  the 
right  ventricle,  the  lung-vessels  become  atheromatous  and  the  lung- 
tissue  the  seat  of  brown  induration.  Owing  to  the  fact  that  the  scle- 
rotic vessels  are  easily  ruptured,  hemoptysis — a  not  uncommon  event 
after  sudden  great  exertion — is  to  be  expected :  intense  pulmonary 
congestion  and  apoplexy  may  also  be  met  wath  in  hypertrophy  with 
dominant  dilatation. 

Ehysical  Signs. — These  have  been  in  the  main  detailed  in  speaking 


682  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  affections  of  the  mitral  valve.  Inspection  discloses  bulging  of  the 
sixth  and  seventh  left  costal  cartilages  and  of  the  lower  sternum.  la 
the  angle  between  the  ensiform  cartihige  and  the  seventh  rib  an  epigas- 
tric impulse  may  be  visible,  but  more  commonly  the  imjiulse  is  in  the 
sixth  interspace,  close  to  the  left  edge  of  the  sternum.  It  is  also  verj 
generally  seen  to  the  right  of  the  sternum,  in  the  third  and  fourth 
interspaces,  and  particularl}^  is  this  the  case  in  eccentric  hypertrophy, 
forming  a  highly  characteristic  sign.  The  apex-beat  is  therefore  diffuse, 
tlie  radial  puhc  is  small,  and  in  dilated  hypertrophy  it  is  increased  in 
fretiuency,  and  is  small,  unsustained,  and  irregular. 

Pcrcuitsion  shows  the  extension  of  cardiac  dulness  to  a  point  an  inch 
(2.5  cm.)  or  more  beyond  the  right  sternal  border.  When  there  is  great 
increase  transversely,  dilatation  is  most  probably  associated  and  may 
predominate  over  hypertrophy.  The  auscuHator//  signs  are  not  distinct- 
ive unless  dilatation  also  exists,  Avhen  the  first  sounds  are  clear  and 
sharp.  In  simple  hypertrophy  the  first  sound  is  slightly  prolonged  and 
lower  than  in  health.  Owing  to  the  high  vascular  tension  throughout 
the  lungs  the  second  sound  at  the  pulmonary  valve  is  accentuated,  and 
reduplication  of  the  second  sound  may  occur  for  the  same  reason. 

It  must  be  kept  in  remembrance  that  when  advanced  emphysema  is 
present  all  the  physical  signs  will  be  greatly  modified,  and  may  even  be 
entirely  negative,  though  the  heart  be  of  large  size.  Under  these  cir- 
cumstances venous  pulsation  in  the  neck  would  be  diagnostic  of  dilated 
hypertrophy  of  the  right  ventricle. 

Hypertrophy  of  the  Left  Auricle. — This  may  be  assumed  to  occur  in 
mitral  stenosis  and  incompetency  in  order  to  compensate  for  these 
lesions  :  it  cannot,  however,  be  recognized  positively  by  physical  signs. 
When  the  chamber  is  at  the  same  time  extensively  dilated,  the  dulness 
may  be  extended  upward  to  the  left  of  the  sternum,  passing  over  the 
third  and  even  second  interspaces.  At  this  point — the  second  inter- 
space— a  presystolic  wave  may  now  be  noticeable. 

Hypertrophy  of  the  right  auricle,  associated  with  dilatation,  is  per- 
haps more  common  than  its  counterpart  on  the  left  side.  It  is  secondary 
to  tricuspid  incompetency  (rarely  stenosis)  and  enlargement  of  the 
right  ventricle,  and  hence  has  the  same  etiology  as  the  latter  conditions. 

The  j)hi/sicaf  signs  are — systolic  jugular-pulsation,  sometimes  a  pre- 
systolic wavy  pulsation  over  the  third  and  fourth  interspaces  to  the  right 
of  the  sternum,  extension  of  cardiac  dulness  to  the  same  interspaces, 
and  other  signs  of  tricuspid  regurgitation. 

Diagnosis. — The  recognition  of  cardiac  hypertrophy  is  possible 
only  by  attention  to  the  physical  signs.  Next  to  these,  in  point  of 
diagnostic  value,  come  the  causes,  which  should  therefore  be  diligently 
searched  for ;  the  rational  symptoms  are  least  in  value,  though  usually 
corroborative.  It  is  difficult  to  establish  a  diagnosis,  even  approx- 
imately, when  extensive  emphysema  coexists.  The  size  of  the  heart  can 
be  accurately  determined  by  the  use  of  the  JT-rays,  or,  at  all  events,  by 
meaiis  of  the  orthodiagram. 

Differential  Diagnosis. — Conditions  that  cause  an  increase  in  tlie  pre- 
cordial area  of  dulness,  except  hypertrophy,  must  be  eliminated.  (1) 
Pericardial  Effusion. — A  careful  analysis  of  the  physical  signs  and  the 
history  will  suffice.     (2)  AneuryHm. — In  this  affection  the  enlargement 


HYPFAITROPHY  OF  THE  HEART.  683 

is  altogether  upward  and  to  the  left  or  right.  This  fact,  joined  with 
the  other  evidences  of  aneurysm,  should  ohviate  error.  (3)  Mediastinal 
growths  also  enlarge  the  dull  space  mainly  upward  and  to  the  right  or 
left,  though  the  point  of  cardiac  contact  may  be  increased  and  the  heart 
carried  forward.  (4)  Displaceme'nt  of  the  heart  does  not  give  a  heaving 
impulse  nor  an  increased  area  of  dulness ;  moreover,  it  usually  furnishes 
its  special  cause  (pleural  effusion).  (5)  Abnormally  narrow-chested 
persons  present  a  considerably  increased  superficial  zone  of  dulness, 
partly  owing  to  the  position  assumed  by  the  lungs  and  partly  (perhaps 
chiefly)  to  their  imperfect  development.  Since  there  is  usually  an 
entire  absence  of  all  other  physical  signs  of  hypertrophy,  ordinary 
caution  will  exclude  the  latter  complaint.  (6)  Affections  of  the  Lungs 
and  Pleurae. — Left-sided  pleurisy  with  retraction  may,  by  exposing  a 
large  part  of  the  anterior  surface  of  the  heart,  give  rise  to  signs  of 
moderate  hypertrophy.  The  presence  of  the  former  condition,  the  lack 
of  lung-expansion  on  deep  inspiration,  the  displacement  of  the  heart  to 
the  left  and  upward,  and  an  absence  of  the  causes  of  hypertrophy  should 
lead  to  a  correct  conclusion.  (7)  Phthisis  and  cirrhosis  of  the  lung,  with 
or  without  pleurisy,  may  in  like  manner  produce  apparent  enlargement 
of  the  heart.  It  must  also  be  remembered  that  cirrhosis  of  the  lung  is 
one  of  the  causes  of  right-sided  hypertrophy,  and  that  the  latter  condi- 
tion may  therefore  be  present. 

ProgrnosiS  and  Course. — The  course  that  will  be  pursued  depends 
largely  upon  the  stage  at  which  the  case  has  arrived  and  the  character 
of  its  special  cause.  I  have  repeatedly  found  postmortem  evidence  of  a 
moderate  grade  of  hypertrophy  in  persons  who  died  of  other  affections, 
and  with  especial  relative  frequency  in  those  who  had  constantly  fol- 
lowed manual  pursuits.  Simple  cardiac  hypertrophy,  being  compensa- 
tory as  a  rule,  exerts  in  nearly  all  instances  a  salutary  influence,  and 
if  the  processes  that  constitute  the  causal  factors  are  not  steadily  pro- 
gressive, life  may  not  only  not  be  curtailed,  but  be  greatly  lengthened 
by  its  existence.  Even  in  organic  valvular  disease  of  the  heart  hyper- 
trophy prolongs  life  by  overcoming  the  ill  effects  of  the  valve-lesion 
and  by  maintaining  the  normal  circulatory  equilibrium.  But  since  in 
this  class  of  cases  the  lesion  is  progressive  despite  treatment,  a  limit  is 
reached  sooner  or  later  beyond  which  the  increased  vigor  on  the  part  of 
the  heart  cannot  be  maintained.  The  nutritive  functions  become  inade- 
quate in  obedience  to  a  natural  law,  and  muscular  degenerations  then 
occur,  followed  by  disturbances  of  the  circulation  due  to  cardiac  weak- 
ness and  secondary  dilatation.  It  must,  however,  be  recollected  that 
the  heart  may  at  no  time,  in  the  course  of  certain  cases,  fully  compen- 
sate for  the  causal  condition — e.  g.  as  when  a  valve  ruptures  with  start- 
ling suddenness.  Failure  of  the  cardiac  nutrition  at  once  renders  the 
prognosis  unfavorable.  The  cardiac  sounds  now  give  notice  that  the 
hypertrophy  no  longer  meets  the  requirements  of  the  case.  The  sys- 
tolic pause  grows  longer  (with  abbreviation  of  the  first  sound),  and  the 
diastolic  shorter.  Occasionally,  as  the  result  of  undue  muscular  exer- 
cise, acute  dilatation,  followed  by  a  speedy  termination  of  life,  is 
observed.  I  believe  that  hypertrophy  of  the  left  ventricle  warrants  a 
more  favorable  prediction  than  can  be  made  in  hypertrophy  of  the  right, 
and  this  for  two  reasons  :  first,  the  increased  capacity  for  work  of  the 


684  DISEASES  OF  THE  CIBCULATORY  SYSTEM. 

left  ventricle ;  second,  the  milder  character  of  the  many  factors  that  are 
j)roductive  of  left  ventricular  hypertrophy,  as  compared  with  those  of 
the  right.  In  special  instances,  however,  the  reverse  may  obtain,  as 
when  left-sided  hypertrophy  is  associated  with  or  caused  by  general 
arterial  degeneration.  It  may  be  of  advantage  to  the  student  and  junior 
physician  to  recapitulate  here  a  few  of  the  chief  points  that  are  prog- 
nostically  favorable  as  well  as  those  that  are  unfavorable:  Favorable 
Conditions. — (1)  When  the  hypertrophic  development  fully  compensates 
the  causal  lesion;  (2)  when  the  causes  are  removable  or  more  or  less 
amenable  to  treatment;  (3)  when  the  external  conditions  under  which 
the  patient  lives,  his  habits,  and  general  nutrition  are  good.  Unfavor- 
able.— (1)  "When  signs  of  imperfect  nutrition  of  the  heart  arise;  (2) 
when  evidences  of  advancing  cardiac  dilatation  (dyspnea,  rapid,  irregular 
pulse,  edema)  show  themselves;  (3)  when  poverty,  poor  food,  intemperate 
habits,  and  an  unhygienic  environment  are  all  combined  ;  (4)  when  appar- 
ent cardiac  vigor  suddenly  gives  place  to  dilatation  and  great  cardiac 
weakness. 

The  treatment  has  for  its  ])rime  object  the  prevention  of  failure  of 
compensation  on  the  one  hand  and  overhypertrophy  on  tlie  other  {vide 
Chronic  Valvular  Disease). 

Over-hypertrophy,  as  indicated  by  certain  cerebral  and  thoracic 
symptoms,  may  require  the  employment  of  measures  to  reduce  the  con- 
tractile energy  of  the  left  ventricle,  although  direct  cardiac  depressants 
(aconite,  and  the  like)  are  rarely  needed.  It  requires  careful  dietetic 
and  hygienic  management.  Briefly,  the  diet  should  be  nutritious,  but 
the  more  concentrated  forms  of  food  should  be  used  very  sparingly,  and 
the  daily  quantity  should  be  slightly  less  than  that  required  in  health. 
It  must  be  non-stimulating,  and  tea.  coifee,  alcohol  in  all  forms,  and 
smoking  must  be  prohibited.  The  physical  exercise  should  be  moderate 
in  amount  and  of  the  gentlest  sort ;  and  if  the  patients  occupation  tends 
to  stimulate  the  heart,  it  must  be  immediately  abandoned.  A  mild 
saline  purge  (gij  to  5ss — 8.0  to  16.0 — of  Rochelle  salts  once  daily)  is 
quite  beneficial. 

For  relief  of  the  cerebral  symptoms  (tinnitus  aurium,  vertigo, 
fulness)  and  the  precordial  discomfort  the  physiologic  relaxants  of  the 
capillaries  and  the  arterioles  are  of  great  service,  particularly  when 
arterio-sclerosis  is  a  traceable  cause.  Among  them  nitroglycerin  in  full 
doses  and  veratrum  viride  are  most  useful ;  the  efiicacy  of  both  may  often 
be  enhanced  by  the  addition  of  the  bromids.  In  cases  of  nervous  origin 
the  bromids,  with  preparations  of  valerian,  are  the  most  valuable  agents. 
Nothing,  however,  is  of  higher  importance  than  the  determination  and 
removal  of  the  cause  when  possible.  After  compensation  has  failed  the 
farther  treatment  is  identical  with  that  of  cardiac  dilatation. 


DILATATION  OF  THE  HEART. 

Definition. — By  dilatation  of  the  heart  is  meant  an  enlargement  of 
its  various  cavities.  The  walls  of  the  chambers  may  in  consequence  be 
thinner  than  in  health,  but  much  more  commonly  they  are  thicker,  as  in 
dilatation  with  hypertrophy.     Both  hypertrophy  and  dilatation  are  rela- 


DILATATION  OF  THE  HEART.  685 

tive  terms,  but  the  latter  has  reference  to  that  condition  in  which  the 
cavities  are  distended  out  of  proportion  to  the  diameter  of  their  walls. 

Varieties. — (1)  Dilatation  with  Hypertrophy. — Here  there  is  a  pro- 
gressive increase  in  the  capacity  of  the  chambers  until  tliey  attain  to 
large  dimensions.  The  cardiac  walls  continue  of  abnormal  thickness, 
yet  the  vigor  of  the  divisions  affected  may  be  relatively  diminished  to  a 
remarkable  degree,  owing  to  the  weakening  influence  of  the  degenerative 
processes  that  attack  the  hypertrophied  muscles.  In  eccentric  hyper- 
trophy the  heart-cavities  are  dilated,  but  the  hypertrophied  cardiac  walls 
are  sufficiently  vigorous  to  meet  the  demands  of  the  circulation.  This 
condition  should  not  be  regarded  as  identical  with  dilatation  with  hyper- 
trophy.,  but  frequently  merges  into  the  latter,  the  size  of  the  cavities 
now  being  proportionately  greater  than  is  the  thickness  or  the  functional 
power  of  their  walls. 

(2)  Dilatation  with  Thinning  of  the  Heart-walls. — The  diminution  in 
the  thickness  of  the  cardiac  muscles  may  be  slight  if  the  capacity  of  the 
chambers  involved  be  only  moderately  increased.  Instances  of  this  sort 
are  sometimes  seen  to  follow  prolonged  fever  (typhoid).  On  the  other 
hand,  the  process  of  attenuation  may  reach  a  high  grade,  the  greatlv 
thinned  cardiac  wall  being  scarcely  capable  of  holding  the  weight  of 
the  contained  blood. 

(3)  Dilatation  with  little  or  no  variation  from  the  normal  cardiac  wall 
has  also  been  described  by  some  authors.  It  is  to  be  observed,  however, 
that  stretching  of  a  cavity  whose  walls  are  of  normal  thickness  must  be 
attended  with  thinning  of  those  walls. 

Pathology. — Dilatation  with  hypertrophy  is  generally  secondary 
to  valve-lesions,  and  aff'ects  more  than  one  cavity  as  a  rule.  It  mav 
happen,  as  in  advanced  aortic  regurgitation,  that  all  the  divisions  are 
dilated.  The  right  ventricle  is  somewhat  more  frequently  dilated  than 
the  left,  however,  for  reasons  previously  adduced.  The  auricles  (espe- 
cially the  left)  are  more  frequently  expanded  than  the  ventricles ;  hence 
of  all  the  chambers  the  left  ventricle  is  least  apt  to  dilate.  The  extent 
of  the  relative  increase  in  the  capacity  of  the  cavities  is  variable,  and 
often  remarkable.  As  an  example  of  extreme  dilatation  of  a  chamber, 
the  left  auricle  in  cases  of  mitral  stenosis  may  be  singled  out ;  I  have 
seen  an  instance  in  which  this  auricle  was  capable  of  containing  twenty- 
two  ounces  of  blood.  The  septum  may  be  seen  to  bulge  when  one  ven- 
tricle only  is  stretched.  Extensive  dilatation  of  the  chambers  produces 
a  dilated  condition  of  the  auriculo-ventricular  rings,  which  in  turn  gives 
rise  to  relative  incompetency.  Other  cardiac  orifices  are  found  to  be 
similarly  dilated.  Dombrowski  ^  has  drawn  attention  to  the  fact,  first 
pointed  out  by  Wolf,  that  the  surface  of  the  mitral  leaflets  greatly  ex- 
ceeds the  orifice,  and  Kirschner  and  Garcin  contend  that  the  anterior 
flap  alone  suffices  to  close  the  mitral  orifice,  "  even  when  the  left  heart 
is  considerably  dilated."  Dombrowski  believes  that  functional  incom- 
petency is  due,  in  many  cases,  ''  to  muscular  dilatation,  producing  a 
separation  of  the  insertions  of  the  papillary  muscles,  which  in  systole 
cannot  approach  each  other  near  enough  to  allow  the  valves  to  close,  the 
contraction   of  the   papillary   muscles   only   increasing   the   difficulty." 

1  "  Functional  Insufficiency  of  the  Valves  of  the  Left  Heart,"  Bertie  de  Mtdccine,  Sept 
10,  1893. 


6S0  DISEASES   OF  THE  CIRrVLATORY  SYSTEM. 

Great  dilatation  ut"  the  left  auriculo-ventricular  ring  is,  however,  prob- 
ably an  important  factor  in  the  causation  of  relative  mitral  incompetency. 
The  tricuspid  valves,  being  scarcely  comj)etent,  normall}^  are  unques- 
tionably incompetent  when  that  orifice  is  considerably  dilated. 

The  shape  of  the  heart  is  altered  according  to  the  seat  and  extent  of 
the  dilatation.  When  all  the  cavities  are  dilated  the  organ  assumes  a 
globular  form,  while  dilatation  of  the  ventricles  only  produces  broaden- 
ing of  the  apical  region. 

Conditiou  of  the  Endocardium  and  Cardiac  Muscle. — The  muscular 
tissue  generally  exhibits  degenerations  (fibroid,  fatty,  or  parenchyma- 
tous). Important  as  is  the  part  played  by  the  ganglia  in  maintaining  the 
nutritive  integrity  of  the  heart  by  supplying  nervous  force,  our  knowledge 
of  the  alterations  that  may  occur  in  them  in  this  condition  is  as  yet  very 
imperfect.  Ott  and  others  have,  however,  found  them  to  be  degenerated. 
Opacity  and  patchy  roughening  of  the  endocardium  are  common.  The  pa- 
rietes  and  endocardium  may,  however,  have  a  normal  color  and  structure. 

Ktiology. — Entering  into  the  causation  of  cardiac  dilatation,  there 
are  two  essential  factors:  (1)  increased  endocardial  tension;  (2)  dimin- 
ished resistance.  These  often  act  together.  Broadbent  contends  that  the 
special  feature  of  dilatation  is  the  imperfect  emptying  of  the  ventricles. 

(1)  Increased  Endocardial  Tension. — It  is  to  be  premised  that  a  pri- 
mary and  a  secondary  form  occur,  the  latter  being  of  greater  importance 
clinically  than  the  former.  Primary  dilatation  occurs  from  a  recent  ob- 
struction to  the  circulation  of  considerable  magnitude  and  at  any  point 
throughout  the  blood-vessel  system.  A  good  example  is  afforded  by 
aortic  constriction,  in  which  condition  the  obstruction  of  the  aortic  ring 
engenders  dilatation  of  the  left  ventricle  by  raising  the  intraventricular 
pressure ;  this  is  quickly  overcome  by  compensatory  hypertrophy.  In 
the  vast  majority  of  these  instances  the  nutrition  of  the  muscular  fibers 
eventually  suffers,  with  consetjuent  dilatation. 

Other  causes  of  augmented  endocardial  pressure  have  been  considered 
in  the  discussion  of  Hypertrophy  and  Chronic  Valvular  Lesions.  In 
eccentric  hypertrophy  dilatation  is  a  compensatory  arrangement,  until 
finally  the  cardiac  nutritive  functions  fail  and  dilatation  at  once  predom- 
inates (dilatation  with  hypertrophy).  Compensation  has  now  been  rupt- 
ured. Among  the  exciting  factors  that  may  precipitate  this  accident 
are — recurrent  endocarditis,  intercurrent  febrile  affections  which  over- 
stimulate  the  heart  and  impair  its  muscular  tissue,  general  disturbances 
of  nutrition,  and  physical  and  mental  overstrain. 

Acute  primary  dilatation  may  be  brought  about  by  sudden,  great  ex- 
ertion, as  in  ascending  mountainous  elevations,  excessive  bicycling,  and 
the  like.  Under  these  circumstances  the  heart  palpitates  violently,  and 
there  are  epigastric  pulsation  and  often  pain  in  the  cardiac  region — evi- 
dences of  dilatation  of  the  right  ventricle.  Although  the  heart's  reserve 
capacity  for  work  has  been  exceeded,  rest  followed  by  moderate  exercisfe 
often  restores  the  conditions  to  the  normal.  I  have  seen  acute  primary 
dilatation  produced  by  strong  emotion  ;  here  sudden  contraction  of  the 
peripheral  vessels  occurs,  attended  with  arrest  of  the  heart's  action  ;  this 
soon  gives  place  to  violent  palpitation  and,  rarely,  to  dilatation.    Angio- 


DILATATION  OF  THE  HEART.  (j87 

spastic  dilatation  is  a  condition  due  to  acute  transitory  spasm  of  the 
vessels  (Jacob). ^     Sudden  fright  may  act  similarly. 

The  remarkable  endurance  of  the  athlete  and  the  gymnast  is  in  part 
owing  to  the  abnormal  amount  of  physiologic  cardiac  reserve  force 
which  they  naturally  possess,  but  it  is  mainly  due  to  the  invigorating 
effect  of  training.  If,  however,  the  training  be  not  so  conducted  as  sym- 
metrically to  develop  the  entire  muscular  system,  or  if  the  exertion  be 
in  excess  of  the  reserve  functional  power  of  the  heart,  then  acute  dila- 
tation may  suddenly  arise.  From  this  accident  (cardiac  fatigue)  recov- 
ery may  take  place;  sometimes,  however,  it  initiates  organic  valvular 
disease,  and  thus  prohibits  the  further  undertaking  of  unusual  feats. 
Acute  dilatation  has  been  made  conspicuous  by  recent  contributions,  in 
which  bicycling  is  assigned  as  the  cause. 

Appareyitly  idiopathic  cases  of  cardiac  dilatation  of  indeterminate 
etiology  rarely  occur. 

(2)  Diminished  Resistance  owing  to  Weakened  Cardiac  Walls. — The 
conditions  that  weaken  the  cardiac  wall  are  numerous,  and  not  a 
few  lead  to  acute  primary  dilatation,  such  as  myocarditis  due  to  acute 
specific  fevers  (scarlatina,  typhoid,  malaria,  typhus).  It  is  especially 
prone  to  occur  in  rheumatic  endocarditis  and  pericarditis.  B.  Robin- 
son' calls  forcible  attention  to  serious  dilatation  due  to  the  toxic  action 
upon  the  heart  muscle  of  the  rheumatic  poison.  The  chronic  degenera- 
tions (fatty,  fibroid)  impair  the  contractile  power  of  the  heart.  Nutri- 
tional disturbances  of  varied  origin,  such  as  digestive  disorders,  ill- 
ventilation,  lack  of  open-air  exercise,  and  improper  or  defective  food- 
supply,  may  induce  enfeeblement  of  the  cardiac  muscle.  Dilatation 
is  met  with  also  in  diseases  of  the  blood  (chlorosis,  anemia,  leukemia). 

Clinical  History. — In  acute  dilatation  the  onset  is  sudden.  It  is 
accompanied  by  rapidly  augmenting  dyspnea  and  cardiac  palpitation,  a 
feeling  of  coldness,  and  frequently  by  pain  in  the  precordial  region. 

The  physical  signs  may  be  incontestable.  They  are  venous  pulsation 
in  the  neck,  a  rapid,  feeble  apex-beat,  and  a  systolic  murmur  at  the  tri- 
cuspid valves,  all  of  which  declare  the  presence  of  tricuspid  regurgita- 
tion. In  angiospastic  dilatation  the  pain  may  begin  in  the  extremities, 
and  the  second  heart-sound  may  be  louder  at  the  apex  than  the  first. 
Among  signs  of  subsidiary  value  are  a  venous  turgescence,  a  marked 
epigastric  pulsation,  and  a  sudden  extension  of  dulness  to  the  right ;  the 
pulse  is  small,  irregular,  and  exceedingly  rapid. 

In  the  more  chronic  form  which  arises  from  slowly-acting  causes,  or 
in  that  which  accompanies  eccentric  hypertrophy  or  follows  simple  hy- 
pertrophy due  to  left-sided  heart-  or  lung-ti'ouble,  the  manifestations 
in  the  earlier  stages  are  not  striking.  They  indicate  weak  heart-walls, 
and  such  chambers  expel  their  contents  imperfectly  during  systole. 
With  each  subsequent  diastole  the  abnormal  amount  of  blood  contained 
in  them  is  increased.  This  blood-stasis  often  extends  from  the  left  heart 
to  the  pulmonai'y  vessels,  from  the  latter  to  the  right  heart,  and  finally 
to  the  general  venous  system.  Increased  viscosity  of  the  defibrinated 
blood  is  said  to  be  an  early  sign  of  cardiac  failure.  Both  in  the  acute 
and  chronic  forms,  however,  failure  of  the  right  ventricle  more   often 

'  Zeitschr.f.  klin.  Med.,  February  4,  1899. 

^  American  Journal  of  the  Medical  Sciences,  Dec,  1899. 


688  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

determines  rupture  of  compensation.  The  symptoms  are  chiefly  those  of 
tricuspid  incompetency.  Dilatation  of  the  right  heart,  without  tricuspid 
insufficiency,  is  a  frequent  complication  of  pulmonary  tuberculosis 
(Maisonneuvc  '). 

Physical  Signs. — Inspection  in  dilatation  of  the  left  ventricle  sho\y8 
the  apex-beat  to  be  displaced  outward  and  downward,  and  a  diffuse, 
weak,  fluttering,  and  often  distinctly  undulating  impulse.  The  apex- 
beat  will  show  a  greatly  diminished  vigor  in  its  normal  area;  or  there 
may  be  no  recognizable  point  of  strongest  impulse  as  in  health.  Dis- 
tinct pulsation  in  the  second  left  interspace  is  not  rare.  Its  feebleness 
and  diff'use  character  are  confirmed  by  palpation.  It  may  be  quick  and 
sharp,  though  always  lacking  in  power.  Walsh  first  made  the  capital 
observation — since  abundantly  corroborated — that  the  impulse  may  be 
visible,  yet  not  palpable.  There  may  be  a  mere  vibration  or  an  utter 
absence  of  the  apex-beat  in  advanced  cases.  The  pulse  is  small  (rarely 
large),  short,  often  rapid,  and  irregular.  Palpation  of  the  pulse  should 
always  be  combined  with  tiic  use  of  the  sphygmomanometer,  which  may 
show  an  unexpected  exaltation  of  the  blood-pressure,  especially  when 
dilatation  develops  somewhat  abruptly.  Percussion  shows  a  lateral 
increase  in  dulness  to  the  left,  to  or  even  beyond  the  mid-clavicular  line, 
upward  to  the  second  rib,  and  downward  as  for  as,  though  rarely  below, 
the  sixth  interspace,  except  perhaps,  in  rare  instances,  in  dilatation  with 
hypertrophy.     In  emphysema  the  lungs  unduly  overlap  the  heart. 

Dilatation  of  the  right  ventricle  demands  separate  consideration  so 
far  as  the  impulse  and  percussion-dulness  are  concerned.  The  normal 
impulse  is  largely  replaced  by  the  abnormal  apex-beat  of  the  right  ven- 
tricle, which  advances  to  the  anterior  chest-wall.  The  chief  impulse  is 
now  seen  and  feebly  felt,  as  a  rule,  below  the  xiphoid  cartilage,  or,  less 
commonly,  to  the  right  or  left  of  the  latter.  A  wavy  pulsation  is  seen 
to  the  left  of  the  sternum,  over  the  fourth,  fifth,  and  sixth  interspaces 
and  close  to  its  right  edge.  If  dilatation  of  the  right  auricle  be  asso- 
ciated, as  is  often  the  case,  a  distinct  pulsation  also  occurs  in  the  third 
right  interspace.  Dulness  reaches  to  a  point  1  inch  (2.5  cm.)  or  more 
beyond  the  right  sternal  border  on  a  level  with  the  fourth  interspace. 

On  auscultation  variable  results  are  obtained  according  to  the  state 
and  diameter  of  the  cardiac  walls.  When  thin  and  not  much  disorgan- 
ized, the  first  sound  is  much  shorter,  sharper,  and  louder  than  in  health. 
In  advanced  cases  the  systolic  sounds  may  be  feeble,  tliough  almost 
always  audible  in  the  aortic  area  (unlike  the  first  sound  in  hypertrophy). 
The  first  closely  resembles  the  second  sound,  the  long  pause  being  short- 
ened, resembling  the  systolic  pause  {fetal  heart-sounds).  This  form  of 
arrhythmia  is  a  serious  indication  of  failure  of  the  ventricles.  The  ran- 
ter rhythm  is  equally  common.  Irregular  and  intermittent  cardiac  action 
are  usual  phenomena.      Reduplication  rnay  occur,  but  is  not  fre(iuent. 

Pre-existing  organic  murmurs  obscure  the  sounds  due  to  dilatation, 
and,  on  the  other  hand,  the  dilatation  may  also  alter  the  murmurs  (pre- 
viously audible),  and  even  cause  them  to  disappear,  as,  for  example,  in 
mitral  stenosis.  Again,  dilatation  may  induce  relative  incompetency  or 
superadd  a  murmur,  as  in  cases  of  chronic  valvular  disease  at  the  auriculo- 
ventricular  orifices.  It  is  interesting  to  recall  here  that  proper  treat- 
1  G'oa.  hehdom.  de  Med.  et  de  Ghir.,  Oct.  30, 1898,  No.  45 ;  Ann^e,  No.  87. 


DLL  AT  AT  [ON  OF  THE  HEART.  fJ89 

ment  may  remove  a  murmur  due  to  relative  insufficiency,  and  that  this 
treatment  may,  in  turn,  reproduce  an  organic  murmur. 

Diagnosis. — This  is  made  readily  when  theie  is  obtainable  a  clear 
history,  together  with  the  following  characteristic  features:  a  weak, 
irregular  heart  action  (throbbing  of  the  precordium) ;  an  extended,  wavy 
impulse ;  a  small,  vigorless,  and  intermittent  pulse  ;  often  an  indistinct 
apex-beat;  an  outward,  upward  increase  in  the  percussion-dulness  on  one 
or  both  sides,  causing  the  outline  to  resemble  a  square ;  and  a  brief, 
sharp,  yet  feeble  first  sound  that  resembles  the  second,  which  is  enfeebled. 

Differential  Diagnosis. — Hypertrophy.,  like  dilatation,  gives  rise  to  an 
extended  area  of  impulse  and  of  percussion-dulness ;  hence  by  the  care- 
less observer  these  conditions  are  sometimes  sadly  confounded.  From 
dilatations,  in  which  the  diagnosis  rests  upon  the  points  above  enumer- 
ated, hypertrophy  is  to  be  distinguished  by  symptoms  of  an  opposite 
nature,  such  as  indicate  increased  energy  on  the  part  of  the  heart.  The 
latter  are — a  slovr,  heaving  impulse  ;  a  full,  sustained,  regular  pulse ;  an 
increase  in  the  area  of  dulness,  chiefly  outward  and  downward  ;  abnor- 
mal position  of  the  apex-beat ;  and  the  prolonged,  dull  first  and  accen- 
tuated second  sounds.  To  determine  the  point  at  which  eccentric  hyper- 
trophy ends  and  dilatation  (with  hypertrophy)  begins  is  often  difficult; 
and  I  have  already  discussed  the  initial  symptoms  of  dilatation  following 
hypertrophy  (chiefly  of  the  right  ventricle)  in  connection  with  Chronic 
Valvular  Disease.  Occurring  in  left  ventricle  hypertrophy,  dilatation 
first  betrays  itself  by  a  change  in  the  position  of  the  visible  apex-beat  and 
the  palpable  impulse.  Thus,  the  maximum  point  of  the  apex-beat  of 
hypertrophy  very  early  becomes  rounded  and  indefinite,  and  later  is 
diffuse  and  wavy.  The  strong,  heaving  thrust  of  the  impulse  gives  place 
to  the  shorter,  more  sudden  shock  of  commencing  dilatation,  indicating 
weakness.  These  signs,  together  with  a  reduction  in  the  strength  and  an 
increased  frequency  or  irregularity  of  the  pulse,  show  the  condition  to  be 
dilatation  with  hypertrophy. 

The  prognosis  is  bad,  as  a  rule,  being  that  of  the  causative  factors. 

Treatment. — This  in  all  essential  particulars  is  identical  with  the 
treatment  of  organic  heart  affections  after  rupture  of  compensation.  The 
etiology  in  many  cases  differs  from  that  of  the  organic  valvular  affections 
of  the  heart;  and  the  removal  of  the  remote  and  near  causes  of  the 
dilatation  is  the  most  important  part  of  the  treatment.  Individual  cases 
frequently  present  special  indications  ;  but  in  all  the  work  of  the  heart 
is  increased  and  the  propulsive  power  of  the  organ  diminished.  The  indica- 
tions are  to  diminish  the  heart's  labor  by  bodily  and  mental  rest,  light 
diet,  purgation  and  relaxing  the  peripheral  vessels  (T.  A.  Claytor),  and  to 
increase  the  functional  power  of  the  heart  by  the  use  of  cardiants,  baths, 
and  massage.  In  cases  of  non-valvular  origin  digitalis  and  other  heart 
stimulants  may  be  omitted  early,  as  a  rule ;  though  they  should  be  resumed 
if  there  be  a  recurrence  of  serious  indications  of  dilatation.  The  best  guide 
in  the  treatment  is  the  sphygmomanometer,  which  should  be  employed  at 
intervals  of  several  days.  When  the  dilatation  has  been  overcome,  care- 
ful attention  is  to  be  bestowed  upon  all  the  details  of  the  patient's  life  and 
sanitary  surroundings  in  order  to  force  his  bodily  nutrition  to  the  utmost. 
Every  precautionary  measure  having  for  its  aim  the  prevention  of  a  recur- 
rence of  the  dilatation  must  also  be  advised  and  enjoined. 

44 


690  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

MYOCARDITIS. 

( Carditis.) 

Definition. — An  inflammation  of  the  muscle-substance  of  the  heart 
It  may  hv  acute  or  chronic. 

ACUTE    MYOCARDITIS. 

Pathology  and  Varieties. — (1)  Acute  Parenchymatous  Myocarditis. 
— This  is  characterized  by  a  granular  degeneration  of  the  muscular  fibers 
of  the  parenchyma  of  the  organ,  with  a  numerical  increase  in  their  nu- 
clei. The  muscle-structure  throughout  looks  pale,  is  turbid,  and  very 
soft.      Many  cases  of  a  severe  ty])e  terminate  in  fatty  degeneration. 

(2)  Acute  Diffuse  Interstitial  Myocarditis. — Here  the  primary  altera- 
tions affect  the  connective  tissue  of  the  myocardium ;  the  histologic 
changes  consist  in  round-cell  infiltration. 

(3)  Acute  Circumscribed  Myocarditis. — In  this  variety  the  degenerative 
processes  result  in  necrosis  of  the  tissues  over  large  or  small  areas,  with 
abscess-formation.  Though  usually  multiple,  these  abscesses  vary  in 
number,  and  may  rupture  either  into  the  various  cardiac  chambers  or 
into  the  pericardium.  Thus,  the  purulent  contents  of  the  abscess,  when 
there  is  established  a  fistulous  communication  with  an  endocardial 
chamber,  find  their  way  into  the  blood-stream,  frequently  setting  up  em- 
bolic processes  of  an  infectious  nature  in  the  various  viscera.  The  blood 
in  turn  enters  the  abscess-cavity,  exerting  pressure  on  its  walls,  and 
may  either  produce  an  acute  aneurysmal  dilatation  of  the  heart-wall  or 
occasion  fatal  rupture  into  the  pericardium.  More  commonly  the  con- 
nective-tissue wall  of  the  abscess  yields  gradually  during  the  ventricular 
diastole.  Occurring  in  the  vicinity  of  one  of  the  auriculo-ventricular 
valves,  abscesses  may  cause  mitral  or  tricuspid  incompetency.  They 
may  perforate  the  interventrictilar  septum,  thus  creating  a  fistulous  con- 
nection between  the  two  sides  of  the  heart,  and  resulting  in  an  inter- 
min^lincr  of  venous  and  arterial  blood.  The  abscess  mav  become  en- 
cysted,  then  caseous,  and  finally  undergoes  a  calcareous  process.  Multiple 
abscesses  usually  afi"ect  the  left  ventricle. 

Ktiology. —  The  causes  of  myocarditis  are — {a)  endo-  and  pericar- 
ditis in  the  course  of  rheumatism  :  it  is  probable  that  rheumatic  myo- 
carditis may  also  exist  without  involvement  of  the  endo-  or  pericardium  ; 
(6)  the  infectious  processes  in  acute  specific  fevers  (influenza,  diphtheria, 
typhoid);  (f)  infectious  emboli,  lodging  in  the  branches  of  the  coronary 
arteries  in  connection  with  septicemia,  pyemia,  and  acute  ulcerative 
endocarditis,  and  commonly  terminating  in  abscesses  (circumscribed 
myocarditis).  The  first  two  of  these  causes  give  rise  to  acute  diffuse 
interstitial  and  acute  parenchymatous  myocarditis,  as  a  rule,  although 
Freund  calls  attention  to  the  frequency  with  which  circumscribed  myo- 
carditis is  associated  with  rheumatism  and  diseases  of  the  joints.  As  com- 
pared witli  the  female  .sv'.r,  the  male  suffers  much  more  frequently. 

Symptoms  and  Diagnosis. — The  symptoms  are  practically  nega- 
tive. They  point  merely  to  great  cardiac  enfeeblement.  When  cardiac 
weakness,  as  shown  by  a  rapid,  small,  compressible,  and  arrhythmic /j»m^s<?, 
and  by  attacks  of  cardiac  palpitation  and  syncope,  comes  on  suddenly 


CHRONIC  MYOCARDITIS.  601 

in  the  course  of  rheumatism,  septicemia,  or  other  causal  affections,  myo- 
carditis may  be  suspected.  Later,  signs  of  venous  stastH  appear.  The 
systolic  blood-pressure  is  commonly  low,  though  fluctuating,  varying 
from  100  to  less  than  80  mm.  Jig.  The  mental  symptoms  may  sugf'cst 
meningitis  or  salicylic-acid  poisoning.  Koplik^  calls  attention  to  certain 
symptoms  (pallor,  faintness,  vomiting,  irregular,  feeble  h(;art-action,  dis- 
turbed respiration,  and  pulse-ratio)  that  should  arouse  suspicion  of  myo- 
carditis in  the  course  of  an  infectious  disease  in  childhood. 

The  physical  signs  simulate  those  of  dilatation,  and  may,  indeed,  be 
largely  dependent  upon  the  presence  of  the  latter  condition.  Early  the 
action  of  the  heart  is  tumultuous ;  the  sounds  on  auscultation  are  short, 
sharp,  and  finally  very  feeble.  Murmurs  ilV  myocarditis  are  not  rare,  and 
are  not  necessarily  dependent  upon  dilatation.  Krehl's  work  shows  the 
dependence  of  the  valves  for  their  complete  closure  upon  a  normal  state 
of  different  portions  of  the  heart-muscles,  and  thus  explains  these  mur- 
murs. The  special  conditions  rendering  the  murmurs  audible  are  great 
dilatation,  softening  of  the  papillary  muscle,  and  abscesses  near  the  valves. 

The  great  variability  as  to  the  intensity  of  these  murmurs  is  an  im- 
portant point,  especially  in  attempts  to  discriminate  from  murmurs  due 
to  endocardial  changes.  The  latter  usually  coexist  with  a  more  marked 
accentuation  of  the  second  pulmonary  sound.  For  the  recognition  of 
cardiac  aneurysm,  see  p,  700.  The  symptoms  of  visceral  or  cutaneous 
embolic  processes,  combined  with  a  murmur  and  a  septic  type  of  fever, 
are  suspicious  of  the  existence  of  circumscribed  myocarditis.  The  murmur 
of  relative  tricuspid  regurgitation  and  the  venous  pulse  may  eventually 
develop,  accompanied  by  the  symptoms  of  general  venous  engorgement. 

Prognosis. — The  diffuse  forms  are  often  fatal ;  the  circumscribed 
form  rarely  eventuates  in  recovery.     Myocarditis  may  end  life  suddenly. 

The  treatment  is  identical  with  that  indicated  for  endocai'ditis  and 
pericarditis — diseases  of  which  myocarditis  is  often  a  complication.  The 
effects  of  digitalis,  particularly  when  myocarditis  supervenes  upon  old 
heart-lesions,  are  quite  unsatisfactory,  but  diffusible  stimulants — e.  g., 
aromatic  spirit  of  ammonia,  brandy,  and  the  like — are  useful.  When 
myocarditis  is  suspected  as  an  independent  condition  absolute  rest  must 
be  enjoined,  the  general  nutrition  maintained,  and  the  more  urgent 
symptoms  relieved. 

CHRONIC   MYOCARDITIS. 

( Fibrous  ■  Myocarditis.) 

Definition. — A  gradually  developing  inflammation  of  the  cardiac 
interstitial  connective  tissue,  resulting  in  induration.       • 

Pathology. — The  characteristic  changes  may  be  diffuse,  though 
most  frequently  they  are  confined  to  certain  portions  of  the  muscular 
structure,  the  left  ventricular  wall,  the  septum,  and  the  papillary  muscles 
being  the  three  favorite  seats  of  the  process.  This  is  sometimes  of  ante- 
natal development,  and  then  its  usual  seat  is  near  the  apex  of  the  right 
ventricle.  The  hardened  spots  take  the  form  of  more  or  less  rounded 
patches  or  broad  lines.  In  color  they  are  gray,  grayish-white,  or  gray- 
ish-yellow, the  latter  tint  being  due  to  the  intermingling  of  fibers  that 
have  undergone  fatty  degeneration.  Their  size  is  exceedingly  variable, 
some  being  so  minute  as  to  elude  detection  by  the  unaided  eye.  while 

^  Medical  News,  March  31,  1900. 


692  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Others  measure  1  or  2  inclies  (2.5-5  cm.)  in  diameter.  Inflamma- 
tory induration  (contraction)  of  tlie  con  us  arteriosus  of  either  ventricle 
causes  narruwinji;  of  the  j)uhuonary  and  aortic  orifices,  with  the  usual 
signs  and  symptoms.  Similar  changes,  hy  disturbing  the  functions  of  the 
papillary  muscles,  produce  valvular  incompetency.  Compensatory  hyper- 
trophy of  the  uninvolved  portion  of  the  heart  is  also  observed  ;  the  hyper- 
trojihic  enlargement  may  frecjuently  be  accounted  for  in  part  either  by  an 
associated  chronic  endocarditis  or  general  arterial  sclerosis.  Dilatation  of 
the  ventricles  follows,  with  fresh  and  grave  disturbances  of  the  circulation. 

Chronic  inflammation  usually  attacks  early  the  intima  of  the  coro- 
naries,  and  leads  to  thrombosis,  with  the  formation  of  anemic  infarcts 
(ride  p.  695).  It  is  probaMe  that  most  cases  of  localized  fibrous  myo- 
carditis have  their  origin  in  an  obliterating  endarteritis.  Pasquier  ofters 
proof  that  myocarditis  results  from  chronic  congestion  due  to  stopping  of 
the  vessels.  The  calloused  zone  may  yield  to  the  endocardial  blood- 
tension,  and  tlms  produce  saccular  dilatation  (aneurysm).  Mlrroscnplcallif, 
the  affection  is  characterized  by  hyperplasia  of  the  interfibrillar  connec- 
tive tissue  with  subsequent  development  of  new  fibrous  tissue.  Fatty 
degeneration  and  atrophy  of  the  muscle-fibers  (due  to  compression)  are 
also  observed.  Fragmentation  of  the  muscle-fibers  (the  etat  segvieutaire 
of  Renant)  has  also  been  observed.     This  occurs  as  a,  2)ostmorfetn  change. 

!Btiology. — The  disease  is  most  commonly  traceable  to  the  action 
of  one  or  more  of  the  following  factors :  an  excess  in  the  use  of  alcohol 
or  tobacco,  lead-jyoisoning ,  phosphorous,  gout,  rheumatism,  tUahetes, 
chronic  nephritis,  malaria,  and  sijphilis.  Thus,  it  may  be  produced  by 
many  infections  and  chemical  irritants,  the  latter,  in  most  cases,  first 
causing  a  sclerosis  of  the  coronary  arteries,  to  which  the  patchy  fibroid 
degeneration  is  secondary.  Some  of  the  causes  of  acute  diff'use  interstitial 
myocarditis  may  by  their  more  slightly  irritant  effect  lead  to  the  subse- 
quent development  of  the  general  chronic  form  {e.  g.,  rheumatism). 
Certain  irritants  that  engender  localized  lesions  of  chronic  myocarditis 
may  affect  the  entire  myocardium  (syphilis,  alcohol,  gout).  Certain 
exhausting  diseases,  as  dysentery,  carcinoma,  and  the  anemias,  may  act 
as  causes.  Chronic  myocarditis  may  arise  in  consequence  of  a  direct 
extension  of  the  inflammatory  processes  in  chronic  endo-  and  pericarditis ; 
it  may  also  follow  injuries  of  the  anterolateral  thoracic  region.  Sex 
and  age  possess  a  predisposing  eff'ect,  the  disease  being  more  common  in 
males,  and  after  middle  life  than  before  that  period.  The  right  ventricle 
is  apt  to  be  the  seat  of  chronic  myocarditis  during  fetal  life,  if  at  all. 

Symptoms. — Extensive  indurated  myocarditis  has  been  met  with 
vast  mortem  in  numerous  instances  that  have  been  unattended  by  per- 
ceptible symptoms  during  life.  In  many  of  these  cases  the  presence  of 
compensatory  hypertrophy  accounts  for  the  absence  of  any  symptoms, 
and  it  may,  therefore,  be  inferred  that  mild  grades  that  fail  to  manifest 
themselves  must  fretjuently  exist.  The  symptoms  when  present  are, 
almost  without  exception,  untrustworthy  for  diagnostic  pu^^poses,  since 
thev  bear  a  striking  resemblance  to  those  of  the  organic  valvular  dis- 
eases,  minus  their  more  characteristic  physical  signs.  Among  the 
earliest  phenomena  tliat  point  merely  to  failing  heart-power  are  dys- 
pnea, and  sometimes  also,  on  exertion,  palpitation  and  a  sense  of  heavi- 
ness or  constriction  in  the  precordia.  The  patient  suff'ers  from  marked 
general  debility,  and  becomes  fatigued  in  consequence  of  the  slightest 


CHRONIC  MYOCARDITIS.  ^393 

physical  exertion.  Mental  inerlia  is  tlio  rule,  and  chronic  mania  may 
come  on  and  last  to  the  close.  Later,  more  positive  disturbances  of  the 
circulation  gradually  arise,  and  when  the  breathing  becomes  more  diffi- 
cult (cardiac  asthma)  signs  of  venous  stasis  affecting  the  liver,  gastro- 
intestinal tract,   and  kidneys,  and  edema  finally  appear. 

Two  symptoms  that  are  frequently  manifested,  and  not  without  some 
diagnostic  import,  remain  to  be  mentioned :  (1)  Angina  pectoris.,  Avhich 
is  attributable  to  the  sclerosed  condition  of  the  coronary  arteries. 
(  Vide  Angina  Pectoris,  p.  713).  It  is  often  followed  by  some  form  of 
arrhythmia.  Recurring  paroxysms  of  angina  pectoris,  with  or  without 
arrhythmia,  may  be  the  only  phenomena  of  the  disease. 

(2)  Cardiac  Arrhythmia. — Brachycardia  is  associated  as  a  rule,  there 
being  a  reduction  in  the  pulse-rate  to  50  or  even  40  beats.  With  this 
decreased  rate  intermittency  is  often  combined,  and  various  other  forms 
of  disturbed  rhythm  are  also  observed — e.  g.,  the  phenomena  of  the 
Stokes.-Adams  syndrome  and  extrasystoles.  Slowing  of  the  pulse  does 
not  prohibit  the  cardiac  palpitation  tiiat  is  apt  to  arise  during  anginal 
attacks.     Arrhythmia,  however,  may  be  entirely  absent. 

Chronic  myocarditis  may  be  the  sole  cause  of  the  pseudo-a2}02)lectic 
seizures  that  often  terminate  life  abruptly.  Preceding  the  unexpected 
attack  the  patient,  usually  advanced  in  life,  may  have  experienced  from 
time  to  time  slight  vertigo,  syncope,  and  oppression.  These  seizures  may 
also  be  caused  by  a  heavy  meal  or  intense  mental  or  physical  exertion, 
and  may  consist  in  a  momentary  loss  of  consciousness.  At  other  times 
they  last  a  number  of  hours,  and  are  accompanied  by  paralysis  which 
outlasts  the  coma,  as  a  rule,  by  a  few  hours  onl}^  Convulsive  twitchings 
may  be  present.  During  the  attack  cerebral  hemorrhage  may  occur  and 
leave  the  patient  hemiplegic.  It  is  highly  characteristic  of  these  pseudo- 
apoplectic  seizures  that  they  tend  to  recur,  sometimes  at  intervals  of  a 
few  hours  for  a  day  or  two,  but  more  commonly  at  longer  intervals  during 
many  weeks  or  months. 

Physical  Signs. — The  impulse  may  be  feebly  heaving  (sometimes 
absent) ;  the  apex-beat  is  displaced  downward  and  to  the  left,  while  the 
dull  area  is  enlarged  correspondingly  in  the  same  direction.  The  pulse 
is  slow,  irregular,  and  the  blood-pressure  more  or  less  elevated.  Should 
fatty  degeneration  be  conjoined,  the  pulse  may  be  quickened  and  irregu- 
lar, and  this  effect  likewise  obtains  when  the  patient  escapes  sudden  death 
and  the  usual  dilatation  supervenes.  Quite  early  the  heart-sounds  may 
be  clear  and  strong,  owing  to  compensatory  hypertrophy  of  the  healthy 
portion  of  the  myocardium,  but  subsequently  they  become  weak  and 
muffled. 

With  the  occurrence  of  dilatation  comes  an  apical,  systolic  murmur 
(due  to  relative  incompetency),  with  a  gallop  rhythm  of  the  heart.  A 
contraction  of  the  papillary  muscles  and  of  the  chordse  tendinfe  may  cause 
mitral  incompetency  with  its  customary  murmur  during  compensation. 

Differential  Diagnosis. — (1)  Chronic  valvular  disease  can,  as  a 
rule,  be  eliminated  prior  to  the  occurrence  of  secondary  dilatation,  in 
the  course  of  fibrous  myocarditis,  but  not  after  that,  even  though  chronic 
endocarditis  manifests  the  greater  degree  of  hypertrophy.  During  the 
period  of  compensation  murmurs  do  not  occur  in  myocarditis  unless  the 
valvular  adnexa  (the  chordae  and  papillary  muscles)  are  affected.  In 
cases  in  which  these  structures  are  involved,  the  secondarv   alterations 


694  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

in  the  heart,  tlie  symptoms,  and  whole  course  of  the  comphiint  are  the 
same  as  in  certain  chronic  valvuhir  lesions. 

{'2)  Idiopathic  llypcrtroiiliy. — After  the  occurrence  of  dilatation., 
following  indurated  myocarditis,  the  difterential  diagnosis  between  the 
latter  and  hy))ei;trophy,  with  secondary  dilatation,  so  far  as  the  physical 
signs  and  accompanying  symptoms  are  concerned,  is  purely  conjectural. 
A  clear  history  may  furnish  differential-diagnostic  points  before  failure 
of  compensation  occurs  :  for  example,  evidences  of  decided  arterio-sclero- 
sis,  due  to  syphilis,  would  be  in  favor  of  chronic  myocarditis. 

(3)  Fatty  overyroicth  must  be  distinguished  from  fibrous  myocarditis, 
and  is  met  with  chiefly  in  brewers,  publicans,  and  butlers.  The  disease 
is  also  found  to  be  specially  related  to  obesity,  and  sometimes  to  over- 
eating and  drinking,  combined  with  indolent  habits.  These  subjects 
suffer  more  frei|uently  from  bronchitis,  emphysema,  and  nocturnal  asthma 
than  j)atients  having  chronic  myocarditis  alone.  Slight  vertigo  is  com- 
mon, but  true  syncopal  attacks  are  rare.  In  fatty  overgrowth  the  heart- 
sounds  are  weak  and  decidedly  muffled  throughout ;  the  pulse  is  weak, 
though  regular  as  a  rule  and  of  normal  rate. 

Progfnosis. — Chronic  myocarditis  is  a  fatal  disease.  Its  course  and 
duration,  however,  are  subject  to  great  variations.  Among  unfavorable 
surroundings  are  certain  causal  and  associated  conditions,  particularly 
arterio-sclerosis,  chronic  interstitial  nephritis,  and  diabetes  raellitus.  On 
the  other  hand,  if  syphilis  has  been  the  cause,  hope  for  temporary  improve- 
ment, if  not  for  actual  cure,  may  be  reasonably  entertained.  Sudden 
death  may  result  from  a  blocking  of  a  vessel  that  is  the  seat  of  sclerosis. 

Treatment. — The  treatment  should  be  managed  according  to  the 
considerations  pointed  out  in  the  treatment  of  Organic  Valvular  Dis- 
ease. Rest  of  body  and  mind  is  imperative.  Next  to  this  come  the 
dietetic  and  hygienic  details.  Residence  in  a  mild  climate  in  winter 
and  a  change  to  the  country  or  to  a  moderate  elevation  in  summer  are 
advisable.  Cases  caused  by  syphilis  are  favorably  influenced  by  the 
iodids.  Those  rather  frequent  cases  that  present  such  closely  united 
conditions  as  arterio-sclerosis,  gout,  and  chronic  nephritis  sometimes  do 
well  while  sojourning  at  certain  mineral  springs,  such  aa  Marienbad, 
Carlsbad,  Kissengen  abroad,  and  Bedford  or  Saratoga  at  home  These 
waters  must,  however,  be  cautiously  used.  Bell,^  after  excluding  ad- 
vanced arterial  fibrosis,  aneurysm,  and  advanced  cardiac  insufficiency 
with  droi)sy,  recommends  saline  baths  administered  in  a  manner  similar 
to  the  artificial  Nauheim  baths  [vide  p.  672).  The  Oertei  cure  (protein 
diet,  restriction  of  fluid  intake,  graduated  exercises  up  hill)  may  prove 
serviceable. 

When  dilatation  arises  cardiac  stimulants  are  called  for,  but  must  be 
used  with  an  unusual  degree  of  caution.  Strychnin  has  proved  itself 
to  be  valuable  if  perseveringly  exhibited,  and  here,  as  elsewhere,  digi- 
talis deserves  a  trial ;  its  careless  administration,  however,  may  give  bad 
results  if  the  pulse  be  much  retarded  or  arterio-sclerosis  coexist.  For 
the  anirina  pectoris  morphin,  administered  hypodermically,  is  to  be  pre- 
ferred. Recurrences  of  this  distressing  symptom  may  be  averted  by  the 
cautious  use  of  nitroglycerin,  the  use  of  which  should,  however,  be 
limited  to  cases  that  seem  to  be  dependent  upon  arterial  degeneration 
1  Medical  News,  New  York,  May  7,  1904. 


DISEASES  OF  THE  CORONARY  ARTERIES.  695 

with  high  tension.  Attacks  of  syncope  are  most  successfully  met  by  the 
hypodermic  use  of  the  diffusible  stimulants  (ammonia,  etlier),  and  at  tbe 
same  time  by  putting  the  patient  at  rest  with  the  heud  lowered. 


DISEASES  OP  THE  CORONARY  ARTERIES. 

It  has  previously  been  noted  that  in  pyemia  and  allied  disorderB 
septic  emboli  may  block  the  branches  of  the  coronary  arteries,  causing 
suppurative  infarcts  (acute  circumscribed  myocarditis). 

It  has  also  been  shown  that  one  of  the  chief  effects  of  sclerosis  affect- 
ing the  coronary  arteries  is  the  production  of  chronia  myocarditis. 
Sudden  blocking  of  one  coronary  artery  by  an  embolus  causes  instant 
death.  In  numerous  instances  in  which  death  has  occurred  suddenly 
either  thrombotic  or  embolic  obstruction  has  been  the  only  discoverable 
post-mortem  lesion.  In  others  the  pathologic  evidences  of  local  or  general 
atheroma  have  coexisted.  Ligation  or  plugging  of  the  coronary  vessels 
in  the  lower  animals  causes  arrhythmia  or  even  an  abrupt  arrest  of 
cardiac  action ;  a  partial  or  even  slight  reduction  in  the  lumen  of  the 
coronary  vessels  by  diminishing  the  supply  of  blood  to  the  heart-muscle 
induces  degenerations  in  the  latter.  Kronecker  found  that  occlusion  of 
the  coronary  arteries  by  injecting  paraffin,  even  when  it  solidified  in 
only  the  smaller  branches,  caused  the  heart  to  become  irregular,  and 
to  stop  almost  at  once.  The  anatomic  peculiarity  of  the  coronary 
arteries  in  that  they  are  end-arteries  is  to  be  noted,  since  it  affords  a 
ready  interpretation  of  the  usual  effects  following  total  or  partial  occlu- 
sion. According  to  F.  H.  Pratt,  however,  the  vessels  of  Thebesius, 
which  extend  from  the  auricles  and  ventricles  to  the  myocardial  capil- 
laries and  coronary  veins,  may  rarely  maintain  the  nutrition  of  the 
heart-muscles  even  after  occlusion  of  the  coronary  arteries. 

The  blocking  of  the  terminal  branches  by  emboli  or  by  the  formation 
of  thrombi  usually  produces  the  so-called  anemic  necrosis  or  xvhite  in- 
farct— a  condition  that  deserves  brief  description : 

Anemic  necrosis  (anemic  infarct)  is  met  with  most  frequently  in  the 
left  ventricle  and  septum,  which  receive  their  blood  from  the  anterior 
coronary  artery.  The  involved  areas  are  small  and  circumscribed,  and 
present  ii-regular  margins  that  project  slightly  above  the  surface.  Rarely 
the  infarct  is  wedge-shaped.  Its  color  is  grayish-white  or  grayish-red, 
while  the  central  portion  is  often  white  and  firm ;  less  frequently  it 
breaks  down  into  a  soft  detrital  mass  {^myomalacia  cordis).  When 
softening  does  not  occur  the  fibers  lose  their  nuclei,  becoming  first  hya- 
line and  subsequently  sclerotic.  The  histologic  changes  are  of  two  sorts : 
(a)  the  striae  of  the  muscle-fibers  are  lost,  the  latter  becoming  granular 
and  breaking  down ;  and  (h)  the  fibers  assume  a  homogeneous  hyaline 
appearance,  the  nuclei  having  disappeared. 

The  symptomatic  consequences  of  the  lesions  are  often  obscure  and 
unreliable.  Sudden  death  may  take  place,  and  rarely  this  accident 
may  be  due  to  rupture  of  the  heart.  Weak  and  irregular  action  of  the 
heart,  evidences  of  embarrassed  circulation  (especially  in  the  cardio- 
pulmonary circuit,  as  shown  by  cough  and  dyspnea),  and  finally  an- 
gina pectoris,  are  among  the  principal  features  observed.  Death  may 
ensue  in  the  first  attack.     The  paroxysms  are  presumed  to  be  due  to 


G'M  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

sudden  occlusion  of  a  branch  of  the  coronary  artery  ;  but  it  shoukl  be 
stated  that  occasionally  in  fatal  instances  of  true  .in;i;ina  pectoris  a  total 
absence  of  lesions,  including  emboli,  has  been  noted.  I  desire  to  lay 
stress  upon  the  medico-legal  importance  of  coronary  disease;  it  may  be 
the  only  lesion  found  in  cases  of  quick  death. 


DEGENERATIONS  OF  THE  HEART. 

(a)  Fatty. — The  term  "fatty  heart"  includes  two  pathologically  dis- 
tinct affections:  (1)  Fatty  degeneration,  in  which  the  cardiac  muscle- 
fibers  have  been  converted  into  fat ;  and  (2)  Fatty  overgrowth,  in  which 
an  abnormal  quantity  of  fat  is  deposited  in  and  about  the  heart.  Ac- 
cording to  Leyden,  the  cases  of  "  fat-heart''  (fatty  overgrowth)  are  divis- 
ible into  two  subclasses :   {a)  fatty  overgrowth,  and  (6)  fatty  infiltration. 

FATTY  DEGENERATION. 

Pathologfy. — The  condition  may  be  either  general  or  localized.  Its 
most  frequent  seat  is  in  the  left  ventricle,  the  papillary  muscles  and 
trabeculse,  first  appearing  as  yellowish  spots  or  stripes  beneath  the  en- 
docardium. The  affected  portions  are  light  yellow  or  yellowish-brown 
(faded  leaf)  in  color,  due  to  an  associated  brown  atrophy ;  they  are  soft 
and  friable,  and  are  easily  lacerated.  The  heart  is  enlarged  and  its  walls 
lack  firmness.  The  microscope  reveals  characteristic  changes  :  the  striae 
and  nuclei  begin  to  fade,  oil-drops  and  granules  appear  in  the  fibers,  and 
finally  the  latter  are  occupied  throughout  by  minute  globules. 

Htiology. — Fatty  degeneration,  as  already  mentioned,  occurs  in  both 
the  pi'iniari/  an<l  secondary  forms  of  cardiac  Jiyijertropliy .  It  is  found 
in  association  Avith  fatty  change  in  other  organs  in  severe  forms  oi primary 
and  secondary  anemias.  It  is  most  common,  however,  in  the  cachectic 
states  produced  by  such  chronic  diseases  as  carcinoma  and  phthisis,  and 
in  the  course  of  acute  infectious  diseases  of  intense  type.  Warthin  finds 
that  focal  or  diffuse  fatty  degeneration  of  the  myocardium  may  be  asso- 
ciated with  numerous  spirochfetse  of  syphilis  without  interstitial  change. 
In  poisoning  by  arsenic  and  phosphorus  and  in  pernicious  anemia  it  ad- 
vances to  a  high  grade.  The  various  lesions  of  the  coronary  arteries 
previously  considered  bear  the  most  significant  causal  relation. 

Predisposing  causes  are — {a)  age — it  being  most  common  after  forty 
years  oi  age  ;  (/-)  sex — it  occurs  somewhat  more  frequently  in  men  than 
in  women,  notwithstanding  the  fact  that  there  are  predisposing  influ- 
ences at  work  in  the  latter  that  do  not  obtain  in  the  male  sex,  such  as 
childbirth  and  amenorrhea;  and,  lastly,  (e)  whatever  may  be  its  apparent 
etiology,  it  is  invariably  preceded  by  a  defective  nutritive  supply  to  the 
muscle-cells :  this  may  be  dependent  upon  a  narrowing  of  the  lumen  of 
the  coronary  vessels,  or  upon  impairment  of  the  oxygen-carrying  power 
of  the  blood,  as  in  the  anemias.  An  excessive  supply  of  glucose,  gly- 
cogen, and  nuclein  may  be  a  factor. 

Symptoms. — The  disease  may  exist  in  an  advanced  form  without 


FATTY  DEGENERATION   OF  THE  JIFAET.  697 

noticeable  symptoms,  though  the  conditions  under  wliich  it  is  most  liable 
to  occur  aflford  secure  ground  for  suspicion.  The  evidences  of  cardiac 
enfeeblement  are  usually  present,  but  in  pernicious  anemia  and  chlo- 
rosis the  pulse  may  even  be  full  and  regular. 

Dilatation  is  apt  to  supervene  early,  owing  to  the  weakened  state  of 
the  heart ;  and  hence  many  of  the  symptoms  are  due  to  secondary  dila- 
tation. Among  these  are  palpitation,  dyspnea,  a  amall,  irregular,  and 
somcAvhat  quickened  pulse,  and  cool  and  clammy  extremities.  The  heart- 
sounds  are  weak,  as  a  rule,  and  the  action  of  the  heart  often  irregular. 
Dropsy  is  rare  in  uncomplicated  cases.  Sometimes  sudden,  great  physical 
exertion  produces  equally  sudden  dilatation,  whereupon  a  canter  rhythm 
and  an  apical  systolic  murmur  develop.  In  most  instances,  however, 
the  symptoms  of  dilatation  are  more  gradually  brought  to  light. 
Breathlessness  on  exertion  is  often  a  striking  feature,  and  syncopal 
attacks  are  sometimes  troublesome.  The  pulse,  in  consequence  of 
irritation  of  the  inhibitory  center  in  the  medulla,  often  becomes  greatly 
retarded,  dropping  from  the  normal  rate  to  30  -or  40  beats  per  minute, 
and,  in  rare  cases,  to  10  or  12  beats.  The  fatty  arcus  senilis  is  devoid 
of  diagnostic  value.  There  are  frequent  attacks  of  cardiac  asthma  in  the 
mornings,  and  these  are  apt  to  be  accompanied  at  intervals  by  angina 
pectoris.  Disturbance  of  the  intellect,  sometimes  taking  the  form  of 
maniacal  delusions,  may  come  on  and  persist.  Syncopal  attacks  occur. 
Pseudo-apoplectic  attacks,  such  as  have  been  described  (vide  Chronic 
Myocarditis),  may  occur.  Oheyne-Stokes  breathing  is  among  the  later 
manifestations.  It  happens  that  this  symptom  and  pseudo-apoplectic 
seizures  are  found  in  association ;  they  are  more  apt  to  be  due  to  uremic 
toxemia,  perhaps,  than  to  fatty  degeneration  of  the  heart.  Epileptiform 
attacks  resembling  petit  mal  may  arise. 

The  diagnosis  is  sadly  obscure.  The  history,  the  age  of  the  patient, 
and  the  symptoms  of  cardiac  weakness  and  subsequent  dilatation, 
together  with  retardation  of  the  pulse,  apoplectic  attacks,  and  Cheyne- 
Stokes  breathing,  in  the  absence  of  precedent  hypertrophy  merely 
justify  a  probable  diagnosis.  With  a  clear  history  and  the  presence 
of  the  more  significant  symptoms,  including  the  signs  of  dilatation 
following  hypertrophy,  fatty  changes  may  be  inferred  with  some  de- 
gree of  assurance,  although  a  positive  opinion  should  be  withheld. 

The  progftiosis  is  as  varied  as  the  etiology.  Death  may  come 
quickly,  the  process  being  commonly  associated  with  sclerosis  of  the  cor- 
onaries,  though  oftener  the  end  is  reached  in  a  gradual  manner,  the  signs 
and  symptoms  of  advanced  dilatation  dominating  the  closing  scene.  The 
more  corpulent  the  subject,  the  graver  the  prognosis. 

Treatment. — The  cause  in  each  individual  case  should  be  deter- 
mined, and  when  ascertained  a  bold  attempt  should  be  made  to  remove 
it.  This  course  often  places  the  patient  in  the  most  favorable  position 
for  the  successful  treatment  of  the  cardiac  condition.  Anemia  in  one 
form  or  other  plays  an  important  role  in  the  majority  of  the  cases, 
and  the  particular  variety  present  in  each  instance  must  determine 
the  character  of  the  remedies  to  be  employed.  In  that  large  cate- 
gory of  cases  occurring  in  certain  cachexias  (cancerous,  tuberculous) 
hematinics,  arsenic,  and  strychnin  are  the  remedies  of  choice. 


698  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

A  frequent,  irregular  pulse  and  other  signs  of  cardiac  failure  indicate 
commencing  dilatation,  and  under  these  circumstances  digitalis  should 
be  euipliiyed  in  S7)iall  doses.  AVhcn  found  to  be  serviceable,  its  use 
should  be  continued  until  tlie  dilatation  is  overcome;  it  may  be  conven- 
iently combined  with  other  cardiants. 

I  believe  that  gentle  indulgence  in  physical  exercise  and  light  gym- 
nastics is  beneticial,  since  it  tends  to  invigorate  the  heart-muscle ;  it  is 
to  be  increased  in  proportion  to  the  manifest  improvement  in  the 
patient's  condition.  It  sometimes  happens,  however,  that  even  gentle 
exercise  is  badly  borne,  and  it  should  then  be  discontinued.  Kinesi- 
therapy,  particularly  the  milder  Swedish  method  of  gymnastic  exercises 
(alternating  movements  of  resistance),  increases  the  contractile  power 
of  the  heart  and  at  the  same  time  lessens  the  peripheral  resistance,  and 
should  be  accorded  a  careful  trial.  I  have  been  in  the  habit  of  advising 
daily  inhalations  of  ox^'^gen  gas  in  this  class  of  cases  with  good  results. 
Recourse  to  massage  is  also  in  the  line  of  sound  practice,  but  the  sittings 
should  not  exceed  half  an  hour  in  duration  at  the  start.  The  more 
prominent  symptoms  may  require  special  measures.  The  syncopal  and 
anginal  attacks  are  to  be  handled  in  the  manner  indicated  for  the  same 
symptoms  in  chronic  myocarditis.  For  the  pseudo-apoplectic  attacks 
rest  in  the  recumbent  posture,  with  the  head  slightly  elevated,  is  use- 
ful. Therapeutic  agents,  as  digitalis,  ammonia,  and  ether,  may  be 
used  hypodermically  to  stimulate  the  heart ;  it  is  also  good  practice 
to  withdraw  from  12  to  24  ounces  (355.0-710.0)  of  blood  directly 
from  a  vein.  If  the  arteries  be  hard  and  tense,  nitroglycerin  is  of 
distinct  service. 

A  strictly  horizontal  posture  and  the  application  of  ice  to  the  pre- 
cordial region  often  quickly  terminate  the  attacks  of  cardiac  asthma, 
and  spartein  sulphate,  with  nitroglycerin,  is  worthy  of  a  trial.  Hot  toddy 
and  other  diffusible  stimulants  are  valuable  adjuvants.  Should  these 
remedies  fail,   hypodermic  treatment  by  morphin  is  to  be  adopted. 

FATTY   OVERGROWTH. 

Pathology. — The  normal  fat,  particularly  in  the  auriculo-ventricu- 
lar  furrows,  is  increased.  I  have  elsewhere  suggested  the  term  "  sub- 
pericardial  over-fatness,"  ^  to  indicate  the  condition  Avhen  unaccompanied 
by  fatty  infiltration.  This  over-production  of  fat  may  become  so  exces- 
sive as  to  form  a  complete  enveloping  mantle  measuring  an  inch  or  more 
in  thickness.  In  these  extreme  grades  the  muscular  fibers  may,  from 
too  great  pressure,  undergo  atrophy  and  thus  become  weakened. 

etiology. — The  principal  cause  is  general  corpulency.  (For  a 
consideration  of  the  factors  predisposing  to  fat  production  see  Obesity.) 
In  the  cachexias  of  carcinoma  and  phthisis,  and  the  general  atrophy  of 
old  age,  fatty  overgrowth  and  fatty  degeneration  coexist. 

Symptoms. — The  condition  may  be  unaccompanied  by  any  symp- 
toms. The  muscle-fiber  is  weakened  (not  degenerated,  as  a  rule),  hence 
extra  labor  suddenly  thrown  upon  the  organ  excites  the  clinical  indica- 
tions of  a  weak  (dilated)  heart,  as  urgent  dyspnea,  vertigo,  syncope, 
palpitation,  and  cyanosis.  Later  recurrences  arise  on  every  provocation, 
^  Amer.  Jour.  Med.  Sri.,  April,  1901. 


FATTY  OVEBQBOWTIf  OF  Till':  /fJ^JART.  699 

Distressing  attacks  of  asthma  may  develop  after  a  full  meal  or  without 
an  apparent  exciting  cause.  A  passive  form  of  bronchrtis  may  supervene. 
The  cardiac  impulse  is  feeble  and  may  even  be  missing.  The  pulse 
is,  as  a  rule,  regular  and  moderately  tense.  Slight  intermittence  and.  in 
marked  heart-weakness,  decided  arrythmia  may  be  noted.  In  moderate 
grades  the  heart-sounds  may  be  clear  ;  in  marked  cases  with  ensuing 
dilatation  a  systolic,  apical  murmur  may  be  audible. 

The  diagnosis  rests  upon  the  combined  presence  of  marked  obesity 
and  cardiac  enfeeblement.     (For  the  differential  diagnosis,  see  p.  694). 

Treatment. — I  wish  to  advocate  warmly  the  system  of  treatment 
introduced  by  Oertel,  as  I  have  seen  excellerit  results  from  its  employ- 
ment. It  should  not  be  resorted  to  in  chronic  valvular  disease,  in  the 
stage  of  broken  compensation,  nor  in  marked  atheroma. 

Oertel's  method  comprises  three  parts :  (1)  The  reduction  of  the 
amount  of  liquid  taken  with  the  meals  and  during  the  intervals,  the 
total  for  each  day  being  36  ounces  (1064.0).  Frequent  bathing  (includ- 
ing the  Turkish  bath  in  suitable  instances)  and  pilocarpin  are  employed 
to  promote  free  diaphoresis. 

(2)  The  diet  is  composed  largely  of  proteids,  as  follows :  Morning. — 
A  cup  of  coiFee  or  tea,  with  a  little  milk — about  6  ounces  (178.0)  alto- 
gether ;  bread,  3  ounces  (93.0). 

iVbow.— -Three  to  4  ounces  (90.0-120.0)  of  soup  ;  7  to  8  ounces  (218.0- 
248.0)  of  roast  beef,  veal,  game,  or  poultry,  salad  or  a  light  vegetable, 
a  little  fish  ;  1  ounce  (32.0)  of  bread  or  farinaceous  pudding ;  3  to  6 
ounces  (93.0-186.0)  of  fruit  for  dessert.  No  liquids  at  this  meal,  as  a 
rule,  but  in  hot  weather  6  ounces  (178.0)  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  (178.0)  of  coffee  or  tea,  with  as  much  water. 
An  ounce  of  bread  as  an  indulgence. 

Evening. — One  or  two  soft-boiled  eggs,  1  ounce  (32.0)  of  bread,  per- 
haps a  small  slice  of  cheese,  salad,  and  fruit ;  6  to  8  ounces  (178.0— 
236.0)  of  wine,  with  4  or  5  ounces  (120.0-148.0)   of  water  (Yeo). 

(3)  Graduated  exercise  up  inclines  of  various  grades.  The  distance 
to  be  undertaken  each  day  is  to  be  carefully  specified  and  frequently, 
though  gradually,  increased.  A  like  plan  is  to  be  pursued  with  refer- 
ence to  the  degree  of  inclination.  This  is  the  most  important  part  of 
the  system,  since  it  directly  invigorates  the  heart-muscles. 

Fatty  Infiltration. — This  condition  may  be  associated  with  grave 
forms  of  myocardial  degeneration,  principally  fibroid  and  fatty.  In  this 
place  the  term  is  limited  in  application  to  an  infiltration  or  a  dipping 
of  fat  between  the  muscle-fibers  even  to  the  endocardium,  that  is  second- 
ary to  extreme  obesity  {e.  ^.,  the  anemic  variety).  It  is  clearly  a  rare 
condition,  if  we  except  the  not  uncommon  instances  in  which  the  morbid 
process  is  limited  to  a  thin  layer  of  muscle-fibers  situated  directly 
beneath  the  epicardium.  I  have  reported  5,  and  collected  7  additional 
cases  from  the  literature. i     The  subjects  are  extremely  obese. 

The  symptoms  may  develop  abruptly,  after  some  unusual  muscular 
exercise  or  after  a  profound  systemic  shock.  More  commonly,  however, 
the  clinical  indications,  which  are  not  sharply  defined  as  a  rule,  manifest 
themselves  in  a  gradual  manner.  The  principal  features  are  urgent 
dyspnea  (often  an  asthmatic  form  of  breathing),  and  utter  exhaustion 

^  Ldc.  eit. 


700  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

upon  muscular  exercise,  precordial  discomfort,  pain  under  the  sternum, 
cardiac  palpitation,  arrht/thvn'a,  ajpieope,  vertigo,  cyanosis,  and  a^if/ina 
pectoris.  Marked  and  constant  disturbance  of  the  cardiac  rhythm  is 
symptomatic  of  fatty  infiltration.  Hydrostatic  bronchitis,  with  cough 
and  expectoration,  is  commonly  present.  The  angina  pectoris  ma}'  be 
dependent  largely  upon  associated  sclerosis  of  the  arterial  system. 
Emotional  disturbance  and  mental  apprehension  were  the  chief  nervous 
phenomena  in  my  cases.  The  phi/sical  sifinf>  are  neither  constant  nor 
characteristic  ;  thcv  are,  in  the  main,  those  of"  cardiac  dilatation.  The 
pidsc  may  be  regular  and  of  good  tension,  but  after  dilatation  comes 
on  it  becomes  irregular,  fre(|uent,  and  easily  compressible.  Moderate 
hypertrophy  probably  exists  in  the  majority  of  cases,  but  cannot  always 
be  demonstrated  owing  to  the  extreme  subpericardial  over-fatness.  A 
basic  systolic  murmur  may  be  heard  ;  it  is  not  due  to  valvulitis  as  a 
rule.  The  prognosis  as  to  cure  is  almost  hopeless,  although  marked 
improvement  may  follow  appropriate  treatment.  A  fatal  termination 
is  often  due  to  spontaneous  rupture  of  the  heart.  The  treatment  must 
be  directed  especially  to  the  over-fatness  and  the  cardiac  dilatation. 

{h)  Brown  Atrophy. — A  form  of  degeneration  in  which  accumulations 
of  yellowish-brown  pigment-granules  occur  in  the  muscular  fibers.  The 
color  exhibited  by  the  heart-muscle  is  a  reddish-brown,  and  in  pro- 
nounced cases  a  dark-red  brown.  Brown  atrophy  is  most  commonly 
seen  in  the  hearts  of  the  aged,  though  also  quite  often  in  cases  of 
chronic  valvular  disease  that  have  reached  an  advanced  stage. 

{c)  Calcareous  Degeneration  {Calcification). — Calcareous  infiltration  of 
the  muscular  fibers  of  the  myocardium  has  been  noted,  though  very 
rarely.  Somewhat  more  common  are  the  bony  callosities  that  result 
from  myocardial  abscesses  (vide  Circumscribed  Myocarditis). 

{d)  Amyloid  Degeneration. — This  form  of  degeneration  is  rare.  It 
is  limited  to  the  blood-vessels  and  interstitial  connective  tissue;  its 
causes  are  the  same  as  those  of  amyloid  degeneration  of  other  viscera. 

(e)  Hyaline  Degeneration. — This  is  sometimes  seen  in  association  with 
amyloid  change.  It  also  occurs  independently  in  prolonged  fevers 
{hyaline  transformation  of  Zenker).  The  fibers  are  swollen,  translu- 
cent, and  homogeneous,  and  their  striae  almost  entirely  disappear. 


CARDIAC  ANEURYSM. 

[Aneurysm  of  the  Ueart.) 

A  CARDIAC  aneurysm  may  involve  either  the  whole  diameter  of  the 
myocardium  (aneurysm  of  the  walls),'  or  merely  the  valves,  together 
with  a  few  myocardial  fibers.  Aneurysmal  dilatation  of  the  coronaries 
due  to  sclerosis  or  embolism  is  also  recognized. 

Aneurysm  of  the  Walls. — This  is  not  i)f  freqiu^nt  nccuvrenco.  Its  most 
common  seat  is  the  wall  of  the  left  ventricle  near  the  apex  :  it  is  quite  gen- 
erally a  sequel  to  chronic  myocarditis,  which  occurs  oftenest  at  this  point. 
In  size  cardiac  aneurysms  are  exceedingly  variable,  and  may  either  be 
very  small  or  as  large  as  the  average-sized  head  of  an  adult.     As  to  form, 

'  Of  87  cases  collected  by  Pelv<>t,  57  were  in  this  situation,  and  of  90  collected  by 
Legg,  59. 


RUPTURE  OF  THE  HEART.  701 

two  types  should  be  recof;;nizo(l:  (a)  an  equable  dilatation  of  a  part  of 
the  ventricular  wall,  and  {!>)  the  sacculated  form.  Layers  of  fibrin  are 
often  found  in  these  aneurysmal  dilatations — an  indication  of  Nature's 
attempt  at  a  cure,  and  occasionally  she  is  successful.  Once  an  aneurysmal 
distention  has  begun,  a  straining  efibrt  may  cause  sudden  increase  of  its 
dimensions  or  rupture  it.  The  structures  adjacent  to  the  aneurysm 
exhibit  fibrous  overgrowth.  This  condition  may  rarely  be  congenital. 
Males  are  more  commonly  affected  (74  per  cent. — llare). 

Diagnosis. — Aneurysm  of  the  myocardium  has  no  characteristic 
features.  Usually  the  sym.'ptoiiu  and  local  signs  of  chronic  myocarditis 
or  dilatation  are  more  or  less  conspicuous,  but  the  presence  of  the 
aneurysm  is  not  even  suspected  unless  certain  physical  signs  develop. 
These  are — a  pulsating  pj'ominence  in  the  apex  region  that  may  even 
perforate  the  chest-wall,  and  a  coextensive  dulness.  The  abnormal  area 
of  dulness,  which  is  peculiarly  circumscribed,  is  best  appreciated  early 
by  stethoscopic  percussion.  An  aneurysmal  dilatation  may  also  be 
confirmed  by  the  ^-rays  or  the  orthodiagram.  The  course  of  these 
cases  is  unfavorable,  death  ensuing  (rarely)  from  rupture  of  the  sac  or 
(more  frequently)  from  gradual  cardiac  exhaustion. 

Valvular  aneurysms  sometimes  arise  in  acute  ulcerative  endocarditis, 
which  destroys  the  segmented  endocardium  and  permits  of  dilatation  as 
the  result  of  the  intracardial  blood-pressure.  They  occur  with  much 
greater  frequency  on  the  aortic  than  on  the  mitral  valves.  They  are 
spheroid  in  shape,  and  project  into  the  left  ventricle  when  found  at  the 
aortic  segments,  and  into  the  left  auricle  when  at  the  mitral.  Rupture 
of  these  aneurysms  is  common,  with  the  subsequent  development  of 
valvular  incompetency.      They  cannot  be  diagnosticated  during  life. 


RUPTURE   OF  THE  HEART. 

This  rare  and  serious  accident  may  either  be  complete  or  partial. 
The  term  partial  rupture  implies  laceration  of  the  trabeculse  ventriculi, 
whereby  the  chordse  are  liberated.  Rarely,  the  papillary  muscles  are 
torn,  causing  valvular  incompetency.  Complete  rupture  consists  in  a 
solution  of  continuity  of  the  total  diameter  of  the  myocardium. 

Pathology. — The  chief  seat  of  rupture  is  the  anterior  wall  of  the 
left  ventricle,  though  it  may  also  occur  in  the  right  ventricle  and  in  the 
auricles.  The  rent  runs  parallel  with  the  muscular  fibers,  and  is  to  a 
certain  extent  the  result  of  laceration,  although  chiefly  of  a  separation, 
of  the  fibers.  The  fissural  communication  presents  irregular  edges,  and 
at  autopsy  is  seen  to  contain  blood-clots ;  the  pericardial  sac  is  also 
occupied  by  coagula.  If  pericardial  adhesions  have  previously  obliter- 
ated the  cavity,  the  escaped  blood-clots  may  occupy  the  pleural  cavity. 
Histologic  examination  of  the  adjacent  muscle-structure  shows  the 
characteristic  changes  of  fatty  and  other  forms  of  degeneration. 

histiology. — Both  predisposing  and  exciting  causes  may  be  at  work. 
The  former  are  the  more  important  and  named  in  the  order  of  their  fre- 
quency of  occurrence  are, — disease  of  the  coronary  arteries  (with  anemic 


702  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

necrosis  ami  abscesses),  fatty  degeneration,'  fatty  infiltration,  chronic 
myocarditis,  parietal  tumors,  and  parasites  in  the  heart-wall. 

The  influence  of  age  is  notable :  rupture  of  the  heart  usually  occurs 
after  the  sixtieth  year  has  been  passed.  Males  suffer  somewhat  more 
frequently  ihan  females.  The  exciting  cause  is,  as  a  rule,  some  form  of 
muscular  exertion,  tliough  it  may  occur  during  sleep. 

Symptoms. — In  the  majority  of  instances  rupture  of  the  heart  re- 
sults in  suddeti  death.  Sometimes,  however,  the  patient  survives  the 
accident  for  several  hours  or  even  for  as  many  days.  The  symptoms 
are  those  o^  internal  bleeding^  and  pain  that  may  be  agonizing  and  is 
referred  to  the  heart.  The  body-temperature  falls,  the  skin  surface  be- 
comes pale  and  cool,  and  it  may  be  covered  with  cold  perspiration,  while 
the  puhe  grows  small,  very  frequent,  and  finally  almost  vanishes.  Occa- 
sionally gastro-intestinal  symptoms  and  s^'ncope  tending  to  convulsions 
appear  in  consequence  of  the  irritation  of  the  vagus  centers  due  to  cere- 
bral anemia.  The  physical  signs  of  cardiac  failure  rapidly  develop,  and, 
if  the  leak  be  not  too  large,  those  of  pericardial  effusion  more  gradually. 

Diagnosis. — Heart-anguish,  rapidly  progressive  cardiac  failure,  the 
evidence  of  internal  hemorrhage,  and  the  speedy  development  of  the 
signs  of  pericardial  effusion  should  always  excite  suspicion  of  rupture, 
and  in  many  cases  suffice  for  a  correct  inference. 

The  prognosis  is  hopeless.  When  immediately  fatal,  death  is  the 
result  of  heart-sliock  ;  it  may  result  from  anemia  of  the  brain  or  com- 
pression of  the  heart  by  the  effused  blood. 

Treatment. — Prcq^hylaxis  is  of  the  utmost  importance.  The  phy- 
sician should  give  ample  warning  of  the  dangers  connected  Avith  muscular 
strain  of  whatever  sort.  If  rupture  has  either  occurred  or  is  suspected, 
the  patient  must  be  put  at  complete  rest  in  the  horizontal  position.  Full 
doses  of  morphin  should  be  given  hypodermically,  and  the  ice-bag  locally 
applied.  Warmth  to  the  extremities  may  be  useful.  The  use  of  cardiac 
stimulants  Avill  be  attended  with  increased  bleeding  from  the  rent,  but 
agents  that  relax  the  peripheral  arterioles,  such  as  nitroglycerin,  may  be 
employed  with  a  view  to  diminishing  the  heart's  labor  without  diminish- 
ing its  power.  Should  the  rupture  be  partial  and  the  hemorrhage  slight, 
the  patient's  life  may  be  prolonged,  or  even  saved,  by  keeping  him  at 
absolute  rest  for  a  long  period. 


MINOR  AFFECTIONS  OF  THE  HEART. 

(a)  New  Growths. — Primary  carcinoma  or  sarcoma  is  rare  indeed. 
Metastatic  growths  occur,  but  are  very  rarely  sufficiently  large  (except 
perhaps  the  colloid  variety)  to  be  detected  by  physical  examination.,  or 
to  give  rise  to  symptoms.  Rarely,  large  tumors  may  weaken  the  heart. 
The  separation  of  portions  of  the  tumor  may  block  one  of  the  valvular 
orifices  and  cause  sudden  death,  or  more  minute  portions,  becoming  re- 
leased, may  give  rise  to  embolism  in  distant  parts. 

(li)  Parasites. — Four  forms   may  invade  the  heart-muscle — the  taenia 
echinococcus,  actinomyces,  cysticercus  cellulosrc.   and   the  })cntastomum 
denticulatum.      The  former  two  only  are  productive  of  mischievous  re- 
'  According  to  Quain's  statistics,  about  75  per  cent,  of  the  cases  are  due  to  this  caase. 


NEUROSES  OF  THE  HEART.  703 

suits.  The  echinococcus  growths  may  attain  to  considerable  dimensions 
and  are  often  multi[)le;  they  are  secondary  to  echinococcus-cysts  in 
other  organs.  Their  effects  are  produced  in  a  purely  in<;chanical  man- 
ner unless  fragments  become  detached,  when  they  may  excite  embolic 
lesions  at  different  points  in  remote  organs. 

(e)  Misplacement  ( 7 V•aw.s/>o.s^V^ow  of  the  Heart). — During  inti-a-uterine 
life  the  heart  (and  rarely  all  the  other  thoracic  and  abdominal  viscera) 
may  either  be  transposed  to  the  right  side  of  the  thorax,  or  the  fetal 
position — in  the  median  line — may  be  retained.  The  sternum  may  be 
missing  in  whole  or  in  part,  and  the  heart,  which  now  lies  immediately 
beneath  the  skin,  can  be  seen  and  felt  as  a  throbbing  tumor.  Recently 
a  healthy  man  of  about  forty  years  applied  at  the  Medico-Chirurgical 
Hospital  in  whom  the  lower  half  of  the  sternum  was  absent;  his  heart 
occupied  a  position  in  the  median  line  directly  underneath  the  skin. 

Very  exceptionally  other  anomalous  positions  are  acquired  during 
ante-natal  development,  and  the  heart  may  become  displaced  upward  in 
the  chest-cavity  even  to  the  neck  or  downward  into  the  abdominal  cavity. 

{d)  Floating  Heart. — The  structures  that  serve  to  maintain  the  heart 
in  its  normal  anatomic  relations  may  become  weakened  or  unduly  lax, 
in  consequence  of  which  the  organ  may  exhibit  increased  motility. 


III.  NEUROSES   OF  THE   HEART. 

PALPITATION. 

Definition. — A  more  or  less  rapid  action  of  the  heart  that  is  per- 
ceptible to  the  patient,  and  usually  accompanied  by  an  increased  force 
of  the  cardiac  contractions  or  a  disturbance  of  the  rhythm,  including 
extra-systole  {vide  infra).,  and  often  also  by  precordial  distress,  anxiety, 
and  dyspnea. 

Htiology. — Chronic  valve-disease  and  other  organic  affections  of 
the  heart  seldom  produce  palpitation.  Among  predisposing  causes  are — 
(1)  Mental  excitement,  depression  or  emotion;  (2)  Anemia  (from  the  local 
irritant  action  of  the  altered  blood-state);  (3)  The  acute  infectious  dis- 
eases, in  which  the  toxins  in  the  blood  irritate  the  cardiac  accelerating 
nerves;  (4)  Dyspepsia,  even  in  robust-appearing  persons  (as  in  the  gouty) 
who  wittingly  or  unwittingly  commit  dietetic  errors.  Special  articles  of 
diet  may  excite  over-action  {e.  g.,  strawberries,  shell-fish),  the  palpitation 
thus  arising  from  reflex  irritation  being  dependent  upon  gastric  catarrh. 
(5)  The  use,  and  more  especially  the  abuse  of  tea,  coffee,  alcohol,  and 
tobacco.  (6)  The  female  sex  manifests  a  greater  disposition  to  the  com- 
plaint than  the  male,  especially  about  the  period  of  puberty  and  the 
menopause.  In  the  male  it  is  most  common  at  or  after  the  middle  period 
of  life,  a  time  when  the  effects  of  the  work  and  worry  of  life  show  them- 
selves. (7)  Disturbances  of  the  ovaries  and  other  pelvic  organs  may  in- 
duce palpitation  reflexly. 

Symptomatology. — Cardiac  over-action,  as  a  rule,  displays  a 
definitely  poroxi/smal  character.  The  onset  is  sudden,  and  immediately 
preceding  the  attack  there  are  often  a  blanching  of  the  face  and  a  slow- 


704  DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 

ing  of  the  cardiac  action,  svniptonis  clue  to  the  niomentary  inhibitory 
eflfect  of  the  nerve  affections  that  cause  the  "  palpitation."  The  patient's 
perception  of  increased  force  and  rapidity  of  the  heart's  action  is  the 
essential  symptom.  The  patient  may  complain  of  palpitation,  "svith  a 
normally  acting  (or,  more  rarely,  abnormally  slow)  heart,  the  symptoms 
being  wholly  subjective  in  character.  Mental  anxitt)/  is  common,  and 
dyspnea,  the  latter  synij)tom  assuming  curious  piiases. 

Physical  Signs. — Inspection  shows  the  impulse  to  be  somewhat  diffuse 
and  forcible.  Visible  throbbing  of  the  superficial  vessels  is  also  common. 
The  finger-tips  easily  appreciate  the  increased  strength  of  the  impulse. 
At  the  wrist  the  pulse,  though  strong  and  full,  as  a  rule  is  rapid,  the 
rate  varying  from  120  to  160  per  minute.  Percussion  does  not  show  the 
area  of  cardiac  dulness  to  be  enlarged  as  a  rule,  while  auscultation  reveals 
louder  sounds  than  the  normal.  Anemic  murmurs  may  1)0  ])resent.  The 
attack  is  usually  of  brief  duration — but  a  few  minutes — though  some- 
times it  may  last  for  hours  or  days. 

Attention  should  here  be  called  to  the  irritable  heart  described  by 
DaCosta — a  form  of  palpitation  common  among  young  soldiers  during 
the  late  Civil  "War.  It  was  caused  partly  by  mental  excitement  and 
partly  by  inordinate  muscular  exertion.  A  minor  part  in  Jts  production 
was  also  plaved  by  diarrliea.  The  leading  symptoms  were  palpitation,  a 
very  frequent  pulse,  dyspnea,  and  cardiac  pains  of  varying  intensity. 

Differential  Diagnosis. — Nervous  palpitation  must  be  distin- 
guished from  the  comparatively  rare  cases  in  which  the  heart  contracts 
rapidly  and  irregularly,  but  does  not  excite  subjective  sensations.  Some 
of  the  latter  instances  are  to  be  looked  upon  as  physiologic,  while  others 
are  due  to  exhaustion  and  other  causes.  They  do  not  constitute  cases 
of  palpitation,  since  they  are  unperceived  by  the  patient. 

Palpitation  due  to  chronic-valve  disease  should  also  be  differentiated. 
Here  ciiief  reliance  is  to  be  placed  upon  the  presence  of  a  murmur  and 
other  physical  signs  during  the  intervals  between  the  attacks.  The 
presence  of  a  diastolic  murmur  would  exclude  nervous  palpitation. 

Prognosis. — The  condition  is  free  from  real  danger  to  life.  Most 
authors,  however,  are  agreed  that  cardiac  hypertrophy  may  be  a  sequel. 
Treatment. — The  chief  indications  for  treatment  are — (1)  The  arre:t 
of  the  paroxi/sm.  The  patient  must  be  put  at  absolute  rest  in  bed  in  a 
Targe,  well-ventilated,  darkened  chamber,  and  his  clothing  loosened  so 
that  the  respiration  is  unimpeded.  Pressure  upon  the  vagus  in  the  neck 
or  upon  special  points  on  the  abdominal  parietes  (the  ovaiian  region  in 
particular)  sometimes  arrests  the  attack.  An  ice-bag  applied  to  the  pre- 
cordial region  is  useful;  it  should  be  removed  every  third  hour  in  pro- 
tracted cases,  and  the  patient  be  told  to  take  large  draughts  of  cold  water 
or  to  swallow  bits  of  ice.  On  the  other  hand,  I  have  observed  a  few  in- 
stances which  were  speedily  relieved  by  the  ingestion  of  hot  and  some- 
Avhat  stimulating  drinks. 

Among  the  many  drugs  that  have  been  employed,  morphin  alone  has 
given  good  results,  and  particularly  when  administered  hypodermically. 
However,  before  employing  morphin,  other  sedatives  and  narcotics  should 
be  tried,  such  as  the  bromids  (in  large  doses),  hyoscyamus.  hyoscin,  and 
camphor  raonobromate.     In  hysteric  subjects  the  bromids  and  the  prep- 


TAC'irVCARDIA.  705 

arations  of  valerian  are  liighly  serviceable.      I  have  found  tlie  following 
capsule  of  great  utility: 

I^.   Zinci  valerianat.,  gr.  x  (0.648); 

Strychninae  sulph.,  gr.  ^  (0.0216); 

Ext.  sumbul.,  gr.x  (0.648); 

Ext.  hyoscyami,  gr.  v  (0.324); 
M.  et  ft.  capsulge  No.  x. 
Sig.   One  after  meal-time. 

If  a  special  article  of  diet  or  an  overloaded  state  of  the  stomach  is 
the  cause,  an  emetic  may  be  given  and  the  attack  thus  speedily  con- 
trolled.    Oxygen-inhalations  have  been  warmly  advocated. 

(2)  To  prevent  a  recurrence  of  the  paroxysms^  the  causal  conditions, 
some  of  which  may  long  antedate  the  occurrence  of  palpitation,  must  be 
removed,  if  this  be  possible.  All  exciting  fiictors  must  also  be  avoided. 
When  cardiac  palpitation  occurs  in  neurasthenia  and  hysteria,  the  Weir- 
Mitchell  rest-cure  should  be  advised.  If  the  heart  be  weak,  digitalis  may 
be  exhibited.  I  have  observed  good  effects  from  the  use  of  baths  (car- 
bonated). 


TACHYCARDIA. 

{Tachycardia  Paroxysmalis ;  Synchopexia;  Rapid  Heart.) 

Definition. — A  rapid  movement  of  the  heart  occurring  in  parox- 
ysms of  variable  duration,  and  directly  dependent  upon  either  paralysis 
of  the  pneumogastric  or  stimulation  of  the  sympathetic  nerves.  Martius 
believes  that  the  condition  is  attributable  to  sudden  dilatation.  Gordon^ 
claims  that  tachycardia  may  be  determined  by  dilatation  of  the  splanchnic 
area,  diminishing  greatly  the  supply  of  blood  to  the  left  ventricle. 

Pathology  and  etiology. — It  occurs  as  a  physiologic  condition 
in  certain  individuals  ;  in  such  cases  the  pulse  may  range  from  90  to  100 
beats  per  minute  or  over.  Certain  persons  can  increase  the  pulse-rate  by 
their  own  volition.  The  pathologic  forms  are  divisible  into — (1)  Essential 
or  neurotic  tachycardia,  and  (2)  Symptomatic  tachycardia. 

(1)  Neurotic  Tachycardia. — The  causes  of  this  variety  are  identical 
with  many  of  those  that  excite  palpitation.  Thus,  among  disposing 
factors  are  hysteria,  anemia,  neurasthenia,  chlorosis,  and  toxic  agencies 
(tea,  coffee,  tobacco,  the  poisons  of  fevers).  Violent  exercise,  intense 
mental  agitation,  fright,  grief,  and  other  forms  of  shock  are  determining 
influences.     Not  a  few  cases  are  met  at  or  about  the  menopause. 

(2)  Symptomatic  Tachycardia. — The  lesions  that  induce  this  form  are 
— (a)  central  and  [h)  peripheral.  In  the  former  group  are  especially  to 
be  placed  tumors,  clots  (due  to  hemorrhage),  and  softening  of  the  me- 
dulla and  cord  ;  and  in  the  latter,  tumors,  aneurysms,  enlarged  lymph- 
glands  (which  paralyze  the  vagus  by  exerting  pressure  upon  it  either 
in  the  neck  or  thorax),  and  neuritis,  affecting  the  pneumogastric  nerve. 
The  latter  lesion  may  be  associated  with  polyneuritis  (alcoholic  or  infec- 
tious). Rapid  heart  may  be  due  to  reflex  irritation  (gastric,  intestinal, 
arterial,  uterine,  ovarian),  or  gastro-intestinal  intoxication. 

^British  Medical  Journal,  March  12,  1910. 
4.^ 


706  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Symptoms. — The  clinioal  picture  in  most  instances  of  the  com- 
plaint is  made  up  of  rei'un-in<:  paroxysms  of  heart  hurry  [paroui/sinal 
tachi/cardia).  These  attacks  may  come  suddenly  without  prodromes. 
If  the  latter  occur,  they  consist  of  vertigo,  tinnitus,  a  sense  of  inijiending 
danger,  and  sometimes  a  "  heart-flop  "  due  to  extra  systole.  The  "  flop," 
however,  more  commonly  ends  the  paroxysm.  With  the  onset  of  the  parox- 
ysms the  cardiac  7novemi'7its  leap  to   150,  175,  200,  and  250,  or  even 


J^AAA/\AJ\AAAi\A^^^AA/'^^^/^AA/^A^AA/^>^A.^-^^ 


Fig.  50.— Radiul  pulse  during  an  attack  of  paroxysmal  tachycardia. 

to  800  beats  per  minute.  The  puhe  is  feeble,  smnll,  readily  compres- 
sible, as  a  rule,  and  sometimes  irregular  (Fig.  56).  liarcly  it  is  full, 
strong,  and  of  good  tension.  The  respiration  may  or  may  not  be  in- 
creased in  frequency,  but  dyspnea  is  not  common.  At  first  pale,  the 
skin  soon  becomes  flushed,  and  the  countenaitce  may  wear  an  anxious  ex- 
pression;  but  unless  "palpitation"  is  associated  there  are  no  symptoms 
present  that  denote  an  intense  degree  of  suffering.  In  many  cases  the 
patient  is  not  conscious  of  palpitation,  or  there  may  be  a  sense  of  slowing 
of  the  heart,  when  in  reality  the  cardiac  contractions  may  be  increased  to 
200  or  more ;  this  is  typical  tachycardia.  In  a  chlorotic  girl  I  found 
that  the  pulse-rate  increased  from  the  normal  rate  to  20U  beats,  and 
lasted  for  a  few  minutes  at  each  visit  to  my  oflfice.  H.  C.  Wood  reports 
a  case  occurring  in  a  physician  in  his  eighty-seventh  year,  who  has  had 
attacks  since  his  thirty-seventh  year,  the  pulse  rising. 

Physical  Signs. — A  diff'use,  rapid,  and  sometimes  irregular  impulse 
may  be  observed  on  inspection  and  palpation^  but  seldom  is  there  an 
enlargement  of  the  heart.  The  sounds  are  slightly  modified,  the  first 
being  accentuated  and  the  second  aortic  greatly  diminished  in  intensity, 
owing  to  the  lessened  amount  of  blood  thrown  into  the  aorta  with  each 
systole ;  the  intensity  of  the  second  pulmonic,  liowever,  may  be  increased. 
An  apical  systolic  murmur  is  occasionally  audible.  The  carotids  pulsate, 
and  on  auscultating  over  them  a  murmur  is  sometimes  heard. 

Diagnosis. — I  would  restate  the  fact  that  a  high  pulse-rate  (200  or 
over  a  luinute)  and  an  absence  or  only  a  slight  sense  of  palpitation  or 
rapid  heart-action  are  the  distinctive  features  of  true  tachycardia.  In 
palpitation  (previously  considered)  the  pulse-rate  is  not  usually  so  high, 
"while  the  associated  phenomena  of  dyspnea  precordial  constriction, 
smothering,  and  painful  anxiety  are  correspondingly  more  pronounced. 

Prognosis. — In  the  majority  of  cases  no  serious  impairment  of  the 
general  health  follows,  though  the  course  is  exceedingly  chronic  and 
recoveries  are  comparatively  rare.  The  duration  of  tachycardia  varies 
from  one  to  two  or  more  decades.  When  symptomatic  tachycardia  is 
due  to  lesions  that  are  removable,  it  is  often  curable,  though  not  invari- 
ably so. 

The  treatment  is  to  be  conducted  on  the  lines  advanced  for  "  Pal- 
pitation "  {vide  p.  704).  Fairbrother  has  cut  short  the  jiaroxysm  in  his 
own  case  by  either  walking  or  an  exercise  like  a  girl  .skipping  the  rope. 


BBAGHYCAEDIA.  707 

An  abdominal  binder,  witli  a  view  to  emptying  the  Bplancbnic  vessels. 
may  reduce  the  excessive  rate  of  tlie  heart.  The  attacks  can  be  averted 
by  the  taking  of  ice-water  or  strong  coffee. 


BRACHYCARDIA. 

( lirddifatrdui.) 


Definition. — Slowness  of  the  pulse.  The  condition  may  be  physio- 
logic, the  rate  of  the  pulse  being  sometimes  60  or  less,  and  very  rarely 
as  low  as  40  per  minute  during  perfect  health. 

All  cases  of  pathologic  brachycardia  fall  naturally  and  conveniently 
into  two  groups  :  (1)  those  that  are  secondary  to  other  complaints  (symp- 
tomatic brachycardia) ;  and  (2)  those  that  are  due  to  a  neurosis. 

Pathology  and  ]^tiology. — Symptomatic  Brachycardia. — (a)  Aris- 
ing during  convalescence  from  acute  infectious  diseases,  especially  pneu- 
monia, typhoid,  diphtheria,  influenza,  and  acute  rheumatism.  Accord- 
ing to  Riegel,  who  analyzed  1047  cases,  the  acute  fevers  must  be  awarded 
the  first  place  among  the  causal  factors.  I  have  met  3  cases  of  diphtheria 
in  which  the  pulse  fell  to  30  a  minute.  That  such  instances  are,  as 
Traube  contends,  due  to  exhaustion  is  true  of  some  cases,  but  not  of  all. 
The  slowing  of  the  pulse  that  is  observed  after  premature  or  full-time 
delivery  is  similarly  produced,  (b)  The  second  place  belongs  easily  to 
gastro-intestinal  and  hepatic  disorders  (chronic  g astro-intestinal  catarrh, 
ulcer,  or  carcinoma  of  the  stomach),  (c)  Brachycardia  occurs  in  diseases 
of  the  circulatory  system — in  coronary  disease,  fibroid  and  fatty  myo- 
cardial change,  most  frequently ;  and  chronic  valvular  disease  much  less 
frequently,  if  we  except  aortic  stenosis,  (d)  Pulmonary  complaints  (em- 
physema and  asthma),  (e)  Toxic  agencies,  as  in  jaundice,  blood-poisoning, 
alcoholism,  the  unwonted  use  of  tea,  coffee,  tobacco,  and  a  few  drugs  (e.  g., 
digitalis,  strophanthus).  (/)  Constitutional  affections  (anemia,  chlorosis, 
gout,  diabetes),  (g)  Rarely  skin  diseases  and  affections  of  the  sexual 
organs,  and  commonly  myxedema,  are  associated  with  brachycardia.  (h) 
In  various  organic  nerve  affections  (apoplexy,  meningitis,  epilepsy,  tumors 
of  the  cerebrum  and  the  medulla,  injuries,  and  diseases  of  the  cervical 
portion  of  the  cord).  Brachycardia  is  produced  by  direct  or  reflex  irrita- 
tion of  the  center  or  peripheral  portion  of  the  vagus,  except  in  cases  in 
which  it  is  brought  about  by  exhaustion  of  the  automatic  motor  apparatus 
of  the  heart.     The  condition  is  more  common  in  men. 

(2)  Brachycardia  associated  with  a  neurosis  may  be  found  to  be 
marked  in  epilepsy  ;  less  so  in  hysteria,  melancholia,  mania,  and  general 
paresis  of  the  insane.     It  precedes  palpitation. 

Symptoms. — The  sole  characteristic  symptom  is  the  slow  action  of 
the  heart,  and  this  may  either  be  temporary  or  permanent.  If  parox- 
ysmal, both  the  onset  and  termination  are  apt  to  be  sudden.  A  slow 
emergence  is,  however,  more  common  than  a  slow  beginning.  Among 
prodromes  are :  vertigo,  tinnitus,  and  a  sense  of  impending  danger. 
During  the  paroxysm  the  patient  may  suffer  from  syncopal  attacks  or 
become  unconscious  for  hours  at  a  time ;  physical  prosfratioti  may  be 
marked,  and  especially  when  secondary  to  chronic  valve-disease.  The 
pulse  is  weak  and  small,  and  the  beats  per  minute  vary  from  50,  40.  30. 


708  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

20,  to  10,  or  even  8.  When  the  condition  arises  in  the  course  of  organic 
valve-lesions  the  cardiac  contractioyis  may  be  increased  in  power,  though 
greatly  reduced  in  freciuency.  The  heart-action  must  be  noted  by  aus- 
cultation, and  the  rate  compared  -with  that  of  the  peripheral  pulse.  The 
'i)nj>uh'ii'  and  the  heart-soundu  are  feeble. 

Diagnosis. — A  pulse  below  48  beats  per  minute,  with  correspond- 
inor  slowness  of  the  systole,  suffices  for  a  certain  diagnosis. 

The  prognosis  is  governed  by  the  cause,  being. very  grave  in  cerebral 
and  advanced  cardiac  diseases.      When  fatal  sudden  death  is  the  rule. 

Treatment. — Rest  in  the  recumbent  posture,  particularly  if  the  con- 
dition complicates  organic  heart  disease,  and  such  remedies  as  atropin, 
strvchnin,  caftein,  nitroglycerin,  and  ammonia  are  to  be  tried.  Since 
atropin  })aralyzes  the  vagus  terminals  in  the  heart,  a  marked  increase  of 
the  heart-rate  after  the  exhibition  of  atropin  points  to  an  extracardial 
cause  of  the  bradycardia.  In  the  intervals  between  the  attacks  the  gen- 
eral health  must  be  improved  and  the  causal  states  eradicated. 


ARRHYTHMIA. 

( Irregular  Heart-  and  Puhe-beat.  ) 

Our  knowledge  of  this  subject  has  been  advanced  by  the  investiga- 
tions of  Wenckebach  and  by  J.  Mackenzie,  Walter  B.  James,  Lewellys 
F.  Barker,  and  others  as  the  result  of  observations  with  the  electrocar- 
diogram. James  suggests  that  the  cases  be  classified  into  rhythmic  irreg- 
ularity and  arrhythmic  irregularity.  Doubtless,  the  myogenic  theory 
explains  the  functional  rhythmicity  of  the  heart's  action.  Among  recog- 
nized functions  of  the  heart  muscle  are  excitability,  stimulus  produc- 
tion, contractility,  conductivity,  and  tonicity  (Gaskell).  As  shown  by 
Mackenzie  and  others,  not  all  of  the  heart  muscles  are  equally  endowed 
with  these  functions.  The  clinician  must  attempt  to  correlate  the  symp- 
toms of  the  different  forms  of  arrhythmia  with  the  condition  of  the  differ- 
ent functions  of  the  cardiac  muscle. 

(1)  Bxtra-systole. — (a)  Intermittent  heart-beat.  This  signifies  a 
missed  or  dropped  beat.  This  occurs  at  irregular  intervals  in  most 
of  the  cases,  though  sometimes  a  cyclical  irregularity  is  observed 
— i.  e.,  every  second,  fourth,  sixth,  or  eighth  beat  being  lost.  To 
explain  this  variety  of  arrhythmia  we  have  the  so-called  "  refractory 
phase  "  of  the  heart-muscle,  in  which  it  lacks  excitability.  Again  the 
stimulus  may  be  insufficient  to  excite  a  normal  degree  of  contractility. 
In  the  absence  of  the  refractory  stage  (beginning  shortly  before  the  sys- 
tole and  continuing  a  short  time  after  it)  the  ventricle  may  again  contract 
during  this  phase,  producing  an  extra-systole  following  which  there  is  a 
long  pause.  As  explained  by  Engelmann,  this  long  pause  is  a  conse- 
quence of  an  extra-systole,  the  ventricle  being  still  in  the  refractory  stage 
when  the  next  physiological  stimulus  reaches  it,  and  it  is  not  until  the 
following  stimulus  arrives  that  contraction  can  again  be  produced.  It  is 
probable  that  the  various  forms  of  arrhythmia  described  below  are  due 
to  the  occurrence  of  these  extra-systoles.  (/>)  Twin-pulse  (coupled  beats, 
ollorrlnjtlimia).  When  two  beats  follow  each  other  (juickly  (the  diastole 
being  shortened),  and  the  next  two  not  so  (juickly  (the  diastole  being 


ARRHYTHMIA. 


709 


lengthened),  we  have  produced  the  puhus  fnrjeminus.  The  first  and 
second  beats  may  be  of  equal  .strength,  but  oftcsn  the  second  is  relatively 
feeble.  This  is  best  determined  by  auscultation  of  the  heart,  since  the 
second  systolic  contraction  (of  the  ventricle)  may  indeed  be  so  "weak  as 
not  to  give  rise  to  a  palpable  beat  at  the  wrist.  I  have  frefjuently  ob- 
served the  pulsus  higeminus  in  mitral  disease.  With  respect  to  the  dias- 
tole, the  approximated  pulsations  may  be  in  blocks  of  tliree  {pulsus 
tr{gemi)ius),  or  even  of  four  (pulsus  quadrifjeniinus).  (2)  Combined 
irregularity  of  time  and  volume.  (3)  The  paradoxical  pulse  of  Kussmaul 
also  consists  in  irregularity  of  volume,  strength,  and  time,  though  not 
indicative  of  so  great  peril  as  the  preceding.  It  is  dependent  upon  the 
act  of  inspiration — the  beats  during  inspiration  being  more  rapid,  though 
weaker,  than  during  expiration  (vide  adhesive  pericarditis,  pleuro-peri- 
carditis).  (4)  Delirium  cordis  is  a  term  very  appropriately  given  to  great 
irregularity  and  inequality  of  the  pulse-beats.  It  is  seen  in  extreme 
dilatation  and  advanced  exophthalmic  goiter.  (5)  Embryocardia  or  Fetal 
Heart-rhythm. — There  is  a  shortening  of  the  long  pause  with  a  striking 
similarity  of  the  first  and  second  sounds,  as  in  the  fetal  heart.  I  have 
already  pointed  this  out  in  connection  with  cardiac  dilatation.  (6) 
Cantering  Rhythm  (bruit  de  galop). — The  sounds  simulate  the  triple 
footfall  of  a  horse  at  a  canter.     The  interpolated  sound  is  due  to  a  re- 


FiG.  57.— Extra-systoles  of  ventricular  type  at  c'  and  r'  (Mackenzie). 

duplication  of  the  second,  though  rarely  it  is  the  first  that  is  doubled 
instead.  It  is  developed  in  the  hypertrophy  of  arterio-sclerosis  and 
Bright's  disease,  in  profound  anemias,  and  in  the  myocarditis  of  certain 
acute  infectious  diseases. 

etiology. — Baumgarten's  classification  of  the  causes  of  arrhythmia 
(quoted  by  Osier)  is  the  best,  and  is  here  given  : 

(1)  Those  due  to  central — cerebral — causes,  either  organic  disease,  as 
in  hemorrhage  or  concussion,  or  more  commonly  psychical  influences. 

(2)  Reflex  influences,  such  as  produce  the  cardiac  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

(3)  Toxic  influences.  Tobacco,  coff"ee,  and  tea  are  common  causes. 
Various  drugs,  as  digitalis,  belladonna,  and  aconite,  may  induce  it. 

(4)  Changes  in  the  heart  itself,  (a)  In  the  cardiac  ganglia.  Eatty, 
pigmentary,  and  sclerotic  changes  have  been  described  in  cases  of  this 
sort,  (h)  Murnl  changes  are  common  in  conditions  of  this  kind.  Simple 
dilatation,  fatty  degeneration,  and  sclerosis  are  most  commonly  present. 
A  high  blood-pressure  may  be  the  cause  of  extra-systoles. 

Symptoms. — Arrhythmia,  particularly  when  functional  or  of  reflex 
origin,  may  exist  for  many  years.  Symptoms  referable  to  the  heart  may 
be  absent,  although  in  some  instances  the  extra-systole  causes  a  thud  to 
be  experienced. 


710  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Diagnosis. — Palpation  and  auscultation  of  the  heart  while  examin- 
ing the  pulse  are  matters  that  should  never  be  neglected  if  reliable  results 
are  to  be  obtained.  Sphygmograms  will  often  show  the  kind  and  degree 
of  arrhythmia  and  also  distinguish  marked  dicrotism  from  irregularity. 

It  is  important  to  d/Jfereniiate  functional  arrhythmia  or  that  of  reflex 
origin  from  arrhythmia  due  to  more  or  less  grave  myocardial  disease. 
Important  information  is  supplied  by  carefully  reviewing  the  varied  etio- 
logic  factors  and  close  observation  of  the  cardiac  symptoms. 

The  progfliosis  is  variable.  A  gentleman  with  whom  I  am  acquainted 
was  rejected  bv  a  life-insurance  company  twenty-five  years  ago  on  account 
of  occasional  slight  arrliytlimia,  though  he  is  still  in  active  business  life. 
When  the  myocardium  becomes  involved,  as  occurs  in  chronic  valvular 
and  coronary  disease,  the  prospect  is  gloomy  ;  on  the  other  hand,  when 
it  is  functional  or  due  to  extracardial  causes,  the  course  pursued  is,  as  a 
rule,  favorable.  When  the  second  sound  follows  closely  tlie  first  (marked 
abbreviation  of  tlie  systolic  pause)  it  is  a  serious  indication. 

Treatment. — There  are  many  cases  of  the  more  benign  form  in 
which  no  treatment  is  required  apart  from  methodic,  physical  training 
to  improve  the  strength  of  the  heart-muscle  and  the  general  systemic 
development.  Removal  of  the  causal  forces,  as  tea,  coffee,  alcohol,  in- 
digestible food-stuffs,  conditions  acting  in  a  reflex  manner,  must  be 
executed  promptly.  When  the  condition  is  due  to  changes  in  the 
heart-structures,  cardiants  in  addition  to  the  general  tonics  should  be 
prescribed.  I  prefer  strychnin,  arsenic,  and  the  dried  sulphate  of  iron 
in  combination.  Nitroglycerin  is  of  service  if  the  arterial  tension  be 
high.  If  the  arrhythmia  be  due  to  cardiac  dilatation,  digitalis  should  be 
employed.  In  functional  cases,  in  which  there  is  a  predominating  neurotic 
element,  the  subjoined  formula  has  been  useful  in  my  hands: 

I^.  Ferri  valerianatis, 

Zinci  valerianatis,      da.  gr.  xxx  (1.94) ; 
Strych.  sulph.,  gr.  j        (0.0648); 

Pulv.  digitalis,  gr.   viij  (0.518). 

Ft.  capsulae  No.  xxx. 
Siff.   Take  one  after  meal-time. 


AURICULAR  FIBRILLATION. 

Definition. — A  condition  due  to  abnormal  impulses  arising  in  differ- 
ent auricular  areas,  and  replacing  the  normal  regular  stimulus  which  is 
produced  by  a  single  area. 

The  condition  is  closely  connected  with  extra-systoles,  auricular  flutter, 
and  heart-block.  The  systoles  of  the  auricle  and  ventricle  do  not  follow 
one  another  regularly.  The  ventricle  receives,  instead  of  an  abnormal 
stimulus  or  impulse,  as  in  extra-systole,  a  variety  of  impulses,  and  in  en- 
deavoring to  respond  to  these  "  increases  its  rate  and  its  contraction  be- 
comes entirely  irregular  "  (Talley).  There  are  no  constant  or  definite 
morbid  lesions,  and  in  some  of  the  cases  nothing  abnormal  is  noted. 
Certain  microscopic  changes  in  the  auricular  tissue  are  most  commonly 
met  with — e.  g.,  atrophy  of  the  muscle  cells  and  a  diffuse  fibrosis. 

Btiology. — Lewis'  analysis  of  126  cases  showed  an  antecedent  his- 


AURICULAR  FIBRILLATION.  711 

tory  of  either  rheumatism  or  chorea  in  70  per  cent.  Among  non- 
rheumatic  suhjects  it  was  more  frequent  in  males  than  females,  and  was 
commonest  in  advanced  life.  In  the  rheumatic  type  the  vast  majority 
of  patients  are  from  twenty  to  fifty  years  of  age.  Of  Lewis'  series  of 
fibrillating  cases,  52  per  cent,  presented  mitral  stenosis.  Other  cardio- 
vascular conditions  with  which  fibrillation  is  associated  are  mitral  regur- 
gitation, aortic  disease  (rare),  myocarditis,  and  interstitial  nephritis. 

Symptoms  and  Diagnosis. — In  general,  the  ventricular  rate 
varies  from  100  to  160.  With  normal  conduction  the  rate  may  reach  200 
or  over,  while  impairment  of  this  function  may  reduce  it  to  40  or  even 
less.  An  accurate  diagnosis  requires  the  use  of  the  electro-cardiogram. 
Graphic  curves,  both  arterial  and  venous,  show  an  irregular  succession  of 
strong  and  weak  contractions.  The  ventricular  form  of  venous  pulse  is 
present,  but  this  is  also  found  in  tricuspid  regurgitation  and  certain  forms 
of  heart-block. 

Auricular  fibrillation  is  also  often  recognizable  by  clinical  observation. 
The  pulse  is  rapid,  usually  over  120  per  minute,  and  irregular ;  this  is 
best  appreciated  by  the  stethoscope  at  the  apex.  The  associated  phe- 
nomena and  cardio-vascular  lesions,  often  grave  and  indicating  cardiac 
failure,  are  of  great  diagnostic  import. 

From  other  forms  of  arrhythmia,  such  as  extra-systoles  and  partial 
heart-block,  auricular  fibrillation  is  distinguishable  by  its  greater  per- 
sistence by  the  effect  of  exercise,  which  increases  the  irregularity  of  the 
latter  while  it  tends  to  remove  that  of  the  former.  Similarly  drugs  of 
the  belladonna  group  aggravate  fibrillation  and  diminish  that  of  extra- 
systoles  and  partial  heart-block.  The  presystolic  murmur  generally  van- 
ishes in  auricular  fibrillation,  but,  as  pointed  out  by  Talley,  not  in- 
variably. 

Prognosis. — This  depends  upon  the  associated  conditions,  the  ven- 
tricular rate,  and  the  response  to  treatment.  If  the  patient  is  willing 
not  to  make  any  unwonted  exertion,  a  guardedly  favorable  prognosis  is 
permissible  in  many  cases. 

Treatment. — Rest  is  an  important  item  of  treatment.  Digitalis  acts 
most  satisfactorily,  more  particularly  in  the  rheumatic  forms.  On  the 
other  hand,  in  cases  of  myocardial  degeneration,  this  drug  may  fail.  The 
rate  of  the  pulse  serves  as  a  guide  to  its  administration,  and  when  normal 
again  for  the  individual  it  should  be  discontinued.  The  hygienic  and 
dietetic  details  are  quite  similar  to  those  recommended  in  chronic  valvu- 
litis [vide  supra). 

Auricular  Flutter. — This  term  implies  extremely  rapid  action  of 
the  auricle,  the  rate  being  usually  between  200  and  330.  The  condition 
is  closely  related  to  auricular  fibrillation  and  tachycardia  of  less  rapid 
rate,  and  particularly  to  heart-block.  It  may  be  paroxysmal  in  char- 
acter. In  general,  the  ventricular  rate  is  either  one-half  or  one-fourth 
that  of  the  auricle,  or  the  impulse  to  the  ventricle  may  be  quite  irregular. 
Fulton  ^  reports  a  case  of  the  paroxysmal  type  lasting  seven  years  with 
progressive  improvement.  Digitalis  should  be  cautiously  employed  in 
the  treatment,  although  in  the  presence  of  evidences  of  heart-block  the 
atropine  series  deserve  a  trial. 

1  "  Auricular  Flutter,"  read  by  Dr.  Frank  T.  Fulton  before  the  American  Climato- 
logical  Association,  May  6, 1913. 


712  DISEASES   OF   THE  ClRCl'LATORY  SYSTEM. 

STOKES-ADAMS  DISEASE. 

{JJatrt-O/oc/:.} 

The  syndrome  known  by  the  above  name  was  first  recognized  by 
Adams  (1827),  although  more  accurately  described  later  by  Stokes 
(184G).  It  is  characterized  clinically  by  bradycardia,  vertigo,  syncope, 
and  auricular  impulses  in  the  veins  of  the  neck.  The  Stokes-Adams 
syndrome  may  rarely  be  al)sent  in  fatal  cases. 

Physiologic  Pathology. — Physiologists  have  conclusively  shown 
that  the  rhythmic  contractions  of  the  heart  have  as  their  basis  a  stimulus 
conducted  not  from  the  nerve-centers  of  the  organ  but  from  the  sinus 
region  to  the  auricle  and  ventricle.  Gaskell's  experiment  elucidates  the 
pathogenesis  of  the  condition  in  man;  he  showed  that  constriction  of  the 
circular  layer  of  muscle  at  the  auriculo-ventricular  junction  in  the  heart 
of  tortoises  causes  a  cessation  of  the  rhythmic  action  of  the  heart  so  that 
the  auricles  and  ventricles  become  independent  in  their  contractions,  the 
former  beating  more  rapidly  than  the  latter.  The  impulse  in  the  human 
subject  flows  through  a  bundle  of  muscular  tissue  extending  from  the 
right  side  of  the  interauricular  septum  to  the  interventricular  septum 
just  below  the  pa7'S  memhranacea  ;  it  is  approximately  18  mm.  long,  2 
mm.  broad  and  1.5  mm.  thick.  Now,  if  this  pathway  for  the  impulse  is 
blocked  the  phenomena  of  Stokes-Adams  disease  are  produced.  Erlanger 
has  been  able  to  gradually  compress  the  bundle  of  His  and  bring  about 
varying  degrees  of  heart-block  :  e.  g.^  at  first  there  occui's  an  occasional 
failure  of  ventricular  contraction,  then  a  ratio  of  auricular  to  ventricular 
beats  of  2  to  1,  3  to  1,  4  to  1,  and  finally  complete  block  when  the  ven- 
tricles contract  slowly  and  independently  of  the  auricular  rhythm. 

Various  pathologic  changes  in  the  bundle  of  His  have  been  found 
post-mortem,  thus  confirming  the  results  of  physiologic  experiment. 
For  example,  Stengel  found  an  atheromatous  patch  over  the  bundle  of 
His ;  Ashton,  Norris,  and  Laveson  and  others  a  gummatous  involvement 
of  this  structure,  while  Walter  James  ^  noted  recent  ulceration.  Tempo- 
rary and  incomplete  heart-block  has  been  noted  in  certain  acute  infections 
(tvphoid  fever,  diphtheria,  influenza,  pneumonia,  and  others)  and  in  the 
fibroid  heart.      It  may  also  follow  the  prolonged  use  of  digitalis. 

Symptoms. — The  important  features  are :  (a)  Bradycardia,  {h)  cere- 
bral attacks,  and  {c)  visible  auricular  pulsation  of  the  cervical  veins. 

(a)  Bradycardia — the  slow  pulse  is  a  persistent  feature  in  most  cases, 
but  it  may  be  paroxysmal.  The  rate  falls  to  forty,  thirty,  twenty,  or 
even  less  beats  per  minute,  and  it  often  bears  a  definite  relation  to  the 
normal  for  the  sufferer.  The  pulse  is  scarcely  influenced  by  exercise  or 
drugs  that  quicken  the  heart  action.  Arrhythmia  of  the  ventricular 
contractions  may  be  noted,  but  is  not  common. 

[h)  We  often  observe  a  2  to  1  or  3  to  1  rhythm  on  comparing  the 
auricular  impulses  as  noted  in  the  veins  of  the  neck  with  the  ventricular 
systole.  This  is  due  to  the  fact  that  most  of  the  former  fail  to  cross  the 
bundle  of  His.  Feeble  auricular  sounds  may  be  heard,  when  the  ven- 
tricle is  in  asystole.    The  blood-pressure  is  notably  increased  (De  Renzi). 

(c)  The  cerebral  attacks  consist  principally  of  vertigo,  which  is  usually 
momentary,  syncope,  rarely  convulsive  seizures,  and  pseudo-apoplectiform 
attacks.      The  attacks  of  unconsciousness  may  prove  fatal. 
1  Amer.  Jour.  Med.  Sciences,  October,  1908. 


ANGINA   PECTOJIIS.  713 

Renal  clianges  and  albuminuria  have  been  observed. 

Diagnosis. — Braili/cardia  munt  be  distinguiHhed  from  Stokes- 
Adams  disease.  The  former  is  characterized  by  a  pulse  below  forty- 
eight  beats  per  minute,  with  corresponding  slowness  of  the  systole  and 
the  auricular  impulse,  and  it  has  a  different  etiology  {vide  ante).  Doubt- 
less, atypical  cases  of  the  Stokes-Adams  syndrome  occur,  due  to  slight 
degenerative  changes  in  the  bundle  of  llis,  and  these  may  exist  for  years 
before  the  clinical  picture  becomes  typical. 

Recurring  extrasj/stole,  sinnilating  heart-block,  may  be  due  to 
hyperrhythmicity  of  the  atrioventricular  bundle  and  not  due  to  blocking 
of  this  structure  (functional  variety).  Here  there  occurs  a  forcible 
venous  pulsation  in  the  neck  "without  either  a  radial  pulse  or  a  dis- 
coverable pulsation  in  the  innominate  artery"  (James).  Seven  cases  have 
been  recorded  in  the  literature.^ 

The  prognosis  is  grave  in  cases  showing  anatomic  lesions.  There 
are  instances  in  which  the  bundle  of  His  shows  no  pathologic  changes 
(Edes  and  Councilman).     The  functional  form  gives  a  favorable  prognosis. 

Treatment. — This  consists  in  rest  in  bed  and  in  overcoming  the 
feeble  condition  of  the  circulation  by  free  stimulation.  In  cases  presum- 
ably due  to  syphilis,  the  iodids  in  massive  doses  should  be  given.  In  the 
functional  form,  atropin  changes  the  ratio  between  auricular  and  ventric- 
ular beat,  so  as  to  cause  the  heart-block  to  disappear. 


ANGINA  PECTORIS. 

{Stenocardia,  Breast- pang.) 

Definition. — A  paroxysm  of  violent  precordial  pain  extending  into 
the  neck,  back,  and  left  arm,  and  at  times  attended  by  a  sense  of  im- 
pending death.  It  scarcely  deserves  to  be  classified  as  a  separate  dis- 
ease, being  merely  symptomatic  of  either  cardiac  or  aortic  lesions. 

Pathology. — It  is  claimed  to  be  a  neurosis  affecting  the  cardiac  sen- 
sory filaments  that  are  given  off  chiefly  from  the  pneumogastric,  and  in 
many  cases  the  vasomotor  apparatus  is  also  involved.  Albutt^  believes 
that  the  symptoms  owe  their  origin  to  disease  in  the  aorta — acute  and 
chronic  aortitis.  Sudden  anemia  of  the  myocardium  consequent  upon 
sclerosis  of  the  coronaries,  and  irritation  of  the  ganglia  and  sensory  nerves 
explain  its  origin  (Leube).  May^  suggests  chemical  change  in  the  myo- 
cardium as  the  stimulus  to  the  nerve-endings,  while  Bramwell  believes 
spasmodic  contraction  of  the  mnscular  fibers  of  the  left  ventricle,  due  to  a 
sudden  strain  in  cases  of  atheroma  of  the  coronary  arteries,  to  be  the 
cause.  Heberden  first  made  the  observation  that  angina  is  essentially  a 
vascular  pain,  and  showed  its  extra-cardiac  origin. 

Etiology. — Cases  of  angina  unassociated  with  arterial  sclerosis, 
hypertrophy,  aortic  regurgitation,  or  adherent  pericardium,  are  rarely 
encountered.  With  few  exceptions  sclerosis  of  the  aorta  and  coronaries 
is  present,  and  predisposes  to  the  condition.  This  view  receives  some 
degree  of  color  from  the  fact  that  angina  usually  occurs  after  the  fortieth 
year,  and  principally  in  the  male  sex.     Angina  pectoris  in  the  young 

^See  Pepper  and  Austin,  Amer.  Jour.  Med.  Sci.,  May,  1912,  716. 

^Phila.  Med.  Jour.,  June  30,  1900.  ^ Brit.  'Med.  Jour.,  January  1,  1910. 


714  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

should  ahvays  suggest  syphilis.  It  may  be  a  sequel  of  influenza.  Dys- 
peptic disturbances  may  be  responsible  for,  or  at  least  aggravate,  the  dis- 
ease. The  overuse  of  tobacco  may  rarely  cause  it.  The  determining 
factors  of  tlie  attack  are  undue  exertion  and  mental  emotion. 

Symptoms. — Tiie  paroxj/sm  begins  (juite  suddenly  during  the  action 
of  one  or  other  e.tciting  cause.  There  is  excruciating  pain  of  a  grip-like 
character,  affecting  the  entire  chest  and  rendering  the  body  motionless. 
The  pain  radiates  most  frequently  to  the  left  shoulder,  though  also  to  the 
right,  and  thence  to  the  back,  neck,  and  down  the  arms  to  the  fingers. 
Not  lees  agonizing  than  the  pain  is  the  awful  sense  of  impending  death. 
Coldness  and  numbness  of  the  fingers  or  in  the  })recordial  area  may  be 
present.  The  cuHntenance  is  frequently  pale,  and  may  assume  a  leaden 
hue,  and  is  usually  bathed  in  cold  perspiration.  The  respirations  are 
shallow  or  even  temporarily  arrested,  and  the  patient's  anxiety  is  ex- 
treme. The  heart's  action  may  be  regular,  and  the  arterial  tension  is 
generally  increased.  The  duration  of  the  paroxysm  varies  from  a  few 
seconds  to  a  minute  or  two  (rarely  it  lasts  for  hours),  and  after  the  attack, 
which  subsides  suddenly,  gaseous  eructations,  vomiting,  or  the  discharge 
of  a  large  amount  of  clear  urine  may  occur.  Cheyne-Stokes  breathing 
has  been  observed.  After  the  seizure  there  may  be  an  absence  of  signs, 
and,  though  there  is  weakness,  this  soon  disappears.  The  attack  may 
recur  at  intervals  varying  from  a  few  days  to  as  many  years. 

Varieties. — 1.  Angina  major,  or  severe  form,  in  which  arterial  dis- 
ease is  uniformly  present.  Its  subvarieties  are  thus  classified  by  Osier: 
(a)  the  fulminant  or  rapid  form  with  one  or  two  attacks  only,  or  some- 
times with  the  condition  known  as  status  anginosus ;  (6)  the  form  with 
a  duration  of  one  and  a  half  to  two  years  and  a  varying  number  of  at- 
tacks ;  (c)  the  chronic  form,  lasting  upward  of  ten  years  with  a  varying 
number  and  growing  intensity  of  attacks,  that,  for  instance,  of  John  Hun- 
ter, whose  first  seizure  occurred  twenty  years  before  his  death  ;  and  {d) 
lastly,  the  small  group  of  cases  which  may  last  for  months,  or  as  long  as 
two  years,  with  attacks  of  great  severity,  and  yet  may  completely  recover. 

2.  Angina  minor,  or  mild  form,  usually  described  as  "  false  or  pseudo- 
angina,"  with  its  well-known  subgroups,  the  neurotic,  the  vasomotor 
(Nothnagel),  and  the  toxic  forms. 

In  angina  vasomotoria  the  pain  in  the  heart-region  is  preceded  for  a 
few  minutes  by  pallor  of  the  face,  coldness  and  stiffness  of  the  limbs,  due 
to  spasm  of  the  peripheral  vessels. 

Angina  pectoris  without  pain  {angina  sine  dolore)  may  occur,  the 
main  feature  is  an  indescribable,  almost  painless  sensation  or  precordial 
oppression. 

In  addition,  angina  abdomiriis  is  recognized,  and  simulates  the  gastric 
crisis  of  locomotor  ataxia. 

Diagnosis. — The  characteristic  events  are  a  sudden,  intense  pain 
in  the  substernal  and  left  parasternal  regions  with  marked  constriction 
of  the  chest,  the  peculiar  manner  of  radiation  of  the  pain,  and  the  fear 
of  death.  Less  diagnostic,  though  of  considerable  value,  are  the  brevity 
of  the  attack,  its  sudden  cessation,  the  age  and  sex,  and  the  anxious, 
moistened  features.  There  are  light  forms,  in  which  one  or  more  of  the 
diagnostic  phenomena  above  described  are  absent.  If  they  occur  between 
the  ages  of  forty  and  sixty  years  in  persons  in  whom  either  arterial  sole- 


ANGINA   PKCTORLS.  715 

rosis  or  aortic  regurt^itation  is  present,  this  disease  should  In;  tliour^lit  of; 
and  after  the  exclusion  of  certain  complaints  in  whicli  paroxysmal  pain 
is  prominent,  such  as  gastralgia,  intercostal  neuralgia,  and  locomotor 
ataxia,  the  diagnosis  of  angina  becomes  reasonably  certain. 

The  term  pseudo-angina  pectoris  is  probably  a  misnomer  in  the  present 
state  of  our  knowledge,  and  apparently  tyj)ical  cases  have  been  observed 
to  merge  into  true  angina  pectoris.^  It  must  be  confessed  that  one  meets 
with  hysterical  and  neurasthenic  females,  in  whom  paroxysms  of  difl'use 
pains  over  the  thoracic  region,  accompanied  by  restlessness  and  emotional 
disturbance,  and  lasting  from  one  to  several  hours,  occur.  These  cases, 
however,  have  nothing  in  common  with  angina  pectoris. 

The  prognosis  is  bad,  yet  uncertain.  When  the  arteries  are  scle- 
rosed (particularly  the  coronaries)  life  is  often  suddenly  terminated. 
Occasionally  the  sufferer  dies  of  syncope.  The  nature  of  the  causal  and 
associated  lesions  must  be  considered,  e.  g.^  when  it  accompanies  aortic  in- 
competency, the  prospect  of  life  is  bad.  In  the  vasomotor  angina  of 
Nothnagel  the  outlook  is  less  grave. 

Treatment. — Prevention  of  the  attacks  in  persons  who  are  subject 
to  them  is  of  the  utmost  importance.  The  exciting  factors  are  to  be 
avoided.  The  patient  should  be  instructed  to  carry  constantly  such 
agents  as  nitroglycerin  and  amyl  nitrite  ferles  (strength  3  to  5  drops), 
and  how  to  use  them. 

The  treatment  of  the  attack  must  be  prompt  and  energetic,  though 
carefully  conducted,  amyl  nitrite  being  inhaled  at  once  from  a  handker- 
chief in  doses  of  3  to  5  drops  according  to  the  severity  of  the  attack. 
The  patient  should  then  be  placed  in  a  cool  apartment  at  absolute  rest  in 
bed,  with  restriction  of  food.  Locally,  the  use  of  the  ice-bag  may  prove 
efficacious  and  should  be  tried  at  first.  Rarely,  hot  applications  (hot 
cloths  or  sinapisms)  give  better  results  than  cold.  If  the  pain  is  not  con- 
trolled promptly  by  this  method,  the  nitrite  should  be  reinforced  by  the 
hypodermic  injection  of  morphin  (gr.  -^ — 0.0216)  combined  with  atropin 
(gr.  yl^ — 0.0005).  This  usuully  brings  speedy  relief,  and  is  best  suited 
to  those  instances  in  which  there  is  no  increase  of  arterial  tension.  In 
cases  exhibiting  high  arterial  tension  the  spirits  of  nitroglycerin,  hypo- 
dermically,  should  be  employed  (dose  tTLj — 0.066,  to  be  repeated  once  in 
a  minute  if  needful). 

During  the  intervals  between  the  attacks  the  aim  should  be  not  only 
to  obviate  the  action  of  the  exciting  causes,  but  also  to  overcome  any 
predisposing  influences  that  may  exist.  Prolonged  rest  in  bed  should 
be  enjoined  in  true  organic  cases,  and  in  those  who  cannot  walk  without 
pain.  Excessive  tobacco  smoking  must  be  discontinued.  Schott^  prefers 
baths  (efiervescent)  and  passive  movements  to  drugs  or  other  methods. 
In  true  angina,  passive  movements  alone  should  first  be  performed  by 
an  assistant,  but  later  may  be  safely  entrusted  to  the  patient.  In  cases 
in  which  the  arterial  tension  is  habitually  exalted,  nitroglycerin  in  in- 
creasing doses  is  to  be  used  perseveringly,  beginning  with  TTLJ  (0.066)  and 
increasing  by  TTLj  (0.066)  every  five  or  six  days  until  the  physiologic 
effects  are  produced.  Sodium  nitrite  may  be  employed  alternately  with 
the  nitroglycerin,  the  dose  being  gr.  j-iij   (0.0648-0.184)  three  or  four 

1  "Angina  Pectoris,  True  and  False,"  Jour.  Amer.  Med.  Assoc,  ISTov.  3,  1906,  by  the 
writer.  "^  Medical  Record,  March  11,  1899. 


716  DISEASES   OF  THE  CTRCULATORY  SYSTEM 

times  daily.  Marked  arterial  sclerosis,  particularly  if  there  be  a  syphilitic 
history,  is  favorably  intluenced  by  a  long  course  of  potassium  iodid.  In 
cases  in  which  there  is  quick  recurrence,  sodium  nitrite  in  2|-gr.  tablets 
(dose,  1  to  4  tablets)  is  recommended.  Albutt  lauds — (n)  the  high- 
frequency  current,  and  (b)  the  administration  of  the  hictic  acid  bacillus. 
AVhcn  hypertrophy  of  the  left  ventricle  is  excessive,  I  use  the  following : 

]^.   Tr.  aconiti  rad.,  Hlxlviij  (3.10) ; 

Sodii  bromidi,  5ss  (16.0) ; 

Elix.  simplicis,  q.  s.  ad  5iij  (96.0). — M. 

Sig.  3j  (4.0)  t.  i.  d. 

It  may  be  omitted  at  the  end  of  every  two  weeks  for  two  or  three  days. 
The  presence  of  a  gouty  diathesis  would  call  for  special  treatment.  Dys- 
peptic troubles  should  be  rectified.  For  Cheyne-Stokes  breathing  Albutt 
ailvises  the  inhalation  of  oxygen  and  carbon  dioxid  alternately.  Vene- 
section may  be  employed  in  high  arterial  tension. 

In  the  vasomotor  form  amyl  nitrite  and  nitroglycerin  are  most  valuable. 
Additionally,  hot  foot-baths  are  also  of  tlie  highest  utility. 


IV.  CONGENITAL  AFFECTIONS  OF  THE  HEART. 

These  result  from  two  leading  causes :  (1)  Arrested  development,  and 
(2)  Fetal  endocarditis.      Occasionally,  both  these  factors  are  operative. 

(1)  Arrested  development  may  produce  a  great  variety  of  anomalies : 
(rt)  Acardia,  absence  of  the  organ,  (h)  Cor  biloculare,  or  reptilian  heart, 
in  which  the  septum  between  the  auricles  and  ventricles  is  absent,  thus 
reducing  the  number  of  chambers  to  two.  {c)  Absence  of  the  interven- 
tricular septum,  the  heart  consisting  of  three  chambers  {cor  triloculare). 
((7)  Patency,  or  incomplete  closure  of  the  foramen  ovale.  Persistence  of 
the  foramen  is,  in  the  majority  of  cases,  associated  with  obstruction  of  the 
pulmonarv  valve,  though  it  may  be  solitary,  (c)  An  anomaly  known  as 
ectopia  cordis  deserves  mention.  The  sternum  is  usually  divided  verti- 
cally, and  the  heart  is  either  entirely  exposed  or  beating  just  beneath 
the  skin  in  the  cardiac,  thoracic,  or  abdominal  region.  The  most  com- 
mon form  of  malposition,  however,  is  dextrocardia  (vide  supra,  misplace- 
ment, p.  703).  (/)  Anomalies  of  the  valves.  There  may  be  either  a 
numerical  increase  or  decrease  of  the  cardiac  valves,  particularly  the  seg- 
ments of  the  semilunar  valves  of  the  aortic  and  pulmonary  orifices.  Su- 
pernumerary segments  are  usually  rudimentary. 

(2)  Fetal  Endocarditis. — The  valve-lesions  originating  during  fetal  life 
are  most  frequently  situated  on  the  right  side.  They  may  occur  at  the 
pulmonic,  the  aortic,  or  the  auriculo-ventricular  orifices.  The  changes 
are  of  the  sclerotic  form.  The  leaflets  present  smooth,  thickened,  and 
contracted  borders.  Union  of  the  mitral  segments  is  common,  and  the 
chord;x3  are  often  thickened  and  contracted. 

The  most  frequent  congenital  valvular  lesion  is  stenosis  of  the  pulmo- 
nary orifice  as  the  result  of  chronic  endocarditis.  Ilarely.  it  is  due  directly 
to  defective  development,  and  perhaps  more  rarely  still  to  endocarditis 
verrucosa.  Pulmonic  constriction  of  antenatal  origin  may  be  an  associ- 
ated lesion  in  other  forms  of  valvular  disease  in  the  voung  adult.     With 


CONGENITAL  AFFECTIONS  OF  THE  HEART.  717 

stenosis  at  this  orifice,  there  usually  coexist  stenosis  of  the  conus  ai'terio- 
sis  of  the  right  ventricle,  an  open  foramen  ovale,  and  a  paterjt  ductus 
arteriosus;  according  to  Peacock,  "  in  86  per  cent,  of  the  patients  with 
congenital  heart  disease  living  beyond  the  twelfth  year  the  lesion  is  at 
this  orifice."     Atresia  of  the  pulmonary  orifice  occurs,  though  rarely. 

At  the  tricuspid  orifice  there  may  he  stenosis  or  contraction  of  the 
valves,  producing  either  obstruction  or  i-egurgitation.  Similar-  lesions  of 
the  aortic  orifice  are  infrequent.  Congenital  mitral  disease  occurs  only 
exceptionally ;  it  is  usually  associated  with  tricuspid  stenosis.  Boys  are 
more  liable  to  congenital  affections  of  the  heart  than  girls. 

Symptoms. — There  is  a  constant  and  striking  symptom  in  con- 
genital heart-disease — cyanosis.  The  tint  of  skin  observed  is  variable, 
being  at  one  time  a  general  duskiness,  at  another  a  deep  violet,  and 
rarely  almost  black.  This  coloration  is  noted  about  the  lips  and  mucous 
membrane  of  the  mouth,  the  nostrils,  conjunctivae,  the  fingers,  toes,  and 
lobules  of  the  ears,  and,  as  a  rule,  is  general,  though  it  may  be  a  local 
condition.  The  tint  may  grow  less  distinct,  when  the  child  is  in  perfect 
repose  or  sleeping;  excitants  or  efforts  at  coughing,  however,  increase 
the  intensity  of  the  discoloration.  The  cyanotic  hue  comes  on  almost 
invariably  during  the  first  week  of  life.  The  fingers  present  a  decidedly 
clubbed  appearance,  and  the  nails  are  thickened  and  claw-like.  The 
temperature  is  subnormal,  while  the  extremities  are  cool  to  the  feel. 
Dyspnea  on  exertion  and  cough  are  usual  concomitants.  Variot  reports 
two  cases,  namely,  interventricular  perforation  and  narrowing  of  the  pul- 
monary artery.  Cyanosis  was  absent  from  one  case,  and  "this  disproves 
the  two  leading  theories  with  regard  to  the  origin  of  cyanosis — the  mixt- 
ure of  the  two  bloods  and  the  obstruction  to  the  pulmonary  circulation." 

Physical  Signs. — In  the  very  young  the  impulse  is  feeble,  the  percus- 
sion-dulness  is  increased,  especially  to  the  right,  and  a  loud  systolic  mur- 
mur is  audible  at  the  pulmonary  orifice.  When  the  auriculo-ventricular 
valves  are  the  seat  of  endocarditis,  the  murmur  may  be  apical.  In  pure 
pulmonary  stenosis  the  second  sound  is  feeble. 

In  older  children  the  area  of  dulness  is  only  slightly  extended,  par- 
ticularly to  the  left,  while  the  murmurs  heard  are  loud  and  often  musical. 

In  rare  instances  cerebral  abscess  is  an  associated  condition. 

Differential  Diagnosis. — 

Congenital  Lesions.  .  Acquired  Lesions. 

History  of  almost  constant  cyanosis,  be-  Not   so  ;    history   of   endocarditis    or  of 

ginning  in  the  first  week  after  birth.  rheumatism    or    other   complaints   in 

which   endocarditis  occurs   as  a  com- 
plication. 

Sli,s;ht  enlargement  of  the  heart.     It  is  the  Enlargement  marked,  frequently  involv- 

riglit  ventricle  and  non-progressive.  ing  the  left  ventricle,  and  progressive. 

Loud  and  musical  murmurs  present,  au-  Audible  over  apex  or  base  ;  definite  large 

dible  over  upper  third  of  sternum,  with  areas  of  transmission.     Second  sound 

small  area  of  transmission  upward  and  frequently  accentuated, 
to  the  left ;  second  sound  weak. 

Deficient  bodily  development.  Bodily  development  good,  as  a  rule. 

Mental  faculties  in  abeyance.  Mental  faculties  normal. 

Prognosis. — The  prognosis  is  exceedingly  grave.  Many  succumb 
within  a  few  days  after  birth,  more  than  one-half  before  the  expiration 
of  one  year,  and  not  less  than  three-fourths   before  the  end  of  the   third 


71 S  DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

year.  Few  survive  the  first  decade  of  life,  and  fewer  still  reach  full 
adolescence.  The  form  giving  tlie  most  favorable  prognosis  is  pulmon- 
ary stenosis  with  defective  septa.  There  is  a  disposition  to  affections  of 
the  lungs  (jihthisis),  nerve-complaints  (convulsions). 

Treatment. — The  treatment  is,  in  the  main,  hygienic.  The  body 
must  be  warmly  clad.  The  diet  is  to  be  judiciously  arranged,  yet  liberal. 
Gentle  exercise,  when  it  can  be  taken,  is  valuable,  as  are  also  daily  spong- 
ings  of  the  surftice  followed  by  friction.  Special  therapeutic  indications 
may  arise,  and  must  be  met  in  accordance  with  general  principles. 


V.    DISEASES  OF  THE  ARTERIES. 

ACUTE  AORTITIS. 

Pathology. — The  morbid  changes  coincide  with  those  noted  in  acute 
endocarditis,  including  the  ulcerative  variety. 

Ktiology. — The  causes  are  not  clear,  but  the  condition  generally 
follows  the  acute  infectious  diseases  (typhoid  fever,  pneumonia,  miliary 
tuberculosis).  Alcoholism  and  syphilis  are  among  the  rarer  causes. 
Various  microorganisms  have  been  discovered  to  be  causal  irritants. 
Boinet  and  Romary  have  recently  shown  that  in  experimentally  pro- 
duced aortitis  a  point  of  lessened  resistance  (either  from  traumatism  or 
other  previous  arterial  lesion)  is  necessary. 

Ssntiiptoms. — The  symptoms  are  local  and  general.  Of  the  former, 
diffuse  thoracic  pain,  with  substernal  tenderness  under  pressure  and 
cardiac  palpitation,  are  the  chief.  The  pain  may  assume  the  type  of 
true  angina  pectoris.  Among  the  general  symptoms  a  moderate  feb- 
rile movement  is  almost  constant.  In  a  certain  percentage  of  cases 
embolism  is  betrayed  by  the  usual  signs,  as  rigors,  accompanied  by  a 
steep  temperature-curve.  These  forms  are  analogous  to  the  malignant 
variety  of  endocarditis.     A  cardiac  murmur  may  be  heard  over  the  base. 

Diagnosis. — All  that  the  best  clinicians  can  do  is  to  establish  a 
probable  diagnosis  even  in  the  presence  of  the  most  frankly  expressed 
features  of  the  affection.  From  acute  endocarditis,  aortitis  is  to  be  die- 
criminated  by  its  diffuse  pain  and  by  the  higher  seat  of  its  murmur. 

The  prognosis  is  serious,  owing  to  the  liability  to  infectious  embi^Lli 
and  aneurysmal  dilatation  and  the  possibility  of  aortic  rupture. 

The  treatment  is  similar  to  that  of  acute  endocarditis. 


ARTERIAL  SCLEROSIS. 

{^Arteriosclerosis;  Arterio-cnpillary  Fibronis;   Endarteritis  Chronica  Deformans ;  Atheroma.) 

Definition. — An  atrophic  degeneration  of  the  median  arterial  coat 
followed  by  compensatory  thickening  (hyaline)  of  the  intima. 

Pathology. — The  most  frecjuent  seat  of  the  sclerotic  process  is  the 
aorta,  and  the  next  most  common  the  coronary  arteries.  Other  vessels 
implicated  are  the  arteries  of  the  brain,  the  temporals,  radials,  brachials, 
ulnars,  femorals.  and  iliacs.      On  the  other  hand,  certain  arteries,  as  the 


ARTERIAL  SCLKIiOSIS.  719 

gastric,  Iiepatic,  and  mesenteric,  are  rarely  aflfecte'l.  ^Pwo  forms  may  be 
recognized  :  {a)  the  circumscribed  (athcrom;))  and  (h)  the  diffuse.  ''J'here  is 
also  a  secondary  variety  due  to  hypertension,  causing  dilatation  of  the  ves- 
sels, slowing  of  the  current,  and  compensatory  thickening  of  tlie  intima. 

(a)  Circumscribed  Arterio-sclerosis. — Naturally,  the  intima  presents  a 
smooth  internal  surface,  but  when  atheromatous  changes  occur  it  shows 
localized  areas  of  thickening,  often  hemispheric  in  outline,  yellowish-white 
in  color,  and  their  favorite  seats  are  the  orifices  of  the  branches,  ^fhey 
increase  in  depth  and  superficial  area,  and  on  reaching  an  advanced  stage 
their  interior  disintegrates  into  granular  material  [atheromatous  abscess). 

Histologically,  in  circumscribed  or  nodular  atheroma,  the  middle  coat 
is  the  primary  seat  of  the  changes,  which  consist  of  localized  infiltrations. 
These  lesions  weaken  the  media  and  then  (as  shown  by  Thoma)  compen- 
satory processes  are  set  up  in  the  intima  and  adventitia  (Adami),  which 
lead  to  the  formation  of  the  so-called  atheromatous  button.  The  latter 
consists  in  a  hyperplasia  of  the  intima  with  a  deposit  of  round  cells, 
which  causes  a  gradual  compensatory  thickening.  Josue  and  Pearce  and 
Stanton  ^  have  confirmed  experimentally  Thoma's  view  of  the  nature  and 
sequence  of  pathologic  events  in  arterio-sclerosis.  When  the  prominences 
in  the  intima  undergo  softening  or  liquefaction,  rapid  dilatation  {aneur- 
ysmal) of  the  aifected  vessels  may  occur ;  more  commonly  this  accident 
arises  early  or  before  the  intima  has  reinforced  the  other  layers. 

[b)  Diffuse  Arterio-sclerosis. — The  morbid  process  (histologically  similar 
to  that  described  above)  is  distributed  throughout  the»greater  part  of  the 
arterial  system ;  the  circumscribed  form  is  generally  "but  not  necessarily  " 
(Councilman)  combined  with  it  in  the  aorta.  Dilatation  of  the  aorta  and 
of  its  branches  commonly  coexists.  Apart  from  the  yellowish,  translu- 
cent, elevated  areas,  the  intima  may  be  smooth  and  the  naked-eye  appear- 
ances almost  normal.  Klotz's  experiment  shows  that  increased  intravas- 
cular pressure  alone  may  be  the  cause  of  the  medial  degeneration  and 
weakening  in  the  first  place  ;  of  the  giving  way  of  the  arterial  wall  in  the 
second ;  and  of  the  intimal  hypertrophy  in  the  third.  The  primary  cause 
of  arterio-sclerosis  is  degeneration  and  exhaustion  of  the  elastica  (W.  E. 
Sanders^).  ShefFer  holds  that  hypertension  is  the  cause,  rather  than  the 
result,  of  arterio-sclerosis.  Microscopically,  there  is  observed  an  exten- 
sive proliferation  of  the  subendothelial  connective  tissue  and  a  hyaline 
transformation  of  the  entire,  media,  particularly  in  the  larger  vessels.  The 
muscular  fibers  and  elastic  tissue  have  in  advanced  cases  almost  totally 
disappeared.  Necrotic  degeneration  of  the  media,  especially  in  the  smaller 
arteries,  is  also  observed,  and  calcareous  deposits,  causing  rigidity  of  the 
walls,  occur.  This  is  particularly  true  of  the  so-called  senile  arterio- 
sclerosis. In  this  variety  the  larger  arteries  are  elongated  and  tortuous, 
with  thin,  stiff  (calcified)  walls.  Atheromatous  abscesses  that  burst,  form- 
ing atheromatous  ulcers,  are  likewise  common  pathologic  events  in  the 
aged.  There  may  be  associated  atrophy  of  the  heart,  liver,  and  kidneys, 
due  to  a  lack  of  nutritive  supply  in  consequence  of  the  narrowing  of  the 
vessels. 

Sclerosis  of  the  pulmonary  artery  exhibits  all  the  changes  observed  in 
connection  with  atheroma  of  the  systemic  arteries,  including  aneurysmal 

1  Journal  of  Experimental  Medicine,  1906,  vol.  viii. 

2  Anier.  Jour.  Med.  Sciences,  November,  1911. 


720  DISEASES  OF  THE  CIRCULATOR Y  SYSTEM. 

ililatatidii.     From  the  terminal  tributaries  the  process  may  extend  to  the 
capiUaries.  and  even  to  the  pulmonary  veins  [ain/iosclerosis). 

The  effect  of  arferio-selerosis  upon  the  physiologic  functions  of  the 
vessel-walls  are  of  first  importance.  The  elastic  coat  is  either  destroyed 
or  impaired;  this  predisposes  to  dilatation  of  the  vessels  (aneurysm). 

Another  result  of  extensive  atliororaatous  degeneration  of  the  vessels 
is  an  increase  in  the  resistance  to  the  blood-current,  and  a  consequent 
hypertension.  As  a  consequence,  the  left  ventricle  generally  becomes 
hypertrophied  (especially  if  the  splanchnic  area  is  involved),  "  provided 
the  general  nutrition  of  the  patient  is  still  well  maintained  "  (Strunipell). 

The  reduction  of  the  lumen  of  the  vessel,  owing  to  the  thickening  of 
the  intima.  must  lessen  the  blood-supply  to  the  vai'ious  viscera,  and  tlius 
are  explained  such  secondary  affections  as  fibrous  myocarditis,  renal 
cirrhosis,  chronic  interstitial  pancreatitis  (Opie),  and  cerebral  softening. 

Selerosis  of  the  veins  (phlebosclerosix)  may  accompany  arterio-sclerosis. 
It  is  often  found  in  association  with  hepatic  cirrhosis  and  mitral  disease 
(due  to  increased  tension)  when  the  portal  system  and  pulmonary  veins 
are  involved.  Arterio-sclerosis  apart  from  sclerosis  of  the  peripheral 
veins  may  be  encountered,  though  rarely.  MicroscopieaUi/,  thickening 
of  the  intima  and  atrophic  degenerative  changes  in  the  media  are  com- 
monly observed.  Calcification  and  hyaline  degeneration  of  the  layers 
also  occur.     Moderate  dilatation  is  not  exceptional. 

Ktiology. — The  diffuse  form  has,  in  part,  a  special  etiology.  It  may 
appear  in  the  young,  though  rarely ;  I  have  met  with  a  case  in  the 
Medico-Chirurgical  Hospital  in  a  man  aged  twenty-four  years.  It  is, 
however,  most  frequent  in  strongly  built,  middle-aged  men,  and  in  the 
aged.  At  an  earlier  period  it  occurs  as  a  result  of  aleoholism,  syphilis 
(the  overshadowing  factor),  lead-poisoning^  gout.,  and  chronic  nephritis — 
agencies  that  subject  the  vascular  system  to  undue  wear  and  tear. 
Fremont-Smith  has  collected  144  cases  in  the  young.  Congenital 
syphilis  may  cause  either  diffuse  or  localized  arteriosclerosis.  In  old 
persons  atheroma  is  often  physiologic  and  characterizes  the  natural 
involution  period  of  life.  Heredity  may  play  no  inconspicuous  part  in 
arteriosclerosis  dependent  upon  the  age.  This  fact  furnishes  the  reason 
why  senile  changes  in  the  arteries  occur  at  a  much  earlier  period  of  life 
in  some  families  than  in  others.  Negroes  are  more  liable  than  whites, 
and  males  than  females,  though  it  is  more  frequent  in  the  latter  sex  than 
the  circumscribed  variety.  The  frecjuent  occurrence  of  emphysema  and 
diffuse  angiosclerosis  has  been  noted  (Anderson). 

The  general  causes  may  be  thus  classified — (1)  Biologic  irritants.,  as 
the  specific  micro-organisms  of  malaria,  rheumatism,  and  syphilis. 
Thayer  ^  examined  18:2  patients  who  had  had  typhoid  from  one  month  to 
eighteen  years  previously,  and  found  the  blood-pressure  in  all  cases  some- 
what high,  and  over  50  per  cent,  of  the  cases  over  twenty  years  of  age 
showed  palpable  arteries.  Klotz's  experiments  indicate  that  diphtheritic 
toxins  lead  to  medial  degeneration,  while  others — e.g.,  typhoid  toxins — 
have  no  effect  on  this  coat,  but  induce  a  primary  intimal  degeneration. 
(2)  Qhemical  irritants  (chronic  alcoholism,  lead-poisoning,  uric  acid  in 
gout,  diabetes,  obesity).  The  above  toxic  agents,  including  endogenous 
toxins  (indol,  in  particuLir).  produce  their  effects  partly  by  tlieir  direct 
1  Medical  News,  New  Yoik,  Xov.  21,  190?,,  p.  1004. 


ARTERLAL  SCLEROSIS.  721 

irritant  action  and  partly  by  increasing  the  resistance  in  tiie  peripheral 
vessels  and  thus  raising  the  arterial  pressure.  (3)  Brirjld'H  DineaHe. — 
There  is  a  class  of  cases  in  which  arterio-sclerosis  is  secondary  to  Bright's 
disease,  but  when  found  in  association  the  former  is  more  frequently  the 
primary  disease  than  the  latter.  Tlie  two  diseases  may  develop  independ- 
ently of  one  another,  and  yet  simultaneously,  in  consequence  of  the  action 
of  a  common  cause.  (4)  Constant  overfilling  of  the  blood-vessels,  result- 
ing from  excesses  in  eating  and  drinking,  also  causes  arterio-sclerosis. 
(5)  Muscular  overstrain,  which  augments  the  blood-pressure  while  at  the 
same  time  obstructing  the  peripheral  circulation,  is  a  leading  factor.  (6) 
The  main  causes  of  sclerosis  of  the  pulmonary  artery  are  mitral  disease 
and  emphysema. 

Clinical  History. — The  disease  may  be  latent  for  years ;  or  it  may 
be  discovered  at  autopsy.  In  many  cases  the  earlier  symptoms  resemble 
those  of  neurasthenia,  and  these  are  accompanied  by  a  slowly  progressive 
failure  of  the  general  nutrition.  The  accessible  peripheral  vessels  (radial, 
temporal,  femoral,  and  brachial)  should  be  carefully  felt  when  the  pres- 
ence of  the  disease  is  suspected.  In  developed  cases  the  walls  of  the 
affected  artery  feel  hard,  and  the  pulse.,  owing  to  increased  tension,  is 
incompressible ;  as  a  result  of  this  rigidity  of  the  arterial  walls  the 
degree  of  vascular  tension  is  difficult  of  estimation.  In  marked  cases  the 
pulse-wave  may  not  be  detectable  on  palpation.  Again,  the  tension  may 
be  high,  and  yet  sclerosis  of  the  vessel- wall  be  slight  or  absent.  When 
doubt  arises,  the  pulse  should  be  palpated  by  means  of  two  fingers.  If 
now,  while  compression  of  the  ])ulse  is  made  with  the  index-finger, 
the  middle-finger  detects  a  pulse-wave,  arteriosclerosis  is  present. 
Rarely,  however,  a  recurrent  pulse  may  be  felt  notwithstanding,  but, 
as  Ewart  points  out,  pressure  .on  the  ulnar  artery  at  once  arrests  it.  On 
account  of  the  loss  of  elasticity  of  the  vascular  walls  the  pulse  is  retarded, 
and  the  sphygmogram  shows  a  short  sloping  ascent,  a  wide  top,  and  a 
slow,  gradual  descent,  with  almost  an  effacement  of  the  dicrotic  notch. 
The  blood-pressure  is  high,  as  a  rule,  in  arterio-sclerosis,  but  this  may 
also  precede  the  sclerotic  process. 

The  increased  resistance  to  the  circulating  medium  (due  to  the  rigid 
vessel-walls)  calls  forth  a  correspondingly  increased  cardiac  action,  and  thus 
hypertrophy  of  the  left  ventricle  is  engendered,  with  its  customary  symptoms 
and  signs,  including  the  ringing,  accentuated  second  sound.  The  balance 
of  the  cardio-vascular  forces  may  thus  be  maintained  for  a  long  period  of 
time,  during  which  the  health  of  the  patient  often  remains  unimpaired. 
It  happens  sometimes  that  hypertrophy  preponderates  and  veils  com- 
pletely the  symptoms  of  arterio-sclerosis.  In  elderly  persons  suffering 
from  atheroma  the  first  sound  is  often  surprisingly  feeble.  Myocardial 
degenerations  frequently  come  on  in  the  later  stages,  when  dilatation  of 
the  left  ventricle,  accompanied  by  a  mitral  systolic  murmur  and  marked 
rapidity  of  the  pulse,  may  supervene.  The  aorta  may  be  so  dilated  as 
to  give  rise  to  an  abnormal  area  of  dulness  in  the  upper  sternal  region. 
Palpitation,  dyspnea  on  exertion,  a  feeling  oi precordial  constriction,  and 
M^i  febrile  attacks  are  not  uncommon.  Angina  pectoris  \&  2i>n  mix q({^q  t 
symptom  except  in  coronary  atheroma.  Certain  writers  have  emphasized 
abdominal  pain,  flatulence,  and  other  gastro-intestinal  features. 

It  cannot  be  stated  that  involvement  of  the  external  arteries  implies 

46 


722  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

a  serious:  involvement  of  the  aorta  and  its  main  branches.  On  tlie  other 
hand,  the  circumscribed  variety  is  not  attended  Avith  characteristic 
alteration  of  the  pulse.  The  pathologic,  and  particularly  the  clinical, 
events  may  be  more  pronounced  at  one  portion  of  the  body  than  at 
others,  and  this  fact  has  iriven  rise  to  several  distinct  or  special  types, 
as  follows:  [(()  cerebral.  [/>)  iMiliuonarv.  (<•)  renal,  and  ((/)  perijiheral  tyjies. 

(a)  Cerebral  Type. — In  the  milder  grades  of  this  type  such  symptoms 
as  headache,  tinnitus,  vertigo,  syncopal  attacks,  and  local  palsies  are 
variously  blended  as  a  rule.  Especially  in  the  aged,  the  condition  is  apt 
to  lead  to  thrombosis  or  cerebral  embolism,  emboli  being  detached  from  the 
aortic  area  and  conveyed  to  the  brain,  ^ith  the  development  subsequently 
of  the  symptoms  of  anemic  softening  of  the  latter.  The  loss  of  elasticity 
of  the  vessel-walls  in  atheroma  renders  them  more  liable  to  rupture  than 
normal  arteries,  while  the  tension  is  much  increased.  Under  these  cir- 
cumstances the  danger  from  cerebral  apoplexy  is  obvious. 

(b)  Pulmonary  atheroma  is  considered  in  its  clinical  relations  in  con- 
nection with  the  diseases  of  the  heart  and  lungs. 

(c)  The  renal  type  includes  those  instances  of  kidney-lesion  that  are 
associated  with  or  follow  general  arterio-sclerosis.  The  condition  is  essen- 
tially an  atrophic  nephritis,  due  to  the  diminution  of  the  blood-supply 
to  the  organs  in  consequence  of  the  narrowed  lumen  of  the  renal  arteries. 

(d)  In  this  ti/pe  the  peripheral  arteries  become  obliterated  and  cause 
starvation  of  the  tissue,  with  resulting  cramps  and  even  gangrene. 

Diagnosis. — Hardened  arteries,  increased  arterial  tension,  left  ven- 
tricular nypertrophy,  and  marked  accentuation  of  the  aortic  second  sound 
form  a  group  of  clinical  characters  that  leaves  no  doubt  as  to  the  diag- 
nosis. It  may  be  the  occurrence  of  apoplexy,  acute  cardiac  dilatation, 
or  of  some  other  such  accident  that  leads  to  the  discovery  of  general 
arterial  sclerosis.  Slight  albuminuria  is  generally  present.  A  murmur 
may  be  heard  over  the  base.  An  ophthalmoscopic  examination  is  of  the 
utmost  value  as  a  diagnostic  aid. 

C.  Beck  ^  and  others  have  found  that  the  a--rays  are  useful  in  deter- 
mining the  extent  of  arterio-sclerosis  (e.  g.,  whether  local  or  general). 

To  differentiate  the  murmurs  of  dilatation  of  the  left  ventricle  follow- 
ing the  hypertrophy  of  this  disease  from  organic  mitral  lesions  is  only 
possible  by  the  history  or  the  results  of  treatment.  In  aortic  stenosis 
the  second  sound  is  weak  and  the  pulse  less  voluminous  than  in  arterio- 
sclerosis {vide  Aortic  Stenosis). 

Prognosis. — Arteriocapillary  fi1>rosis  is  an  exceedingly  chronic, 
though  usually  a  progressive,  disease,  and  frequently  it  terminates  life. 
The  axiom  that  a  man  is  as  old  as  his  arteries  has  been  borne  out  by  the 
test  of  extensive  clinical  observation.  The  condition  may  prove  fatal, 
either  with  great  suddenness,  as  when  it  occasions  apoplexy,  or  with  un- 
wonted slowness.      Very  rarely  the  aorta  ruptures,  causing  instant  death. 

Treatment. — Though  the  progress  of  the  disease  cannot  in  most  in- 
stances be  successfully  stayed,  it  can  be  retarded  fre(|uently  by  correcting 
aggravating  habits  and  by  removing  the  influence  of  ascertainable  causes. 
The  syphilitic  taint,  if  present,  ret^uires  the  liberal  use  of  the  iodids. 

The  diet  must  be  simple  and  free  from  stimulating  properties;  skimmed 
milk  is  excellent,  particularly  if  renal  symptoms  be  manifested.  The 
»iV.  Y.  Med.  Jour.,  Jan.  22,  1898. 


ANEURYSM.  723 

lactic  aci<l  and  sour  milk  treatment  may  bo  employed  in  cases  in  wliich 
auto-intoxication  is  an  etiologic  factor.  A  salt-free  diet  (green  vegetables, 
fruits,  fresh  butter,  cream,  potatoes,  rice,  sugar,  salt-free  bread)  is  useful 
for  a  week  or  two  at  a  time  wiien  the  blood-pressure  rules  higb.  Jn  the 
earlier  stages  potassium  iodid  is  serviceable ;  it  should  be  administered 
for  several  years,  combined  with  appropriate  physical  exei'cise  (e.  (j.,  golf, 
horseback  riding,  walking)  to  regulate  the  bodily  function.  Recent  re- 
searches show  that  small  doses  of  potassium  iodid  reduce  tlie  viscosity  of 
the  blood  by  acting  on  the  corpuscles  without  diluting  it.^ 

For  the  increased  arterial  tension,  more  especially  if  due  to  temporaiy 
vasoconstriction,  nitroglycerin  or  the  other  nitrites  should  be  employed,  in 
increasing  doses,  until  an  impression  has  been  made  upon  the  blood-pressure, 
after  which  this  effect  should  merely  he  maintained.  Guipsine  (dose, 
gr.  |- — 0.05,  every  three  or  four  hours,  in  pill  form)  acts  well  in  cases  due 
simply  to  arterial  spasm.  Electrical  discharges  in  the  form  of  auto- 
condensation  reduce  the  hypertension  to  an  appreciable  extent,  and  also 
probably  stimulate  the  metabolic  processes.  In  persistent  (chronic) 
hypertension  the  tincture  of  aconite  is  useful.  Venesection  has  a  more 
lasting  eifect  than  have  any  of  the  drugs  used  (Lawrence).  The  cases  in 
which  the  blood-pressure  is  quite  elevated  in  consequence  of  vaso-con- 
striction  due  to  nervous  causes,  combined  Avith  a  mild  grade  of  arterio- 
sclerosis, need  mental  and  physical  rest,  arterial  relaxants,  and  liberal 
feeding. 

For  the  local  aortic  symptoms  (fever,  pain)  absolute  rest,  a  liquid  and 
unirritating  diet,  and  a  small  blister  are  most  efficacious,  together  with 
internal  minute  doses  of  calomel,  quinin,  and  potassium  iodid. 


ANEURYSM. 

Definition. — A  true  aneurysm  is  a  circumscribed  dilatation  of  an 
artery,  formed  of  one  or  more  of  its  coats. 

Classified  according  to  their  form,  aneurysms  are — (1)  sacculated.  (2) 
cylindric,  and  (3)  fusiform.  They  are  termed  axial  when  the  complete 
circumference  of  the  vessel  participates  in  this  dilatation,  and  peripheral 
when  a  single  sac  is  confined  to  the  side  of  the  vascular  duct. 

Miliary  aneurysms  occur  along  the  course  of  the  cerebral  vessels.  On 
the  other  hand,  aneurysms  may  attain  the  size  of  the  human  skull. 

By  Sb  false  aneurysm  is  meant  one  in  which  the  coats  are  ruptured. 

A  dissecting  aneurysm  is  one  that,  owing  to  laceration  of  the  internal 
coat,  dissects  between  the  layers  of  the  vessel-wall.  For  its  seat  it  usu- 
ally selects  the  aorta,  and  may  traverse  its  entire  length. 

An  arteriovenous  aneurysm  arises  from  a  direct  fistulous  connection 
between  an  artery  and  a  vein  {aneurysmal  varix),  or  an  aneurysmal  sac 
may  intervene  {varicose  anenrysni). 

Pathology  and  Pathogenesis. — The  wall  of  the  aneurysm  is 
commonly  the  seat  of  arteriosclerosis,  which  Malkofi"^  claims  is  a  com- 
pensatory arrangement.  Osier  states  that  the  origin  of  aortic  aneurysm  is 
to  be  traced  to  mesaortitis,  so  different  from  chronic  aortic  degeneration. 
The  common  atheromatous  disease  does  not  often  produce  aneurysm. 
Extreme  atrophy  of  both  the  intima  and  media  is  not  uncommon  in  the 
'  E.  Romberg,  DexUsch.  med.  Woch.,  Aug.  31,  1905.  -Zieglei-'s  Beitrdge,  1899,  xxv. 


724  DISEASES  OF  THE  CIRCULATORY  SY^STEM. 

later  stages,  the  wall  of  the  sac  being  fonneJ  chieHy  by  the  adventitia. 
The  iuiima  (as  in  Dalaml's  case  of  aortic  aneurysm,  in  which  there  were 
both  an  old  and  a  new  transverse  rent)  may  become  lacerated,  and  finally 
the  media  and  adventitia  tear  ;  this  results  in  rupture  unless  the  adherent 
neij^hboring  structures  compensate  for  the  natural  wall. 

The  blood  in  the  aneurysmal  sac  is  composed  of  old  and  new  thrombi. 
The  latter  when  comparatively  recent  may  be  soft,  and  when  old  may  be 
firm  or  even  calcified,  yellowish  in  color,  and  adherent  to  the  wall. 

Ktiology. — Among  recognized  causes  are — (1)  Arterio-sclerosis. — 
Some  of  the  conditions  that  originate  the  latter  at  all  events  also  tend  to 
bring  about  aneurysms.  According  to  Kasch,  syphilis  was  present  in  56 
per  cent,  of  25  aneurysms  of  the  aorta  discovered  in  the  course  of  3165 
necropsies  at  Copenhagen,  and  Annsperger  found  it  in  48.6  per  cent,  of 
37  cases.  (2)  Sudden  Great  Strain. — This  may  be  productive  of  aneurysm, 
particularly  in  the  early  stage  of  arterio-sclerosis  or  before  compensatory 
endarteritis  occurs.  Thus  may  the  fact  be  accounted  for  that  most  in- 
stances of  aneurysm  occur  during  the  period  of  greatest  bodily  activity 
in  the  male  sex.  (3)  Embolic  plugging  of  a  vessel,  if  complete,  may  cause 
aneurysmal  dilatation  on  the  pro.ximal  side  of  the  point  of  obstruction. 
The  development  of  aneurysm  may  be  facilitated  by  the  mechanical  effects 
of  the  embolus,  which  may  be  of  calcareous  hardness,  as  when  it  comes  from 
diseased  heart-valves.  Infectious  emboli  set  up  inflammation  and  soft- 
ening. (4)  Mycotic  Aneurysms. — That  aneurysms  sometimes  owe  their 
existence  to  mycotic  origin  was  first  pointed  out  by  Osier,  who  found  an 
abundant  growth  of  micrococci  in  the  aneurysmal  sacs.  They  are  met 
Avith  in  ulcerative  endocarditis,  and  are  often  small  and  usually  multiple. 
(5)  Traumatism. — Aneurysms  have  been  produced  experimentally  by 
traumatism  (MalkoflF);  hence  it  is  obvious  that  it  may  become  one  of 
the  assignable  causes.  (6)  Age  and  Sex. — Aneurysms  are  most  frequent 
between  the  thirtieth  and  fiftieth  years,  this  being  the  period  of  great- 
est physical  exertion.  The  male  sex  is  more  frequently  affected  than  the 
female,  owing  to  differences  in  occupation. 

ANEURYSM  OF  THE  THORACIC  AORTA. 

(^Aneunji^ina  Aortce.) 

The  thoracic  portion  of  the  aorta  is  involved  in  about  75  per  cent,  of  the 
cases,  and  the  abdominal  aorta  and  its  branches  in  25  per  cent.  Within  the 
thorax  nearly  60  per  cent,  of  the  cases  originate  in  the  ascending  portion 
of  the  aorta  (Lyman).  Hare  and  Holden  ^  collected  570  cases  of  aneurysm 
of  the  ascending  arch,  of  which  504  were  of  the  saccular  variety. 

Symptoms. — Intrathoracic  aneurysms  may  exist,  particularly  if 
they  are  small,  without  symptoms  or  noticeable  physical  signs.  When 
they  attain  to  any  considerable  dimensions,  however,  they  usually  excite 
characteristic  signs  and  distressing  symptoms,  the  latter  being  the  results 
of  direct  pressure,  and  hence  varying  with  the  seat  and  direction  of  the 
progressive  enlargement.  In  a  few  instances  diagnostic  symptoms  are 
present  in  the  absence  of  a  detectable  tumor  or  physical  signs.  Aneurysms 
of  the  ascending  portion  of  the  arch  usually  compress  the  vena  cava, 
causing  distention  of  the  veins  of  the  head  and  arms,  though  in  a  pro- 
1  Amer.  Jour.  Med.  Sci.,  Octobei-,  1899. 


Plate  VI. 


Aneurysm  of  Aorta. 


ANEURYSM.  T2b 

portionately  small  number  of  cases  the  subcluvian  may  be  the  only  vein 
compressed,  with  resulting  enlargement  and  ederiM.  of  the  right  arm.  ^Jlie 
largest  aneurysms  may  even  compress  the  inferior  vena  cava,  causing 
edema  of  the  lower  extremities.  The  lieart  is  displaced  outward  toward 
the  left  pleura,  and  usually  upward,  and  rarely  causing  erosion  of  the 
ribs  and  sternum.  The  right  recurrent  laryngeal  nerve  may  be  implicated, 
giving  rise  to  dyspnea  and  aphonia.     Pain  is  a  constant  feature. 

Aneurysms  of  the  transverse  portion  of  the  aorta,  when  they  attain 
any  considerable  size,  cause  the  most  intense  symptoms,  owing  to  the 
relatively  shorter  antero-posterior  diameter  of  the  chest  at  this  point,  in 
consequence  of  which  greater  compression  of  the  neighboring  tissues  takes 
place.  By  protruding  backward  they  may  exert  pressure  upon  the 
trachea,  causing  paroxysmal  cough  and  dyspnea^  or  on  the  esophagus, 
causing  dysphagia ;  these  are  common  events.  The  pressure  may  fall 
also  upon  the  bronchus,  inducing  dyspnea,  hronchorrhea.,  and  dilatation, 
the  latter  in  turn  sometimes  leading  to  circumscribed  abscess.  The  left 
recurrent  laryngeal  nerve  may  be  implicated,  with  resulting  aphonia. 

Upward  extension  of  the  aneurysmal  process,  Avith  involvement  of  the 
coats  of  the  carotid  and  subclavian  on  the  left  side,  or  of  the  innominate 
and  carotid  on  the  right,'  may  occur.  The  sympathetic  nerves  in  the  cervical 
region  may  be  irritated,  causing  dilatation ;  or  they  may  be  paralyzed,  caus- 
ing contraction  oi^CnQ pupils.  Compression  of  the  thoracic  duct  may  occur, 
with  resulting  rapid  emaciation.    A  tumor  may  appear  in  the  jugular  fossa. 

The  aneurysm  may  grow  forward,  in  which  event  it  lies  directly  be- 
hind the  manubrium,  which  from  the  pressure  becomes  eroded  and  may 
finally  disappear  in  part.  In  aneurysms  involving  the  transverse  portion 
of  the  arch,  lateral  pressure,  both  toward  the  right  and  the  left,  is  also 
made,  causing  recession  and  compression  of  the  lungs. 

When  the  descending  portion  of  the  arch  is  affected  the  pressure  is  ex- 
erted upon  the  spinal  column  to  the  right,  and  upon  the  tissues  as  far  as 
the  shoulder-blade  to  the  left.  As  a  consequence  of  destruction  and  ab- 
sorption of  the  vertebrae,  compression  of  the  spinal  cord  may  ensue,  and  is 
an  intensely  painful  process.  Pressure  may  be  made  upon  the  esophagus, 
causing  dysphagia,  or  upon  the  left  bronchus,  causing  bronchiectasis,  with 
its  usual  sequelce  (hronchorrhea,  fetid  bronchitis,  gangrene  of  the  lung). 

The  sac  may,  in  consequence  of  the  slow  ulcerative  process  that  attends 
its  progress,  rupture  (vide  Prognosis).  Frequently  repeated  small  hem- 
orrhages, due  to  weepings  from  the  thinned  walls,  may  precede  the  fatal 
rupture.  I  saw  a  case  of  aneurysm  of  the  transverse  portion  in  which 
rupture  into  the  esophagus  resulted,  with  instantaneous  death. 

When  the  tumor  has  reached  the  subcutaneous  tissue  and  bulges  ex- 
ternally, the  skin  covering  it  becomes  tense  and  shining,  and  with  in- 
creased pressure  the  surface  becomes  reddened  and  finally  necrotic.  The 
necrosed  area  is  covered  with  a  dry  brown  scab,  which  later  is  thrown 
off,  leaving  an  oozing  surface.     Rupture  soon  follows. 

Leading.  Symptoms  in  Detail. — Among  these  pain  stands  primarily, 
being  the  first  and  most  constant.  It  is  of  two  kinds :  (a)  due  to 
direct  pressure  upon  and  stretching  of  the  nerves.  When  aneurysm 
is  developed  suddenly,  a  sharp,  excruciating  pain  is  felt  in  the  upper 
sternal  region,  accompanied  by  a  feeling  of  "something  giving  way." 
In  consequence  of  the  stretching  of  the  nerves  a  constant  pain  is  expe- 


726  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

rionced  that  is  subject  to  oxact'i-batious  ulicn  tlio  iiitra-aiiourysiiial 
pressure  is  raised.  Pressure  against  the  bony  struetures  causes  erosion, 
and  usually  produces  a  continuous  boriuir  pain.  In  a  recent  case  of 
aneurysm  shown  in  clinic  at  the  Medico-Chirurgical  College,  how- 
ever, a  tumor  of  the  size  of  a  goose's  egg,  had  given  rise  to  no  suffering  what- 
ever. In  latent  aneurysm  there  is  an  absence  of  pain.  Anginose 
attacks  sometimes  occur  when  the  sac  has  its  seat  near  to  the  heart,  (b) 
Reflected  pains  of  a  neuralgic  character  may  be  excited  by  aneurysm. 
This  is  true,  in  particular,  of  aneurysms  situated  in  the  transverse  por- 
tion of  the  aorta,  in  which  instances  pain  is  commonly  felt  in  the  region 
of  the  neck  and  occiput  and  down  the  left  arm.  When  the  growth  is 
situated  along  the  course  of  the  descending  aorta,  intercostal  neuralgia 
may  be  excited,  due  to  pressure  upon  the  nerve-trunks. 

Cough. — The  cough  is  paroxysmal,  and  frequently  has  a  peculiar 
brazen,  ringing  character  that  points  to  its  laryngeal  seat.  Pressure 
upon  the  windpipe  excites  a  paroxysmal  dry  cough.  Compression  of  a 
bronchus  may  lead  to  bronchiectasis,  and  the  cough  then  occurs  only  in 
severe  paroxysms  which  recur  at  intervals  of  a  day  or  even  longer,  and 
are  attended  with  copious,  ropy  expectoration  {vide  Bnmchiectasis). 

Dyspnea  is  a  conspicuous  symptom  in  aneurysm  of  the  transverse  por- 
tion of  the  aorta  (the  aneui-ysm  of  symptoms — Broadbent).  It  arises 
(a)  most  frequently  in  consequence  of  pressure  upon  the  recurrent  laryn- 
geal nerve,  [b)  direct  pressure  on  the  trachea,  and  (c)  from  pressure  on 
the  left  bronchus.     Marked  stridor  may  accompany  the  first  variety. 

Paralysis  of  the  vocal  bands  is  occasioned  by  compression  of  the  recur- 
rent laryngeals,  particularly  the  left,  while  a  slight  degree  of  compression 
or  irritation  of  the  same  nerve  causes  spasm  of  the  vocal  cords.  The 
symptoms  of  these  conditions  are  hoarseness,  cough,  and  aphonia  respec- 
tively. The  laryngoscope  should  be  employed,  since  paralysis  of  one 
of  the  abductors  may  be  present  without  giving  rise  to  appreciable 
symptoms. 

Hemorrliage  may  occur  as  a  slow  oozing,  either  from  the  point  of  com- 
])ression  in  the  trachea  or  externally ;  in  either  case  the  bleedings  are 
small.  Profuse  bleedings  (producing  sudden  death)  take  place  in  con- 
sequence of  rupture  of  the  sac  into  the  lung,  the  bronchus,  or  the 
trachea. 

Deglutition  may  be  difficult,  owing  to  compression  of  the  esophagus. 
When  an  aneurysm  has  been  diagnosticated  or  even  suspected,  the  esoph- 
ageal sound  should  not  be  passed,  lest  the  sac  be  ruptured. 

Compression  and  irntation  of  the  sympathetic  system  of  nerves  cause 
pupillary  changes  that  have  already  been  mentioned.  With  dilatation 
of  the  pupil  there  may  be  observed  pallor  of  one  side  of  the  face,  due  to 
stimulation  of  the  vasodilator  fibers ;  on  the  other  hand,  with  contraction 
of  the  pupil  (duo  to  paralysis  of  the  constrictor  fibers)  there  is  hyperemia 
of  one  side  of  the  face  and  unilateral  sweating,  with  drooping  eyelid. 
The  most  common  cause  of  anisocoria  is  unequal  blood-j)ressure  in  the 
ophthalmic  arteries  (Wall  and  Walker). 

Clubbing  of  the  fingers  and  incurvation  of  the  nails  (at  times  unilat- 
eral) are  not  rarely  met  with  in  thoracic  aneurysm. 

Physical  Signs. — Inspection. — Visible  pulsation  is  one  of  the  earliest 
appreciable  signs.      It  is  most  frequently  observed  at  the  right  side  of 


ANEURYSM.  121 

the  sternum,  above  the  level  of  the  third  rib  (second  interspace),  and 
much  less  frequently  on  the  left  side  over  a  corresponding  area.  In 
aneurysm  of  the  transverse  portion  pulsation  may  be  seen  at  the  episternal 
notch,  though  an  impulse  here  may  also  be  due  to  nervous  palpitation, 
and  have  no  connection  -with  aneurysmal  growths.  Wlien  pulsation  is 
associated  with  swelling,  its  diagnostic  value  becomes  greater. 

Involvement  of  the  innominate  artery  produces  pulsation  in  the  neck 
above  the  sterno-clavicular  junction,  or  less  commonly  above  the  sternum. 
Corresponding  to  the  site  of  visible  impulse,  there  is,  sooner  or  later, 
bulging  in  most  instances.  It  may,  however,  be  so  slight  as  to  elude  de- 
tection unless  the  keenest  observation  be  practised,  and  in  not  a  few 
instances  the  tumor  itself  is  invisible  from  the  front  of  the  body,  but  is 
recognizable  looking  from  behind  or  from  either  side.  Again,  on  allow- 
ing the  light  to  fall  obliquely  upon  the  chest  slight  prominences  may  be 
brought  to  view  that  would  otherwise  be  inappreciable. 

When  the  aneurysm  is  situated  in  the  ascending  part  of  the  arch,  the 
most  frequent  seat  of  the  bulging — which  varies  in  size  from  a  hen's 
egg  to  a  cocoanut — is  over  the  first  and  second  right  interspaces  near 
to,  and  frequently  involving,  a  portion  of  the  sternum  ;  when  seated  just 
beyond  the  aortic  orifice,  a  pulsating  prominence  may  occupy  the  third 
interspace  along  the  left  sternal  border ;  situated  in  the  transverse  section 
of  the  aorta,  bulging  of  the  upper  part  of  the  sternum  is  common.  In 
the  descending  portion  the  swelling,  when  present,  is  in  the  second  and 
third  left  interspaces  near  to  the  sternum,  or  in  the  left  scapular  zone. 
The  apex-beat  is  displaced  downward  and  outward,  chiefly  from  pressure, 
though  also  from  hypertrophy  (functional). 

Palpation. — The  protrusion  presents  a  more  or  less  yielding  and 
elastic  mass,  and  when  superficially  seated  fluctuation  may  be  obtainable. 
The  degree,  and  the  rhythmic  expansile  character  of  the  pulsation  are 
to  be  noted,  and  also  the  fact  that  there  is  an  alternate  contraction  and 
dilatation  of  the  sac  in  every  direction — a  distinctive  feature. 

If  the  aneurysm  is  largely  concealed,  bimanual  palpation  should  be 
employed,  the  palm  of  one  hand  being  placed  over  the  spine  and  that 
of  the  other  over  the  sternum.  In  rare  cases  aneurysmal  pulsation  is 
only  yielded  when  the  finger-tips  are  used,  and  especially  at  the  end 
of  expiration.  A  diastolic  shock  is  often  perceived,  and  forms  a  sign  of 
no  little  value.  A  distinct  systolic  shock,  sometimes  accompanied  by  a 
purring  fremitus,  can  also  be  felt  over  the  aneurysmal  sac. 

Percussion. — If  the  growth  be  deep-seated,  percussion  may  give 
negative  results ;  when,  however,  the  tumor  causes  bulging  or  comes  in 
contact  with  the  chest-wall,  a  proportionate  area  of  flatness  is  pre- 
sented. The  abnormal  field  of  dulness  may  be  the  only  symptom  present. 
Aneurysms  of  the  ascending  arch  give  flatness  to  the  right  of  the  ster- 
num ;  those  of  the  transverse  arch,  over  the  upper  part  of  the  sternum 
and  to  the  left ;  while  those  of  the  descending  portion  are  revealed  by  a 
flat  area  between  the  spine  and  the  left  scapula.  With  flatness  of  the 
percussion-note  there  is  a  sense  of  increased  resistance.  There  is  gen- 
erally a  moderate  increase  in  the  area  of  cardiac  dulness.  Conversely 
the  left  ventricle  has  been  found  of  diminished  size  at  necropsy. 

Auscultatory  percussion  (practised  after  the  method  of  Sansom  and 
Ewart)  quite  often  gives  valuable  results. 


728  DISEASES   OF  THE  VIliCULATORY  SYSTEM. 

Auscultation. — Since  inunmns  owe  their  origin,  in  great  part,  to 
the  presence  of  fihrin  m  the  sac.  they  may  be  absent,  and  this  even  in 
the  case  of  hirge  aneurysms.  When,  as  is  usual,  a  murmur  is  present,  it 
is  systolic  in  rhythm,  heard  with  greatest  intensity  over  the  flat  area  or 
body  of  the  tumor,  and  is  transmitted  in  the  direction  of  tlie  blood-stream, 
being,  therefore,  distinctly  audible  in  the  vessels  of  the  neck  and  along 
the  course  of  the  aorta.     The  murmur  has  a  booming  quality. 

Aortic  regurgitation  may  be  considered  as  associated  with  aneurysm 
near  the  aortic  ring  when  a  double  murmur  is  heard.  In  a  few 
instances  the  diastolic  bruit  is  alone  detectable.  A  much  intensified, 
ringing  second  sound  is  present  (unless  marked  aortic  regurgitation 
coexists). 

The  Peripheral  Arteries. — The  pulse  in  the  vessels  beyond  the  aneui*ysm 
is  delayed.  Hence  the  two  radial  pulses  may  exliibit  differences  in  time. 
The  colume  of  the  pulse  beyond  the  aneurysm  is  lessened,  and  in  aneu- 


FiG.  58.  — Sphygmogram  of  a  case  of  aneurj'sm  of  the  left  subclavian  artery  (Foster). 

rysm  of  the  abdominal  aorta  or  the  femorals  it  may  be  obliterated.  Such 
diflferences  as  these  will  not  only  point  to  the  existence  of  thoracic  aneu- 
rysm, but  also  its  neat.  Thus,  if  there  be  dilatation  of  the  transverse 
arch  with  no  implication  of  the  innominate,  the  pulse  at  the  right  wrist 
is  strong  and  almost  simultaneous  with  the  cardiac  impulse,  while  that 
on  the  left  side  is  small,  weak,  and  delayed.  If  the  reverse  be  true,  then 
the  aneurysm  may  be  near  to  or  involve  the  innominate.  0.  K.  William- 
.son  has  found  a  marked  difference  in  the  blood-pressure  of  the  two  ai-ms 
in  cases  of  thoracic  aneurysm,  a  variation  of  more  than  20  mm.  Hg  being 
in  favor  of  aneurysm. 

The  sphygmogram  exhibits  a  slanting  up-stroke  with  obliteration  of 
the  secondary  wave  (Fig.  58),  though  its  characters  are  inconstant. 

Tracheal  Tugging. — This  sign  may  be  practised  while  the  patient  is 
sitting  or  standing  with  the  chin  slightly  elevated.  The  cricoid  cartilage 
is  grasped  between  the  thumb  and  forefinger  and  pushed  upw^ard  so  as  to 
stretch  the  trachea.  The  patient  must  cease  breathing  momentarilj-, 
when,  if  this  sign  be  present,  there  will  be  a  downward  tugging  at  each 
systole.  The  transmitted  pulsations  from  the  cervical  vessels  must  not 
be  confounded  with  the  vertical  movement  of  the  trachea.  A  new 
method  of  eliciting  tracheal  tugging,  first  suggested  by  Ewart,  has  been 
widely  adopted  and  possesses  the  advantage  of  ensuring  greater  delicacy 
of  touch  than  the  old.  lie  stands  behind  the  patient,  supporting  the 
head  of  the  latter  against  his  body,  and  grasps  the  cricoid  between  the 
tips  of  the  forefingers.  The  method  is  in  other  respects  similar  to  that 
previously  described.  As  shown  by  Toulmin,  the  tracheal  tug  may  be 
present  in  health  and  in  other  diseases,  hence  it  is  of  little  value. 

Diagnosis. — In  the  presence  of  the  following  points  the  existence 


ANJWRYSM.  729 

of  thoracic  aneurysm  may  be  confidently  inferred  :  (1)  Antecedent  arterio- 
sclerosis (with  the  appropriate  causes  of  the  latter) ;  (2)  History  of  other 
etiologic  factors,  as  age  (between  thirty  and  forty-five  yearsj  and  occu- 
pation (such  as  entail  unusual  muscular  strain) ;  (3)  Pressure-symp- 
toms, as  pain,  dyspnea,  aphonia,  cough  (either  laryngeal  or  bronchial), 
bronchorrhea,  dysphagia,  edema,  vasomotor  disturbances  ;  -(4)  Physical 
signs  of  a  pulsating  tumor  (including  the  abnormal  area  of  dulness,  sys- 
tolic murmurs,  the  systolic  and  diastolic  shock,  and  tracheal  tugging) 
somewhere  along  the  course  of  the  arch  or  its  great  branches,  with  or 
without  differences  in  the  blood-pressure,  and  in  the  volume  and  time  of 
the  radial  pulses.  There  are,  however,  several  classes  of  cases  which 
offer  difficulties  that  are  sometimes  insurmountable  :  (a)  Those  in  which 
the  aneurysm  is  small  and  deep-seated.  Here  the  symptoms  and  physical 
signs  are  indefinite.  There  may  be  thoracic  oppression,  in  which  pain 
may  radiate  to  the  left  shoulder,  and  mild  pressure  symptoms — a  group 
of  suspicious  features  merely — sometimes  appear.  In  one  of  my  cases 
left-sided  intercostal  neuralgia  was  the  only  symptom  present,  (h) 
Aneurysm  of  the  transverse  arch,  in  which  the  pressure  symptoms  are 
more  or  less  pronounced,  but  with  no  physical  signs.  In  such,  a  clear 
history  suffices  to  complete  the  diagnosis.  Pressure  symptoms  without 
etiologic  factors  are  just  as  likely  to  be  due  to  other  causes,  {c)  Those 
cases  in  which  the  more  characteristic  features  are  manifested  intermit- 
tently. Fortunately,  a  proper  diagnosis  of  aneurysm  in  obscure  and 
latent  cases  can  be  often  made  by  the  aid  of  the  .-r-rays,  and  it  can  also 
be  excluded,  in  suspected  cases,  by  fluoroscopic  examination. 

Extremely  obscure  are  many  of  the  cases,  in  which  the  only  symptoms 
manifested  point  to  irritation  of  the  trachea  or  bronchial  tubes,  with  par- 
oxysmal cough,  or  the  signs  of  bronchiectasis.  In  a  recent  case  of  this  sort 
tracheoscopic  examination  revealed  compression  of  the  windpipe.  In 
another  instance  the  laryngoscope  determined  the  diagnosis,  in  that  it 
brought  to  view  bilateral  paralysis  of  the  abductors  of  the  vocal  bands. 
A  symptom,  which  has  been  designated  by  its  author,  R.  V.  Hoesslin, 
as  "diastolic  expiration,"  is  due  to  compression  of  the  trachea  by  an 
aneurysm,  so  that  air  can  escape  from  the  lungs  only  during  diastole, 
when  the  sac  diminishes  in  size. 

Differential  Diagnosis. — The  affections  from  which  intrathoracic  aneur- 
ysm must  be  distinguished  are  pulsating  empyema,  'pulmonary  tubercu- 
losis, abnoi'mal  pulsation  of  the  aorta,  and  solid  tumors.  Of  the  latter, 
those  simulating  aneurysm  are  carcinoma,  sarcoma,  and  enlarged  lymph- 
glands.  These  mediastinal  tumors  may  duplicate  all  of  the  pressure- 
symptoms,  though  less  apt  to  cause  bulging,  and  less  apt  still  to  excite 
abnormal  pulsation  ;  when  pulsation  is  noted  it  is  quick,  and  not  heaving 
and  expansile,  as  in  aneurysm.  Solid  growths  also  lack  the  characteristic 
shock — both  systolic  and  diastolic- — of  aneurysm.  The  cardio-vascular 
symptoms  are  usually  wanting  in  the  case  of  solid  tumors,  especially  the 
moderate  hypertrophy,  accentuation  of  the  second  sound,  tracheal  tugging, 
and  the  difference  between  the  radial  pulses. 

Carcinoma  of  the  mediastinum  usually  gives  a  history  of  the  disease  in 
other  parts  of  the  body,  with  enlargement  of  the  axillary  or  other  super- 
ficial lymphatic  structures,  and  later  the  characteristic  cachexia,  this 
being  particularly  marked  in  carcinoma  of  the  esophagus. 


730  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Abnormal  pulsativn  in  the  aorta  is  noted  in  neurotic  subjects,  mostly 
females,  and  in  aortic  regurgitation  ;  less  frequently  it  is  associated  witli 
retraction  of  the  right  lung,  with  spinal  curvature,  and  with  displaccuiont 
of  the  aorta.  In  the  case  of  the  latter  two  conditions  a  careful  considera- 
tion of  the  causal  states  and  the  absence  of  the  charaetcristic  physical 
signs  would  lead  to  a  correct  diagnosis.  Aortic  rctjuriiitdtioit  is  frequently 
associated  with  aneurysm  of  the  arch,  and  in  its  course  there  is  often  de- 
veloped a  dilatation  of  the  ascending  portion  of  the  aorta.  The  diagnosis 
of  aneurysm  of  the  arch  of  the  aorta  should  not  be  made,  therefore,  in 
these  cases,  unless  the  physical  signs  and  synij)t()ms  be  unmistakable. 
Dynamic  pulsation  of  a  neurotic  origin  is  seen  and  fi'lt  in  the  episternal 
notch,  as  a  rule,  and  a  correct  appreciation  of  the  nervous  element  will 
prevent  the  observer  from  committing  an  error. 

Pulsating  empyema  can  only  be  confounded  with  large  aneurysmal 
growths,  and,  as  pointed  out  by  Wilson,  it  does  not  have  the  same  definite 
relation  to  the  central  long  axis  of  the  body  as  do  aneurysms.  The 
abnormal  field  of  dulness  is  situated  at  the  base  of  the  lung  in  empyema, 
and  is  less  circumscribed  than  in  aneurysm.  In  empyema,  moreover, 
the  pulsation  is  not  expansile,  but  is  caused  by  pressure  of  the  respiratory 
movements.  Auscultation  in  empyema  renders  audible  neither  a  bruit 
nor  the  double  shock  of  aneurysm  ;  the  pressure-symptoms  and  pulse- 
characters  are  also  entirely  wanting. 

Pulmonnrji  tuberculosis  may  be  mistaken  for  thoracic  aneurysm. 
When  an  aneurysm  compresses  a  bronchus,  bronchiectasis,  attended  with 
cough,  bronchorrhea.  fever,  and  emaciation,  may  be  the  result ;  but  in 
phthisis  the  fever  and  emaciation  are  more  pronounced,  tubercle  bacilli 
are  present,  whilst  the  cardio-vascular  signs  of  aneurysm  are  absent. 

Prognosis. — The  occurrence  of  perforation  and  consequent  speedy 
death  in  unsuspected  cases  must  be  recollected.  In  other  instances  the 
end  is  approached  in  a  very  gradual  manner,  and  cases  in  which  rupt- 
ure does  not  supervene  sometimes  pursue  the  general  course  of  chronic 
valvular  aflfections  of  the  heart.  The  condition  ends  in  death  as  a  rule, 
and  the  immediate  causes  of  the  fatal  issue  are  as  follows :  (1)  Rupture 
of  the  aneurysm,  followed  by  hemorrhage  into  any  of  the  adjacent  cav- 
ities or  organs  (pericardium,  heart,  large  vessels,  mediastinum,  trachea, 
a  bronchus,  esophagus,  lungs,  pleura,  spinal  canal) ;  it  may,  though 
rarely,  rupture  externally,  in  which  case  slight  hemorrhages  occur  and 
life  may  last  for  weeks ;  (2)  Gradual  asthenia ;  (3)  Direct  pressure  ;  (4) 
Independent  diseases,  either  primary  or  secondary  to,  and  induced  by, 
the  aneurysm.  Among  these  pulmonary  complications — fibrinous  pneu- 
monia, abscess,  gangrene,  tuberculosis — are  of  first  importance. 

Treatment. — There  are  two  main  objects  of  treatment — first,  the 
promotion  of  coagulation  of  the  blood,  and  secondly,  the  contraction  of 
the  sac.  The  clotting  of  the  blood  within  the  growth  may  be  greatly 
favored  by  retarding  the  blood-current.  Nothing  so  well  accomplishes 
this  object  as  absolute  rest  in  the  recumbent  posture.  This  cannot 
always  be  rigidly  enforced,  but  muscular  exertion  must  be  minimized, 
mental  application  regulated,  and  emotional  excitement  avoided ;  stimu- 
lants, arterial  and  nervous,  are  to  be  eschewed  for  like  reasons.  Palpita- 
tion of  the  heart,  when  present,  is  to  be  allayed  by  the  local  use  of  the 
ice-bag.     The  coagulability  of  the  blood  is  also  increased  by  removing 


ANEURYSM.  731 

as  fill-  as  possible  the  liquid  portion  of  tlie  diet.  T?ie  measures  already 
indicated  tend  to  lessen  the  volume  of  blood  and  the  intra-aneury.smal 
pressure,  thus  inviting  contraction  of  the  sac  as  well  as  consolidation  of 
its  contents.  A.  E.  Wright  has  insisted  upon  the  value  of  calcium  salts 
to  increase  the  coagulability  of  the  blood  (gr.  x  to  xv — 0.648  to  0.972, 
t.  i.  d.,  may  be  given).  T.  R.  Boggs^  thinks  calcium  salts  increase  the 
coagulability  of  the  blood,  the  best  for  this  purpose  being  the  acetate  and 
lactate  of  calcium. 

Injections  of  gelatin  in  aneurysm  may  have  a  specially  favorable 
effect  according  to  certain  observers.  Moyer^  reviews  the  literature,  and 
in  the  main  his  conclusions  are :  Gelatin  solutions  are  of  some  value  in  the 
treatment  of  saccular  aneurysms,  but  not  of  the  diffused  forms.  Solu- 
tions not  stronger  than  1  per  cent,  should  be  used  ;  they  should  be  kept 
in  a  brood-oven  to  determine  bacterial  growth,  and  great  care  should  be 
taken  in  the  technique.  Absolute  rest  in  bed  should  be  enjoined.  This 
method  is  worthy  of  extended  trial,  but  great  caution  and  watchfulness 
must  be  exercised  in  its  administration. 

Among  medicinal  agents,  to  contract  the  sac,  ergot  and  potassium 
iodid  have  been  employed,  the  latter  with  good  effects.  The  exact 
manner  in  which  the  iodid  produces  its  favorable  results  in  these  cases 
is  unknown,  though  most  probably  it  acts  upon  the  vascular  walls, 
and  hence  would  be  most  efficacious  when  the  disease  is  of  syphil- 
itic origin  ;  this  view  accords  with  my  own  personal  experience.  I  would 
advise  against  the  prolonged  internal  use  of  ergot.  Langenbeck  and  others 
have  obtained  good  results  from  the  direct  injection  into  the  sac  of  the 
aqueous  extract  of  ergotin  dissolved  in  water  or  glycerin,  every  day  or  two. 
When  employed  in  this  manner  ergotin  induces  contraction  of  the  smooth 
muscles  in  the  wall  of  the  aneurysm.  Numerous  observers  have  resorted  to 
the  use  of  horse-hair,  fine  wire,  fine  catgut,  slender  watch-springs,  with  a 
view  to  coagulating  the  blood  as  it  comes  in  contact  with  these  foreign 
bodies.   Electrolysis  is  a  method  that  has  been  warmly  advocated  (Loreta). 

Combined  wiring  and  electrolysis  (Corradi's  method)  has  been  suc- 
cessfully employed  by  Rosenstein,  Kerr,  D.  D.  Stewart,  and  Hereby. 
The  details  of  the  method  are  briefly  as  follows : 

A  piece  of  fine  wire,  several  feet  in  length,  is  passed  from  a  spool 
through  a  small  insulated  canula,  so  that  the  wire  curls  up  within  the 
sac.  It  is  attached  to  the  positive  pole,  while  the  negative  is  connected 
with  a  surface  pad  placed  over  the  abdomen.  The  current  is  then  passed 
through,  and  gradually  increased  in  strength  to  40  to  80  milliamperes. 
Before  stopping  the  current  its  strength  should  be  slowly  decreased. 
Each  application  of  the  current  should  last  from  one  to  two  hours.  It 
is  not,  however,  without  serious  dangers  (hemorrhage  and  embolism). 

Galvano-puncture  has  long  been  resorted  to,  and  in  some  instances 
with  encouraging  results.  The  cases  that  receive  most  benefit  from  the 
above  measures  belong  to  the  saccular  variety ;  this  is  also  true  of  the 
plan  first  commended  by  Tufnell,  which  is  especially  applicable  in  the  earlier 
stages.  Tufnell's  method  is  founded  upon  two  principles — absolute  rest  in 
the  recumbent  posture,  and  a  much-restricted,  dry  diet.  A  quiet  mental 
state  should  be  conjoined.  The  diet  is  as  follows :  Breakfast,  2  ounces 
(64.0)  of  bread  and  butter  and  2  ounces  (64.0)  of  milk  ;  for  dinner,  2  or 

^N.  Y.  Med.  Jour.,  February  1,  1908.  ^Medicine,  March,  1899. 


732  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

3  ounces  (64.0-96.0)  of  meat  and  3  or  4  ounces  (96.0-128.0)  of  milk  or 
claret;  for  supper,  2  ounces  (64.0)  of  bread  and  2  ounces  (64.0)  of  milk. 

The  cliief  advantages  growing  out  of  this  method  are  the  lessened 
number  and  force  of  tlie  heart-beats  in  consequence  of  the  bodily  rest, 
and  the  diminution  of  the  blood-volume  in  consequence  of  the  dietetic 
restrictions.  It  should  be  persevered  in  for  several  months.  The  bowels 
should  be  regulated,  and  straining  at  stool  prohibited. 

Special  Sj/fupto7ni>. — Pain  is  often  relieved  by  potassium  iodid.  When 
arterial  sclerosis  is  present  I  have  seen  relief  from  pain  afforded  by  the 
use  of  nitroglycerin  (TTlj  to  ij — 0.066  to  0.133,  four  times  a  day).  In 
the  later  stages  morphin  should  be  given.  When  there  is  bulging  the 
pain  may  be  relieved  by  the  the  ice-bag  or  by  a  belladonna  plaster. 

Dyspnea  and  great  venous  congestion  are  to  be  met  by  venesection, 
and  tracheotomy  may  be  rctiuired  in  bilateral  paralysis  of  the  abductors. 
In  dyspnea  from  nressure  on  the  trachea  or  bronchus,  however,  trache- 
otomy would  be  a  valueless  expedient.  When  the  aneurysm  forms  a  large 
external  tumor  the  application  of  an  elastic  bandage  to  the  chest  may  be 
both  agreeable  and  advantageous,  as  in  a  case  referred  to  by  Osier. 

Among  subjects  of  arterio-sclerosis,  tortuosity  and  elongation  of  the 
aorta  may  exist  and  give  rise  to  some  of  the  signs  of  aneurysm  of  the  arch. 
Holzknecht^  was  the  first  to  point  out  this  pseudo-aneurysmal  dilatation, 
but  he  classified  them  as  dislocations  of  the  aorta.  Joseph  Sailer  and 
G.  E.  Pfahler^  have  made  fluoroscopic  and  radioscopic  examinations  of 
eighteen  cases,  some  of  which  were  autopsied  at  a  later  date,  and  showed 
that  pulsating  hemispheric  shadows  above  the  heart  were  not  always  aneu- 
rysms, but  often  mere  tortuosities  of  the  aorta,  which  cast  a  shadow  from 
one-half  to  two  inches  to  the  left  of  the  fifth  and  sixth  dorsal  vertebrae. 

The  symptoms  of  atheroma  with  tortuosity  are  for  the  most  part  nega- 
tive, but  certain  physical  signs  which  strongly  suggest  aneurysm  are 
commonly  observed.  "  Probably  it  would  be  justifiable  to  suspect  tor- 
tuosity in  cases  in  which  there  is  inequality  of  the  radial  pulse,  slight 
tracheal  tugging,  dyspnea,  and  in  Avhich  the  symptoms  are  stationary 
for  a  considerable  period  of  time  and  the  fluoroscope  shows  a  projection 
to  the  left  of  the  descending  portion  of  the  arch  of  the  aorta  that  has  no 
true  expansile  pulsation  "  (Sailer  and  Pfahler). 

ANEURYSM  OF  THE  ABDOMINAL  AORTA. 

The  vicinity  of  the  celiac  axis  is  the  favorite  seat  of  abdominal  aneu- 
rysm, which  is  less  common  than  intrathoracic  aneurysm,  though  not 
rare.      It  may  assume  a  fusiform  or  saccular  nature. 

Symptoms. — The  tumor  may  grow  backward ;  but  more  frequently 
it  grows  forward.  Projecting  from  the  posterior  wall,  it  usually  erodes 
the  vertebrie,  and  compression  of  the  cord  is  apt  to  take  place,  producing 
paraplegia,  preceded  by  tingling  and  nwnbness  of  the  legs. 

Pain  is  the  leading  symptom.  It  may  be  neuralgic  or  of  a  boring  or 
gnawing  character,  due  to  destruction  of  the  bone.  Rarely,  the  aneurysm 
perforates  the  diaphragm,  and  finally  ruptures  into  the  lungs  or  pleiira. 
Arising  from  the  anterior  frafl.  it  may  early  form  a  well-defined  tumor. 
It  may.  however,  when  situated  high  up  or  near  the  diaphragm,  conceal 

»  Wiener  Iclin.  Woch.,  1900,  No.  10. 

2  "  Tortuosity  of  the  Aorta,"  The  Amer.  Jour,  of  the  Med.  Sci.,  October,  1903. 


ANEURYSM.  7.33 

itself  until  it  has  attained  a  comparatively  large  size,  as  in  a  case  recently 
under  my  care  at  the  Medico-Chirurgical  Hospital.  Vomiting  ■d.wd  yan- 
tralgic  seizures  may  be  troublesome,  and  the  fact  that  embolism  of  the 
superior  mesenteric  artery  may  occur  and  give  rise  io  severe  colicky 
pains  must  be  recollected.     Jaundice  has  been  observed. 

Physical  Signs. — Epigastric  pulsation  may  be  visible,  and  occasion- 
ally an  epigastric  swelling.  The  palpating  hand  detects  a  heaving, 
expansile  pulsation  that  may  be  accompanied  by  a  thrill.  When  the 
tumor  hugs  the  diaphragm  the  pulsation  may  be  double.  The  femoral 
pulse  is  diminished  in  volume  and  delayed.  An  abnormal  area  of  dul- 
ness  may  be  present.  In  most  instances  a  soft  bruit  is  audible.  The 
diastolic  murmur  and  shock  of  intrathoracic  aneurysm  are  usually  absent. 

Diagnosis. — A  certain  diagnosis  demands  the  presence  of  a  definite 
growth  that  is  seizable  and  has  a  heaving,  expansile  pulsation.  Mere 
pulsation  attended  with  a  thrill  and  a  systolic  murmur  are  insufficient. 

Differential  Diagnosis. — A  throbbing  aorta,  as  met  with  in  neurotic 
females  and  in  anemia  (particularly  in  instances  of  the  traumatic  form), 
is  sometimes  distinguished  from  aneurysm  of  the  abdominal  aorta  with 
great  difficulty.  It  does  not,  however,  present  a  pulsating  tumor  that 
can  be  held  in  the  grasp,  as  in  aneurysm. 

When  solid  growths  lie  upon  the  aorta  the  latter  may  manifest  pulsa- 
tion, a  thrill,  and  a  systolic  murmur,  but  the  vei-y  general  absence  of 
pulsation  (when  the  patient  is  placed  in  the  knee-elboAv  position),  owing 
to  the  fact  that  the  tumor  falls  forward,  suffices  usually  to  differentiate 
the  condition  from  genuine  aneui-ysm.  Again,  expansile  pulsation  is  not 
evinced  by  a  solid  growth. 

The  prognosis  is  very  gloomy.  Very  rarely,  however,  nature  effects 
a  cure  if  the  conditions  be  favorable.  "  Death  may  result  from  (a)  the 
complete  obliteration  of  the  lumen  by  clots  ;  {b)  compression-paraplegia  ; 
[c]  rupture  either  into  the  pleura,  retroperitoneal  tissues,  peritoneum,  the 
intestines,  or,  very  commonly,  into  the  duodenum  ;  {d)  embolism  of  the  su- 
perior mesenteric  artery,  producing  infarction  of  the  intestines"  (Osier). 

Treatment. — Apart  from  the  measures  indicated  for  thoracic  aneur- 
ysm, there  is  one  means  of  cure  that  may  be  tried  if  the  growth  be  low 
down — viz.  pressure.  This  must  be  maintained  for  twenty-four  hours  at 
least  under  an  anesthetic.  It  is  best  to  make  steady  pressure  on  the 
proximal  portion  of  the  vessel,  and  unless  practised  with  great  care  the 
sac  will  be  damaged  and  death  ensue. 

ANEURYSM   OF   THE   PULMONARY   ARTERY. 

Dilatation  of  the  pulmonary  artery  is  of  frequent  occurrence  in 
affections  that  oppose  obstruction  to  the  lesser  circulation  {e.  g.  mitral 
disease,  emphysema,  phthisis).  Very  rarely  extreme  dilatation  of  the 
vessel  is  followed  by  semilunar  incompetence,  when  a  diastolic  murmur 
at  the  pulmonary  orifice  (second  left  interspace)  becomes  audible. 

Aneurysms  involving  the  pulmonary  artery  are  quite  rare :  such  as 
occur  are  small  and  of  the  saccular  and  fusiform  varieties. 

The  symptoms  resemble  those  of  intrathoracic  aneurysm,  though 
they  are  rarely  well  marked,  owing  to  the  fact  that  they  remain  of  small 
size  as  a  rule. 

Physical  Signs. — Pulsation  (and,  rarely,  a  small  tumor)  is  detectable 
in  the  second  left  interspace.     Palpation  may  also  render  appreciable  a 


734  DISEASES  OF   THE  CIRCCLATORY  SYSTE^[. 

thrill  and  diastolic  shock.  Coextensive  with  the  area  of  pulsation  there 
inav  be  (hibicss  on  percussion,  and  over  the  second  interspace  to  the  left 
of  the  sternum  a  loud  ■-mperjicial si/stolic  j)}urmu7-  is  heard  on  auscultation, 
torrether  with  a  diastolic  shock.  Before  attaining  to  a  large  size,  these 
aneurysms  usually  rupture  into  the  heart  itself. 

The  prognosis  is  altogether  unfavorable,  the  treatment  having  refer- 
ence to  the  principles  that  are  appropriate  in  thoracic  aneurysm. 

The  coronary  arteries  may  be  the  seat  of  aneurysm,  tiiough  exception- 
ally. The  condition  arises  in  consequence  of  weak  points  (due  to  arterio- 
Bclerosis)  in  the  course  of  the  vessels,  and  is  unrecognizable  during  life. 

ANEURYSM    OF   THE    CELIAC   AXIS. 

This  condition  is  sometimes  observed  in  combination  with  aneurysm 
of  the  upper  portion  of  the  abdominal  aorta. 

ANEURYSM    OF    THE    SPLENIC    ARTERY. 

This  branch  of  the  celiac  axis  is  occasionally  the  seat  of  aneurysmal 
dilatation.  It  may  be  single  or  multiple,  and,  whilst  it  is  small  as  a  rule, 
may  in  rare  cases  be  quite  large. 

The  symptoms  are  indefinite,  but  distressing.  Deep-seated  abdomi- 
nal pain,  which  shows  a  tendency  to  radiation,  forms,  with  vomiting,  and 
rarely  hematemesis.  the  main  features.  By  percussion  a  tumor  may  be 
mapped  out  in  the  left  hypochondriac  region,  the  dulness  merging  with 
that  of  the  spleen  and  the  left  lobe  of  the*livcr.  Usually,  pulsation, 
and,  rarelv,  a  tumor  can  be  felt,  and  systolic  murmur  is  often  heard. 
The  condition  may  be  confounded  with  gastric  ulcer. 

ANEURYSM  OF  THE  HEPATIC  ARTERY. 

This  is  exceedingly  rare,  the  total  number  of  cases  on  record  being 
about  20.  H.  B.  Schmidt  has  recently  reported  a  case  associated  with 
symptoms  of  gall-stones,  in  which,  as  shown  by  the  autopsy,  death  was 
caused  by  rupture  of  the  sac  into  the  bile-ducts.  Schmidt  found  records 
of  but  5  cases  of  this  mode  of  termination.  Osier  and  Ross  have  reported 
an  instance  associated  with  multiple  hepatic  abscesses. 

The  symptoms  are,  in  the  main,  colichii pains,  vomiting,  hemateme- 
sis, and  obstructive  jaundice.  A  tumor  is  rarely  discernible,  though  an 
abnormal  area  of  pulsation  is  relatively  more  frequent.  The  recognition 
of  the  condition  during  life  is  entirely  conjectural. 

Aneurysm  of  the  superior  mesenteric  artery  is  of  rare  occurrence. 
Pain  in  the  epigastric  and  lumbar  regions,  and  demonstrable  tumor  near 
to  or  directly  over  the  median  line  of  the  abdomen,  are  the  symptoms  dis- 
played. Detached  fragments  of  the  clot  may  produce  embolism  of  the 
terminal  branches  of  the  mesenteric  arteries.  The  condition  terminates 
usually  in  rupture  into  the  peritoneal  cavity. 

Aneurysm  of  the  inferior  mesenteric  artery  runs  a  course  similar  to 
the  above.      It  is  (|uit('  rare  and  possesses  slight  interest. 

Aneurysm  of  the  Renal  Arteries. — Small  multiple  dilatations  are  occa- 
sionally seen,  but  large  ones  are  of  great  rarity.  They  are  prone  to 
rupture  into  the  retroperitoneal  cavity. 


ANEURYSM.  735 


ARTEBIO-VENOUS   ANEURYSM. 

Definition.— vVn  artificial  communication  between  an  artery  and  a 
vein.  A  sac  may  intervene  betw^een  the  two  vessels  (varicose  aneuri/sm) 
or  there  may  be  a  direct  fistulous  communication  without  an  intervening 
sac  [aneurysmal  varix). 

In  varicose  aneurysm  the  sac  is  developed  from  the  structures  that 
mark  the  boundaries  of  the  communicating  duct.  The  majority  of  cases 
are  caused  by  the  simultaneous  wounding  of  an  artery  and  a  vein  during 
venesection.  Hence  their  most  frequent  seat  is  at  the  bend  of  the  elbow. 
Pepper  and  Griffith  have  analyzed  the  records  of  29  cases  in  which  the 
ascending  portion  of  the  aortic  arch  had  opened  into  the   vena  cava. 

Symptoms. — The  symptoms  are  largely  aneurysmal,  and  in  addi- 
tion there  appear  in  rapid  sequence  great  swelling  of  the  veins, 
cyanosis,  and  edema  of  the  upper  portion  of  the  body.  A  continuous 
thrill  and  buzzing  murmur,  with  systolic  intensification,  are  the  chief 
signs. 

In  the  treatment  of  thoracic  arterio-venous  aneurysm  the  same  gen- 
eral plan  is  to  be  pursued  as  advised  in  the  purely  arterial  variety. 

CONGENITAL   ANEURYSM. 

This  condition  arises  because  of  a  defective  ante-natal  development  of 
the  elastic  coat.  It  is  often  multiple,  and  the  tumors  are,  as  a  rule, 
small  in  size,  ranging  from  that  of  a  pea  to  a  hazel-nut.  The  most  com- 
mon situations  for  these  growths  are  the  coronary  and  pulmonary  ar- 
teries. To  Eppinger  belongs  the  credit  for  having  pointed  out  the  fact 
that  the  aneurysmal  walls  consist  only  of  the  adventitia  and  intima. 
""  Peri-arteritis  nodosa,''  a  rare  condition,  which  Eppinger  holds  to  be  a 
form  of  congenital  aneurysm,  presents  the  symptoms  of  general  infection 
rapidly  developed.  "  On  examination  after  death  the  arteries  are  found 
beset  with  nodules  of  active  inflammatory  products,  chiefly  on  the  outer 
coat "  (Allbutt).  The  condition  may  be  met  with  in  children  and 
rarely  in  adults. 


i 


PART  VII. 

DISEASES    OF   THE    DIGESTIVE   SYSTEM. 


I.   DISEASES  OF  THE  MOUTH. 


STOMATITIS. 


CATARRHAL   STOMATITIS. 

{Stomatitis  Erythematosa.) 

Definition. — A  simple,  acute  inflammation  of  the  buccal  mucous 
membrane.     It  is  more  commonly  met  with  in  children  than  in  adults. 

Ktiology. — As  a  'primary  aifection  its  causes  are  mainly  mechanical 
and  chemical  irritation,  such  as  the  presence  in  the  mouth  of  hard  and 
sharp  bodies,  dental  caries,  acids,  hot  or  cold  food,  condiments,  tobacco, 
certain  drugs  (as  mercury),  eruption  of  teeth,  and  bad  feeding,  par- 
ticularly in  illy-nourished  children.  It  is  the  result  often  of  a  neglect 
of  the  mouth-toilet,  leading  to  the  decomposition  of  accumulated  bits 
of  food  and  mucus,  and  many  cases  probably  owe  their  origin  to  infec- 
tion. Secondarily,  catarrhal  stomatitis  may  be  associated  with  certain 
of  the  eruptive  fevers  (scarlet  fever,  measles,  typhoid),  also  with  gastro- 
enteric derangements,  and  may  follow,  by  direct  inflammatory  extension, 
ulcerative  tonsillitis,  and  pharyngitis. 

Symptoms. — The  local  symptoms  of  this  affection  are  those  usually 
seen  in  an  inflammation  of  a  mucous  membrane — redness,  heat,  swelling, 
and  dryness,  soon  followed  by  increased  secretion  and  soreness.  The 
lips  and  gums  only,  or  the  membrane  of  the  whole  mouth,  may  be  in- 
flamed, and  the  swollen  lips,  cheeks,  and  furred  tongue  may  be  indented 
by  teeth-marks.  Enlarged  and  reddened  papillae  on  the  tongue  and 
minute  vesicles  inside  the  cheeks  and  lips  from  projecting  mucous  fol- 
licles are  sometimes  seen  to  terminate  in  small  ulcers.  A  craving  for  cold 
drinks  is  nearly  always  noted,  and  distress,  pain  on  taking  food,  and  a 
disagreeable  taste  due  to  the  perverted  buccal  secretions.  Chemical 
examination  of  the  dribbling  saliva  shows  an  acid  reaction,  but  should 
the  condition  progress  to  ulceration  an  alkaline  reaction  is  usual.  Mi- 
croscopically, desquamated  epithelium  that  has  undergone  partial  fatty 
degeneration,  leukocytes,  and  occasionally  red  blood-cells  are  seen.  The 
leptothrix  buccalis,  micrococci,  and  bacilli  are  also  present.  Aside  from 
restlessness  and  the  symptoms  common  to  slight  febrile  disturbances,  the 
constitutional  condition  is  rarely  disturbed,  except  when  the  stomatitis  is 

47  737 


738  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

secondary  either  to  inflammations  lower  down  in  the  digestive  tract,  or  to 
the  specific  infectious  fevers. 

The  course  of  the  disease  is  usually  acute,  and  the  duration  about 
one  week. 

The  diflferential  diagnosis  of  catarrhal  stomatitis  is  easily  made 
bv  inspection  of  the  nienibrane. 

The  prognosis,  though  favorable,  will  vary  as  to  time  and  severity 
according  to  the  cause. 

Treatment. — After  proper  attention  to  the  hygienic  surroundings 
of  the  patient  and  the  removal  of  all  irritant  influences,  the  treatment  is 
mainly  local.  The  first  indications  are  to  cleanse  the  mouth  and  allay 
the  pain,  and  these  may  be  met  by  the  use  of  cool  solutions  of  boric  acid, 
sodium  bicarbonate,  or  potassium  chlorate,  5  and  10  grains  (0.324  and 
0.648)  respectively  to  the  ounce  (32.0)  of  glycerin  and  rose-water,  as 
mouth-washes,  or  for  swabbing  in  the  case  of  infants.  When  iced  drinks 
are  ungrateful  and  the  inflammation  is  more  intense  and  protracted,  the 
use  of  hot  milk  and  lime-water,  mucilaginous  decoctions,  and  sedative 
and  antiseptic  sprays  of  1  or  2  per  cent,  solutions  of  cocain  or  carbolic 
acid  are  often  beneficial ;  or  mild  astringents  may  be  needed,  as  ^  to  1 
per  cent,  solutions  of  silver  nitrate,  alum  (5  to  10  grains — 0.324  to  0.648 
— to  the  ounce — 32.0 — of  honey),  and  glycerite  of  tannin  (2  drams  to 
the  ounce — 8.0  to  32.0 — of  water),  especially  if  there  is  a  tendency  to 
chronicity  of  the  trouble,  as  in  topers  and  inveterate  smokers.  Tender 
and  spongy  gums  may  be  relieved  by  the,  application  of  equal  parts  of 
the  tinctures  of  myrrh  and  rhatany  on  a  camel's-hair  brush  (Strlimpell). 
G-eneral  symptoms  must  be  met  as  they  arise.  Small  doses  of  aconite  or 
potassium  citrate  for  the  pyrexia,  with  a  minimum  dose  of  bromid  for 
irritability  and  sleeplessness,  may  be  all  that  is  required.  The  internal 
use  of  potassium  chlorate  in  children  is  not  to  be  recommended  in  this 
affection,  both  because  of  its  deleterious  action  upon  the  kidneys,  and 
also  because  it  seems  to  be  unnecessary  (Forchheimer,  Blackader). 
Sometimes  an  associated  gastro-intestinal  catarrh  needs  correction  by  the 
use  of  laxatives.  The  administration  of  bland  foods  and  mild  ferruginous 
tonics  should  be  continued  throughout  convalescence. 

APHTHOUS    STOMATITIS. 
i  Follicular  Stomdiitis  :    Slomalitis  Aphthosa.) 

Definition. — A  variety  of  catarrhal  stomatitis  characterized  by  the 
eruption  of  one  or  more  vesicles  upon  the  edges  of  the  tongue,  the  cheek, 
or  the  lips,  rapidly  passing  into  small  round  or  oval  discrete  spots  that 
are  slightly  raised  and  surrounded  by  yellowish-white  bases  with  narrow 
red  areolae. 

Ktiology. — Tliough  more  common  in  children  between  the  ages  of 
two  and  six  years,  it  is  by  no  means  rare  in  adults.  Predisposing  influ- 
ences may  be  found  in  the  seasons  (spring  and  autumn),  malnutrition, 
tuberculosis,  dentition,  persistent  gastro-enteric  disorders,  anemia,  and 
the  acute  exanthemata.  The  exciting  causes  are  supposed  to  be  certain 
deleterious  substances,  bacterial  or  toxic,  though  no  special  parasite  has 
vet  been  isolated. 


Al'HTlIOUS  STOMATITIS.  709 

Symptoms. — The  herpetic  vesiclen  soon  rupture,  leaving  the  aphthous 
ulcers  as  described  above.  '^1  l»ey  are  found  singly,  or  at  times  as  many 
as  twenty  in  number,  pin-head  to  split-pea  in  si/x',  inside  tlie  lips,  espe- 
cially near  the  frenum,  along  the  tongue-edges,  and  sometimes  inside 
the  cheeks  near  the  edges  of  the  back  teeth.  They  are  exquisitely 
tender,  so  that  almost  any  motion  of  the  affected  parts  causes  sharp 
burning  pain  ;  nourishment  is  therefore  difficult.  J*atches  of  cafarrhal 
stomatitis,  and  even  of  gingivitis,  are  seen  adjacent  to  the  aphthous  spots. 
There  is  an  increased  flow  of  the  secretions  of  the  mouth,  and  the 
breath  is  heavy,  but  seldom  offensive.  General  symptoms,  as  slight 
fever,  anorexia,  and  furred  tongue,  constipation  or  diarrhea,  and  irrita- 
bility, are  usually  present,  with  the  additional  symptoms  of  any  associated 
disease  that  may  coexist.  Gastro-intestinal  affections,  though  often 
associated  with  aphthous  stomatitis,  are  most  probably  due  to  the  common 
cause,  and  are  not  necessarily  the  cause  of  the  stomatitis  in  these  in- 
stances. In  some  of  the  specific  infectious  fevers  many  aphthae  may 
appear  and  tend  to  run  together ;  these  form  large  irregular  ulcers,  and 
give  rise  to  the  conflueyit  form  of  stomatitis  aphthosa.  The  special  form 
known  as  Bednars  aphthce,  occurring  in  young  marantic  babes,  is  a 
rare  condition  in  America.  Large  white  patches  are  seen  on  both  halves 
of  the  posterior  part  of  the  hard  palate  near  the  alveolar  processes,  and 
these  may  cause  large  ulcers  and  involve  the  bone.  Pressure  of  the 
tongue  upon  the  thin  mucous  membrane  during  nursing,  or  other  forms 
of  traumatic  irritation,  appear  to  act  as  causes. 

Aphtha  Qaehectica  (Riga's  disease). — Fede  has  described  a  form 
of  aphtha,  occurring  principally  in  Southern  Italy  (a  raised,  gray  swell- 
ing), situated  on  the  fraenum  and  under  surface  of  the  tongue.  It 
affects  children  soon  after  the  eruption  of  the  lower  incisors.  A  severe 
type  is  sometimes  met,  and  this  may  terminate  fatally.    • 

The  average  duration  of  the  ordinary  discrete  aphthous  eruption  is 
from  four  to  seven  days ;  in  very  ill-nourished  and  poorly  cared-for  cases 
the  appearance  of  successive  crops  of  aphthae  will  prolong  the  distress. 

Diagnosis. — This  is  based  upon  the  characteristic  appearance  of 
the  ulcers  and  the  degree  of  soreness.  Aphthae  must  be  differentiated 
from  thrush  (see  page  743),  where  the  distinguishing  features  will  be  dwelt 
upon  in  the  description  of  the  latter  aff'ection.  Herpes  of  the  mouth, 
so  called,  and  aphthous  vesicles  are  probably  identical  in  most  cases. 

Prognosis. — The  discrete  form  is  mild,  and  favorable  in  its  course 
toward  recovery  ;  confluent  aphthae  is  more  troublesome,  and  follows  a 
prolonged  course  on  account  of  the  general  debility  induced  by  the 
associated  disease  (Starr).  In  certain  cases  the  aff'ection  is  apt  to  recur ; 
relapses  are  also  frequent  in  those  having  weak  digestive  and  imperfect 
assimilative  functions.      Recovery  from  Bednar's  aphthae  is  rare. 

Treatment. — It  is  first  necessary  to  remove  all  irritating  influences, 
and  in  order  to  minimize  the  intense  pain  of  the  aphthous  spots  the 
blandest  liquids  and  the  softest  foods  that  are  consistent  with  the  sus- 
tenance of  the  patient  are  imperative.  Absolute  cleanliness  of  the 
mouth,  the  foods,  and  the  vehicles  of  administration,  especially  in  bottle- 
fed  children,  is  important.  Local  applications  are  of  obvious  value. 
Demulcents,  as  mucilage  of  sumac,  or  of  marshmallow,  with  boric 
acid  (gr.  v  to  oj — 0.324  to  32.0),  sodium  bicarbonate  (gr.  v-x  to  5J — 
0.324—0.648  to  32.0),  carbolic  acid,  or   potassium  permanganate  (gr.  iv 


740  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  5J — 0.259  to  32.0),  are  invariably  useful.  Swab-applications  of  wine 
of  opium  (TTLv  to  5J — 0.333  to  32.0)  or  of  cocain  (4  per  cent,  solution) 
may  be  necessary  when  the  pain  is  intense,  and  prior  to  taking  food. 
To  promote  the  healing  of  the  ulcer.s  a  very  light  touch  with  the 
silver-nitrate  stick  or  solution  (gr.  x-xxx  to  3J — 0.648-1.94  to  32.0) 
is  often  beneficial.  Much  favor  is  deservedly  given  also  to  potassium 
chlorate  in  solution  (gr.  x  to  5J — 0.648  to  32.0),  or  applied  in  the  dry 
powdered  form.  In  the  confluent  aphthous  ulcer  the  use  of  sodium 
salicylate  (oj  to  5J — 4.0  to  32.0)  has  been  recommended,  while  an  ethereal 
solution  of  iodoform  (^ij  to  sj — 8.0  to  32.0)  has  been  advised  by  J.  Lewis 
Smith.  For  bleeding  and  spongy  gums  the  mild  astringents  mentioned 
in  the  treatment  of  catarrhal  stomatitis  are  indicated.  Stronger  astrin- 
gents may  answer  for  application  to  sluggish  ulcers ;  thus  copper  sul- 
phate, either  solid  or  in  solution  (gr.  x  to  5J — 0.648  to  32.0),  and  zinc 
sulphate  (gr.  xv  to  sj — 0.972  to  32.0)  are  useful.  Potassium  chlorate 
acts  as  a  specific  in  ulcers  of  the  mouth,  and  is  eliminated  by  the  buccal 
secretions,  which  keep  the  ulcerated  surfaces  constantly  bathed  with  the 
drug,  so  that  its  internal  use  is  to  be  recommended,  though  in  very  small 
doses  in  children,  well  diluted,  as  in  the  following  formula : 

^t.  Potassii  chlorat.,  gr.  xxiv  (1.55); 

Tinct.  myrrhse,  gtt.  x       (0.666) ; 

Syr.  acacicB,  fsij  (64.0); 

Aquffi  dest.,  q.  s.  ad  f,5iij         (96.0). — M. 

Sig.  Teaspoonful  every  three  hours  for  a  child  three  years  of  age. 

Constitutional  symptoms  are  to  be  combated  on  general  principles 
and  require  careful  attention.  Remedies  directed  to  the  correction  of 
digestive  derangements  and  to  the  stimulation  of  assimilation  are  also 
often  required.      Good  food  and  ferruginous  tonics  are  necessary. 

MEMBRANOUS    STOMATITIS. 
{Stomatitis  Crouposa.) 

Definition. — In  this  form  of  stomatitis  the  inflammation  is  more 
intense  and  more  extended  in  area  than  in  the  aphthous  form,  being 
also  attended  with  the  formation  of  a  false  membrane. 

The  pathology  of  these  membranous  patches,  which  are  very  sel- 
dom confined  to  the  mouth  alone,  is  embraced  in  the  article  on  Diph- 
theria. If  in  the  latter  disease  the  typical  false  (diphtheritic)  mem- 
brane is  removed,  it  leaves  a  deeper  ulcer  than  does  the  removal  of  a 
croupous  membrane,  in  which  the  coagulation-necrosis  involves  the  more 
superficial  layers  only. 

The  etiology  of  membranous  stomatitis  is  usually  specific  (diphther- 
itic, streptococcic).  Membranous  stomatitis  may  also  be  due  to  gonor- 
rhoeal  or  syphilitic  infection  of  the  new-born. 

Symptoms. — Some  of  these  cases  are,  doubtless,  true  diphtheria 
of  the  oral  cavity  (usually  secondary  from  extension),  and  an  account 
of  the  symptoms  presented  may  be  found  in  the  chapter  on  Diphtheria, 
p.  151.  The  writer  has  seen  instances  of  extensive  membranous  stoma- 
titis, in  which  bacteriologic  examination  showed  the  presence  of  strep- 
tococci   (principally),   and    also    staphylococci.       The    symptoms    were 


ULCERATIVE   OR  FETID  STOMATITIS.  7  J] 

analogous  to  streptococcic  membranous  pharyngitis  with  this  difference, 
in  my  cases  of  membranous  stomatitis,  that  salivation  was  marked  and 
distressing.     T}ie  general  features  may  be  quite  pronounced. 

ULCERATIVE    OB   FETID    STOMATITIS. 

{Stomatitis  Ulcerosa.) 

Definition. — A  specific  ulcerative  inflammation  of  the  buccal  mu- 
cous membrane  and  gums,  attended  with  marked  fetor  of  the  breath,  and 
having  a  tendency  to  extend  widely  and  deeply. 

Ktiology. — The  predisposing  causes  of  this  malady  are  principally 
as  follows :  Childhood,  after  the  commencement  of  the  first  dentition, 
and  usually  between  the  ages  of  three  and  eight  years ;  damp  weather, 
especially  during  spring  and  autumn  ;  unhygienic  surroundings,  partic- 
ularly the  lack  of  pure  air,  of  good  and  abundant  food  and  clothing,  and 
the  added  detriments  to  health  for  which  neglect  and  filth,  specific  in- 
fectious diseases,  uncleanliness  of  the  mouth,  caries  and  loosening  of 
the  teeth,  and  congenital  heart-disease  (Duckworth)  are  responsible. 
An  endemic  type  of  this  affection  has  been  observed  among  soldiers  in 
camps  and  barracks,  among  children  in  crowded  eleemosynary  institu- 
tions, and  in  jails.  Its  epidemic  and  contagious  character  likewise 
points  to  a  microbic  origin.  The  specific  exciting  cause,  it  has  been 
held,  corresponds  to  the  hoof-and-mouth  disease  of  cattle,  the  poison 
being  conveyed  in  milk.  Payne  suggests  the  identity  of  the  virus  with 
that  of  impetigo  contagiosa.  The  careless  administration  of  mercury 
may  also  be  followed  by  this  affection.  Scurvy  {scorbutic  stomatitis) 
and  the  persistent  use  of  lead  and  phosphorus  are  also  excitants. 

Clinical  Symptoms. — Locally/,  the  disease  starts,  as  a  rule,  at  the 
edges  of  the  gums  opposite  the  lower  incisor  teeth,  gradually  spreading 
backward  and  to  the  adjoining  portions  of  the  lips  and  cheeks.  The 
gingival  mucous  membrane  is  deeply  red  and  swollen  ;  the  gums  soon 
become  spongy,  bleed  easily,  and  break  down  into  thick,  soft,  grayish 
sloughs,  which  leave  deep  and  ragged  ulcers  surrounding  the  necks  of 
the  teeth.  The  latter  even  become  loosened,  and  in  protracted  cases 
the  alveolar  periosteum  may  become  inflamed  and  cause  necrosis  of  the 
bone.  Profuse  salivation,  a  foul  breath  (that  once  earned  for  the  con- 
dition the  term  of  "  putrid  sore  mouth  "),  occasional  slight  hemorrhages 
from  the  gums,  and  excessive  discomfort,  or  even  pain,  on  mastication 
are  nearly  always  present.  The  tongue  is  coated,  swollen,  and  tooth- 
marked  ;  aphthae  are  sometimes  seen,  and  the  submaxillary  glands  are 
generally  swollen.  The  general  symptoms  attending  this  ailment  are 
those  of  a  lowered  state  of  vitality,  produced  by  an  unhygienic  envi- 
ronment, or  cachexia,  or  severe  illness  primary  to  it,  Avith,  usually,  mod- 
erate fever.  Nausea  and  vomiting  or  an  offensive  diarrhea  may  super- 
vene as  the  result  of  SAvallowing  the  putrid  discharges. 

Course  and  Duration. — Usually  acute  in  its  course,  the  highly 
debilitating  character  of  the  disease  may  tend  to  make  it  chronic,  espe- 
cially when  there  is  alveolar  necrosis  and  a  neglect  of  proper  treat- 
ment. Ordinarily,  with  careful  management,  convalescence  may  be 
established  in  from  four  days  to  a  week.  Goodhart  regards  the  occa- 
sional termination  of  the  pyrexia  by  lysis,  with  an  accompanying  im- 


742"  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

provement  of  the  local  symptoms  in  such  oases  at  least,  as  suggestive 
of  the  specific  nature  of  ulcerative  stomatitis. 

Neurotic  Ulceration.  —  Under  the  head  of  stomatitis  neurotica 
chronica  Jacobi  describes  an  herpetic  (rarely  pemphigoid)  eruption  in 
neurotic  subjects.  Sibley  has  met  three  cases,  all  of  which  occurred  in 
women  beyond  middle  age.  In  all  the  condition  iiad  lasted  for  a  number 
of  years  and  produced  great  difficulty  in  talking  and  mastication. 

Diagnosis. — Upon  examining  the  mouth  and  noting  the  character- 
istic ulceration,  the  fetid  breath  and  saliva,  and  the  cachectic  appear- 
ance, the  disease  is  usually  recognized,  and  should  not  be  confounded 
with  the  dark,  extensive,  jjanirreuous  sloucrlis  of  noma. 

The  prognosis  is  favorable  in  ty})ical  cases,  though  less  so  in 
marasmic  and  neglected  cases.  When  caucrum  oris  or  necrosis  of  the 
jaw  occur,  chrouicity,  deformity,  and  even  death,  may  take  place. 

Treatment. — It  is  well  in  nearly  all  ill-nourished,  uncleanly-kept, 
and  sickly  children,  as  well  as  in  cases  in  which  mercury  is  to  be  admin- 
istered for  any  length  of  time,  to  prescribe  mouth-washes  of  potassium 
chlorate  (gr.  xv  to  .^j — 0.972-32.0),  in  order  to  prevent  the  occurrence 
of  mercurial  or  ulcerative  stomatitis.  The  liynioiic  treatment  of  ulcer- 
ative stomatitis  is  important.  On  account  of  the  contagiousness  of  the 
disease  cases  occurring  in  a  family  or  in  institutions  should  be  isolated, 
and  fresh  air,  light  nourishment,  and  cleanliness  are  sine  qud  non  of 
recovery.  The  local  treatment  is  virtually  a  specific  one  in  the  use 
of  potassium-chlorate  washes  (gr.  x-xx  to  .5J — 0.648—1.296  to  32.0 — 
of  rose-water  or  demulcent),  aided  by  the  internal  administration  of 
the  same  salt  in  small  doses.  For  the  disagreeable  fetid  odor  the  alter- 
nate use  of  antiseptic  washes  is  indicated.  Solutions  of  carbolic  acid 
or  potassium  permanganate,  in  strength  equal  to  or  slightly  over  that 
indicated  in  the  treatment  of  aphthae,  or  hydrogen  peroxid  (sj-iij  to 
Sj  ;  4.0-12.0  to  32.0),  or  listerin  and  water  (ecjual  parts),  are  useful. 
Pencilling  the  spongygums  with  such  astringents  as  tincture  of  rhatany, 
silver  nitrate  (gr.  x  to  .5j — 0.648-32.0),  alum,  and  also  with  tannic-acid 
solutions,  may  be  necessary.  Loosened  teeth  shoukl  not  be  disturbed, 
as  they  may  grow  firm  with  convalescence,  though  surgical  interference 
may  be  required  in  cases  of  necrosis  of  the  alveolar  process.  Kissel's 
method  in  obstinate  cases  is  to  curette  the  ulcers  and  rub  into  them 
powdered  iodoform  once  daily.  Careful  attention  to  the  teeth  is  always 
requisite.  During  the  height  of  the  disease  constitutional  treatment 
may  have  to  be  directed  toward  stimulating  the  languid  and  lowered 
vitality.  For  this  purpose  either  whiskey  or  brandy,  in  half-  or  one- 
teaspoonful  doses  in  milk,  is  extremely  useful ;  the  elixir  of  cinchona, 
with  some  vegetable  salt  of  iron,  as  the  citrate  or  tartrate,  also  forms  a 
useful  combination.  When  there  is  pyrexia  or  a  diminished  urinary 
secretion  the  internal  use  of  potassium  chlorate  must  be  cautiously 
employed.      The  following  prescription  is  almost  specific: 

'Sf.   Potassii   chloratis,  gr.  xlviij  (3.11); 

Acidi  hydrochlor.  dil.,  fHJ  (4.0); 

Syrupi,  f^vj  (24.0);     . 

Aquie  destillat.,  q.  s.  ad  f.siij  (96.0).— M. 

Sig.   Teaspoonful  diluted,  every  two  hours  for  a  child  three  years 
old  (Starr). 


PARASITIC  STOMATITIS.  743 

The  prolonged  use  of  tonics  and  cod-liver-oil  emulsion  with  lime- 
salts  in  scrofulous,  rachitic,  and  scorbutic  subjects  must  be  carried  on  in 
order  to  prevent  relapses  of  ulcerative  stomatitis. 

PARASITIC   STOMATITIS. 
(^Thrush;   SlomuHlis  Mycoaa.) 

Definition. — A  specific,  contagious  fungous  disease,  characterized 
by  the  rapid  formation  upon  the  oral  mucous  surfaces  of  small,  whitish, 
soft,  and  lightly  adherent  spots  or  flakes,  tending  to  coalesce  and  spread 
throughout  the  entire  buccal  cavity. 

l^tiologfy. — Predisposing  causes  are — infancy  with  its  concomitant 
disorders  of  the  gastro-intestinal  tract  (especially  when  unhygienic  sur- 
roundings prevail),  congenital  syphilis,  tuberculosis,  and  the  exanthe- 
mata. The  disease  may  attack  adults  and  complicate  the  typhoid  and 
cachectic  states,  as  in  the  final  stages  of  low  fevers,  carcinoma,  chronic 
tuberculosis,  and  diabetes.  The  growth  of  thrush-patches  is  due,  specific- 
ally, to  the  saccharomyces  albicans,  though  micrococci  have  also  been 
found.  It  is  a  characteristic  of  this  fungus  to  develop  from  round  or  oval 
spores  in  the  formation  of  long-branching  mycelium  filaments,  from  the 
ends  of  which  a  multiplication  of  ovoid  torulae-cells  takes  place  by  the 
process  of  simple  budding.  These  mycelia  exhibit  a  tendency  to  penetrate 
the  deeper  layers  of  the  mucosa  of  the  mouth  and  also  into  the  mucous 
glands  (Starr).  Since  the  growth  of  this  organism  requires  both  an  altered 
condition  of  the  mucous  membrane  and  an  acid  medium,  the  primary  or 
exciting  cause  of  thrush  is  to  be  found  in  whatever  produces  such  a  favor- 
able nidus.  Most  important  in  this  connection  is  uncleanliness,  particu- 
larly in  the  case  of  poorly-nourished  and  bottle-fed  children.  The 
development  of  catarrhal  stomatitis  and  the  acid  fermentation  of  remnants 
of  food  (especially  of  saccharine  substances),  which  impair  the  nutrition 
of  the  mucosa  and  acidify  the  normally  alkaline  oral  secretions,  are  com- 
mon causes  of  thrush.  The  further  growth  of  the  fungous  patches  also 
contributes  to  the  acid  state  of  the  already  abnormal  buccal  fluids.  The 
fact  that  the  spores  of  thrush  maybe  transferred  to  other  cases  by 
bottle-tips,  spoons,  and  ill-kept  feeding-bottles  is  well  recognized  as  an 
explanation  for  the  occasional  endemic  character  of  the  malady. 

Symptoms. — Any  marked  local  symptoms  are  due  rather  to  the 
coexisting  stomatitis  than  to  the  thrush  itself  (Allchin).  There  will  be 
some  soreness,  heat,  persistent  dryness,  and  Uvidity  of  the  mucous  mem- 
brane. Thrush-spots,  slightly  raised  above  the  surface,  begin  to  appear 
on  the  tongue,  and  grow  into  patches  that  may  coalesce  and  spread  to 
the  cheeks,  lips,  and  hard  palate :  they  may  even  invade  the  tonsils, 
pharynx,  and  esophagus,  and,  rarely,  the  true  vocal  cords,  the  stomach, 
and  cecum  (Parrot).  At  first  pearly-white  in  color,  the  curd-like  flakes 
may  become  yellow  and  even  brown,  owing  to  slight  hemorrhages  caused 
by  the  irritation.  Though  early  adherent,  in  a  few  days  they  become 
loose,  and  when  brushed  ofi"  leave  a  smooth  surface  ;  when  complicating 
some  serious  gastro-intestinal  disease  or  dyscrasia,  however,  their  attach- 
ment is  deeper,  and  the  deposit  may  sometimes  appear  in  successive 
crops.     A  microscopic  examination  of  the  thrush-patches  shows  inter- 


744  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lacing,  irregular,  and  brant-hed  mycelial  threads,  spores,  occasional 
bacilli,  and  leptothrix-tilameuts  imbedded  in  a  mass  of  granular  debris 
and  fetid  particles.  The  buccal  fluids  are  acid  in  reaction.  The  (jcn- 
ei'itl  si/mptoins  depend  upon  the  associated  disease,  and  are  usually  those 
of  -wasting,  artificially-nourished  children  having  digestive  troubles  or  a 
constitutional  taint. 

Diagnosis. — This  may  be  accurately  made  upon  the  discovery  of 
the  fungus  by  microscopic  examination.  Only  very  rarely  are  portions 
of  the  thrush-organism  found  in  the  false  membrane  of  diplitlt critic 
stomatitis.  Milk  curds  may  be  readily  removed,  and  are  not  necessarily 
associated  with  the  stomatitis  accompanying  thrush  or  the  grave  sys- 
temic states.  The  important  point  of  differential  diagnosis  arises  in  the 
case  of  aphthce.     The  following  table  will  express  the  main  points : 

Parasitic  Stomatitis  (Thrush).  Aphthous   Stomatitis. 

Dryness  of  the  mouth.  Salivation. 

"Whitish,  raised  spots  or  patches  with  no  An  ulcer  with  a  yellowish-white,  de- 
red  areola  -,  these  are  easily  removed,  pressed  base,  surrounded  by  a  red  are- 
leaving  no  ulcer  and  causing  no  bleed-  ola.  The  base  is  removed  with  difli- 
\xi<r,  culty  by  forceps,  and  bleeding  results. 

Spots  are  numerous.  Usually  few  in  number  and  discrete. 

Begins  in  the  form  of  minute  spots.  Not  so  ;  ulcers  appear,  preceded  by  the 

formation  of  herpetic  vesicles. 

Ulcers  not  painful.     Discomfort  depends  Ulcers  exquisitely  tender, 
on  the  associated  stomatitis. 

The    characteristic  thrush-fungus  is  al-  No  specific  micro-organism  determined, 

ways  detectable  with  the  microscope.  though  probably  present. 

Prognosis. — This  is  favorable  as  regards  the  thrush  alone,  but, 
occurring  in  marantic  cliildren  and  cachectic  adults,  its  appearance  is 
of  grave  significance,  and  may  portend  a  speedy  death. 

Treatment. — Prophylaxis  is  of  great  moment,  since  it  is  much  easier 
to  keep  the  mouth  clean  and  the  secretions  normal,  and  to  attend  to 
proper  food,  and  thus  avoid  creating  a  soil  for  the  growth  of  the  vegetable 
parasite,  than  it  is  to  prevent  absolutely  the  entrance  of  thrush-spores. 
Efforts  directed  toward  preventing  acidity  are  especially  indicated.  This 
is  to  be  done  by  the  use  of  mild  alkaline  mouth-washes,  as  soda- 
Avater  and  lime-water.  The  dietary  should  be  carefully  looked  after, 
and  should  exclude  sugars  and  all  starchy  food ;  the  addition  of  lime- 
water  to  the  milk  (about  one  part  to  four)  is  a  desirable  precaution 
to  take,  particularly  Avith  children.  Cleansing  the  feeding-apparatus 
and  the  mouth  after  each  feeding  is  essential,  both  in  the  prevention  of 
the  formation,  and  in  decreasing  the  further  growth,  of  thrush  when  pres- 
ent. The  local  treatment  consists  in  the  use  of  alkaline  and  antiseptic 
applications,  preferably  by  means  of  the  spray.  Solutions  of  boric 
acid  or  sodium  hyposulphite  (.^j — 4.0— of  either  to  §j — 32.0 — of  water, 
with  the  addition  of  a  little  glycerin),  potassium  permanganate,  or  hydro- 
gen peroxid,  are  useful.  Syrupy  excipients  are  to  be  excluded.  Potas- 
sium chlorate  may  exert  a  beneficial  effect  in  those  cases  in  which  stom- 
atitis is  associated,  as  may  also  pencilling  with  a  solution  of  silver  nitrate. 
Concetti  ^  urges  the  use  of  a  3  to  5  per  cent,  solution  of  silver  nitrate 
instead  of  the  weaker  strength  usually  employed.  The  use  of  the  gal- 
vano-cautery  is  often  serviceable. 

*  Rev.  mens,  des  Mai.  de  rEnfance,  July,  1899. 


GANGRENOUS  STOMATITIS.  745 

When  esophageal  obstruction  exists  it  may  he  necessary  to  gently 
force  a  rubber  tube  through  the  mass  of  thrusli-deposit  in  order  to  give 
nourishment  (Forchheimer). 

Medicinal  treatment  embraces  the  administration  of  nourishing  and 
easily  digestible  food,  occasional  stimulation,  and  the  correction  of 
gastro-intestinal  disorders.  Attention  must  also  be  paid  to  the  pri- 
mary affections  to  which  the  thrush  is  superadded.  Iron,  cod-liver  oil, 
and  acid  and  bitter  tonics  in  palatable  form  are  usually  indicated  in 
debilitated  subjects,  along  Avith  general  hygienic  measures.  The  inter- 
nal use  of  small  doses,  frequently  repeated,  of  calomel  or  mercuric  chlorid 
may  also  be  tried  for  a  possible  specific  effect  in  combating  thrush. 

LA  PERLECHE. 

This  contagious  disease  is  confined  to  the  angles  of  the  mouth.  It 
was  first  described  by  Lemaistre  in  1886  as  prevalent  among  the  children 
of  Limousin  in  France.  It  was  found  that  the  drinking-water  in  that 
locality  contained  cocci  similar  to  the  spherobacteria  that  infested  the 
epithelial  thickenings,  and  that  these  were  probably  conveyed  to  human 
beings  by  drinking-vessels.  Little  elevations  and  fissures,  said  to  resemble 
those  of  congenital  syphilis,  were  seen  around  the  oral  angles.  The  latter 
were  the  seat  of  smarting  pain,  particularly  on  opening  the  mouth  sud- 
denly or  too  far,  and  caused  the  patient  to  lick  (perlichey)  them  con- 
stantly. The  disease  seemed  to  be  entirely  local,  and  lasted  from  two 
to  three  weeks.     Alum  and  copper-sulphate  solutions  were  most  useful. 

GANGRENOUS    STOMATITIS. 

{Noma;   Canamm  Oris.) 

Definition. — A  rapidly-spreading  gangrenous  affection  of  the  cheek 
and  gums,  of  rare  occurrence,  usually  asymmetric,  and  ending  fatally  in 
most  cases. 

Pathology. — In  addition  to  the  necrotic  changes  in  the  cheeks,  the 
process  may  extend  to  the  jaws  and  lips.  The  blood-vessels  contain 
thrombi,  thus  preventing  hemorrhage  from  the  sphacelus.  The  submaxil- 
lary and  cervical  glands  may  be  slightly  enlarged  and  soft.  Blood-changes 
of  an  uncertain  character  have  been  noted.  Hemorrhagic  infarctions, 
aspiration  broncho-pneumonia,  or  gangrene  by  inhalation  of  gangrenous 
particles  or  metastasis,  may  bo  met  in  the  lungs.  Wharton  has  described 
an  associated  membranous  form  of  colitis,  and  a  metastatic  infiltration 
of  the  cardiac  muscle  and  purulent  pericarditis  may  also  be  seen  post- 
mortem. Klementorosky  met  with  a  peculiar  and  fatal  form  of  gangrene 
limited  to  the  gums  of  babes  and  occurring  a  few  days  after  birth. 

Ktiologfy. — Predisposmg  Causes. — This  uncommon  affection  attacks 
girls  more  frequently  than  boys,  usually  between  the  ages  of  two  and 
five  years ;  it  appears  to  be  endemic  in  low,  moist  countries,  as  Holland, 
though  apparently  it  has  not  been  regarded  as  contagious  in  the  past. 
Children  suffering  from  the  effects  of  overcrowding  and  previous  disease 
are  especially  liable  to  noma.  Most  often,  however,  it  is  secondary  to 
measles ;  it  may  also  follow  scarlet  fever,  typhoid,  small-pox,  or  less  fre- 


746  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

quenilj    pertussis.       The    causative    influence   of    mercurialization    and 
ulcerative  stomatitis  has  been  overrated. 

Bacteriology. — Jos.  Sailer*  recovered  diphtheria  bacilli  from  the 
gangrenous  areas  of  noma  of  the  buccal  cavities.  Guzzetti  found 
pseudo-diphtheritic  bacilli  together  with  staphylococci  and  strepto- 
cocci. 

Symptoms. — The  mucous  membrane  of  one  cheek,  near  the  corner 
of  the  mouth,  is  usually  first  affected,  a  dark,  rofifjed,  sfouqhing  ulcer 
a]>pearing  and  spreading  insidiously  for  two  or  three  days  before  the 
substance  of  the  cheek  is  involved.  A  hard  and  sensitive  nodule  may 
then  be  felt  by  grasping  the  thickness  of  cheek  between  the  thumb 
and  finsrer.  Brawnv  induration  of  the  skin  over  this  nodule  soon  becomes 
manifest,  and  then  there  appear  collateral  edema  and  an  unctuous-looking, 
deeply  livid,  gangrenous  spot,  soon  becoming  bullous  and  leaving  a 
black  eschar.  Perforation  of  the  cheek  may  occur  on  the  third  day, 
though  usually  not  until  a  week  has  passed.  There  is  an  irhorous  dis- 
cJianje  of  shreds  of  gangrenous  tissue  from  the  unhealthy  wound.  The 
fetor  of  the  breath  is  almost  intolerable  and  characteristically  gangren- 
ous. The  necrosis  may  extend  over  one-half  the  face  oi  the  side  affected, 
and  may  involve  the  gums  and  jaws,  but  seldom  does  it  attack  the 
opposite  side  of  the  face.  The  general  symptoms  of  such  a  grave  mal- 
ady may  be  slight  at  a  very  early  period,  but  with  the  formation  of  the 
eschar  they  become  rapidly  severe  and  typhoid  in  type.  Great  prostra- 
tion, delirium,  pyrexia  (104°  F. — 40°  C.),  diarrhea,  and  edema  of  the 
feet  are  common.     The  course  rarely  extends  beyond  two  weeks. 

Complications. — Septic  lobular  pneumonia  may  occur  from  aspira- 
tion of  gangrenous  particles ;  colitis  and  gangrene  of  the  genitalia  in 
females  {n<>ma  pudenda')  are  also  seen.  In  those  very  rare  cases  that 
recover  granulations  form,  the  gangrenous  edges  become  clean,  and 
cicatrization  follows,  often  with  great  disfigurement  of  the  face  and  even 
restricted  jaw-motion. 

Diagnosis. — The  disease  when  fully  established  is  easily  diagnosed 
by  its  characteristic  origin,  the  gangrenous  ulcer-nodule,  the  eschar-for- 
mation, and  perforation,  associated  with  a  previous  history  of  measles  or 
other  acute  infectious  fever  of  childhood.  The  offensive  fetid  odor  and 
severe  constitutional  depression  are  also  of  great  value. 

DiflFerential  Diagnosis. — From  anthrax  it  differs  in  that  the  latter 
affection  is  more  common  in  adults,  with  a  history  of  contagion,  and  in 
the  fact  that  malignant  pustule  starts  on  the  exterior  of  the  cheek,  and 
perhaps  in  a  previous  abrasion  in  the  skin.  The  discovery  of  the 
bacillus  anthracis  in  the  blood  aiid  discharges  is  conclusive.  tflcerative 
stomatitis  of  a  severe  and  neglected  type  may  be  confounded  with  can- 
crum  oris,  but  in  the  former  the  destruction  of  tissue  is  mainly  of  the 
gums  and  alveoli,  the  cheeks  being  simply  ulcerated  and  no  extensive 
sloughing  taking  place ;  the  breath,  though  fetid,  is  not  gangrenous, 
and  the  oral  discharge,  though  sometimes  bloody,  is  not  mixed  with 
shreds  of  gangrenous  tissue  (Starr).  Finally,  the  course  of  ulcerative 
stomatitis  is  less  severe,  a  fatal  termination  being  extremely  rare. 

Prognosis. — Noma  is  seldom  recovered  from,  the  mortality  being 
about  80  to  90  per  cent.  (Bogel).     When  recovery  does  take  place  the 

^  Philadelphia  County  Medical  Society,  Nov.,  1901,  p.  301. 


MEIKJURIAL   STOMA  TIT fS.  747 

development  of  ectropion,  facial   deforrnity,  and  local   diHal)ility,  willi   a 
protracted  convalescence,  render  life  burdensome. 

Treatment. — Quarantine  all  cases  until  tliey  are  j)roveM  by  bac- 
teriologic  study  to  be  of  a  nondiphtberic  nature,  and  tbe  avoidance  of 
mercurialization  will  also  be  of  undoubted  use.  Tbe  primary  indication 
in  tbe  local  treatment  is  tbe  arrest  of  the  gangrenous  process,  thus 
causing,  if  possible,  a  healthy  reaction  on  the  part  of  the  surrounding 
tissues.  All  sloughs  should  be  cut  away,  followed  by  cleanliness  of  the 
mouth  and  wound ;  and  by  the  application  of  strong  caustics,  as 
fuming  nitric  acid,  the  acid  nitrate  of  mercury,  solid  zinc  chlorid, 
silver  nitrate,  carbolic  acid,  a  concentrated  solution  of  perchlorid  of 
iron,  Vienna  paste,  and  the  actual  cautery.  For  the  protection  of  the 
healthy  parts  and  for  efficiency  the  Paquelin  or  the  galvanic  cautery  is 
probably  best.  Anesthesia  is  requisite  for  such  strong  measures. 
Milder  applications,  however,  seem  to  be  quite  adequate  in  some  cases. 
Thus,  bismuth  subnitrate,  potassium  chlorate,  and  aristol,  or  the  following 
formula  by  Dr.  Coates,  may  be  tried : 

^.   Cupri  sulph.,  3ij     (8.0); 

Pulv.  cinchonge,  3ss    (16.0); 

Aquae,  q.  s.  ad  fgiv  (128.0).— M. 

As  a  mouth-wash  employ  mild  antiseptic  washes  of  carbolic  acid,  hydro- 
gen peroxid,  Labarraque's  solution,  potassium  permanganate,  etc. ;  and 
for  the  diminution  of  the  fetor,  antiseptic  charcoal  poultices  containing 
boric  or  salicylic  acid  are  useful.  Mild  antiseptic  and  astringent  lotions 
of  boric  acid,  zinc  sulphate  (gr.  ij  to  ^j — 0.129  to  32.0),  or  balsamic 
ointments  with  vaselin,  may  aid  in  healing  the  granulating  surfaces  in 
favorable  cases.  The  internal  treatment  must  be  directed  toward  sus- 
taining the  strength  of  the  patient  by  the  administration  of  the  most 
nourishing  food,  stimulants,  and  tonics.  Rectal  feeding  may  be  neces- 
sary. Plastic  operations  may  be  needful  after  recovery  to  mitigate  oral 
disabilities  or  facial  deformities.  W.  C.  Cahall  has  successfully  treated 
a  case  of  noma  with  anti-streptococcus  serum.  Antitoxin  should  be  given 
early  where  the  diphtheria  bacillus  is  found. 


MERCURIAL   STOMATITIS. 

{Mercurial  PtyaUsm.) 

Definition. — An  inflammation  of  the  mouth  and  salivary  glands, 
caused  by  the  excessive  use  of  mercury  ;  a  similar  condition  is  rarely 
seen  as  a  result  of  the  therapeutic  use  of  other  drugs. 

etiology. — Predisposing  causes  are  dyscrasia  and  occupation, 
mainly.  The  peculiar  individual  susceptibility  of  these  subjects  to 
dyscrasia  will  not  permit  the  use  of  even  minimum  doses  of  mercury 
without  serious  and  almost  immediate  symptoms  of  ptyalism.  This  is 
also  seen  in  barometer-makers,  mirror-silverers,  chemists,  and  others 
who  handle  mercury  in  their  daily  work.  The  exciting  cause  of  ptya- 
lism is  the  ingestion,  inhalation,  or  cutaneous  absorption  of  mercury. 

Symptoms. — A  metallic  taste  in  the  mouth  is  first  noticed  by  the 
patient.     Soon  the  gums  become  "touched" — i.  e.,  red,  swollen,  tender 


748  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  the  touch,  and  sore  during  the  act  of  mastication.  A  marked  secre- 
tion und  floiv  of  salica,  witli  a  fetid  hreai/i  and  swollen  tongue,  follow. 
Very  rarely  in  this  disease  the  affection  passes  into  an  ulcerative  stoma- 
titis, and  causes  loosening  of  the  teeth  and  necrosis  of  the  uuixilla. 
G-eneral  symptoms,  as  constitutional  depression,  anorexia,  diarrhea, 
mental  anxiety,  and  nervousness,  may  supervene. 

The  recognition  of  the  foregoing  causal  factors — predisposing  and 
exciting — renders  the  diagnosis  easy.  The  proi/nosis  is  favorable,  and, 
although  the  local  symptoms  may  be  harassing,  recovery  is  attainable 
within  a  few  weeks  as  a  rule. 

Treatment. — The  toxic  action  of  mercury  in  the  ])roduction  of 
ptyalism  can  be  avoided  by  a  knowledge  of  individual  susceptibility  and 
by  the  local  and  internal  use  of  potassium  chlorate.  Upon  the  first 
appearance  of  the  symptoms  there  must  be  a  prompt  withdrawal  of  the 
mercurial  influence,  and  a  change  of  occupation  if  that  be  the  predis- 
posing cause.  Locally,  soothing,  alkaline,  and  mildly  antiseptic  mouth- 
washes, as  in  the  treatment  of  catarrhal  stomatitis,  may  be  all  that  is 
necessary.  For  the  fetid  breath  solutions  of  boric  acid  or  potassium 
chlorate  may  be  used.  Ulcers  may  be  brushed  with  silver-nitrate  solu- 
tion. The  internal  treatment  should  be  directed  toward  keeping  the 
bowels  soluble ;  in  addition,  alkaline  mineral  waters  may  be  used,  and 
in  severe  cases  potassium  chlorate  in  5-  to  10-grain  (0.324-0.648)  doses. 
Atropin  (gr.  ^or — 0.0006)  and  opium  have  been  recommended  to  de- 
crease the  excessive  salivary  secretion  and  to  allay  pain,  and  hot  baths 
will  aid  the  treatment  materially.  In  severe  cases  the  resulting  debility 
and  anemia  should  be  met  by  the  use  of  highly  nourishing  liquid  foods 
and  by  tonics. 

Osier  points  out  that  the  condition  of  the  teeth  known  as  erosioUy 
which  sometimes  follows  infantile  stomatitis,  and  especially  the  mercurial 
form,  is  to  be  discriminated  from  the  deformed  teeth  of  congenital  syph- 
ilis. In  the  former  the  first  permanent  molars,  and  then  the  incisors, 
are  observed  to  have  small  pits  or  discolored  and  eroded  spots,  due  to  a 
morbid  deficiency  in  enamel-formation.  The  notched  and  irregular 
teeth  of  hereditary  syphilis  in  children  (Hutchinson)  are  sufficiently 
distinctive. 


II.   DISEASES  OF  THE  TONGUE. 
GLOSSITIS. 

ACUTE    GLOSSITIS. 
{Glossitis  Acufa.) 

Definition. — An  acute  parenchymatous  inflammation  of  the  tongue, 
sometimes  ending  in  abscess. 

Ktiology. — Predisposing  causes  are  supposed  to  be  an  impaired  gen- 
eral health  and  exposure  to  cold,  humid  weather.     The  exciting  causes 


CHRONIC  SUPERFICTAL   GLOSSITIS.  749 

are  most  frequently  tbe  stings  and  bites  of  insects,  or  burns,  scalds,  and 
the  action  of  corrosives.  I  believe  that  many  cases  follow  slight  in- 
juries to  the  tongue  that  allow  of  the  introduction  of  inflammatory 
poisons  or  microbes.  A.  J.  Hall  describes  a  case  of  membranous  glos- 
sitis complicating  acute  nephritis. 

Symptoms. — These  come  on  rapidly  and  with  more  or  less  local 
severity  and  danger.  The  tongue  becomes  much  swollen,  and  may  even 
protrude  beyond  the  lips.  It  is  very  tender  and  painful,  and  coated 
with  a  thick,  soft  yellowish-white  fur,  and  it  may  also  be  dry,  cracked, 
and  ulcerated.  Oatarrhal  stomatitis  is  often  associated,  salivation  is 
usually  profuse,  and  talking,  swallowing,  and  even  breathing  are  ren- 
dered difficult  and  distressing.  Dyspnea,  even  to  suffocation,  may  be 
imminent.  The  cervical  and  sublingual  glands  may  be  swollen,  mode- 
rate/et^^r  is  always  present,  and  the  obstruction  to  breathing  and  admin- 
istration of  nutriment  may  assume  a  dangerous  aspect. 

The  inflammation  reaches  its  height  in  about  three  or  four  days, 
tending  to  subside  almost  entirely  about  the  seventh  day.  Not  rarely 
the  inflammatory  infiltration  passes  into  suppuration  with  the  formation 
of  a  circumscribed  abscess  of  variable  size  in  one-half  of  the  tongue ; 
fluctuation  may  not,  however,  be  obtainable,  spontaneous  rupture  being 
sometimes  the  first  indication  of  abscess.  The  prognosis  is  favorable, 
except  that  serious  obstruction  is  likely  to  remain. 

Treatment. — When  the  case  is  seen  quite  early  and  during  the 
congestive  stage,  the  topical  use  of  ice,  allowed  to  slowly  dissolve  in  the 
mouth,  is  serviceable.  Mucilaginous  mouth-washes,  containing  some 
mild  antiseptic,  as  sodium  borate  with  sodium  bicarbonate  (gr.  v-xx  to 
^j — 0.324-1.296  to  32.0),  should  also  be  employed.  A  brisk  saline 
purge,  given  early,  will  aid  in  reducing  the  inflammation,  and  should 
the  tongue  become  alarmingly  swollen,  deep  scarification  and  the  use  of 
half  a  dozen  leeches  between  the  hyoid  bone  and  the  jaw-angles  may  be 
of  decided  service.  Steam-atomization,  medicated  with  the  compound 
tincture  of  benzoin  or  ammonium  chlorid  (3j  to  5J — 4.0  to  32.0),  favors 
resolution  (Cohen).  Abscesses  must  be  incised  and  washed  out  with 
antiseptic  solutions.  Tracheotomy  is  rarely  called  for  to  relieve  the 
dyspnea.  Rectal  alimentation  with  predigested  foods  may  be  necessary, 
and  during  convalescence  ferruginous  tonics  in  glycerin  and  bland 
foods  should  be  continued  for  some  time,  in  order  to  prevent  chronic  in- 
flammation and  thickening.  Any  local  source  of  irritation,  as  from 
carious  or  sharp  teeth,  should  be  removed. 

CHRONIC    SUPERFICIAL   GLOSSITIS. 

Definition. — A  chronic  inflammation  of  the  mucosa  of  the  tongue. 

ll^tiology. — This  disease  is  often  preceded  by  several  acute  attacks, 
the  habitual  use  of  tobacco,  both  in  smoking  and  chewing,  and  of  strong 
spirituous  liquors  being  mainly  productive  of  the  original  aff"ection. 
The  frequent  use  of  irritating  foods  is  also  a  factor  in  some  instances. 

Symptoms. — The  surface  of  the  tongue  is  continually  sensitive  and 
more  or  less  reddened.  Often  there  are  seen  ovoid  patches  of  various 
size,  smooth  and  shiny,  on  account  of  the  loss  of  papillte,  and  separated 
by  furrows  that  extend  to  the  depth  of  the  mucosa  itself.     The  tongue 


750  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

may  also  be  slightly  furrowetl  in  intervening  spaces,  especially  at  the 
base.     The  general  health  is  somewhat  deteriorated. 

Diagnosis. — This  rests  upon  the  history  of  the  case  and  upon  the 
results  of  e.xaniination  of  the  organ. 

The  prognosis  is  favorable  as  to  alleviation,  but  guarded  as  to  cure. 

Treatment. — The  blandest  dietary  must  be  insisted  on,  as  well  as 
absohiti'  abstention  from  the  causal  irritants.  The  local  use  of  demul- 
cents and  of  mildly  alkaline  and  antiseptic  lotions,  sucli  as  Seiler's  tablets 
in  solution,  and  of  solutions  of  chromic  acid  or  silver  nitrate  (gr.  v— x  to 
31 — 0.824-0.648  to  32.0)  in  water  or  honey,  applied  once  or  tw^ice  daily 
by  gentle  brushing,  is  to  be  ret'onimended.  General  tonics  and  the 
avoidance  of  irritatiuii  drinks  will  be  indicated. 


GLOSSITIS   DESICCANS. 

A  rare  disease,  chronic  in  nature  and  of  unknown  causation.  It  is 
characterized  by  ''the  gradual  development  upon  the  surface  of  the 
tongue  of  a  number  of  deep  fissures  and  indentations,  giving  the  organ 
an  uneven  and  ragged  look.  The  pain  is  due  to  the  frequent  presence 
of  excoriations  and  ulcers  in  these  fissures  "  (Striimpell).  The  prognosis 
of  the  affection  is  favorable  as  regards  any  danger.  The  treatment  is 
hygienic,  consisting  of  cleanliness  of  the  mouth  and  the  use  of  disinfect- 
ant mouth-lotions,  together  with  the  topical  use  of  alterative  or  astrin- 
gent applications,  as  silver  nitrate  or  chromic  acid,  to  any  ulceration. 

LINGUAL   PSORIASIS    (TYLOSIS    LINGU^). 

In  this  disease  there  are  small  regular  areas  of  hyperplasia  of  the 
glossal  epithelium,  eventually  causing  a  map-like  appearance  of  the  sur- 
face of  the  tongue — "lingua  geographica."  The  trouble  is  obscure  in 
its  etiology  and  persists  for  years.  Seldom  is  there  any  discomfort  asso- 
ciated, although  mental  anxiety  or  hypochondriasis  may  develop. 

LEUKOPLAELIA   ORIS    (BUCCAL   PSORIASIS). 

In  this  affection  the  mucous  membrane  of  the  mouth  and  tongue  may 
be  involved.  On  the  lateral  borders  of  the  tongue  white  or  bluish-white 
scar-like  spots  or  patches,  often  slightly  notched,  make  their  appearance. 
Som^  of  these  pass  away  to  be  replaced  by  others,  and  the  affection  pro. 
gresses  despite  all  attempts  to  cure  it.  The  true  cause  is  unknown, 
but  it  has  been  suggested  that  some  irritant,  as  the  use  of  a  pipe, 
may  account  for  the  condition.  The  malady  has,  however,  been  seen 
in  women.  A  syphilitic  taint  is  said  to  especially  predispose  to  the  dis- 
ease (Strumpellj.  The  affection  must  be  carefully  diagnosed  from  the 
oral  manifestations  of  syphilis,  if  for  no  other  reason  than  to  relieve 
the  mind  of  a  morbidly  anxious  patient.  Excepting  some  pain  con- 
nected with  possible  ulceration,  there  are  no  annoying  symptoms,  and 
the  treatment  suggested  for  glossitis  desiccans  is  appropriate.  Kyle 
touches  the  white  patches  daily  with  pure  tincture  of  iodin. 

In  children  a  similar  tongue-affection  has  been  named  "  wandering 
rash."     The  patches  are  circinate  and  enlarge  peripherally,  forming  rings 


I 


DISEASES  OF  THE  SALIVARY  GLANDS.  751 

of  epithelial  hyperplasia,  within  which  is  a  red,  glossy  center,  "devoid of 
filiform  papillae,  tliough  the  fungiform  remain  "  (Allchinj. 

ANGINA   LUDOVICI. 
{Ludwixfs  Antji/nii.) 

Definition. — A  rare  acute  phlegmonous  inflammation  of  the  floor  of 
the  mouth. 

Ktiology. — The  condition  is  more  common  in  males,  and  may  be 
secondary  to  specific  infections  (scarlet  fever,  diphtheria).  Thomas  states 
that  insignificant  lesions  in  the  mouth  (e.  g.,  carious  tooth,  ulcer,  ton- 
sillitis) are  the  usual  primary  foci  leading  to  lymphatic  involvement. 
The  specific  organism  is  generally  the  streptococcus,  though  rarely  the 
staphylococcus  is  found.     It  may  result  from  trauma. 

Symptoms. — These  are  interxse  at  the  outset^  and  begin  with  swell- 
ing in  the  region  of  the  submaxillary  gland,  with  a  rapid  involvement 
of  the  cellular  tissue  of  the  floor  of  the  mouth  as  well  as  of  the  anterior 
portion  of  the  neck.  Pain  is  marked,  and  this,  with  the  acute  swelling, 
renders  articulation,  mastication,  and  deglutition  extremely  difficult. 
Cornpression  or  edema  of  the  larynx  may  often  cause  dangerous  dyspnea. 
The  constitutional  disturbance  is  usually  febrile,  and  may  either  approach 
the  typhoid  type  or  may  be  septic.  The  condition  generally  terminates 
either  in  abscess  or  extensive  sloughing  {cynanche   gangrcenosd). 

The  diagnosis  is  easily  made  when  complicating  a  specific  fever. 

The  prognosis  is  always  grave.  Of  106  cases  collected  by  Thomas, 
43  died.     Relapses  may  follow  in  weakly  subjects. 

Treatment. — The  most  that  can  be  done  is  to  sustain  the  strength 
of  the  patient  and  secure  prompt  surgical  interference.  Tracheotomy 
may  be  demanded  if  asphyxia  threatens  life. 


III.  DISEASES   OF  THE  SALIVARY  GLANDS. 
HYPERSECRETION. 

{Ptyalism.) 

Definition. — An  abnormal  increase  in  the  secretion  of  saliva. 

histiology. — Salivation  as  an  idiopathic  affection  is  rare,  and  as  such 
is  considered  to  be  a  neurosis.  Thus,  it  has  been  seen  in  emotional 
children  of  from  two  to  eight  years  of  age,  though  apparently  in  perfect 
health.  According  to  Bohn,  the  secretion  in  these  cases  is  mostly  in- 
creased during  active  exercise,  is  reduced  on  lying  down,  and  absent 
during  sleep.  Spontaneous  recovery  takes  place  in  a  few  years.  As 
a  deuteropathic  disease  ptyalism  may  be  the  result  of  oral  disease 
{e.  g.  noma,  ulcerative  stomatitis),  and  also  of  gastro-enteric,  pancreatic, 
uterine  (as  gestation),  centric  (as  diseases  or  tumors  of  the  medulla  or 
of  the  facial  nerve),  toxic,  systemic  (as  small-pox,  the  use  of  mercury, 
iodids,  pilocarpin,  tobacco),  and  hydrophobic  irritation  and  disease. 

Diagnosis. — It  should  be  pointed  out  that  a  failure  in  swallowing 
the  normal  quantity  of  saliva  may  cause  dribbling  from  the  mouth  and 
simulate  true  hypersecretion. 

The  prognosis  is  favorable  in  itself,  but  dependent  on  the  cause. 


/52  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Treatment. — The  causes  are  to  be  removed  and  the  general  health 
toueil  up.  For  stomatitie  salivation  potassium  chlorate  is  first  in  rank 
as  an  internal  and  local  remedy.  Iron  and  arsenic  are  valuable  in  neur- 
otic cases,  and  the  bromids  or  hyoscin  may  be  of  supplemental  use. 
Atropin  (gr.  ^^g-  to  yIu — '^•0003  to  0.0006)  and  belladonna  are  almost 
uniformly  successful  in  idiopathic  as  well  as  in  central  ptyalism. 


XEROSTOMA. 

{Aptyalism  ;   "  Dry  Mouths) 

Definition. — A  morbid  arrest  of  the  salivary  and  buccal  secretions. 

Btiology. — The  disease  is  probably  due  to  an  affection  of  the  nerve- 
supply  of  all  the  glands  of  the  mouth  (Harris).  It  may  follow  sudden 
mental  phenomena  as  a  temporary  condition.  A.  J.  Hall  collected  39 
cases,  of  which  32  occurred  in  females.  In  most  of  the  cases  the  causes 
were  unknown.  Not  uncommonly  xerostoma  is  an  effect  of  the  febrile 
state,  of  mouth-breathing  (due  to  nasal  obstruction),  and  of  diabetes. 

Symptoms. — Apart  from  the  sensation  of  dryness,  mastication, 
deglutition,  and  articulation  are  difficult.  The  local  appearances  show 
a  dazed,  red,  and  sometimes  cracked  condition  of  the  tongue  and  labial 
and  palatine  mucosa.      The  teeth  may  become  diseased  and  crumble. 

The  diagnosis  is  made  on  inspection,  the  prognosis  depending  on 
the  removability  of  the  cause,  and  rightfully  being  guarded  on  account 
of  the  frequent  obstinacy  of  the  trouble. 

Treatment. — Attention  to  the  systemic  condition  is  requisite. 
Small  doses  of  potassium  iodid  and  pilocarpin  (gr.  -^^ — 0.003)  in  gelatin 
lamellse  or  in  lozenge  form,  allowed  to  dissolve  in  the  mouth  with  the 
aid  of  a  sip  of  water,  have  been  productive  of  relief.  In  cases  of  cen- 
tric origin  the  galvanic  current  should  be  tried. 

Glassblowers'  Mouth. — This  condition  is  found  among  glass- 
blowers  and  also  among  musicians.  It  occurs  in  about  2.5  per  cent,  of  all 
glassblowers.  Scheele,^  who  reports  two  cases,  describes  the  condition 
as  a  hernial-outpocketing  of  the  muscles  of  the  cheeks.  The  epithelium 
of  the  mucous  membranes  shows  the  so-called  plaques  opalines.  It  is 
often  combined  with  a  distention  of  Steno's  duct.  In  addition  to  a 
ballooning  out  of  the  buccal  mucosa,  there  is  likely  to  be  a  disturbance 
of  hearing  and  cramp-like  contraction  of  the  cheek.  The  parotids  may 
be  emphysematous  and  crepitate  on  palpation. 


SYMPTOMATIC  PAROTITIS. 

{Parotid  Bubo.) 

Definition. — A  secondary  inflammation  of  the  parotid  gland,  gen- 
erally due  to  septic  infection  and  tending  to  suppuration. 

Btiology. — Not  being  a  primary  affection,  the  causes  giving  rise  to 
it  may  be  mentioned  as  follows :  (a)  Acute  infectious  fevers,  as  typhoid, 
typhus,  pneumonitis,  pyemia,  erysipelas;  (bj  Injury  or  disease  of  the 
abdomen  or  pelvis  (Stephen  Paget),  or  of  the  genito-urinary  tract, 
as  mild  traumatisms  or  derangement  of  the  testes  or  ovaries,  or  even 
1  Berlin,  klin.  Wochenschri/t,  Mar.  12,  1900. 


DISEASES  OF  THE  TONSILS.  753 

menstruation  or  pregnancy;  gastric  ulcer  may  be  accompanied  by  it; 
(c)  Peripheral  neuritis  with  facial  paralysis  (Gowers). 

Most  of  the  cases  are  septic  and  indicative  of  an  unfavorable  course 
in  the  progress  of  the  associated  disease,  '^i'he  Hym/ptjrim^  diafjaoHia,  and 
treatment  of  the  j)ai'otitis  itself  fall  under  the  scope  of  surgery. 

Chronic  Parotitis. — Mikulicz  first  described  this  condition  and 
reported  a  case  in  which  symmetric  enlargement  of  the  lachrymal,  and 
subsequently  of  the  salivary,  glands  occurred.  Kuramel  and  Osier 
Jiave  also  recorded  cases.  It  may  be  caused  by  lead  or  mercury  and 
may  be  secondary  to  mumps,  inflammation  of  the  throat,  and  chronic 
Bright's  disease.     The  condition  may  be  painless. 


IV.  DISEASES  OF  THE  TONSILS. 

ACUTE  TONSILLITIS. 

Definition. — An  acute  inflammation  of  the  tonsil  or  tonsils,  affect- 
ing either  the  mucous  membrane,  the  follicles,  or  the  parenchyma,  and 
ending  either  in  resolution,  suppuration,  or  chronic  enlargement. 

Pathology. — In  the  superficial  variety/  of  acute  tonsillitis  the  mu- 
cosa is  simply  red,  swollen,  and  sometimes  covered  with  a  thin,  soft  exu- 
date of  muco-pus.  The  tonsil  itself  may  also  be  swollen.  In  follicular 
tonsillitis  the  lacunae  become  filled  with  a  cheesy  exudate  which  often 
protrudes  from  the  tonsillar  crypts ;  epithelial  and  pus-cells,  cellular 
debris,  and  occasional  cholesterin-crystals  are  found  in  these  cheesy 
masses.  In  older,  darker-hued  masses  an  offensive  odor  is  given  off, 
and  numerous  micrococci  and  bacteria  are  found.  In  adults,  calcareous 
infiltration  of  the  cheesy  little  masses  may  be  met  with.  Pare7ichynta- 
tous  tonsillitis  is  shown  by  a  greater  enlargement  of  the  tonsil,  due  to 
a  marked  infiltration  of  all  the  tissues.  Suppuration  in  the  tonsil  is 
frequent,  the  follicles  usually  bursting  and  uniting  in  abscess-forma- 
tion. Pus  may  burrow  into  the  cellular  tissue  surrounding  the  tonsil, 
and  find  its  way  even  down  to  the  clavicle.  The  herpetic  or  ulcero-mem- 
branous  form  of  tonsillitis  described  by  Rilliet  and  Barthez,  DaCosta,  and 
others,  in  which  an  eruption  of  herpetic  vesicles  on  the  tonsils  is  followed 
by  their  rupture  and  the  formation  of  a  lightly  adherent  membrane  is 
rare.  In  necrotic  tonsillitis  (Striimpell)  a  grayish-white  adherent  necrotic 
membrane  is  observed,  that  is  limited  by  the  inflamed  membrane  sur- 
rounding the  mucosa  covering  the  tonsils.  The  latter  are  moderately 
s woollen.     A  dirty  ulcer  often  remains  after  the  slough  separates. 

Ktiology. — Predisposing  causes  are  age,  sex,  temperament,  and 
atmospheric  conditions.  The  disease  is  most  common  in  youth  and  in 
early  adult  life.  Boys  and  young  men  appear  to  be  attacked  more  often 
than  the  opposite  sex.  Tonsillitis  is  most  prevalent  during  the  spring 
season.  An  individual  susceptibility  is  most  distinct  in  lymphatic  and 
strumous  constitutions.  It  is  aggravated  by,  or  tends  to"  recur  especi- 
ally in,  the  rheumatic  diathf^sis.  The  proportion  of  cases  in  which  ton- 
sillitis precedes  rheumatism  is  probably  over  30  per  cent.  It  is  certain 
that  one  attack  of  acute  tonsillitis  predisposes  to  subsequent  ones,  par- 

48 


754  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

ticularly  when  the  first  attack  lias  left  some  enlargement  of  the  tonsils. 
Sudden  and  extreme  climatic  changes  predispose  to  the  disease. 

The  existing  causes  of  acute  tonsillitis  are  most  commonly  the  follow- 
ing: (a)  exposure  to  cold  and  dampness,  or  talking  in  a  cold,  moist  at- 
mosphere ;  (b)  exposure  and  talking  in  an  overheated  atmosphere  viti- 
ated with  smoke  or  other  irritating  vapors  or  gases  ;  (c)  bad  drainage, 
sewer-gases ;  (d)  specific  infectious  fevers,  as  scarlatina,  measles,  and 
erysipelas ;  (e)  irritation  from  hard  and  sharp  foreign  bodies  or  chemical 
irritants;  (/)  the  presence  of  microbes  (streptococci,  staphylococci,  pneu- 
mococci ;  {g)  epidemics  of  streptococcic  infection  have  been  traced  to 
the  milk-supply. 

Clinical  Symptoms. — Three  principal  varieties  of  acute  tonsillitis 
occur  clinically,  the  symptoms  of  which  will  be  described  separately. 

(a)  Acute  Catarrhal  or  Superficial  Tonsillitis. — This  form  is  often 
associated  with  acute  pharyngitis.  The  earliest  local  symptoms  are  pain 
and  difficulty  in  swallowing,  the  former  often  becoming  quite  acute  and 
radiating  to  the  ear  and  lymphatics  at  the  angle  of  the  jaw,  where  ten- 
derness on  pressure  may  also  be  elicited.  In  speaking  a  nasal  twang  is 
often  noticed.  During  the  laborious  act  of  swallowing  the  sensation 
of  a  lump  in  the  throat,  especially  when  the  mouth  is  dry,  is  commonly 
complained  of.  Simple  stomatitis  may  be  associated,  and  rarely  there 
is  a  slight  cough  Avith  the  painful  expectoration  of  a  sticky  mucus  which 
accumulates  in  the  throat  (Browne).  There  may  be  salivation,  with 
fetor  of  the  breath.  Inspection  shoAvs  the  tonsil  to  be  red  and  swollen. 
Though  dry  and  glazed  at  first,  the  surfaces  soon  become  covered  Avith 
a  thin  exudate  of  muco-pus,  Avhich  is  easily  detached  by  brushing,  gar- 
gling, or  ''haAvking  "  the  throat.  There  is  usually  some  accompanying 
redness,  and  also  a  tumefaction  of  the  uvula  and  faucial  pillars.  The 
constitutional  symptoms  of  simple  erythematous  tonsillitis  at  the  outset 
are  mildly  febrile.  The  attacks  usually  come  on  rapidly,  and  last  but 
a  fcAv  days,  subsidence  taking  place  rapidly  also.  Otitis  media  may  follow 
the  extension  of  the  tonsillar  inflammation. 

(h)  Acute  Lacunar  or  Follicular  Tonsillitis. — In  this  form,  Avhich  is 
quite  common  in  children,  not  only  the  mucous  membrane  lining  the 
crypts  is  inflamed,  but  that  covering  the  surface  of  the  tonsils  also,  giving 
rise  to  more  or  less  associated  catarrhal  tonsillitis.  The  local  subjective 
symptoms  are,  as  in  the  preceding  variety,  pain,  tenderness,  and  difficult 
deglutition.  The  tonsils  are  seen  to  be  covered  with  small,  slightly 
prominent,  Avhitish-yelloAv  spots  or  patches  of  a  characteristic  creamy 
exudate  corresponding  to  the  position  of  the  crypts  and  numbering 
from  two  to  eight  or  ten  or  more.  These  little  masses  or  plugs 
may  be  pressed  out  of  the  follicles  Avith  a  spatula.  A  predominance 
of  pus-cocci  and  cells  may  rarely  forerun  the  further  formation  of 
little  follicular  abscesses,  and  even  of  slight  erosions  and  ulceration 
of  the  mouths  of  tlie  lacuna?.  Unlike  simple  catarrhal  tonsillitis — at 
least  in  so  far  as  simultaneous  involvement  is  concerned  (Cohen) — both 
tonsils  are  usually  affected  in  this  trouble,  though  one  to  a  greater  degree 
than  the  other.  The  Avhole  tonsil  is  considerably  SAvollen,  and  in  severe 
cases  the  cervical  lymph-glands  also.  The  constitutional  symptoms  of 
follicular  tonsillitis  may  be  (juite  severe.  The  disease  maybe  ushered  in 
with  a  pronoun-ced  chill,  headaclie.  aching  of  the  back  and  limbs,  marked 
anorexia,  and  insomnia,  along  with  a  rapid  rise  in  the  temperature  to 


ACUTE  TONSILLITIS.  755 

103°  or  104°  F.  (39.4°-40°  C.)— in  children  as  high  as  105^  F.  (40.5^  C.). 
Slight  albuminuria  is  an  exceptional  finding,  jjut  acetonuria  is  more  com- 
mon (25.6  per  cent. — Reiche).  The  general  depression  may  Ite  so  great 
as  to  simulate  adynamia.  Though  sudden  in  its  onset  and  rapid  and  often 
intensely  acute  in  its  progress,  the  disease  seldom  lasts  more  than  five  or 
eight  days.  Follicular  abscesses  complicate  the  case,  while  chronic  swell- 
ing of  the  tonsils,  desiccation,  and  bacterial  degeneration  of  the  lacunar 
masses  may  be  sequelae.  Packard  has  reported  five  cases  of  endocarditis 
following  acute  angina.  Pericarditis,  pleuritis,  nephritis,  and  skin-lesions, 
particularly  erythema  nodosum,  may  occur  as  complications.  The  exudate 
may  become  calcified,  and  may  be  expectorated  as  concretions  or  chalk- 
plugs. 

{c)  Acute  Parenchymatous  Tonsillitis  ( Tonsillar  Abscess  or  Quinsy). 
— In  this  form  of  tonsillitis,  which  occurs  most  often  during  adolescence 
and  early  adult  life,  the  symptoms  reach  the  most  pronounced  and  severe 
types.      The  stroma  is  inflamed  and  the  tendency  is  toward  suppuration. 

Local  Syni'ptoms. — Complaint  is  first  made  of  dryness  of  the  throat, 
with  painful  and  diflScult  deglutition.  The  pain  is  a  prominent  subjec- 
tive sign,  and  may  be  referred  to  one  or  both  ears  according  as  one  or 
both  tonsils  are  inflamed.  The  secretion  of  a  viscid  mucus  soon  takes 
place,  and  as  the  tonsillar  swelling  increases,  the  husky  voice  of  sore- 
throat  and  difficult  articulation  supervene ;  in  cases  of  aggravated 
swelling  dyspnea  may  often  appear  later.  On  examining  the  tonsils 
they  are  found  to  be  greatly  enlarged,  deeply  reddened,  firm,  and  edema- 
tous. The  surrounding  soft  parts,  the  faucial  arches,  pillars,  and  the 
uvula,  manifest  a  deep  congestion.  In  severe  cases  the  tonsils  may  meet 
in  the  median  line,  pushing  the  uvula  forward.  Patches  showing  follic- 
ular tonsillitis  are  sometimes  associated.  The  submaxillary  glands  may 
be  engorged,  and  opening  the  mouth  is  often  performed  with  difficulty  ;  it  is 
usually  only  partial,  on  account  of  the  fixation  of  the  jaw. 

In  a  few  days,  perhaps,  softening  and  fluctuation  may  be  detected  in 
the  tonsils,  and  spontaneous  rupture  and  discharge  of  the  pus  may  occur, 
with  almost  instant  relief  to  the  patient.  Resolution,  however,  sometimes 
takes  place  in  the  milder  cases.  The  abscess  may  open  in  one  or  more 
places,  and  should  rupture  occur  during  sleep  it  may,  as  in  one  of 
my  patients,  cause  suffocation  by  the  entrance  of  pus  into  the  larynx. 
The  tonsil  may  regain  its  original  size  in  a  few  days  after  the  discharge 
of  pus,  and  all  the  symptoms  subside.  The  constitutional  phenomena 
of  parenchymatous  tonsillitis  are  usually  severe  from  the  start,  even  in 
children,  and  more  so  than  in  the  follicular  form  (Mackenzie).  The  tem- 
perature rises  to  104°  or  105°  F.  (40°  or  40.5°  C),  and  the  pulse-beats 
may  reach  130  per  minute.  Acetonuria  is  often  present  in  this  disease. 
There  may  be  delirium,  and  the  symptoms  generally  increase  until  the 
abscess  bursts  or  is  opened,  when  all  symptoms  abate. 

Course,  Duration,  and  Terminations. — Though  often  severely  acute 
in  its  course,  quinsy  seldom  goes  on  to  rupture  in  children,  usually  end- 
ing in  resolution  in  from  three  to  five  days.  If  both  tonsils  are  inflamed, 
only  one  suppurates  as  a  rule,  or  but  one  at  a  time.  The  duration  of 
an  attack  ending  in  tonsillar  abscess  is  about  eight  or  ten  days  in  adults. 

Complications  and  Sequelce. — The  tonsillar  suppuration  may  invade 
the  cellular  tissue  between  the  tonsil  and  the  pterygoid  muscles ;  a  peri- 
tonsillar abscess  may  then  result  that  may  burrow  as  far  as  the  clavicle. 


756  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Ulceration  into  the  internal  carotid  or  internal  maxillary  arteries  "with 
fatal  hemorrhage  may  occur,  though  rarely.  Edema  of  the  larynx  is  also 
an  infrequent  com])lication.  French  writers,  as  Guble,  Germain  Sde,  and 
others,  have  re])()rte(l  cases  of  )>aralysis  of  the  soft  ])alate  and  pharynx 
following  inilanimatorv  tiiroat-diseases.  On  subsidence  of  the  tdnsillar 
intlaiiiniatioii  the  trouble  becomes  evident  in  the  difficult  swallowing  and 
})ariial  regurgitation  of  li(|uids  and  solids  into  the  nasal  passages,  and  in 
the  nasal  intonation  of  the  voice.  A  fre([uent  sequel  is  chronic  enlarge- 
ment of  the  tonsils. 

(d)  Necrotic  Tonsillitis. — This  affection  is  considered  by  Strlimpell 
to  be  in  some  instances  entirely  distinct  from  diphtheria  in  its  etiology, 
although  he  admits  that  ([uite  frequently  it  is  simply  a  mild  form  of  the 
latter  disease,  and  that  often  it  is  impossible  to  distinguish  between  the 
local  appearances  of  the  two  conditions :  these  have  been  referred  to 
under  the  heading  of  Morbid  Anatomy.  The  constitutional  distvrhances 
are  severe,  especially  in  children,  though  they  seldom  last  longer  than  a 
week,  and  are  followed  by  a  rapid  convalescence.  The  cervical  glands 
are  not  swollen  to  the  same  extent  as  in  diphtheria.  The  occurrence 
later  of  palatal  and  pharyngeal  ^;ar^///s/s  in  a  supposed  case  of  necrotic 
tonsillitis  would  point  to  its  true  diphtheritic  origin. 

[e)  Streptococcus  Tonsillitis  {"-Septic  Sore  Throat''). — An  ej»idemic 
form,  which  was  first  observed  in  Christiana  in  1908  and  later  in  England, 
has  more  recently  been  described  by  certain  American  authors,  e.  g., 
D.  J.  Davis  and  E.  C.  Rosenow,  and  C.  E.  A.  AVinslow\  The  onset  is 
sudden,  with  or  without  a  chill.  The  throat  presents  a  diffuse  redness 
with  much  mucoid  secretion.  The  crypts  of  the  tonsils  are  always  filled 
with  an  exudate,  and  a  grayish  membrane  resembling  diphtheria  may 
spread  over  a  large  part  of  the  tonsil.  "  The  fever,  the  muscular  pains, 
the  prostration,  and  the  constitutional  symptoms  were  out  of  all  propor- 
tion to  Avhat  one  would  expect  from  the  amount  of  local  involvement."  ' 
The  pulse  is  relatively  slow  and  the  leukocytes  are  only  moderately  in- 
creased. The  acute  symptoms  may  subside  in  a  few  days,  but  at  the  end 
of  a  week  or  ten  days  the  patient  suddenly  manifests  great  enlargement 
of  the  cervical  glands  without  suppuration,  as  a  rule.  Visceral  compli- 
cations occur  most  often  in  the  group  of  cases  having  little  or  no  glandu- 
lar involvement  but  marked  constitutional  disturbances.  Otitis  media  is 
frequent  and  bacteriologic  examination  shows  an  encapsulated  hemolytic 
streptococcus  of  high  virulence. 

Diagnosis. — The  appearance  of  the  several  forms  of  acute  tonsil- 
litis, associated  with  the  clinical  history  of  each  case,  should  enable  a 
ready  diagnosis  to  be  made  in  the  majority  of  cases.  A  difficulty  may, 
however,  arise  in  discriminating  follicular  tonsillitis  from  diphtheria, 
and  apparently  transitional  forms  are  not  uncommon.  The  appended 
table  gives  the  important  points  of  differentiation  between  these  diseases  : 

Follicular  Tonsillitis.  Diphtheria. 

A   soft,   ])ultaceou8,  yellowish-white  de-  A  tough,  ashy-gray,  continuous,  and  uni- 

posit  occurs  in  spots  or  patches  situated  form  pseudo-membranous  deposit  cov- 

over  the  mouth  of  the  follicles,  with  ers  the  tonsils,  pharynx,  or  soft  palate, 
areas  of  redness  intervening. 

The  exudate  is  easily  removed,  leaving  a  Very  adherent,  and  can  be  torn  off  in 

smooth  surface.  strips  only,  leaving  a  bleeding  surface. 

^Pract.  Med  Series,  1912,  vol.  vi.,  110. 


I 


ACUTE  TONSTLLTTrS.  7.07 

Follicular  Tonsillitis.  Dii'iitiikkia. 

The  deposit  is  always  limited  to  the  tonsils  Tiie  pillars  of  tlie  fauces  and    uvula    are 

(important).  involved  as  well. 

If  the  creamy  deposits  unite  to  form  a  con-  Kernoval  of  the  membrane  is  followed  by 

tinuous  layer,  removal  is  cither  not  fol-  re-formation  within  twelve  to  twcnty-foui- 

lowed  by  re-formation,  or  very  late.  hours. 

May  have  high  temperature,  lasting  only  a  Persistent   elevation    of    the    Icmjierature, 

day  or  two,  and  falls  after  administration  which    is    not    materially   influenced    by 

of  sodium    salicylate.     Albuminuria  ex-  salicylates  ;  moi'e  or  less  albuminuria  is 

tremely  rare,  if  present  at  all.  common. 

Cervical    lymphatic   glands    seldom   or  Usually  markedly  swollen  glands. 

slightly  svi^oUen. 

Complications  rare  and  mild.  Complications   frerjucnt  and   grave  (car- 
diac fivilure  and  paralyses). 

Bacteriologic  test  shovrs  no  special  or-  Bacteriologic   examination    shows    pres- 

ganism  ;    often,  however,  streptococci  ence  of  Klebs-LiJfHer  bacillus. 

and  staphylococci. 

Cases  seen  early,  with  severe  constitutional  symptoms  and  red  and 
swollen  tonsils  having  no  deposit,  may  give  rise  to  the  question  whether 
simple  angina  or  scarlet  fever  is  to  follow.  In  such  cases  the  latter  dis- 
ease may  be  excluded  by  a  negative  history  of  exposure  to  contagion, 
by  the  absence  of  a  very  high  pulse-rate,  and  by  the  non-appearance  of 
the  scarlatinal  eruption.  Necrotic  tonsillitis  may  be  discriminated  from 
the  lacunar  variety  in  the  same  manner  as  diphtheria — i.  e.,  by  its  local 
manifestations  (vide  Morbid  Anatomy). 

The  prognosis  is  good  as  regards  life,  and  favorable  as  regards 
complete  recovery.  The  occurrence  of  either  fatal  hemorrhage  or 
asphyxia  in  quinsy  is  extremely  rare.  In  debilitated  and  strumous  in- 
dividuals relapses  are  prone  to  occur,  and  successive  acute  attacks  of 
tonsillitis  tend  to  cause  permanent  hypertrophy  of  the  tonsils.  In  cases 
of  necrotic  to7isillitis,  especially  during  the  earlier  periods,  the  prog- 
nosis should  always  be  guarded. 

Treatment. — Particularly  in  the  lacunar  and  necrotic  forms  of  ton- 
sillitis the  patient  should  be  kept  apart  from  others  as  much  as  possible, 
since  both  types  appear  to  be  contagious  to  a  certain  degree.  Individual 
susceptibility  to  frequent  attacks  of  sore  throat  may  be  lessened  by  sys- 
tematic cold  bathing  of  the  neck.  Constitutional  and  local  rest  is  a  first 
and  constant  requisite.  Efforts  at  swallowing  and  talking  should  be  re- 
duced to  a  minimum.  Bland  nourishing  liquids,  as  milk,  broths,  and 
the  like,  should  constitute  the  only  nutriment  during  the  attack. 

Medicinal  Treatment. — Early  in  the  case  a  free  evacuation  of  the 
bowels  should  be  obtained,  and  small  doses  of  calomel  (gr,  |— | — 0.008- 
0.010,  repeated  hourly  until  about  gr.  1 — 0.0648 — has  been  taken), 
followed  by  a  Seidlitz  powder  or  Rochelle  salts  in  hot  water,  will  be 
effective  in  most  cases.  In  severe  cases  of  quinsy  relief  from  the  pain 
is  urgently  called  for,  and  either  a  Dover's  powder  or  a  hypodermic 
injection  of  morphin  (gr.  |— ^ — 0.010-0.016)  and  atropin  (gr.  y^-jj — 
0.0006)  will  probably  suffice  for  their  relief.  A  high  temperature  must 
be  combated  by  small  doses  of  aconite,  frequently  repeated :  this  drug 
has  been  much  used  in  the  follicular  tonsillitis  of  children.  Quinin,  in 
solution  with  dilute  sulphuric  acid,  is  also  often  given. 

The  administration  of  sodium  salicylate  or  beuzoate,  of  salol,  or  of 
the  ammoniated  tincture  of  guaiac  in  1-dram  (4.0)  doses  (Sajous),  seems 
to  lessen  the  duration  and  severity  of  tonsillitis,  and  even  to  cure  some 
cases  of  the  lacunar  form  within  forty-eight  hours  and  without  local 


758  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

applications.  The  tincture  of  the  chlorid  of"  iron  in  glycerin  (4  or  5 
drops  to  the  dram — 4.0 — given  every  two  hours)  is  regarded  by  Bos- 
worth  as  almost  specitic  at  the  commencement  of  an  attack  of  acute 
follicular  tonsillitis.  During  convalescence  soft,  light  foods  may  be 
allowed ;  and  bitter  tonics  and  iron  are  to  be  administered  if  there  are 
depression  and  anemia.      The  following  is  a  favorite  prescription  : 

^.   Strychnin;\3  sulph.,  gr.  ss  (0.08:2); 

Syr.  acaci;\i,  5ss       (16.0); 

Liq.  ferri  et  ammon.  acetat.,      q.  s.  ad  .siij       (96.0). — M. 
Sig.  3J  (-l-O)  t.  i.  (/.,  in  water,  after  meals. 

Local  Treatment. — If  the  case  is  seen  early,  the  use  of  cold  is  of 
great  value  in  giving  local  relief  and  in  shortening  the  attack.  Ice 
may  be  sucked  and  flannel  wrung  out  of  ice-water  may  be  applied 
around  the  neck,  or  an  ice-bag  used.  Lozenges  of  guaiac  (gr.  ij — 
0.120)  or  the  ammoniated  tincture  in  1-dram  (4.0)  doses  in  milk,  and 
used  as  a  gargle,  are  indicated  early,  and,  according  to  Sajous,  seldom 
fail  to  control  or  arrest  the  inflammation.  Equal  parts  of  the  tincture 
of  the  chlorid  of  iron,  glycerin,  and  water,  applied  gently  with  a  camel's- 
hair  brush,  have  long  been  used  locally  on  the  surfaces  of  the  tonsils, 
and  with  marked  benefit.  Alkaline  and  mild  antiseptic  solutions,  used 
as  gargles  or  sprays  (preferably  the  latter),  are  generally  useful.  Thus, 
Dobell's  solution,  or  Seiler's  tablets  dissolved  in  water,  or  borax  and 
thymol,  or  carbolic  acid,  or  potassium  permanganate  in  weak  solution, 
may  be  serviceable.  Mild  counter-irritation  at  the  angle  of  the  jaw 
by  means  of  iodin  or  slightly  irritating  embrocations  is  helpful. 

Early  scarification  of  the  tonsils  as  a  depletory  measure,  and  painting 
with  cocain  (10  per  cent.),  I  have  found  useful  to  bring  about  resolution. 

Astringent  sprays  containing  alum  or  silver  nitrate  are  often  eflSca- 
cious  after  a  day  or  two.  When  the  case  is  first  seen  and  fully  devel- 
oped, the  atomization  of  a  warm  solution  of  cocain  (4  to  8  per  cent.)  or 
lime-water.  The  external  application  of  the  ice-collar  is  indicated. 
Should  gargling  be  possible,  nothing  is  better  than  hot  water  or  milk. 
If,  in  parenchymatous  tonsillitis,  fluctuation  be  detected  or  su])puration 
be  even  suspected  of  commencing,  the  prompt  use  of  the  bistoury  (the 
blade  being  guarded  by  wrapping  wdth  cotton  or  adhesive  plaster),  with 
the  production  of  free  bleeding  or  the  discharge  of  pus,  will  give  great 
relief.  The  patient's  head,  especially  if  it  be  a  child,  should  be  tilted 
forward  during  the  operation,  so  as  to  allow  most  of  the  blood  and  pus  to 
pass  into  the  mouth.  When  incision  of  the  tonsil  fails  to  bring  pus,  it 
has  been  advised  to  puncture  through  the  anterior  pillar,  where  pus  may 
be  formed  in  the  cellular  tissue  in  front  of  or  behind  the  tonsil.  When 
the  tonsillar  enlargement  threatens  life  through  suffocation,  excision  of 
the  tonsilsj  laryngotomy,  or  tracheotomy  may  have  to  be  perfonned. 


CHRONIC  TONSILLITIS. 

{Hypertrophied  Tonsils ;  Adenoid  Vegetations.) 

Definition. — Enlargement  of  the  tonsils  (faucial  and  pharyngeal), 
due  to  chronic  inflammation  or  hypertrophy,  and  usually  associated  with 
or  causing  a  perverted  local  and  systemic  condition. 


CHRONTC  TONsriJJTrs.  759 

Pathology. — The  faucial  tonsils  show  a  true  chronic  hypertrophy 
of  the  lymphoid  and  fibrous  elements.  If"  the  latter  predominate  the 
organs  will  be  smaller  and  more  indurated.  'l^hey  may  be  rough 
on  the  surface  from  "distended  lacunae  or  ruptured  follicles"  (Berkley 
Robinson),  the  latter  being  in  a  state  of  chronic  inflammatory  thick- 
ening, and  showing  caseous  degeneration  of  their  contents.  The  growths 
in  the  vault  of  the  pharynx  are  adenomatous  papillomata ;  they  are 
either  sessile  or  pedunculated,  and  are  fleshy  in  appearance  and  con- 
sistence and  very  vascular.  They  range  in  size  from  a  grain  of  wheat 
to  an  almond-kernel  (Allen),  and  project  from  the  pharyngeal  vault, 
lying  in  the  depression  posterior  to  and  on  a  line  with  the  fossa  of  the 
Eustachian  tube  (Rosenmiiller's  fossa).  "  Hypertrophy  of  the  pharyn- 
geal adenoid  tissue  may  also  be  present  without  great  enlargement  of 
the  tonsils  proper"  (Osier).  A  congestive  type  of  nasal  catarrh  in 
adults  often  accompanies,  or  is  the  result  of,  neglected  adenoid  growths 
and  hypertrophied  tonsils.      Chronic  pharyngitis  may  be  associated. 

Htiology. — The  predisposing  causes  of  chronic  hypertrophy  of  the 
tonsils  are — {a)  heredity,  especially  in  the  scrofulous  and  syphilitic  diath- 
eses ;  (6)  age,  most  frequently  between  five  and  fifteen  years ;  (c)  sex, 
boys  appear  to  be  affected  more  frequently ;  (d)  hygienic  surroundings. 
The  exciting  causes  are  usually  previous  attacks  of  acute  tonsillitis, 
either  simple  or  that  which  is  symptomatic  of  diphtheria  or  scarlatina. 
According  to  Harrison  Allen,  adenoid  growths  from  the  normal  lymph- 
oid tissue  of  the  vault  of  the  pharynx  (pharyngeal  tonsils)  may  be  con- 
genital, and  are  "  in  some  way  associated  with  the  canal  which  is  found 
in  early  fetal  life  penetrating  the  brain-case  and  uniting  the  anterior 
part  of  the  pituitary  body  to  the  lining  membrane  of  the  pharynx." 

Symptoms. — Local. — With  slight  or  moderate  enlargement  there 
may  be  few  or  no  symptoms.  There  may  be  simply  an  increased  secre- 
tion of  mucus,  and  a  susceptibility  to  fresh  anginal  attacks  or  to  severe 
tonsillar  manifestations  in  diphtheritic  or  scarlatinal  attacks. 

The  first  symptom  to  attract  the  attention  is  the  direct  effect  of  naso- 
pharyngeal obstruction — i.  e.  oral  respiration.  This  mouth-breathing 
is  visibly  labored  and  abnormally  audible,  and  is  especially  marked  at 
night,  the  child's  respiration  being  noisy,  snorting,  and  irregular.  Sleep 
is  disturbed  by  paroxysms  of  dyspnea,  sometimes  due,  perhaps,  to  reflex 
spasm  of  the  glottis.  Nightmare  follows  as  a  result  of  imperfect  aera- 
tion of  the  blood  supplying  the  brain  on  account  of  the  obstruction  to 
perfect  respiration.  The  act  of  swallowing  is  rendered  difficult  by  the 
faucial  obstruction,  and  is  often  painful,  owing  to  the  superadded  acute 
tonsillar  trouble  that  is  so  liable  to  occur  in  the  hypertrophied  glands. 
Indirect  results  of  chronic  tonsillar  enlargement  are  a  laryngeal  stridor 
and  a  croupy  cough.  Sometimes  asthmatic  attacks  coexist,  and  seem 
also  to  be  due  to  the  hypertrophy.  An  excessive  secretion  of  mucus  in 
the  pharynx  is  a  common  symptom,  and  causes  hawking  in  subjects  past 
young  childhood.  The  hearing  is  often  impaired,  and  tinnitus  aurium  is 
complained  of,  being  the  result  of  pressure  of  the  growths  against  the 
orifice  of  the  Eustachian  tube  or  of  extension  of  inflammation  from  the 
nasopharynx.  Absolute  deafness  may  result,  and  the  senses  of  taste  and 
smell  are  likewise  diminished  or  perve-rted.  Jnspeetion  of  the  fauces  will 
show  the  tonsils  bulging  as  two  lumps  covered  with  thick  mucus,  or  the 


760  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

latter  may  ooze  around  the  uvula  from  the  pharynx.  In  mouth-breathers 
of  lonu  standinir  the  superior  dental  arch  is  narrowed  and  the  hard  palate 
is  hiirhly  arched.  The  breath  is  fetid,  owing  to  the  cheesy,  inspissated 
e.xudate  in  tlie  tonsillar  crvpts.  In  very  obi  cases  a  tonsillar  calculus 
may  be  felt,  and  is  the  result  of  calcification  of  the  secretion. 

The  facial  expression  is  characteristically  stupid  and  apathetic ;  the 
disposition  is  dull,  irritable,  and  stubborn ;  the  lips  are  thick,  and  a 
vacant  stare  is  in  the  eyes.  Speech  is  slow,  phonation  nasal  in  quality, 
and  articulation  of  the  nasal  consonants  n  and  m,  I  and  o,  is  changed  or 
nniffled.  Sfam))U'riuji  may  be  associated.  The  anterior  nares  mav  be 
dibiteil  and  present  a  ]iin(;hed  ap]iearance  al)Ove  their  o])enings. 

The  prolonged  interference  with  respiration  gives  rise  to  a  peculiar 
chest-conformation,  simulating  that  of  rickets  {chicken-breast).  The 
ribs  are  prominent  anteriorly,  and  there  is  a  marked  forward  angle 
at  the  manubrio-gladiolar  junction,  as  well  as  a  grooved  depression  at 
the  ensiform  cartilage.  Depressions  between  the  widely-separated  ribs 
exist  anteriorly  also.  Posteriorly,  and  at  the  base  of  the  chest  in  par- 
ticular, the  intercostal  spaces  are  practically  absent  on  account  of  the 
closeness  of  the  ribs.  The  upper  part  of  the  chest  is  very  narrow  and 
the  shoulder-bones  quite  prominent.  On  percussion  the  hepatic  area  of 
dulness  is  diminished  on  the  chest-wall,  but  increased  downward  and  to 
the  left.  The  first  cardiac  sound  is  weak.  On  inspiration  there  is  a 
retraction  of  the  intercostal  spaces  in  the  lower  and  lateral  thoracic 
regions. 

The  resulting  thoracic  deformity  may  express  itself  principally  as  an 
excavation  of  the  lower  sternal,  area  (triichter  brust).  When  chronic 
tonsillar  enlaro-ement  leads  to  oft-recurrino-  asthmatic  attacks,  the  chest 
may  become  barrel-shaped,  as  in  emphysema,  at  an  early  period  of  life. 

The  general  symptoms  of  tonsillar  hypertrophy  are  more  marked 
when  the  growths  exist  in  the  pharyngeal  vault  alone.  Developmental 
processes  in  children,  such  as  dentition,  and  at  puberty,  particularly 
when  the  voice-changes  are  looked  for,  are  often  retarded  or  perverted. 
Anemia,  headache,  especially  during  study,  cardiac  palpitation,  enuresis, 
and  habit-chorea  of  the  facial  muscles,  may  be  associated  with  general 
capriciousness,  mental  dulness,  indisposition  to  intellectual  exertion, 
drowsiness,  and  sullen  irritability.  The  term  aprosexia  has  been  given 
to  the  loss  of  power  to  concentrate  the  mind  for  any  length  of  time  that 
is  so  characteristic  of  these  cases. 

Diagnosis. — Inspection  of  the  fauces  will  reveal  enlarged  tonsils. 
The  act  of  gagging,  however,  often  causes  the  tonsils  to  rotate  forward 
and  inward,  making  them  appear  larger  really  than  is  the  case.  Adenoid 
growths  of  the  pharyngeal  vault  may  exist  without  tonsillar  enlargement, 
and  can  be  detected  by  posterior  rhinoscopy'  or  by  the  insertion  of  the 
finger  into  the  naso-pharynx. 

Differential  Diagnosis. — It  is  important  not  to  attribute  the  obstruc- 
tive symptoms  to  nasal  Jii/j^ertrophies  or  atresia  or  to  malifinant  growths 
in  the  naso-pharyngeal  space.  The  latter  are  infre(|uent  at  the  ages  at 
which  chronic  tonsillar  enlargement  of  the  fauces  and  pharynx  is  most 
apt  to  occur — i.  e.,  early  in  life.  Again,  palpation  of  sarcomatous  or 
carcinomatous  growths  gives  marked  differences  in  consistence,  and 
there  are  usually  spontaneous  hemorrhages  and  local  pain  in  attendance 


PIIARYNUITIS.  761 

upon  these  neoplasms.  "  T/mmh-suckers  "  differ  from  mouth-breathers 
in  that  in  the  former  the  incisors  are  inclined  forward  and  cause  slight 
protrusion  beneath  the  upper  lip;  the  dental  arch  is  flat.  In  mouth- 
breathers,  however,  the  incisors  are  vertical  or  nearly  so,  or  incline  so 
as  to  overlap  each  other  ;  the  dental  arch  is  high  and  curved  (II.  Allen). 
Retropharyngeal  abscess  may  be  confounded  with  tonsillar  enlargement, 
especially  in  children.  But  in  this  disease  the  attacks  of  dyspnea,  the 
dysphagia,  and  the  local  distress  are  more  marked.  Again,  in  the 
pharyngeal  disease  the  swelling  is  in  the  median  line,  pushing  the  soft 
palate  forward  perhaps,  and  on  palpation  it  may  give  a  sense  of  elas- 
ticity or  fluctuation  to  the  finger.      Slight  fever  may  also  be  present. 

Prognosis. — Tonsillar  hypertrophy  is  not  a  severe  disease  as  re- 
gards life.  There  is,  however,  an  increased  liability  to  contract  colds, 
to  recurrences  of  follicular  tonsillitis,  attacks  of  diphtheria,  and  severe 
scarlatinal  angina.  The  prognosis  in  acute  respiratory  affections  asso- 
ciated with  chronic  tonsillar  enlargement  is  always  more  or  less  grave. 
Adenoid  growths,  even  when  neglected,  tend  to  lessen  in  size  after 
puberty.     After  removal  the  growths,  as  a  rule,  do  not  return. 

Treatment. — The  old-fashioned  use  of  astringent  applications  is 
probably  useless  when  there  is  any  marked  chronic  enlargement  of  the 
tonsils,  and  active  surgical  treatment  alone  is  to  be  recommended  for 
the  condition.  The  use  of  absorbents  and  caustics,  either  externally  or 
by  parenchymatous  injection,  is,  I  think,  objectionable. 

There  are  no  more  satisfactory  means  of  doing  radical  good  in  cases 
of  this  kind  than  the  galvano-cautery,  scarification,  and  the  removal  of 
the  tonsils  with  the  tonsillotome,  snare,  or  bistoury.  In  offensive  fol- 
licular disease  applications  of  chromic  acid  may  give  good  results.  Ade- 
noid growths  may  be  removed  by  means  of  the  finger,  curet,  or  forceps. 

Constitutional  treatment  is  often  necessary  in  improving  the  nutrition 
of  the  patient.  Good  food,  a  change  of  air,  systematic  bathing,  prudent 
habits,  careful  dress,  and  medicinal  tonics  and  alteratives,  as  cod-liveJ 
oil,  iodid  of  iron,  and  the  hypophosphites,  are  usually  indicated. 


V.  DISEASES  OF  THE   PHARYNX. 
PHARYNGITIS. 

ACUTE   PHARYNGITIS. 
[Pharyngitis  Acuta  Simplex.) 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous  mem' 
brane  of  the  pharynx. 

Pathology. — The  mucous  membrane  is  congested  diffusely  or  in 
patches,  and  there  may  be  an  inflammatory  exudate  in,  and  a  consequent 
swelling  of,  the  submucosa  and  the  contained  glandular  structures.  The 
surface  of  the  membrane  is  more  or  less  coated  with  a  viscid  muco-pus. 

etiology. — Predisposing  causes  are — age,  it  being  more  frequent 
in  adolescence  and  young  adult  life ;  a  depraved  constitution  ;  digestive 
disorders,  and  a  rheumatic,  gouty,  or  scrofulous  diathesis.      The  usual 


762  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

exciting  cause  is  exposure,  particularly  of  certain  portions  of  the  body, 
as  the  neck  and  chest,  to  cold  or  to  sudden  changes  of  temperature  and 
to  irritating  vapors.  An  acute  naso-pharyngeal  catarrh,  by  bathing  the 
pharyngeal  mucosa  with  its  irritating  secretions,  may  set  up  the  trouble. 
"  Epidemic  pharyngitis  "  is  probably  a  manifestation  of  influenza.  Acute 
simple  pharyngitis  may  be  a  complication  of  scarlatina,  measles,  and 
small-pox  (eranthernatous  pharyngitis).  Micrococci  are  present,  the 
streptococci  often  predominating. 

Symptoms. — Localh/,  the  aft'ection  is  ushered  in  with  a  feeling  of 
dryness  and  .-soreness,  especially  on  swallowing.  With  the  production 
of  the  muco-purulent  secretion  a  tickling  sensation  provokes  hawking  or 
a  slight  "  throat  cough  "  and  eftbrts  at  exspuition.  The  catarrhal  pro- 
cess may  extend  to  the  larynx  and  cause  some  hoarseness,  or  to  the 
Eustachian  tube,  causinfr  dulness  of  hearing.  Movements  of  the  neck 
are  painful  and  stijf,  particularly  if  there  is,  as  is  often  the  case,  slight 
involvement  of  the  lymph-glands.  Inspection  of  the  throat  shows  the 
pharynx,  often  the  posterior  pillars  of  the  fauces  and  the  soft  palate, 
and  even  the  anterior  pillars  and  tonsillar  surfaces,  to  be  deeply  red- 
dened and  tumefied ;  the  coursing  veins  are  enlarged,  and  particles  of  a 
yellowish-white  secretion  appear  here  and  there.  Sometimes  the  phar- 
yngeal follicles  become  subject  to  acute  inflammation,  and  appear  as 
elevated,  discrete,  shiny  spots  {herpetic  pharyngitis — Mackenzie). 

At  the  onset  of  this  affection  there  may  be  chilliness,  followed  by 
slight  fever,  headache,  an  accelerated  pulse,  a  dry  skin,  and  anorexia. 
The  pharyngeal  symptoms  seldom  last  more  than  from  three  to  five 
days,  when  resolution  takes  place,  some  tenderness  of  the  pharynx, 
however,  remaining  for  a  time. 

Diagfnosis. — On  examination  of  the  throat  there  should  neither  be 
any  difliculty  in  diagnosing  the  affection  nor  any  likelihood  of  confound- 
ing the  affection  with  simple  tonsillitis. 

The  prognosis  is  always  favorable.  In  weakly  patients,  however, 
there  is  a  liability  to  subsequent  attacks. 

Treatment. — In  the  early  stages  sucking  of  small  pieces  of  ice 
does  much  to  allay  the  congestion  and  irritability.  A  spray  of  cocain 
or  menthol  in  albolene  (2  per  cent.)  may  also  be  used,  followed  by  a  4 
per  cent,  solution  of  antipyrin.  Eucain  may  be  substituted  for  cocain 
(2  per  cent,  solution),  and  is  preferred  by  Gibbs  and  others.  Dobell's 
solution  is  always  to  be  recommended  for  its  alkaline,  sedative,  and  anti- 
septic action.  Swabbing  the  pharynx  with  a  silver-nitrate  solution  (gr. 
xl  to  the  ounce — 2.59  to  32.0)  is,  according  to  Sajous,  of  great  benefit. 

In  well-established  cases  relief  is  often  obtainable  by  medicated 
steam  inhalation,  as  with  the  compound  tincture  of  benzoin.  In  rheu- 
matic cases  lozenges  of  guaiac  (gr.  iij — 0.194)  are  useful.  The  sipping 
of  hot  milk  in  which  sodium  bicarbonate  has  been  dissolved  is  grateful. 

The  general  treatment  embraces  measures  directed  at  the  fever  and 
the  diathetic  condition.  A  hot  foot-bath  and  a  calomel  purge,  with 
belladonna,  acetanilid,  or  aconite  for  the  fever  and  pain,  and.  sodium 
salicylate  (gr.  Ix-lxxx — i.0-5.1— in  the  twenty-four  hours),  may  be  re- 
quired.    The  diet,  of  course,  should  either  be  liquid  or  semi-solid. 

Persons  susceptible  to  repeated  attacks  must  exercise  caution  in 
retrard  to  exposure  to  severe  cold  and  weather-changes,  irritating  vapors, 


CHRONIC  PHARYNGITIS.  763 

and  the  like.     Daily  cold  sponge-baths  may  be  used  to  harden  the  skin. 
Tonic,  nutrient  treatment  is  also  frequently  called  for. 

MEMBRANOUS   PHARYNGITIS. 

{Pharyngitis  Crowposa.) 

Definition. — An  acute  superficial  inflammation  of  the  pharyngeal 
mucosa,  characterized  by  the  formation  of  a  whitish  false  membrane, 
due  usually  to  the  streptococcus. 

il^tiologfy. — The  principal  causes  of  this  form  of  pharyngitis  are 
exposure  of  persons  in  debilitated  health  to  cold  or  an  impure  or 
a  septic  atmosphere,  particularly  during  epidemics  of  such  diseases  as 
scarlatina. 

Symptoms. — The  local  and  general  symptoms  are  those  of  ordinary 
sore  throat,  though  of  a  more  severe  type. 

DiagfnosiS. — The  pseudo-membrane  is  thin,  of  a  yellowish-white 
color,  and  appears  in  small  patches  over  the  pharynx.  It  is  easily  de- 
tached, and  this  feature,  together  with  the  presence  of  small  vesicles  or 
ulcers  and  the  absence  of  grave  constitutional  disturbances  serve  to  dif- 
ferentiate this  affection  from  diphtheritic  pharyngitis. 

The  prognosis  is  favorable. 

Treatment. — Local  applications  of  solutions  of  hydrogen  peroxid 
or  potassium  permanganate  (gr.  x  to  the  ounce — 0.648  to  32.0)  are  very 
satisfactory.  For  the  painful  dysphagia  the  sedative  and  soothing  rem- 
edies suggested  for  simple  acute  pharyngitis  may  be  used.  Internally, 
sodium  benzoate  (gr.  v-xv — 0.824-0.972)  in  glycerin,  elixir  of  calisaya, 
and  salol  have  each  been  recommended.  Tonic  treatment  is  nearly 
always  needed. 

CHRONIC  PHARYNGITIS. 

Definition. — A  chronic  inflammation  of  the  mucous  membrane  of 
the  pharynx.  It  may  consist  of  either  a  hypertrophic  or  an  atrophic 
involvement  of  the  follicles,  or  both  processes  may  coexist. 

Varieties. — (a)  Chronic  naso-pharyngeal  catarrh  ;  (6)  chronic  hyper- 
trophic pharyngitis  or  naso-pharyngitis  {pharyngitis  sicca) ;  (c)  follicular 
or  granular  pharyngitis.  The  last  named  is  probably  the  result  of,  and 
nearly  always  is  associated  with,  chronic  simple  (or  hypertrophic)  pha- 
ryngeal (or  naso-pharyngeal)  catarrh. 

Pathology. — The  mucous  membrane  in  simple  chronic  pharyngitis 
is  either  reddened,  thickened,  and  viscid  (hypertrophic  form),  or  pale, 
thin,  and  dry  (atrophic  form) ;  in  both  instances  dilated  and  tortuous 
veins  are  prominently  shown.  In  the  follicular  variety  the  pharyngeal 
mucous  glands  are  swollen  into  little  red,  glistening  nodules  studding 
the  congested  membrane.  The  enlarged  follicles  are  due  to  a  hyperplasia 
of  lymphoid  cells  and  an  accumulation  of  retained  dried-up  secretions. 

!^tiology. — A  protracted  impairment  of  the  general  health,  espe- 
cially  in  those  who  over-exert  mentally  and  are  of  sedentary  habits,  is 
a  common  'predisposing  cause  of  chronic  pharyngitis.  Repeated  acute 
attacks  may  precede  the  affection.  It  is  most  common  in  adolescent 
and  middle  life. 

The  exciting  causes  are  frequent  and  prolonged  over-use  and  strain 


764  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  voice  in  clergymen,  singers,  teachers,  army-officers,  and  street- 
venders :  irritation  from  tohacco-smoke,  chemical  vapors,  and  continued 
exposure  to  cold  air.  Among  prevailing  causes  may  be  mentioned  post- 
nasal adenoids,  deviations  of  the  septum,  and  neoplasms.  It  may  arise 
from  gastric  disorders. 

Symptoms. — In  all  varieties  of  chronic  pharyngitis  the  local  dis- 
comfort is  often  very  slight,  and  more  annoying  than  painful,  except 
when  an  exacerbation  takes  place.  There  is  a  sensation  of  dryness  and 
tickling  or  hurnincj  in  the  throat  and  the  desire  to  clear  the  throat  of 
stickv  mucus  bv  hcnvhing  or  a  slwrt  cough.  These  symptoms  arc  usually 
worse  on  rising  in  the  morning,  especially  if  some  unftivorable  influence 
has  been  exerted  during  the  night  previous,  tlie  throat  being  dry  and  a 
viscid  secretion  having  collected.      Swallowing  is  seldom  interfered  with. 

If  the  larynx  is  somewhat  affected  by  extension  of  the  pharyngeal 
inflammation,  hoarseness  and  a  dry,  hacking  cough  are  produced.  After 
using  the  voice  there  is  a  sense  of  fatigue,  w  ith  huskiness  and  irritability. 

The  local  appearances  of  chronic  pharyngitis  vary  according  to  the 
form  of  the  affection  present  in  the  case.  In  chronic  catarrh  of  the 
pharynx  a  considerable  collection  of  muco-pus  is  seen  adhering  to  the 
mucosa  and  extending  downward  from  the  posterior  nares.  The  senses 
of  hearing  and  taste  may  be  impaired.  The  uvula  is  frequently  elong- 
ated, and  its  tip  may  rest  on  the  base  of  the  tongue.  A  nasal  intona- 
tion of  the  voice  is  sometimes  provoked.  The  posterior  nares  as  seen 
by  the  rhinal  mirror  are  often  stopped  up  by  foul  secretions  or  by 
hypertrophy  of  the  nasal  mucous  membrane.  Headache  and  attacks 
of  vertigo  may  occur. 

Chronic  hypertrophic  pharyngitis  and  follicular  pharyngitis  ("  clergy- 
man s  sore  throat  ")  are  commonly  associated.  The  thickened,  reddened, 
pimply,  vein-coursed  appearance  of  the  mucosa  is  characteristic.  The 
follicles  may  be  seen  sometimes  as  polypoid  elevations,  and  the  pharyn- 
geal tonsil  may  be  found  by  the  finger  to  be  enlarged  (Kolliker). 

In  the  dry,  atrophic  pharyngitis  that  occurs  more  often  in  later  life, 
and  as  a  sequel  of  the  simple  chronic  or  follicular  variety,  a  pale,  smooth, 
relaxed,  lustrous,  and  often  quite  painful  membrane  is  observed. 

The  general  symptoms  are  usually  those  of  a  weak,  debilitated,  nerv- 
ous constitution,  though  in  mild  cases  the  general  health  may  be  unim- 
paired.     In  atrophic  pharyngitis  considerable  cachexia  may  be  present. 

Diagnosis. — Care  should  be  exercised  in  discriminating  the  variety 
of  chronic  pharyngitis  present  in  any  given  case,  so  that  the  treatment 
may  be  planned  accordingly.  Careful  and  repeated  inspection  of  the 
throat  renders  the  diagnosis  easy  unless  ulceration  has  taken  place : 
in  such  cases  a  tuberculous  or  syphilitic  sore  throat  must  be  eliminated 
by  the  superficial  character  of  the  ulcers,  by  their  ready  response  to 
pi-oper  treatment,  by  the  history  of  the  case  as  to  specificity,  and  by  tlie 
absence  of  marked  pain  or  symptoms  pointing  to  tuberculosis.  When 
due  to  gastric  disturbance  the  lower  throat  will  be  deeply  congested  and 
the  tongue  will  be  irritable,  with  red  papillae  standing  over  its  base 
(Price-Brown). 

Prognosis. — This  should  be  guarded  as  to  cure,  on  account  of  the 
stubborn  resistance  to  treatment  and  the  difficulty  in  removing  unfavor- 
able influences.  Acute  exacerbations  are  liable  to  recur  unless  rigid 
caution  is  practised  at  all  times  in  avoiding  the  cause  of  the  trouble. 


BETROPIIAIIYNGEAL  AnS(JKHS.  765 

Treatment. — The  local  use  of  astrintrcnt  and  alkaline  antiseptic 
sprays  or  of  the  nasal  douche  is  usually  recommended,  hut  has  only  a 
palliative  effect.  Silver-nitrate  cauterization  may  be  tried.  The  only 
effectual  means,  however,  of  curing  the  follicular  or  hypertrophic  variety 
is  that  used  by  most  throat-specialists — namely,  the  wire  galvano-  or 
actual  cautery.  Applications  of  silver  nitrate  (gr.  x  to  the  ounce — 0.648 
to  32.0)  and  the  internal  use  of  the  oleoresin  of  cubebs  have  been  recom- 
mended for  the  atrophic  pharyngitis.  Insufflation  of  powdered  tannin 
or  alum  is  also  of  service. 

Systemic  disturbances  need  attention  according  as  they  present  them- 
selves. Mineral  baths  are  sometimes  of  great  benefit,  and  tonics  are 
usually  indicated.  All  irritating  causal  factors  must  be  removed  or 
avoided  before  any  favorable  results  can  be  hoped  for  from  local  applica- 
tions. Tobacco-smokers  and  topers  must  deny  themselves  their  habitual 
luxuries. 

ACUTE  INFECTIOUS  PHLEGMON   OF  THE  THROAT. 

Definition. — An  inflammation  of  the  pharyngeal  mucosa  that  passes 
rapidly  into  a  suppurative  process.     It  is  exceedingly  rare. 

Its  etiology  is  not  definitely  known.  I  have  m.et  with  no  cases 
except  in  my  hospital  wards,  though  they  doubtless  occur  in  general 
medical  practice.    The  clinical  features  have  been  described  by  Senator. 

The  symptoms  are  sudden  in  their  onset  and  quite  intense.  They 
are  severe  soreness  of  the  throat,  dysphagia,  and  hoarseness,  as  a  rule ; 
in  advanced  cases  there  has  been  difficult  respiration.  Inspection  shows 
the  pharynx  to  be  deeply  injected  and  the  seat  of  marked  inflammatory 
edema,  the  neck  appearing  greatly  swollen  as  well.  The  general  dis- 
turbance is  correspondingly  severe. 

The  treatment  is  wholly  symptomatic. 


RETROPHARYNGEAL  ABSCESS. 

Definition  and  Pathology. — A  suppurative  inflammation  (rare) 
of  the  glands  or  connective  tissue  anterior  to  the  cervical  spinal  column. 

Ktiology. — The  disease  is  relatively  most  common  before  two  years 
of  age.  It  is  usually  a  primary  affection,  occurring  without  assignable 
cause,  but  a  certain  proportion  of  instances  are  doubtless  caused  by 
caries  of  the  cervical  vertebrae.  It  may  rarely  be  secondary  to  any  of 
the  specific  fevers.     Traumatism  causes  occasional  instances. 

The  symptoms  are  pain  in  swallowing,  impeded  respiration,  soon 
becoming  stertorous  in  character,  the  dyspnea  meanwhile  constantly  in- 
creasing. There  may  be  couyh,  and  the  voice  may  present  abnormal 
characteristics.  The  signs  of  stenosis  finally  declare  themselves  with 
considerable  violence,  and  an  examination  of  the  pharynx  usually  serves  to 
make  the  diagnosis  positive ;  the  projecting  tumor  is  visible,  and  the  pal- 
pating finger  readily  detects  fluctuation.  In  children  the  general  features 
(slight  fever,  anorexia,  languor)  overshadow  for  days  the  local,  while 
in  adults  the  condition  develops  acutely  with  severe  faucial  svmptoms. 

The  course  of  the  disease  may  be  acute,  lasting  one  or  two  weeks ; 
more  frequently,  however,  it  is  subacute  (rarely  chronic),  as,  for  exam- 
ple, when  it  is  due  to  caries  of  the  vertebrae. 


766  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  prognosis  is  favonible  in  all  cases  that  are  early  diagnosticated. 
If  unrecognized  until  the  later  stages  have  been  run,  suffocation  may 
ensue,  or  rupture  into  the  larynx  may  cause  death  by  asphyxia. 

Treatment. — As  soon  as  fluctuation  is  detected  the  abscess  should 
be  freely  opened,  and  preferably,  as  a  rule,  through  the  mouth  by  means 
of  a  guarded  bistoury.  The  throat,  after  the  abscess  is  thoroughly 
evacuated,  should  be  washed  out  with  some  mild  antiseptic  solution 
(salicylic  acid  2  per  cent,  or  boracic  acid  2  per  cent.).  When  pointing 
occurs  at  the  side  of  the  neck,  as  sometimes  happens,  the  incision  should 
be  made  through  the  skin  in  that  locality.  Constitutional  indications 
are  to  be  fulfilled  in  accordance  Avith  general  principles,  and  the  strength 
of  the  patient  is  to  be  maintained  by  a  highly  nutritious  dietary. 


VI.   DISEASES  OF  THE  ESOPHAGUS. 
ESOPHAGITIS. 

ACUTE   ESOPHAGITIS. 

Definition. — An  acute  inflammation  affecting  either  the  mucous 
membrane  or  submucous  tissues  of  the  esophaguSj  or  both. 

Pathology. — The  ordinary  morbid  changes  of  an  acute  esophagitis 
are  those  of  a  simple  catarrhal  inflammation  of  the  mucosa.  It  is  rather 
characteristic  of  the  condition  that  there  is  no  increased  secretion,  a 
sponginess  and  rapid  desquamation  of  the  epithelium  taking  place  in- 
stead, and  causing  a  granular  appearance  of  the  membrane.  Occasion- 
ally the  mucous  glands  are  swollen,  and  may  break  down,  with  the  for- 
mation of  small  follicular  ulcers.  Catarrhal  erosions  may  also  be  seen 
here  and  there.  A  croupous  or  diphtheritic  exudate  is  seldom  found 
in  the  lower  portion  of  the  esophagus,  and  small-pox  pustules  are 
rarely,  if  ever,  seen.  A  diffuse  or  circumscribed  purulent  inflammation 
of  the  submucosa  may  dissect  up  the  mucous  membrane  so  as  to  consid- 
erably diminish  the  esophageal  caliber;  pus  is  usually  discharged  into 
the  tube.  In  severe  cases  of  poisoning  {corrosive  esophagitis)  sloughing 
may  extend  into  the  muscular  layer,  and  may  produce  a  foul,  dark,  hem- 
orrhagic mass.  A  fibrinous  cast  of  the  gullet  has  been  vomited  up  by  an 
hysteric  woman  (Birch-Hirschfeld). 

Htiology. — The  causes  of  acute  esophagitis,  other  than  traumatic, 
are  rare.  Under  the  latter  are  included  the  mechanical,  thermal,  and 
chemical  irritants,  such  as  the  presence  of  foreign  bodies  and  the  swal- 
lowing of  hot  liquids,  corrosive  poisons,  "concentrated  lye,"  mineral 
acids,  and  arsenic.  The  condition  may  also  be  the  result  of  the  follow- 
ing :  (a)  an  extension  of  catarrhal  inflammation  of  the  pharynx ;  (h) 
specific  infectious  fevers,  as  typhoid,  typhus,  and  pneumonitis ;  (c)  diph- 
theria {pseudo-memhranous  esophagitis)  by  the  extension  of  pharyngeal 
diphtheria;  {d)  small- pox,  giving  rise  to  a  pustular  inflammation  of  the 
gullet ;  (e)  local  disease,  as  carcinoma  of  the  esophagus,  glandular  or 
vertebral  abscess,  or  laryngeal  perichondritis  (Striimpell). 

Symptoms. — Pain  during  deglutition  may  be  referred  to  the  region 
of  the  esophagus,  and  a  steady,  dull  pain  may  exist  beneath  the  sternum. 
Dysphagia  and  regurgitation  of  food  may  be  caused  by  spasm  in  severe 
cases.     Mucus,  blood,  and  pus  may  be  discharged  later.     The  absence 


ULCER   OF  TJIP:  ESOPHAGUS.  767 

or  mildness  of  pain  is  not  a  true  indication  of  the  gravity  and  extent  of 
esophageal  inflammation. 

Sequelae. — Simple  catarrhal  or  follicular  ulcers  may  appear,  and  the 
necrotic  form  of  the  disease  may  be  followed  by  suppurating  ulcers, 
which,  if  healing  takes  place,  may  cause  cicatricial  stenosis. 

Diagnosis. — This  may  be  based  upon  the  localization  of  pain, 
especially  during  deglutition ;  upon  the  pain  occasioned  by  the  passage 
of  the  esophageal  sound ;  and  upon  the  mucus,  blood,  or  pus  adherent 
to  its  bulb  on  withdrawal,  provided  carcinoma  at  the  cardiac  orifice  of 
the  stomach  can  be  excluded.  The  expulsion  of  a  pseudo-membrane 
(diphtheritic)  from  the  gullet  should  be  diff'erentiated  from  esophago- 
mycosis  (thrush),  especially  in  children.  The  diagnosis  of  the  particu- 
lar form  of  esophagitis  will  depend  upon  the  facts  elicited  relating  to 
the  etiology. 

The  prognosis  is  good  in  mild  cases,  and  should  be  guarded  in 
those  associated  with  grave  disease.  Death  may  occur  in  either  the 
purulent  or  necrotic  form. 

Treatment. — This  is  entirely  symptomatic,  and  in  severe  cases  is 
of  little  value.  A  soft,  bland  diet,  preferably  of  milk,  may  be  borne  in 
ordinary  instances ;  if  not,  rectal  alimentation  should  be  resorted  to. 
For  the  mild  cases  swallowing  of  bits  of  ice,  and  later  of  warm  demul- 
cent drinks,  should  be  recommended.  In  cases  of  marked  pain  and 
esophageal  spasm  relief  may  be  afforded  by  a  hypodermic  injection  of 
morphin  and  atropin. 

CHRONIC  ESOPHAGITIS. 

Chronic  catarrh  of  the  gullet  may  result  from  continued  irritation 
by  the  causes  of  the  acute  form,  and  also  from  passive  congestion  due  to 
hepatic  cirrhosis,  chronic  cardiac  or  renal  disease.  The  last-named  con- 
ditions may  also  cause  varicose  esophageal  veins,  and  fatal  hemorrhage 
may  result  therefrom.  Chronic  alcoholism  is  a  common  cause.  The 
increased  mucous  secretion  may  cause  eructations  and  nausea. 

Postmortem  evidence  of  esophagitis,  either  acute  or  chronic,  is  found 
with  extreme  rarity. 


ULCER  OF  THE  ESOPHAGUS. 

This  is  a  consequence  of  a  simple  or  follicular  catarrh  of  the  gullet 
or  of  gangrene.  "  Catarrhal  erosions  "  and  follicular  ulcers  may  occur, 
and  also  necrotic  ulcers,  in  bedridden  persons  opposite  the  cricoid  carti- 
lage. The  extensive  purulent  ulceration  following  the  separation  of 
necrotic  sloughs  may  heal  and  cause  stenosis  of  the  tube,  or  it  may  rup- 
ture into  the  trachea,  the  posterior  mediastinum,  or  the  aorta.  Pressure 
ulcers  (e.  g.,  from  aneurysm)  occur.  Ulceration  may  also  be  met  in 
uremia.  Ulcers  simulating  those  occurring  in  the  stomach  (ulceres  ex 
digestione)  may  sometimes  be  found  at  the  lower  end  of  the  esophagus. 
There  may  be  localized  points  of  pain  on  the  passage  of  the  esophageal 
bougie,  with  some  pus  and  blood  on  the  bulb  after  its  withdrawal.  Rest 
from  swallowing  should  be  secured  as  far  as  possible.  The  sipping  of 
hot  milk  may  be  soothing,  and  the  slow  swallowing  of  mild  boric  acid 
and  sodium  bicarbonate  solutions  may  be  tried  with  benefit. 


768  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 


CARCINOMA  OF  THE  ESOPHAGUS. 

This  is  the  most  frequent  affection  of  the  tube,  and.  as  it  is  the  com- 
monest cause  of  stenosis,  it  is  important  from  a  diagnostic  standpoint. 

Pathology. — Carcinoma  of  the  esopliagus  is  primary  and  of  an  epi- 
thelioniatous  nature,  the  mucous  membrane  here  being  composed  of  pave- 
ment-cells. The  new  growth  affects  the  mucosa  first,  and  then,  inci^eas- 
ing  in  size  and  causing  ulceration,  it  involves  the  entire  circumference 
of  the  tube.  This  may  either  be  hard  and  fibrous,  or  soft  and  jelly-like. 
The  esophageal  lumen  is  markedly  diminished,  though  disintegrating 
ulceration  or  "  flat "  carcinoma  may  encroach  upon  the  caliber  but  little. 
There  may  be  a  diffuse  dilatation  of  the  esophagus  above  the  growth,  as 
■well  as  an  hypertrophy  of  the  circular  muscular  fibers.  The  cancerous 
tumor  is  found  most  commonly  in  the  lower  third  of  the  esophagus 
(generally  at  the  bifurcation  of  the  trachea).  A  small  percentage  of  the 
cases  are  surgically  accessible,  being  situated  in  the  neck. 

Htiology. — The  predisposing  causes  of  esophageal  carcinoma  are  age 
and  sex.  males  past  forty  years  of  age  being  the  usual  subjects  of  this 
neoplasm.  The  exciting  causes  are  of  uncertain  origin.  It  has  been 
alleged  that  various  forms  of  protracted  irritation  of  the  mucous  mem- 
brane may  cause  the  development  of  carcinoma ;  and  especially  has  this 
point  been  maintained  in  connection  with  the  frequent  occurrence  of 
carcinoma  of  the  gullet  in  topers.  It  is  also  believed  by  some  that  as 
gastric  carcinoma  may  develop  from  the  scars  of  old  ulcers,  a  like  con- 
dition in  the  esophagus  may  act  as  a  nucleus  for  a  carcinomatous  growth. 

Symptoms. — Dysphagia  is  the  earliest  symptom  of  esophageal  car- 
cinoma with  beginning  stenosis  of  the  tube.  This  gradually  and  steadily 
increases,  so  that  liquids  alone  can  be  swallowed,  and  later  regurgitation 
even  of  small  amounts  (not  above  three  ounces)  of  li(iuid  foods  takes 
place.  There  may  be  considerable  pain.  I  saw  an  instance  with  the 
late  Dr.  W.  Frank  Haehnlen,  in  which  mucus  was  almost  constantly 
regurgitated,  and  bronchiectasis  developed  near  the  close. 

The  ejecta  may  contain  cancerous  fragments,  blood  and  mucus.  The 
dysphagic  symptoms  may  subside  spontaneously,  owing  to  the  disinte- 
gration and  ulceration  of  the  growth,  or  the  dysphagia  may  be  so  slight 
as  to  be  masked  by  the  prominent  symptoms  of  hepatic  or  pulmonary 
carcinoma  and  gangrene  secondary  to  a  very  flat  esophageal  carcinoma. 
Or,  without  secondary  manifestations  of  such  a  growth,  the  esophageal 
symptoms  may  rarely  be  latent.     The  cervical  glands  may  be  enlarged. 

The  most  important  general  symptom  of  esophageal  carcinoma,  as  of 
this  malignant  growth  elsewhere,  is  the  progressive  emaciation,  which 
increases  with  the  stenosis  and  obstruction  to  the  entrance  of  nourish- 
ment into  the  stomach.  Though  seemingly  anemic,  the  patient's  blood 
may  contain  an  excessive  number  of  corpuscles  in  a  given  bulk.  This  is 
due  to  inspissation  from  failure  to  absorb  water  and  food  into  the  body. 

Course,  Duration,  and  Termination. — The  disease  is  chronic, 
becoming  progressively  worse,  and  is  often  beset  with  grave  complica- 
tions {vide  infra).  It  seldom  lasts  longer  than  one  and  a  half  years, 
and  the  duration  of  medullary  carcinoma  of  the  gullet  is  usually  much 
shorter.  A  fatal  ending  is  inevitable,  by  inanition  and  exhaustion,  or 
as  the  result  of  metastasis  and  secondary  complications. 


RUPTUR/'J   OF  THE  ESOPHAGUS.  769 

Complications. — These  follow  extension  of  the  cancerous  growth 
to  neighboring  parts.  Thus,  involvement  of  the  larynx,  trachea,  and 
bronchi  has  been  noted.  The  cancerous  ulcer  may  also  perforate  the 
pleura,  the  pericardium,  or  the  aorta  or  its  branches,  and  cause  fatal 
hemorrhage.  The  vertebrae  have  been  eroded,  and  compression  of  tlie 
cord,  with  resulting  paraplegia,  may  take  place. 

Paralysis  of  the  vocal  cords  may  be  the  effect  of  pressure  by  the 
growth  upon  the  recurrent  laryngeal  nerve;  most  frequently  pulmonary 
gangrene  is  due  to  perforation  of  the  lung  or  to  the  inspiration  of  can- 
cerous and  decomposing  particles  that  have  been  regurgitated. 

Diagnosis. — All  other  causes  of  dysphagia  must  be  excluded.  En- 
larged to7isils,  2)har7/7igeal  tumors,  pressure  from  without  by  cervical  intra- 
thoracic tumors,  as  aneurysm,  or  by  displacement  of  the  sternal  end  of 
the  clavicle,  and  the  presence  of  foreign  bodies  or  cicatricial  strictures 
of  the  gullet — all  figure  in  the  production  of  difficult  deglutition.  The 
history  of  the  case,  the  age  of  the  patient,  the  progressive  emaciation 
(cancerous  cachexia),  and  the  obstinately  increasing  dysphagia  will  enable 
us  to  exclude  the  other  affections  named.  In  using  the  esophageal  bougie 
for  diagnostic  purposes  great  care  should  be  exercised,  as  an  aneurysm 
may  thus  be  ruptured  or  a  deeply  ulcerated  carcinoma  perforated.  The 
"withdrawal  of  cancerous  tissue  upon  the  bulb  will  decide  the  case.  The 
esophagoscope  may  be  useful  in  certain  cases.  G.  E.  Pfahler  ^  has  shown 
that  by  the  skilful  use  of  diaphragms,  the  elimination  of  secondary  rays 
and  of  motion  by  great  speed,  the  disease  can  be  diagnosticated  by  means 
of  the  Rontgen  rays.  The  exceptional  occurrence  of  latent  cases  must 
be  remembered.  Sarcoma  cannot  be  distinguished  from  carcinoma  by 
the  clinical  symptoms.  By  means  of  the  esophagoscope,  however,  a 
small  piece  of  the  tumor  may  be  removed  foi  examination. 

The  prognosis  is  hopeless,  and  the  supervention  of  grave  compli- 
cations renders  the  chances  of  an  early  demise  very  probable. 

Treatment. — This  is  essentially  symptomatic  and  sustentative.  If 
feeding  by  the  mouth  is  difficult  on  account  of  the  extreme  stenosis, 
although  permitting  the  passage  of  an  esophageal  tube,  the  latter  may 
be  used  for  the  passage  of  liquid  nourishment.  Rectal  feeding  may  later 
become  imperative.  The  local  application  of  radium  has  been  recom- 
mended. The  mechanical  treatment  of  the  cancerous  stricture  by  the 
passage  of  the  graduated  esophageal  bougie  is  seldom  of  any  avail.  Soft, 
disintegrating,  and  ulcerating  carcinoma  should  thus  be  treated,  though 
with  the  absence  of  any  force  whatsoever.  The  performance  of  gastros- 
tomy may  prolong  life  in  some  cases  in  which  there  is  formidable  diffi- 
culty in  passing  a  tube  into  the  stomach. 


RUPTURE  OF  THE  ESOPHAGUS. 

The  first  recorded  case  of  this  rare  condition  occurred  under  the  ob- 
servation of  Boerhaave  in  1724  in  the  person  of  the  Baron  Wassemar. 

Pathology. — Softening,   together    with    a  great  friability,  of  the 
esophageal  walls  may  be  found,  this  probably  being  the  efi'ect  produced 
by  the  solvent  action  of  the  gastric  juice  upon  the  mucous  membrane  at 
^  Archives  of  Diagnosis,  January,  1909. 
49 


770  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

a  time  when  the  local  circulation  is  disturbed  and  the  vitality  of  the 
tissues  thus  lessened. 

The  postmortem  evidence  of  this  accident  consists  of  a  longitu- 
dinal (as  a  rule)  tear  about  5  cm.  (2  inches)  in  length,  situated  in  the 
lower  half  of  the  esophagus.  Food  and  air  may  be  found  to  have  es- 
caped into  the  left  pleural  cavity,  and  unless  death  occur  at  an  early 
date  signs  of  purulent  inflammation  will  probably  be  noticed.  Post- 
fiiorti'in  digestion  of  the  esophagus  is  more  common  (Osier).  The  perfo- 
ration is  often  large,  and  is  located  in  the  posterior  wall  of  the  tube. 

Btiology. — Softening  of  the  walls  of  the  gullet  (esophago-malaeia) 
is  suggested  by  Zenker  as  a  condition  that  always  precedes  spontane- 
ous rupture,  so  called.  The  exciting  cause  is  believed  to  be  violent  and 
persistent  vomiting  after  a  particularly  heavy  meal  or  during  acute 
alcoholism. 

Symptoms. — These  come  on  suddenly  or  soon  after  a  full  meal, 
and  commence  with  nausea  and  very  severe  vomiting,  accompanied  by 
great  pain  and  rapid  and  extreme  collapse  of  the  whole  body,  due  to 
the  shock.  A  cutaneous  emphysema  of  the  neck  and  chest  is  mani- 
fested soon  after  the  rupture. 

The  diagnosis,  if  made  at  all,  must  rest  upon  the  clinical  history. 
Death  usually  takes  place  in  a  few  hours  or  days  at  the  most. 

Treatment. — Pain,  if  excruciating,  should  be  dulled  by  the  hypo- 
dermic administration  of  morphin. 


NEUROSES  OF  THE  ESOPHAGUS. 

MUSCULAR   SPASM. 
(Esophagismus.) 

Definition. — A  spasmodic  contraction  of  the  muscular  layer  of  the 
upper  or  lower  portions  of  the  esophagus. 

Htiology. — It  is  almost  always  a  secondary  aff'ection,  met  with  not 
infrequently  in  hysteria,  hydrophobia,  and  rarely  in  chorea  and  epilepsy. 
In  this  case  the  esophageal  bougie  could  be  passed  only  with  a  great  deal 
of  difficulty  during  the  spasm.  It  may  be  observed  in  aged  males,  and 
especially  in  those  suff'ering  from  hypochondriasis.  It  may  be  due  to  re- 
flex causes,  originating,  for  example,  in  the  uterus  ;  thus,  in  some  cases, 
it  occurs  only  during  the  pregnant  state.  Spasm  may  complicate  all  of 
the  lesions  of  the  esophagus,  even  organic  stricture. 

Symptoms. — The  chief  subjective  characteristic  is  dysphagia.  Al- 
though liquids  can  be  swallowed,  solids,  as  a  rule,  cannot.  Post-sternal 
jyain  is  sometimes  noticed,  and  choking  signs  are  quite  common.  In 
the  hysteric  variety  emotional  disturbances  are  found  among  the  pro- 
dromnta.     The  general  nutrition  remains  good. 

Diagnosis. — The  etiologic  factors  must  be  carefully  weighed  in 
connection  with  the  symptoms  and  the  valua1)le  testimony  gained  by 
the  use  of  the  sound.  The  bougie  on  reaching  the  constriction  is  rather 
tightly  gripped,  though  gentle  pressure  soon  causes  it  to  relax.  After 
the  subjective  symptoms  and  spasm  are  over  the  sound  passes  without 
the  slightest  difficulty.  The  siphoned  and  vomited  masses  contain  neither 
blood  nor  pus.     An  examination  Avith  the  esophagoscope  allows  the  diag- 


DILATATION  OF  THE  ESOPIIAOUS.  771 

nosis  to  be  easily  ma,(le.  In  some  cases  tlie  dyspliagia  may  be  due  to 
pharyngeal  paresis.  The  elderly  Itypocfbondriaa  is,  as  before  stated,  liable 
to  develop  a  similar  condition,  wliicb  must  not  be  confounded  with  true 
cancerous  stricture.  The  prognosis  is  good.  Guisez  speaks  of  severe 
spasms  with  lethal  tendency. 

The  treatment  is  directed  to  the  disease  on  which  the  condition  is 
found  to  depend,  and  this  must  receive  careful  attention.  The  sound 
should  be  used  as  previously  indicated  under  the  discussion  of  Esopha- 
geal Stricture.  Its  passage  has  often  been  followed  by  speedy  and  per- 
manent cures.  A  special  electrode  with  which  to  apply  electricity  to 
overcome  the  spasm  of  the  cardia  has  been  employed. 

PARALYSIS  OP  THE  ESOPHAGUS.^ 

.  In  extensive  bulbar  paralysis,  when  adjacent  parts  are  involved,  we 
may  infer  the  existence  of  esophageal  implication,  though  there  be  no 
objective  evidence  to  adduce  in  confirmation.  Doubtless  the  esophagus 
rarely  shares  in  post-diphtheritic  paralysis  also.  Dysphagia  is  the  lead- 
ing symptom.  An  invaluable  peculiarity  belonging  to  diphtheritic 
paralysis  is  the  fact  that  solids  are  more  readily  swallowed  than  liquids. 


DILATATION  OF  THE  ESOPHAGUS. 

Pathology  and  Htiology. — Diffuse  dilatation  of  the  esophagus  is 
usually  secondary  to  organic  stricture  at  or  near  the  cardiac  orifice.  In 
accordance  with  the  common  law  of  compensation,  the  first  effect  of  the 
stenosis  is  to  engender  hypertrophy  of  the  muscular  layer  above  it  with 
a  view  of  overcoming  the  resistance  caused  by  the  obstruction.  The  wall 
of  the  esophagus  becomes  thickened,  and  the  tube  is  generally  somewhat 
narrowed,  above  the  seat  of  the  stenosis ;  but  finally,  as  a  result  of  de- 
generative changes,  the  muscular  coat  weakens,  the  esophagus  dilates,  and 
food  accumulates  above  the  stricture — a  condition  that,  once  begun, 
progresses.  This  condition  also  occurs  without  anatomic  stenosis,  and 
Plummer  records  91  cases,  and  only  5  of  the  patients  were  of  a  neurotic 

type- 

Congenital  dilatation,  in  which  the  whole  extent  of  the  tube  partici- 
pates, has  also  been  met  with,  though  such  a  condition  is  rare  indeed. 
It  sometimes  results  from  fatty  degeneration  of  the  muscular  w^all,  and 
a  predisposition  to  the  complaint  may  be  acquired  as  the  result  of  injury 
or  prior  inflammation. 

Symptoms. — The  essential  symptom  is  chronic  dysphagia.  When 
dilatation  follows  stenosis  the  patient  often  locates  the  point  at  which 
the  food  lodges  in  the  esophagus.  Most  of  the  ingesta  are  regurgitated 
several  hours  after  eating,  and  this  process  is  often  attended  by  more  or 
less  severe  strangling.  The  esophageal  sound  comes  upon  the  stricture, 
and  is  either  gripped  firmly  or  totally  resisted ;  in  the  latter  event  the 
bulb  can  be  moved  about  above  this  point  with  abnormal  freedom.  In  the 
rare  cases  of  spindle-shaped  dilatation  without  stenosis  the  sound  usually 

1  For  remarks  on  the  treatment  of  this  complaint  the  reader  is  referred  to  the  section 
on  Nervous  Diseases. 


772  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

detects  no  obstacle  on  its  way  into  the  stomach.  A  sac  is  occasionally 
formed,  however,  as  the  result  of  localized  bulging  of  the  paralyzed  Avail, 
in  which  food  may  collect  or  the  exploring  sound  may  catch,  thus  lead- 
ing to  erroneous  inferences.  Dysphagia  is  present,  though  it  pre- 
sents peculiarities,  in  that  the  food  may  either  ])ass  down  very  slowly 
until  it  readies  the  stomach,  or  it  may  lodge  in  the  shallow  pouch,  as 
above  described.  In  the  latter  event  the  fond  may  be  gulped  up  from 
time  to  time.  If  the  sound  can  be  easily  introduced  into  the  stomach, 
we  may  safely  eliminate  stricture  as  the  cause  of  the  dilatation. 

The  prognosis  is  good  as  long  as  suffii-ient  food  can  be  gotten  into 
the  stomach  ft)r  the  support  uf  life. 

Treatment. — The  chief  object  in  the  treatment  is  to  keep  the  patient 
nourished.  If  sufficient  food  cannot  be  swallowed,  a  Sjmond's  tube 
should  be  inserted  and  nourishment  given  through  it:  and  when  this, 
mode  of  feeding  is  no  longer  feasible,  tlie  physician  has  to  choose  between 
gastrostomy  and  rectal  feeding.  There  can  be  no  doubt  that  by  means 
of  nutrient  enemata  nutrition  may  be  fairly  Avell  maintained,  but  not 
indefinitely,  as  these  cases  would  seem  to  demand.  In  the  hands  of  a 
competent  surgeon,  on  the  other  hand,  gastrostomy  is  often  fruitful  of 
brilliant  results.  Galvanism  has  been  recommended  on  high  authority. 
Local  lesions,  when  present,  must  be  dealt  with  in  accordance  with  the 
rules  governing  the  treatment  of  the  several  causal  conditions.  The  sac 
may  be  washed  out  daily  "with  an  antiseptic  solution  (e.  </.,  boric  acid  3 
per  cent.). 


ESOPHAGEAL  DIVERTICULUM. 

(Phari/ngocele.) 

Definition. — A  circumscribed  sac  in  the  wall  of  the  esophagus. 

Pathology  and  Btiology. — Two  varieties  are  met  with,  which 
Zenker  has  termed  pressure  and  traction  diverticula  ;  the  latter  are  rare. 
Diverticula  that  occur  at  or  near  the  inferior  constrictor,  and  more  par- 
ticularly the  larger  ones,  are  congenital  in  origin.  When  acquired  they 
are  the  result  of  a  localized  lesion  in  the  muscular  coat,  through  Avhich 
the  mucous  membrane  bulges  like  a  hernia.  This  is  owing  to  repeated 
slight  pressure  occasioned  by  the  passage  of  food.  When  once  such  a 
process  is  started,  various  factors  tend  to  continually  enlarge  the  pouch. 
Chief  among  these  are  the  morsels  of  food  that  find  lodgement  and 
naturally  tend  to  augment  the  size  of  the  diverticulum  by  dragging  it 
downward.  The  sac  may  finally  attain  a  diameter  of  not  less  than  4 
inches  (10  cm.).  Its  situation  is  nearly  always  on  the  posterior  wall  at 
the  pharyngo-esophageal  junction,  and  its  form  is  usually  saccular  or 
pear-shaped.  Most  instances  have  been  met  with  in  males  after  middle 
life.  The  cause  of  the  weakened  area  at  which  the  diverticulum  occurs 
is  to  be  found  sometimes  in  injury,  but  more  frequently  in  an  antecedent 
inflammation.  Histologic  changes  are  observed  only  in  the  mucous  and 
submucous  layers,  these  anatomic  elements  together  forming  the  pouch. 
Traction  diverticula  are  produced  by  the  fringe  of  tissues  th^t  often 


ESOPHAGEAL  DIVERTICULUM.  IIZ 

lecomes  iidhcrent  to  tlic  ui)t)er  nspcct  of  the  esopliafrus,  and  from  tlieir 
mode  of  occurrence  they  will  obviously  be  more  or  less  funnel-shaped. 
Their  dimensions  are  small.  They  are  more  common  in  children  than 
in  adults,  for  the  reason  that  in  the  former,  more  frequently  than  in  the 
latter,  do  the  bronchial  glands  suppurate,  with  subsequent  cicatrization. 
This  circumstance  affords  an  explanation  of  the  fact  that  traction  diver- 
ticula are  usually  seated  on  the  anterior  wall  of  the  esophagus,  near  the 
bifurcation  of  the  trachea. 

Clinical  History. — Traction  diverticula  do  not,  as  a  rule,  give  rise 
to  clinical  symptoms.  Exceptionally,  however,  as  the  result  of  the 
mechanical  irritation  caused  by  bits  of  food  that  are  retained  in  these 
funnels,  ulceration  may  occur  and  be  followed  by  perforation  of  their 
apices.  In  this  manner  the  main  bronchi  are  perforated  (causing  pneu- 
monia and  pulmonary  gangrene),  also  the  pleura  (causing  empyema^,  and, 
more  rarely,  the  pericardium  (causing  suppurative  pericarditis). 

Pressure  diverticula  when  small  cannot  be  recognized,  owing  to  the 
absence  of  signs  and  symptoms.  When  they  attain  considerable  size, 
however,  the}^  are  often  attended  with  severe  symptoms.  The  earliest 
clinical  manifestation  is  difficulty  in  swallowing ;  some  of  the  food  enters 
the  sac,  and,  if  allowed  to  remain,  undergoes  putrefactive  decomposition, 
causing /g^or  of  the  breath.  From  time  to  time,  and  especially  on  at- 
tempting to  swallow,  the  partly  or  wholly  filled  condition  of  the  pouch 
excites  nausea  and  vomiting,  associated  with  prolonged  strangling  ;  this 
results  in  the  ejection  of  a  portion  of  the  accumulated  contents.  These 
contain  no  hydrochloric  acid.  After  such  an  attack  the  patient  is  unable, 
temporarily,  to  swallow  food,  and  in  consequence  of  the  limited  amount 
of  food  taken  signs  of  inanition  soon  appear ;  this  may  finally  become 
extreme,  and  is  sometimes  the  immediate  cause  of  death.  The  appear- 
ance of  a  pear-shaped  sivelling  in  the  side  of  the  neck  has  been  observed. 
As  the  tumor  enlarges  it  displaces  the  larynx  and  presses  upon  the 
enlarged  vessels — more  rarely  upon  the  superior  laryngeal  nerve — giving 
rise  to  dyspnea  and  distressing  fits  of  coughing. 

Diagnosis. — A  point  in  the  differentiation  of  this  affection  is  the 
enlargement  of  the  sac  after  meals  (not  all  the  food  passing  into  the 
stomach),  and  its  disappearance  after  being  emptied.  Another  discrim- 
inating sign  is  the  effect  of  compression  by  the  hand  in  causing  the 
contents  (''  air  and  sodden  food  ")  to  flow  back  into  the  mouth.  In  those 
instances  in  Avhich  the  tumor  is  absent  we  may  demonstrate  its  existence 
by  the  use  of  the  esophageal  sound.  If  the  sound  passes  into  the  sac,  the 
descent  will  soon  be  arrested.  If,  however,  the  instrument  fails  to  enter 
the  mouth  of  the  pouch,  it  readily  glides  into  the  stomach.  An  elbowed 
sound,  bent  at  an  obtuse  angle  near  the  tip,  is  useful  in  such  cases.  It 
may  be  inserted  in  different  directions,  so  as  to  avoid  entrance  into  the 
sac.  Schwalbe  and  Rosenfeld  have  been  able  to  recognize  the  condition 
by  the  aid  of  radiography.  Some  writers  advocate  the  methylene-blue 
test  of  Bokelmann.  The  esophagoscope  should  be  used  last  in  a  routine 
examination,  there  being  danger  of  a  rupture  of  a  possible  aneurysm 
(Mayer). 

Prognosis. — The  outlook  is  unfiivorable  in  the  absence  of  operative 
treatment,  though  modern  surgery  gives  promise  of  curing  a  certain  pro- 
portion of  cases.     Wheeler  has  operated  successfully  in  one  instance  at 


774  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

least.     The  physician  may  prolong  life  by  directing  attention  to  the  nu- 
trition of  tho  });itient.  but  he  cannot  hope  to  promote  a  cure. 

Treatment. — If  the  patient  cannot  swallow  an  adc^juate  amount  of 
nourishment,  he  may  be  successfully  fod  through  a  tube,  which  he  him- 
self should  be  allowed  to  pass.  When  sufficient  food  cannot  be  introduced 
by  this  method,  rectal  feeding  should  be  instituted.  If  excision  of  the 
diverticulum  be  deemed  impracticable  by  the  surgeon,  then  the  establish- 
ment of  a  gastric  fistula  is  worthy  of  extended  trial  in  cases  in  which  the 
above-mentioned  modes  of  feeding  have  failed.  It  has  been  advised  to 
wash  the  sac  daily  with  sterile  water  or  some  mild  disinfectant  to  prevent 
decomposition.  Stetten  collected  statistics  of  GO  radically  operated  cases, 
which  gave  a  mortality  of  only  1G.6  per  cent. 


STRICTURE  OF  THE  ESOPHAGUS. 

Ktiology. — A  stricture  of  the  esophagus  may  be  due  either  to  (a) 
Congenital  narroAving  (exceedingly  rare) ;  (/>)  Squamous  epithelioma, 
usually  producing  an  annular  constriction  ;  (c)  Rarely  to  polypi  pro- 
truding from  the  mucosa,  which  almost  occlude  the  lumen  of  the  tube ; 
(d)  Rarely  to  specific  inflammation,  as  syphilis  and  tuberculosis;  (e) 
Simple  stricture  generally  results  from  the  ingestion  of  corrosive  fluids, 
which  cause  extensive  sloughing  of  the  mucosa,  followed  by  cicatricial 
contraction ;  (/)  Rarely  as  a  sequel  of  typhoid  and  peptic  ulceration. 
Clinical  History. — The  symptoms  vary  with  the  special  cause  and 
with  the  degree  of  stenosis.  The  first  and  most  prominent  indication  of 
narrowing  of  the  gullet  is  a  very  slowly  increasing  di/sphagia.  The 
patient  for  a  long  time  complains  of  a  sense  of  jrressure  at  a  certain  sub- 
sternal point  on  swallowing  solid  f(X)d,  or,  more  rarely,  an  apparently 
healthy  person  will  suddenly  experience  painful  pressure  in  attempting 
to  swallow  a  larger  quantity  of  food  than  usual.  By  and  by  even  fluids 
cause  dysphagia,  and  the  patient  observes  that  the  time  required  for  the 
food  to  reach  the  stomach  is  lengthened.  The  impediment  to  the  act  of 
swalloAving  is  not  due  alone  to  mechanical  stenosis,  but  partly  to  the 
weakness  of  the  muscular  coat,  sometimes  owing  to  its  partial  destruc- 
tion, and  in  exceptional  cases  partly  to  spasmodic  contraction.  When 
due  to  carcinoma,  difficult  deglutition  is,  as  a  rule,  the  only  symptom  com- 
plained of.  When  occasioned  by  corrosive  fluids  or  traumatism,  ^;aw  is 
prominent  from  the  onset. 

Above  the  scat  of  stricture  the  esophagus  is  often  dilated  and  con- 
tains accumulations  of  the  ingesta.  The  latter,  together  with  consider- 
able mucus,  are  regurgitated  three  or  four  hours  after  meals,  and  we  may 
be  certain  that  the  materials  thus  ejected  do  not  come  from  the  stomach 
if  they  are  alkaline  in  reaction.  The  leading  clinical  features  are  the 
gradually  increasing  debility  and  emaciation^  finally  reaching  an  extreme 
degree. 

Diagnosis. — However  characteristic  the  symptoms  may  be,  the 
bougie  should  invariably  be  passed  before  pronouncing  a  positive  diag- 
nosis. By  this  means  we  ascertain  the  degree  and  the  seat  of  the  stric- 
ture.    To  begin  with,  a  medium-sized  gum-elastic  bougie  (No.  16  Eng- 


STRICTURE  OF  THE  ESOPHAGUS.  775 

lish  scale)  should  bo  employed,  after  warming  it  and  lubricating  with 
glycerin.  Its  use  should  be  preceded  by  a  cocain-spray  to  prevent 
spasm.  The  patient  should  occupy  a  low  seat,  with  his  head  supported 
by  an  assistant  from  in  front  of  the  operator.  The  head  should  be  only 
slightly  thrown  backward.  The  forefinger  of  the  left  hand  sliould  then 
be  passed  back  over  the  tongue  until  it  touches  the  epiglottis,  and  the 
bougie  inserted  along  it  with  the  right  hand,  thus  avoiding  the  error 
of  passing  it  into  the  naso-pharynx  or  the  larynx.  When  the  bougie 
reaches  the  cricoid  cartilage  it  is  sometimes  gripped  pretty  firmly  even 
in  a  healthy  person — a  fact  that  is  always  to  be  remembered.  No  force 
should  be  applied.  The  instrument  may  pass  the  constriction  with  a 
jerk,  or  it  may  not  only  be  gripped,  but  distinctly  arrested,  when  a 
smaller  bougie  should  be  tried.  By  moving  the  instrument  upward 
gently  we  may  detect  sometimes  several  strictures  lying  one  above  an- 
other. To  locate  the  obstacle,  the  distance  from  the  teeth  to  the  point 
of  stricture  is  measured  on  the  instrument,  and  the  results  compared 
with  the  normal  measurements,  which  are  as  follows :  from  the  teeth  to 
the  cricoid  cartilage,  7  inches  (17.7  cm.) ;  to  the  left  bronchus,  11  inches, 
(27.8  cm.) ;  and  to  the  opening  into  the  diaphragm,  15  inches  (37.9  cm.). 

Auscultation  of  the  esophagus  has  been  practised,  but  the  clinical 
indications  afforded  are  of  little  practical  value.  The  stethoscope  is 
placed  to  the  left  of  the  spine,  and  the  patient  takes  a  mouthful  of  water, 
when,  if  a  stricture  be  present,  a  splashing,  cooing  sound  will  be  heard 
at  the  seat  of  the  stricture  instead  of  the  normal  esophageal  bruit. 

Differential  Diagnosis. — It  is  important  for  rational  treatment  to  deter- 
mine not  only  the  existence  of  a  stricture  but  also  the  underlying 
disease.  First  and  foremost,  we  must  exclude  those  affections  that 
simulate  simple  and  malignant  stricture,  in  certain  of  which  the  in- 
troduction of  the  sound  would  be  attended  with  grave  dangers.  Com- 
pression of  the  esophagus  by  enlarged  or  accessory  thyroids,  aortic 
aneurysms,  vertebral  abscess,  enlarged  lymphatic  glands,  and  occasion- 
ally pericardial  effusions,  may  produce  dysphagia,  and  on  passing  the 
bougie  resistance  is  offered  at  the  seat  of  the  external  pressure.  As  a 
rule,  the  extent  of  the  stenosis  is  moderate.  If  the  narrowing  be  due 
to  aneurysm — "(a)  rhythmic  movement  is  sometimes  communicated  to 
the  free  end  of  the  sound  introduced  as  far  as  the  stenosis."  Careful 
physical  examination  will  often  reveal  the  presence  of  an  aneurysm  or 
other  pressing  tumor,  and  should  never  be  neglected.  Passage  of  the 
sound  in  cases  of  aneurysm  has  caused  rupture  of  the  sac  and  death. 
(6)  Spasm  of  the  esophagus  or  paralysis  (the  latter  rarely)  may  closely 
resemble  true  stenosis.  These  neurotic  forms  are  almost  exclusively  met 
with  in  hysteric  females ;  on  the  other  hand,  malignant  strictures  are 
found  generally  in  males  over  forty  years ;  while  in  simple  stricture  there 
is  usually  a  definite  history  and  certain  etiologic  factors. 

To  discriminate  between  simple  and  malignant  stricture  is  not  diffi- 
cult, as  a  rule.  When  a  clear  history  of  gumma,  of  tuberculous  disease, 
or  of  injury  (from  corrosive  liquids)  is  obtainable,  the  presence  of  a 
simple  stricture  may  be  safely  inferred  after  eliminating  the  affections 
previously  mentioned.  In  the  absence  of  etiologic  data  pointing  to  the 
simple  form,  cases  occurring  in  the  male  after  forty  years  of  age  may  be 
looked  upon  as  malignant. 


776  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Prognosis. — In  tunniiig  a  prognostic  opinion  the  chief  factor  to  be 
considered  is  the  nature  of  the  stricture.  Practically,  so  long  as  the 
stenosis  is  dilatable,  the  prognosis  is  not  unfavorable  ])rovided  sufficient 
nourisliinent  can  be  taken  :  moreover,  not  a  few  cases  of  simple  stricture 
are  curable.    The  majority,  however,  come  to  a  fatal  termination  finally. 

Treatment.— The  chief  object  of  the  treatment  is  to  gradually 
and  methodically  dilate  the  stricture.  The  flexible  English  bougie  above 
mentioned  is  the  best  for  the  purpose,  commencing  with  one  of  good  size  ; 
conical  ivory  bougies,  having  a  flexible  whalelione  handle,  may  also  be 
used,  though,  being  (juite  hard,  they  are  apt  to  inflict  injuries  unless  used 
cautiously.  It  is  sometimes  necessary,  on  account  of  the  tightness  of  the 
stricture,  to  begin  with  a  catgut  sound.  The  method  of  introducing 
these  instruments  has  already  been  given.  They  should  be  used  once 
daily,  and  often  can  be  passed  successfully  by  the  patient  himself.  At 
intervals  of  three  or  four  days  trials  of  bougies  of  larger  size  should  be 
made.  I  have  seen  truly  remarkable  results  from  this  treatment  when 
carried  forward  systematically  in  cases  due  to  cicatricial  contraction,  the 
patients  increasing  in  bodily  weight  and  strength.  In  annular  constric- 
tions of  a  malignant  type,  however,  it  is  productive  of  temporary  benefit 
only. 

The  diet  deserves  most  careful  attention.  When  the  stenosis  is  so 
pronounced  as  to  prohibit  sufficient  food  being  swallowed,  a  Symonds 
tube  should  be  passed  into  the  stomach,  and  through  it  liquid  food  is 
introduced.  Concentrated  forms  of  nourishment,  as  raw  eggs,  bovinin, 
and  the  various  infants'  foods,  may  be  administered  with  milk. 

When  the  passage  of  the  bougie  is  no  longer  possible  relief  may  be 
secured  in  one  of  two  ways :  (1)  rectal  feeding ;  (2)  gastrostomy,  if  the 
seat  of  the  stricture  be  near  the  stomach,  and  esophagostomy  if  at  the 
upper  portion  of  the  gullet.  I  have  recently  witnessed  favorable  re- 
sults from  gastrostomy  in  a  case  of  simple  stricture  operated  upon  by 
Laplace.  J.  McCrae  advises  the  wearing  of  a  permanent  tube,  which 
may  be  fixed  by  cords  through  the  mouth  and  fastened  to  the  ear.  It  is 
important  that  the  patient  should  thoroughly  masticate  the  food  before 
introducing  it  into  the  stomach.  Before  resorting  to  operative  procedures, 
however,  careful  trial  should  be  made  of  rectal  feeding.  Various  forms 
of  nutritious  enemata  and  other  points  regarding  rectal  alimentation  will 
be  fjund  in  the  Treatment  of  Gastric  Ulcer. 


VII.   DISEASES  OF  THE   STOMACH. 

METHODS  OF  DIAGNOSIS. 

The  examination  is  begun  by  the  patient's  narration  of  his  past  and 
present  troubles,  family  histoiy,  and  any  special  peculiarities  in  health. 
It  is  all  important  to  ascertain  whether  the  patient  has  lost  or  gained 
in  weight,  and  the  condition  of  the  bowels.  The  necessary  knowledge 
is  best  acquired  by  asking  a  series  of  questions  whicli,  for  sake  of  con- 
venience, I  have  arranged  under  the  following  subheadings : 


diseasp:s  of  the  stomach.  777 

Pain.-^I*;iin,  when  present,  may  ?>e  located  at  tlic  pit  of  the  stomach 
(cardialgia),  or  in  the  gastric  region  (gastralgiaj.  The  pain  may  be 
severe,  slight,  or  merely  a  discomfort  and  uneasiness.  All  important 
is  it  to  know  when  and  how  (sudden  or  gradual)  the  pain  appears,  and 
what  conditions  excite  or  relieve  such  distress.  Does  the  pain  develop 
before  meal  time  and  when  the  stomach  is  empty,  and  is  appeased  by  the 
taking  of  food;  or  is  it  excited  by  taking  food,  and  does  it  ap[)ear  imme- 
diately after  food,  or  one  to  four  hours  later?  Is  the  pain  constant,  and 
is  it  local  or  diffused  ?     Does  it  radiate  to  the  back  or  scapular  regions  ? 

Appetite. — The  loss  of  appetite  (anorexia),  or  a  desire  for  unusual 
foods  (parorexia),  are  frequently  noted.  When  the  appetite  is  increased, 
or  the  patient  becomes  hungry  a  short  time  after  a  meal,  it  is  referred  to 
as  "  bulimia." 

One  should  determine  further  whether  the  appetite  comes  on  when 
the  patient  begins  to  eat,  or  disappears  at  the  sight  of  food,  or  after  a 
few  mouthfuls  of  food  are  taken.  The  taking  of  abnormally  large 
amounts  of  food  at  meal  times  only  is  termed  "  jjolyphagia."  Where  the 
appetite  is  not  satiated,  even  after  a  full  meal,  we  refer  to  such  condition 
as  "  acoria." 

Thirst. — In  certain  maladies  the  thirst  is  increased,  while  in  a  second 
class  of  conditions  there  is  little  or  no  desire  for  water  or  other  liquids. 
Inquire  whether  thirst  is  allayed  by  taking  water. 

Taste. — Many  gastrointestinal  conditions  are  accompanied  with  an 
unpleasant,  sour,  bitter,  or  sticky  taste  which  may  be  experienced  only 
on  waking,  or  it  may  be  more  or  less  persistent. 

Deglutition. — Does  the  patient  swallow  both  solids  and  liquids  natu- 
rally ;  also  is  he  liable  to  cough  while  eating,  and  does  such  effort  cause 
discomfort  or  pain  ? 

Pyrosis. — This  is  a  burning  sensation  in  the  epigastrium  and  sternal 
region.  Note  at  what  time,  before  or  after  food,  it  is  experienced,  its 
duration,  and  how  it  is  influenced  by  various  foods. 

Regurgitation. — Note  how  long  after  taking  food  this  annoying  symp- 
tom is  observed,  and  also  whether  the  food  tastes  sour  ?  Where  the  con- 
tents of  the  stomach  are  expectorated,  it  is  referred  to  as  regurgitation, 
but  should  it  be  again  chewed  and  swallowed,  it  is  termed  "rumina- 
tion." 

Hiccough. — The  time  at  which  hiccough  occurs,  and  Avhether  or  not 
it  is  accompanied  with  a  burning  sensation  in  the  throat  or  by  an  un- 
pleasant odor,  are  points  of  clinical  value.  Prolonged  hiccough  is  of 
j^rave  significance. 

Nausea. — Is  it  occasional  or  frequent,  and  how  influenced  by  food  and 
by  sleep  ? 

Vomit. — Inquire  carefully  as  to  the  frequnecy  of  the  vomiting ;  how 
influenced  by  pain ;  when  the  stomach  is  empty,  after  soft  food,  solid 
food,  or  is  it  excited  by  certain  odors  ?  The  quantity  and  consistency 
of  the  vomit,  as  well  as  Avhether  it  ever  contains  fresh  blood  (red). 
or  blood  that  has  lingered  in  the  stomach  for  a  time  (coffee  brown 
vomit)  ? 

Such  special  symptoms  as  constipation,  mental  dulness,  sleepy  and 
giddy  sensations,  and  a  blurring  of  objects,  are  not  infrequently  observed 
in  gastric  disorders. 


778  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


EXAMINATION   OF   THE    GASTRIC    FUNCTIONS. 

Secretory  Function. — While  gastric  secretion  normally  continues  as 
long  as  food  is  present  in  the  stomach,  during  the  later  stages  of 
gastric  digestion  the  activity  of  the  secretory  function  of  the  stomach 
diminishes,  and  to  obtain  accurate  knowledge  of  any  pathologic  condition 
of  the  ort^an,  examinations  of  the  gastric  contents  must  be  made  under 
conditions  as  nearly  like  the  physiologic  as  possible.  Reliable  results 
cannot,  therefore,  be  obtained  from  an  examination  of  ordinary  vomita, 
but  the  contents  of  the  stomach  must  be  procured  at  a  definite  period 
after  a  so-called  test-meal  (vide  infra). 

Numerous  test-meals  have  been  offered  to  the  profession,  but  those 
that  I  have  found  most  satisfactory  are  "  the  test-breakfast  of  Ewald 
and  Boas"  and  "the  test-dinner  of  Leube-Riegel."  The  former  being 
simpler  and  easier  of  preparation  than  the  latter,  it  is  the  oftenest  used. 

The  Ewald-Boas  test-hreakfast  consists  of  one  or  two  rolls  (50-70  gm.) 
and  one  cup  of  tea  or  water  (300-400  c.c).  I  constantly  advise  the 
use  of  one  roll  and  a  glass  of  water.  About  an  hour  after  this  meal 
has  been  taken  the  contents  of  the  stomach  are  to  be  withdrawn,  and 
at  such  a  time  HCl  should  be  the  only  acid  present. 

The  Leube-Riegel  test-dinner  consists  of  a  large  plate  of  soup  (300- 
400  c.c),  a  large  piece  of  beefsteak  (150-200  gm.),  and  some  potatoes 
(about  50  gm.)  or  a  roll — practically,  a  large  plate  of  soup,  a  piece  of 
meat  (preferably  beefsteak),  and  a  roll  of  bread.  The  examination  is  to 
be  made  about  three  and  a  half  to  four  hours  after  the  meal. 

To  obtain  the  contents  of  the  stomach  we  should  use  a  stomach-tube. 
The  tube  is  moistened  with  water  and  the  end  carried  back  to  the 
pharynx  ;  the  patient  is  now  asked  to  swallow,  and  the  tube  is  gently 
pushed  down  the  esophagus,  these  acts  being  repeated  until  the  tube 
reaches  the  stomach.     The  stomach  is  emptied  by  siphonage. 

The  method  I  have  most  frequently  used  is  that  of  "  expression,"  as 
follows :  The  patient  is  asked  to  take  a  deep  inspiration,  and  then  to 
contract  his  abdominal  muscles  as  in  the  act  of  having  a  stool :  in  this 
way  the  contents  are  quickly  expelled  through  the  stomach-tube.  This 
should  be  first  examined  macroscopically  to  detect  any  residue  from  pre- 
vious meals,  such  as  meat  and  the  like,  and  the  quantity  obtained  should 
be  20  to  40  c.c.  After  filtering  the  gastric  contents  thus  obtained  it  is 
rariously  tested. 

Among  qualitative  tests  the  following  are  important: 

To  determine  the  reaction.,  ordinary  litmus-paper  is  used  ;  if  acid,  the 
blue  turns  red. 

The  presence  oi  free  acids  is  determined — (a)  By  Congo-red,  a  solu- 
tion of  which  is  turned  blue  by  the  addition  of  liquids  containing  free 
acids. 

Free  HCl.—  G'dnzhurgs  test — phloroglucin  gr.  xxx  (2.0),  vanillin 
gr.  XV  (1.0),  absolute  alcohol  5J  (30  c.c).  To  two  or  three  drops  of 
this  reagent  add  an  etjual  number  of  the  gastric  filtrate  in  a  porcelain 
dish,  and  slowly  evaporate  to  dryness  over  a  flame;  if  free  HCl  is 
present,  a  rose-red  tint  appears  along  the  edges.  Blowing  at  the  edge 
will  hasten  the  reaction.  The  great  delicacy  of  this  test  is  conclusively 
shown  by  its  availability  when  HCl  is  present  in  the  proportion  of  1  to 
20,000.     There  are  no  recognized  interfering  conditions. 


EXAMINATION  OF  THE  GASTRIC  FUNCTIONS.  779 

Boan  Resorci7i  Test. — Resublimcd  rcsorcin  5  parts,  -white  sugar  3 
parts,  and  diluted  alcohol  100  parts,  'riie  method  of  procedure  is  the 
same  as  in  Giinzburg's  test,  and  a  purple-red  color  appears.  More 
caution  is  required  in  evaporating,  but  this  method  will  also  detect  the 
presence  of  free  HCl  in  the  proportion  of  about  1  :  20,000. 

Topfer'S  Test. — To  a  few  c.c.  of  filtered  (or  unfiltered)  stomach- 
contents,  1  to  4  drops  of  the  reagent  (diniethylamidoazobenzol  in  a  0.5 
per  cent,  alcoholic  solution)  are  added;  in  the  presence  of  free  HCl  a 
rose-  or  cherry-red  color  is  produced.  Combined  HCl  gives  a  negative 
result.  The  presence  of  acid  salts,  peptones,  mucin,  and  starch  (in  the 
usual  percentage)  do  not  interfere  with  this  reaction. 

Lactic  Acid. —  Uffelmanns  Test. — The  reagent  should  always  be 
freshly  made,  as  follows  :  To  10  to  15  c.c.  of  a  2  per  cent,  aqueous 
solution  of  carbolic  acid  add  1  or  2  drops  of  neutral  ferric  chlorid,  when 
an  amethyst-blue  color  will  appear.  To  1  or  2  c.c.  of  the  mixture 
add  a  few  drops  of  the  filtrate,  and  if  lactic  acid  is  present  a  canary-yellow 
color  appears.  Sources  of  error  may  be  overcome  by  shaking  5  or  10 
c.c.  of  the  filtrate  with  double  the  quantity  of  ether,  and,  after  allowing 
the  ether  to  separate  and  pouring  it  oiF,  adding  more  ether  to  the  filtrate, 
again  shaking,  and  repeating  the  washing.  The  ether  is  then  evaporated 
almost  to  dryness  in  a  water-bath.  To  the  residue  about  1  c.c.  of  water 
is  added,  and  to  this  an  equal  quantity  of  the  Uftelmann  reagent  from  a 
pipette ;  and  if  a  canary-yellow  now  appears,  positive  proof  of  the  pres- 
ence of  lactic  acid  is  afforded.  Bread  contains  lactic  acid,  and  hence  it 
is  better  to  employ  a  thin  gruel  made  by  adding  to  a  quart  of  water 
flavored  with  salt  half  an  ounce  of  oatmeal-flour.  Boas  states  that  no 
lactic  acid  is  present  in  the  filtrate  several  hours  after  this  test-meal, 
except  in  cases  of  carcinoma  of  the  stomach.  Lactic  acid  in  the  stomach- 
contents  also  occurs  with  fermentation-stagnation  from  either  obstruc- 
tion or  deficient  motility. 

A  more  reliable  test  for  lactic  acid  than  the  foregoing  is  that  of 
Boas,  as  follows :  Digest  the  filtrate  several  times  with  ether  to  remove 
the  fatty  acids :  add  a  few  drops  of  phosphoric  acid  and  boil.  Transfer 
the  mixture  to  a  distillate  flask  ;  add  H2SO4  and  MgOj ;  heat,  and  lactic 
acid  will  pass  over.  This  can  be  conducted  into  a  strongly  alkaline 
solution  of  iodin  and  potassium  iodid.  The  presence  of  lactic  acid  is  then 
shown  by  the  production  of  iodoform,  which  can  be  recognized  by  its 
odor  and  by  the  precipitate  formed. 

Fatty  or  Volatile  Acids. — Heat  to  boiling  a  few  c.c.  of  the  filtrate  in 
a  test-tube,  over  the  mouth  of  which  place  a  strip  of  moistened  blue 
litmus-paper ;  the  presence  of  fatty  acids  will  change  the  paper  to  red. 

Acetic  Acid. — In  large  quantities  this  acid  is  detected  by  its  odor, 
and  in  smaller  quantities  its  presence  is  determined  by  neutralizing 
with  sodium  carbonate  the  watery  residue  of  the  ethereal  extract,  and 
adding  neutral  ferric  chlorid,  when  a  blood-red  color  develops.  Quanti- 
tative estimation  of  certain  constituents  is  desirable. 

Total  Acidity. — To  10  c.c.  of  the  filtrate  add  1  or  2  drops  of  a  1  per 
cent,  alcoholic  solution  of  phenophthalein,  and  decinormal  solution  of 
sodium  hydrate  is  added  slowly  from  a  buret  until  the  reddish  color  that 
appears  fails  to  disappear  on  shaking.  The  number  of  cubic  centimeters 
of  the  decinormal   solution    normally   required    ranges    from    4   to    6 ; 


780  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

hence,  if  these  be  niultiplit'd  by  10,  ^\e  have  40  to  60  as  the  per- 
centage of  acidity.  Under  patlii)logic  conditions  these  numbers  may 
be  either  higher  or  k)wer.  This  total  rej)resents  both  free  and  com- 
bined acids.  If  no  organic  acids  be  present,  the  above  figures  will 
represent  the  percentage  of  IICI.  The  latter  is  also  reckoned  thus:  If 
it  re(juired  5  c.c.  of  the  decinormal  solution  of  sodium  liydrate  to  be 
added  to  10  c.c.  of  the  filtrate  to  get  the  red  color  (alkalinity)  with  the 
phenophthalein,  we  say  the  acidity  is  50,  and  multiplied  by  0.003,646  = 
0.1823  per  cent,  of  hydrochloric  acid,  'i'he  noriual  langc  of  percentage 
is  from  0.1  to  0.22. 

£)<tiinatio)i  of  Free  HCl. — Mintzs  method:  To  10  c.c.  of  the  filtrate 
add  a  decinormal  solution  of  sodium  hydrate  from  a  buret  until  no  re- 
action is  given  with  Glinzburg's  reagent.  The  number  of  c.c.  of  the 
decinormal  solution  used,  multiplied  by  10  and  then  by  0.003,646,  gives 
the  percentage  of  free  hydrochloric  acid. 

Topfer's  Method. — To  10  c.c.  of  filtered  gastric  juice  1  or  2  drops 
of  Topfer's  reagent  are  added,  and  then  also  a  decinormal  solution  of 
soda,  drop  by  drop,  until  the  last  trace  of  red  has  changed  to  yellow. 
To  estimate  the  percentage  of  HCl,  the  number  of  c.c.  of  soda  solution 
re([uired  to  neutralize  the  free  HCl  in  100  c.c.  of  stomach-contents  is  multi- 
plied by  0.00365.  Examj)le :  To  remove  the  red  color  4  c.c.  of  soda  solution 
are  retjuired  :  hence,  0.00365  X  40  =  0.14,  the  percentage  of  free  HCl. 

Estimation  of  Combined  HCl. — The  difference  between  the  total 
aciditv  and  the  percentage  of  free  hydrochloric  acid  represents  approxi- 
mately the  percentage  of  combined  hydrochloric  acid. 

Estimation  of  Lactic  Acid. — If  the  volatile  acids  are  present,  they 
should  be  removed  by  boiling.  Take  the  total  acidity  of  10  c.c.  of  the 
filtrate;  then  to  a  second  10  c.c.  add  25  to  30  c.c.  of  ether;  shake 
well,  allow  the  ether  and  filtrate  to  separate,  remove  the  ether,  and 
again  add  25  to  30  c.c.  of  ether  ;  shake,  and  repeat  the  process.  Next 
obtain  the  acidity  of  the  watery  solution,  and  the  difference  between 
this  and  the  total  acidity,  multiplied  by  10  X  0.09,  will  give  approxi- 
mately the  amount  of  lactic  acid. 

In  the  gastric  digestion  of  the  albuminoids  (proteolysis)  the  proteidg 
are  converted  into  peptone.  The  degree  of  hydration  of  albumins  during 
the  various  steps  of  digestion  are  of  little  clinical  value. 

In  a  later  stage  of  the  process  of  albumin-digestion  peptone  is  pro- 
duced and  its  detection  is  easy.  To  a  small  quantity  of  the  filtrate  (the 
propeptone  having  been  removed)  add  enough  sodium  or  potassium  hy- 
drate to  render  the  solution  alkaline ;  then  add  a  few  drops  of  a  1  per 
cent,  solution  of  cupric  sulphate,  and,  if  peptone  be  present,  a  rose-red 
color  is  presented. 

The  Test  for  Pepsin. — To  a  test-tube  containing  15  c.c.  of  filtrate 
add  a  small  piece  of  egg-albumen,  and  keep  at  a  temjierature  of  about 
100"^  F.  ;  if  present,  the  albumen  disappears  in  from  two  to  six  hours. 
If  hydrochloric  acid  is  absent  from  the  filtrate,  add  a  few  drops  of  the 
dilute  acid.  It  should  be  pointed  out  that  laboratory  attempts  to  esti- 
mate the  rate  of  albumin-djgcstion  are  unreliable. 

Rennet  Ferment. — To  10  c.c.  of  raw  milk  aild  five  drops  of  the  gas- 
tric filtrate,  and  keep  it  at  a  temperature  of  about  100°  F. ;  if  rennet  is 
present,  coagulation  into  a  single  cake  occurs  in  from  a  few  minutes  to 
an  hour  or  more. 


EXAMINATION  OF  THE   GA,STniC  FUNCTIONS.  781 

Rennet  Zyinoyea  (which  is  converted  into  rcMuat  fermc/nt  in  tlie  pres- 
ence of  an  acid). — To  5  c.c.  of  gastric  filtrate  add  onougli  sodium  car- 
bonate or  sodium  hydrate  to  make  it 'sli;i;htly  alkaline;  then  add  calcium 
chlorid  (1-2  c.c.  of  a  2  per  cent,  solution);  then  mix  with  an  etjual  quan- 
tity of  milk,  and,  if  zymogen  is  present,  coagulation  occurs  as  in  the 
case  of  rennet  ferment.  Both  rennet  ferment  and  rennet  zymogen  may 
be  assumed  to  be  present  when  IICl  has  previously  been  found. 

Starchy  Derivatives. — To  10  c.c.  of  gastric  filtrate  add  1  or  2 
drops  of  Lugol's  solution;  the  presence  of  dextrin  gives  a  blue  re- 
action— erythrodextrin  purple,  achroodextrin,  grape-sugar,  and  malt- 
ose (intermediate  substances) — showing  a  yellowish  color.  If  there  is  a 
mixture  of  these  starchy  derivatives,  as  when  the  digestion  of  starches 
proceeds  naturally,  the  first  few  drops  of  Lugol's  solution  may  produce 
no  color-reaction,  or  it  may  be  taken  up  by  the  dextrose  or  maltose,  while 
the  addition  of  more  of  Lugol's  solution  will  give  a  purple  (if  erythro- 
dextrin be  present)  or  a  blue  color,  due  to  starch. 

Indeed,  if  a  minute  quantity  of  the  solution  strikes  a  blue  or  purple 
tinge,  conversion  of  starch  into  maltose  has  been  abnormally  tardy.  I 
believe  this  is  oftenest  due  to  hyperacidity,  though  it  may  also  more 
rarely  be  due  to  a  defective  ptvaline-supply.'  For  methods  of  detecting 
occult  blood,  see  p.  832. 

The  Tests  for  the  Motor  Function. — More  important  than  the  secret- 
ory is  the  motor  function  of  the  stomach.     There  are  several  tests. 

The  oldest  method  is  that  of  Leube.  It  consists  in  washing  out  the 
stomach  from  six  to  seven  hours  after  a  large  meal,  preferably  consisting 
of  beef-soup  (13  oz.),  beefsteak  (6|^  oz.),  bread  (IJ  oz.),  and  water  (6J 
oz.),  or  from  two  to  two  and  a  half  hours  after  Ewald's  test-breakfast. 
Normally,  the  stomach  should  be  empty  within  these  periods  of  time,  so 
that  if  a  residue  remains  it  denotes  a  lack  in  the  motor  force.  Boas  rec- 
ommends the  giving  of  400  c.c.  of  water  to  which  20  drops  of  chlorophyll 
(concentrated  aqueous  solution)  have  been  added.  Thirty  minutes  after 
the  patient  has  drunk  this,  the  stomach-tube  is  passed.  With  normal 
motility  about  50  to  60  c.c.  are  recovered. 

To  Test  the  Absorptive  Power. — The  method  described  by  Penzoldt 
has  been  almost  universally  adopted:  A  capsule  containing  0.2  to  0.3 
grams  of  potassium  iodid  is  given  to  the  patient  just  prior  to  the  taking 
of  a  full  meal.  The  iodid  is  absorbed  from  the  stomach  and  appears  in 
the  saliva,  normally  in  ten  to  fifteen  minutes.  The  saliva  being  tested 
every  three  minutes  by  strips  of  filter-paper  wet  with  starch  solution,  the 
characteristic  blue  color  being  observed  as  the  iodin  enters  the  saliva. 
The  reaction  may  be  delayed  for  a  half-hour  or  more  and  rarely  may  fail 
to  appear  at  all.  In  the  Sahli  desmoid  test  the  patient  swallows  a  little 
iodoform  or  methylene-blue  wrapped  in  rubber  tissue  and  tied  with  raw 
catgut ;  the  time  required  for  their  appearance  in  the  urine  corresponds 
to  the  state  of  the  secretory  functions. 

1  The  tests  for  the  estimation  of  the  combined  acids,  of  some  of  the  fatty  acids,  and 
of  many  of  the  products  of  proteolysis  are  complicated  and  unnecessary  in  an  ordinary 
clinical  examination. 


782  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


PHYSICAL    OR   EXTERNAL   EXAMINATION. 

This  implies  the  well-known  pliysical  signs — inspection,  palpation, 
percussion,  and  auscultation,  inehuling  succussion  or  splashing. 

Inspection. — (<;)  General. — This  may  give  an  idea  of  the  nature  of 
the  illness  as  well  as  its  severity  by  noting  whether  the  patient  appears 
to  belong  to  a  neurotic  group,  the  general  health  often  being  good,  or 
whether  the  patient  is  emaciated,  or  has  with  the  latter  the  cachexia  of 
a  malignant  growth.  In  diseases  of  the  stomach  attention  should  be  di- 
rected to  the  mouth,  and  especially  to  the  teeth,  those  may  be  of  causal 
importance  in  gastric  ailments,  and  frequently  prevent  their  cure. 

(5)  Local  Inspection. — In  patients  with  thin  and  relaxed  abdominal 
walls  the  contour  of  the  stomach  can  be  plainly  noted ;  especially  is  this 
the  case  in  very  large,  dilated  stomachs  or  in  those  that  have  been  dis- 
placed. The  examiner  is  greatly  aided  by  inflating  the  stomach  with 
air  or  gas.  The  former  is  to  be  preferred,  for  the  reason  that  the  supply 
is  easily  regulated ;  he  is  enabled  to  Avatch  the  different  steps  of  the  dis- 
tention, and  after  the  examination  is  completed  the  air  is  allowed  to 
escape  through  the  tube.  For  this  purpose  an  ordinary  stomach-tube  is 
most  convenient,  and  its  passage  is  to  be  effected  in  the  same  way  as  in 
removing  the  gastric  contents.  A  double  bulb-attachment  is  connected 
with  the  external  end  of  the  tube,  by  means  of  which  air  is  readily 
forced  into  the  stomach  (Runeberg's  method). 

Frerichg'  method  is  sometimes  used.  It  consists  in  administering 
3j  (4.0)  of  tartaric  acid,  dissolved  in  half  a  glassful  of  water,  and  im- 
mediately afterward  3j  (4.0)  of  sodium  bicarbonate,  dissolved  in  the  same 
amount  of  water.  Effervescence  now  occurs,  with  a  progressive  visible 
distention  of  the  organ.      There  are  many  objections  to  this  method. 

The  inflated  stomach  presents  a  circumscribed  protuberance,  usually 
in  the  epigastric,  and  also  in  the  umbilical  region  if  the  organ  is  dis- 
located or  dilated.  The  air  may  find  its  way  into  the  intestine,  produ- 
cing a  visible  change  in  the  contour  of  the  abdomen.  Tumors  and 
other  abdominal  enlargements  may  also  be  recognized,  and  an  idea 
obtained  as  to  which  organ  is  involved,  after  making  due  allowances  for 
displacement,  as  in  gastroptosis  and  pyloric  carcinoma.  Exaggerated 
peristaltic  waves  may  also  be  noticeable  in  the  upper  portion  of  the 
abdomen,  usually  when  associated  with  the  stomach,  and  in  the  lower 
portion  if  it  is  in  the  small  intestine.  Peristalsis  is  increased  from 
various  causes — inflation  of  the  stomach,  external  tapping,  neuroses, 
pyloric  obstruction,  and  the  like. 

The  value  of  the  gastroscope  in  inspecting  the  interior  of  the  stom- 
ach is,  I  think,  questionable.  Gastro-diaphany  (illumination  of  the 
stomach)  is  sometimes  useful  in  showing  the  fundus  extending  to  a  lower 
level  (at  the  navel)  than  is  indicated  by  percussion,  and  in  indicating 
the  presence  of  tumors  in  the  anterior  wall  of  this  organ.  The  Rontgen 
rays  show  the  outline  of  the  stomach,  though  indistinctly,  after  the  ad- 
ministration of  bismuth  subnitrate  (oj — 31.0). 

Palpation. — This  elicits  at  times  more  trustworthy  information  than 
inspection.  The  patient  should  be  in  the  recumbent  position,  the  lower 
limbs  partially  flexed  on  the  abdomen  and  the  head  low.  The  examiner 
should  stand  at  the  right  side  of  the  patient  and  use  the  right  hand, 


PHYSICAL    OR   EXTEENy\L  EXAMINyiTION.  783 

which  should  be  warm.  With  the  pahnar  .surface  down  f/ientli;  pressure 
should  be  made  with  the  fingers  and  the  ulnar  side  of  the  band.  If 
the  abdominal  wall  is  tense,  it  is  best  to  distract  the  attention  of  the 
patient  from  the  examination  by  talking  to  him.  In  this  manner  we 
can  corroborate  inspection  as  to  the  size,  shape,  and  position  of  the  stom- 
ach, and  can  detect  morbid  growths  as  well  as  determine  their  consist- 
ency and  movability. 

Beep  palpation,  by  increasing  pressure  with  a  slightly  rotatory  move- 
ment, elicits  the  degree  of  sensitiveness,  tenderness,  or  pain,  whether 
circumscribed  as  in  ulcer  or  diflFuse  as  in  generalized  inflammatory  states 
(enterocolitis,  peritonitis).  In  deep-seated  tumors  palpation  should  also 
be  made  in  the  knee-elbow  position,  and  if  movable  they  may  drop  to 
the  abdominal  wall.  Gurgling  and  succussion-sounds  of  some  diag- 
nostic value  may  be  elicited.  In  some  instances  relief  from  pain  may 
be  noted  on  pressure  with  the  broad  hand  in  neuroses.  Variations  in 
the  degree  of  tension  and  of  resistance  are  found  and  prove  helpful. 

Percussion. — The  patient  is  placed  in  the  recumbent  position ;  the 
examiner  uses  his  fingers  and  endeavors  to  discriminate  the  slightest 
differences  in  the  note,  and -percusses  lightly.  If  the  stomach  is  empty 
or  partially  filled  with  gas,  it  gives  a  lower  tympanitic  sound  than  the 
colon.  To  ascertain  the  size  and  position  of  the  stomach  by  percussion 
the  process  should  begin  at  the  symphysis  pubis  and  follow  the  median 
line  upward.  The  upper  border  of  the  stomach  is  at  the  ensiform  car- 
tilage, the  lower  about  two  fingers'  breadth  (3  cm.)  above  the  umbilicus. 
If  the  upper  margin  is  some  distance  below  the  ensiform,  displacement 
of  the  organ  is  indicated ;  this  depression  may  be  occasioned  by  various 
diseases  of  the  thorax.  The  stomach  may  be  elevated  by  great  dis- 
tention of  the  gut  or  peritoneal  sac. 

It  is  well  to  trace  the  limits  of  resonance  of  the  stomach  and  of  any 
areas  of  dulness  met  with,  so  that  their  size  and  position  may  be  graph- 
ically represented.  The  differences  in  the  percussion-note  over  the 
stomach  and  colon  may  be  greatly  exaggerated  by  inflating  the  former. 
Runeberg's  method  is  to  be  preferred.  By  employing  light  percussion 
the  limits  of  the  stomach  can  now  be  easily  and  accurately  defined, 
unless  the  transverse  colon  be  at  the  same  time  greatly  distended 
with  gas.  In  such  instances  Dehio's  modification  of  Piorry's  method  is 
to  be  resorted  to.  It  consists  in  giving  about  1  liter  (1  quart)  of  water 
in  fractional  doses  while  the  patient  is  standing ;  one-quarter  of  the 
liter  is  swallowed  and  percussion  practised,  when  a  dull  note  will  be 
obtained  over  the  most  dependent  portion  of  the  stomach.  A  second 
quantity  of  equal  amount  is  given  and  a  re-examination  made,  and  so 
on,  the  object  being  to  ascertain  to  what  point  the  lower  border  sinks  on 
the  addition  of  more  fluid.  Boas  holds  that  this  method  tests  effectively 
the  tone  of  the  stomach,  and  that  a  marked  descent  of  the  lower  border 
after  each  addition  of  water  is  indubitable  evidence  that  there  exists 
weakness  or  atony  of  its  walls.  If  a  neoplasm  originates  posterior  to 
the  stomach  or  colon,  inflation  of  the  latter  may  cause  the  pre^^ous 
circumscribed  dulness  to  disappear. 

By  striking  the  abdomen  in  the  epigastric  region  splashing-sounds 
may  be  produced.  This  sign  is  of  diagnostic  value  in  dilatation  of  the 
stomach,  though   its  absence  does   not  contradict  the  presence  of  the 


784  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

(lihitatiou.  Again,  if  the  splashing-sound  is  obtained  in  a  fasting  stom- 
ach, it  may  give  a  clue  to  some  abnormal  condition.  The  stomach  may 
contain  large  quantities  of  fluid  and  no  Sj)lashing-sound  be  obtained. 
Caution  should  be  exercised  lest  the  splashing-sound  sometimes  pro- 
duced in  the  transverse  colon  be  mistaken  for  that  originating  in  the 
Stomach  ;  in  the  former  tlie  sound  is  usually  associated  Avith  diarrhea, 
while  in  the  latter  constipation  usually  obtains.  The  outlines  of  the 
stomach  can  be  most  satisfactorily  determined  by  auscultatory  percussion. 

Auscultation. — Various  sounds  are  heard,  none  of  -which  are  pathog- 
nomonic of  any  diseased  condition. 

Succussioyi-soinids  are  produced  by  shaking  the  patient,  and,  if  the 
stomach  is  dilated  and  contains  fluid,  a  splashing  sound'  may  be  audible 
some  distance  from  the  patient,  and  -when  heard  after  digestion  has  been 
completed  they  indicate  some  abnormal  condition.  Heard  below  the 
umbilical  line,  they  usually  indicate  dilatation.  In  motor  insuificiency 
(atony)  of  the  stomach-walls  splashing-sounds  are  audible  after  swallowing 
a  few  ounces  of  water.  Partial  obstruction  of  the  cardiac  orifice  causes 
a  delay  of  the  "deglutition  murmur"  (a  hissing  sound  followed  in  six  or 
seven  seconds  by  either  gurgling,  sprinkling,  or  splashing),  as  heard 
over  the  esophagus  with  the  stethoscope  while  the  patient  is  swallowing 
a  liquid,  "  while  in  complete  or  almost  complete  closure  of  the  cardia, 
this  murmur  is  absent"  (Ewald). 


MALPOSITION  OF  THE  STOMACH. 

The  stomach  may  occupy  a  truly  vertical  position  in  consequence  of 
the  persistence  of  the  normal  infantile  condition  or  of  improper  cloth- 
ing— e.  g.  long-continued  pressure  from  corsets.  Unless  an  angular 
condition  of  the  duodenum,  causing  obstruction  to  the  outflow  of  the 
gastric  contents,  followed  by  dilatation  of  the  stomach,  be  engendered, 
the  malposition  is  of  little  or  no  clinical  significance.  Transposition  of 
the  stomach,  with  the  organ  occupying  the  right  hydochondrium,  is 
rarely  met  in  association  with  transposition  of  other  viscera. 

GASTROPTOSIS. 

Definition. — Downward  displacement  of  the  stomach.  The  lesser 
curvature  of  the  organ  lies  normall}^  about  midway  between  the  ensiform 
cartilage  and  the  umbilicus,  and  the  greater  curvature  may  descend  to 
near  the  symphysis  pubis. 

Btiology.-^So  far  as  our  present  knoAvledge  extends,  the  conditions 
and  circumstances  contributing  mostly  to  the  origin  and  development 
of  gastroptosis  are — {a)  Age  and  sex.  ^Nleinert  of  Dresden  found 
among  girls  of  fourteen  years  gastroptosis  in  80  per  cent.,  and  among 
the  women  who  presented  themselves  at  his  private  clinic  in  90  per  cent. 
According  to  my  observation,  gastroptosis  is  not  as  frequent  among 
American  girls  and  women  as  among  the  Germans.  "  Dislocation 
occurs  in  about  5  per  cent,  of  the  male  population  of  Dresden."  {b) 
Improper  clothing,  particularly  tight  lacing,  (c)  Dislocation  of  the 
right  kidney.  This  operates  potently,  and  prolapse  of  other  abdominal 
organs,   as    the    liver    and    intestines,    is    often    associated,  and    may 


GASTROPTOSIS.  785 

constitute  the  chief  point  of  (h;p;irture.  {(J)  Repeated  pregnancies,  in- 
ducing a  relaxed  state  of  the  abdominal  wall,  (e)  Muscular  strain  and 
local  injury,  by  diminishing  the  tonicity  of  the  gastrohepatic  omentum. 
(/)  Abnormalities  of  the  chest-formation  (kyphosis) ;  gastrectasis  ;  great 
meteorism,  and  enlargement  of  the  abdominal  organs,  especially  of  the 
spleen  and  liver.  Certain  chronic  disea.ses  may  be  active — e.  g.,  chloro- 
sis, tuberculosis,     (g)   Congenital  weakness  of  the  supporting  ligaments. 

Symptoms. — Malposition  of  the  stomach  may  exist  without  symp- 
toms, but  commonly  it  produces  functional  disturbances  of  clinical  im- 
portance. The  latter  are  due,  first,  to  the  difficulty  that  the  stomach 
experiences  in  emptying  its  contents.  Soon  functional  disorders  arise  in 
consequence  of  gastric  atony,  and  later  there  is  apt  to  be  a  greatly 
diminished  gastric  secretion  and  motility,  associated  with  dyspepsia  and 
neurasthenia.  The  stomach  may  be  of  natural  or  of  diminished  size  (as 
the  primary  result  of  the  compression  of  the  corsets — Fleiner)  or  it  may 
be  dilated.  Goyistipation,  due  to  defective  peristalis,  and  coliclzy  jjain%^ 
due  to  spasm  of  the  intestinal  muscles,  are  important  features.  Diarrhea 
is  sometimes  present. 

Physical  examination  of  the  inflated  stomach  '  permits  the  accurate 
demonstration  of  gastroptosis.  The  epigastrium  is  hollowed,  while  the 
lower  quadrants  of  the  abdomen  are  prominent.  The  percussion-note 
now  indicates  the  position  of  the  organ.  It  is  to  be  borne  in  mind  that 
the  cardiac  end  remains  fixed  at  the  twelfth  dorsal  vertebra,  while  the 
pylorus  moves  downward  and  to  the  left:  this  will  explain  why  the 
epigastrium  is  free  of  gastric  tympany.  Dilatation  of  the  pyloric  end  is 
present  in  varying  degree  in  most  cases.  Much  more  rarely  general 
dilatation  is  found  with  gastroptosis.  Succussion  splashhig-sounds  may 
be  heard  if  atony,  with  retained  gastric  contents,  obtains.  The  differen- 
tiation of  gastroptosis  from  dilatation  of  the  stomach  is  also  accomplished 
by  the  method  of  inflation,  since  this  makes  plain  the  course  and  position 
of  the  lesser  curvature  and  of  the  pylorus. 

The  prognosis  is  not  unfavorable  as  to  life  and  is  frequently 
modified  by  the  presence  of  special  causal  agencies,  and  in  others  by  the 
occurrence  of  certain  complications,  as  dilatation  of  the  stomach. 

The  treatment  has  relation  to  the  removal  of  all  causative  condi- 
tions. Sufficient  rest  after  confinement  is  an  important  preventive 
measure.  The  abdominal  walls  should  be  strengthened  by  means  of 
suitable  gymnastic  and  athletic  exercises  in  childhood  and  youth.  Mas- 
sage, and  recumbency,  preferably  on  the  right  side,  after  somewhat  re- 
stricted meals  should  be  enjoined.  Many  cases  are  relieved  by  the  sup- 
port of  a  properly  adjusted  belt  and  pad.  McCoskey  advises,  for  the 
support  of  the  viscera,  a  strip  of  zinc  oxid  adhesive  plaster  across  the 
lower  abdomen,  to  each  end  of  which  is  attached  a  bandage  long 
enough  to  reach  around  the  body  above  the  iliac  crest.^  Borgbjarg  and 
Fischer  lift  the  stomach  by  inflating  a  bag  underneath  an  inelastic  corset. 
Gastrorrhaphy  and  shortening  of  the  gastrohepatic  and  gastrophrenic 
hgaments  have  given  promising  results. 

1  Inflation  may  be  accomplished  by  the  introduction  of  atmospheric  air  {vide  ante). 

2  For  details,  see  Jour.  Amer.  Med.  Assoc.,  Oct.  28,  1911. 

50 


786  DISEASED  OF  THE  DIUESTIVE  SYSTEM. 

DILATATION   OF  THE   STOMACH. 

{Gastrectasis.) 

The  condition  is  to  be  subdivided,  clinically,  into  acute  and  chronic 
forms.  The  normal  capacity  of  the  stomach  varies  within  rather  wide 
limits,  though  the  maxinuuii  normal  capacity,  according  to  Ewald,  does 
not  exceed  1600  c.c.  (1.5  quarts);  enlargements  above  this  capacity 
may  then  be  said  to  fall   under  the  heading  of  dilatation. 

Btiology  and  Patholog"y. — Tlic  chief  factor  in  the  production  of 
chronic  dilatation  is  pyloric  stenosis.  This  is  usually  due  (d)  to  carcinoma, 
cicatrix  of  an  ulcer,  fibroid  overgrowth  and  spasm  of  the  pylorus,  or  the 
contraction  consequent  on  the  action  of  corrosive  poisons;  (b)  to  the  ex- 
ternal compression  arising  from  carcinoma  of  the  liver,  pancreas,  or  gall- 
bladder, the  omental  lym])h-g]ands.  and  a  ilisplaced  right  kidney,  or  from 
large  gall-stones ;  (c)  to  perigastric  and  duodenal  adhesions — c.  //.,  with 
the  gall-bladder,  and  congenital  pyloric  stenosis. 

In  all  such  instances  increased  force  is  necessary  to  propel  the  food 
from  the  stomach  into  the  duodenum,  thus  leading  gradually  to  a  hyper- 
trophy of  the  muscular  fibers,  particularly  in  the  immediate  vicinity  of 
the  pylorus.  So  long  as  this  hypertrophied  state  of  the  muscular  layer 
compensates  for  the  obstructive  lesion,  pathologic  dilatation  cannot  occur. 
Just  as  soon,  however,  as  the  muscles  prove  to  be  inadequate  on  account 
of  secondary  degenerative  changes,  accumulation  of  the  food  in  the 
stomach  ensues.  This  tendency  for  the  contents  of  the  stomach  to  accu- 
mulate is  very  much  augmented  by  the  increasing  weakness  of  the  muscle 
on  the  one  hand  and  the  progressing  degree  of  stenosis  on  the  other. 
Chronic  gastric  catarrh  ensues  in  consequence  of  the  chemical  (from 
putrefactive  changes)  and  mechanical  effect  of  the  undigested  food.  The 
degree  of  dilatation  is  enhanced  by  the  generation  of  excessive  quan- 
tities of  gases  under  these  abnormal  conditions,  as  well  as  by  the  great 
weight  of  the  accumulated  gastric  contents.  "When  produced  in  this 
manner  the  stomach  attains  enormous  dimensions.  Dilatation  is  usually' 
general,  though  there  may  be  mere  diverticula. 

Dilatation  may  also  occur  independnitly  of  pyloric  stmosis,  although 
less  commonly,  and  the  condition  is  not  so  pronounced.  In  this  variety 
there  is  atony  of  the  muscular  coats,  due  to  various  and  dissimilar  causes  : 
(a)  repeated  overstrain  of  the  muscular  layer,  due  to  overfilling  of  the 
organ  with  food  and  drink,  met  with  in  diabetics  and  in  those  who 
habitually  drink  large  quantities  of  beer ;  ih)  chronic  gastric  catarrh  and 
sclerosis,  due  to  old  ulcers,  frequently  Aveaken  the  muscle;  (c)  fatty  and 
other  forms  of  degeneration  or  nutritional  disturbances  associated  with 
certain  constitutional  diseases  (particularly  carcinoma,  anemia,  and  tuber- 
culosis);  (d)  congenital  weakness  of  the  muscular  coat  (myasthenia);  (e) 
impaired  innervation,  leading  to  imperfect  peristalsis  and  consequent  dila- 
tation ;  (/)  omental  hernias  (Bamberger)  that  drag  down  the  stomach; 
(g)  perigastric  and  periduodenal  adhesions  without  narrowing  of  the  gut 
or  pylorus  (F.  Billings) ;  (/<)  gastroptosis. 

Acute  dilatation  has  for  its  chief  causes — (a)  specific  fevers,  producing 
parenchymatous  degeneration  of  the  muscular  coats ;  (b)  the  acute  para- 


DILATATION   OF  TIIK  STOMACH.  7H7 

lytic  distention  of  Fagge,  due  to  chronic  catarrlial  inflanirriation  ;  (<;)  tlie 
drinking  of  largo  qiiiintities  of  eflervoscing  liquids;  (tf)  following  shook 
(Boas,  Rosenheim);  (e)  suddc^n  obstruction  of  the  pylorus  and  of  the  duo- 
denum (Bettmann);  (/)  dietetic  errors;  (^)  traunja  ;  and  (h)  post-opera- 
tive.    According  to  Neck,'  there  are  60  cases  on  record. 

Clinical  History. — Since  the  diseases  causing  dilatation  are  numer- 
ous and  diverse,  the  clinical  history  presents  great  variations.  I'lie 
symptoms  of  dilatation  are  sometimes  overshadowed  by  those  of  the 
causal  affections.  Among  the  earlier  symptoms,  increased  hunger  and 
thirst  are  frequently  observed,  partly  due,  most  probably,  to  inanition. 
The  thirst  is  also  due,  according  to  Von  Weinig,  to  the  fact  that  the 
stomach  does  not  readily  absorb  water,  and  the  pyloric  obstruction  pre- 
vents the  passage  of  water  into  the  intestines.  Vomiting  occurs  at  inter- 
vals of  several  days,  the  matter  ejected  amounting  to  from  1  to  3  gallons 
(4-12  liters).  Occasionally  the  vomiting  occurs  more  or  less  regularly 
some  hours  after  feeding.  The  clinical  characters  of  the  vomitus  are 
strikingly  peculiar.  The  ejecta  often  contain  remnants  of  previous 
meals,  are,  as  a  rule,  excessively  acid,  emitting  a  sour  odor,  and  on  mi- 
croscopic examination  they  show  bacteria,  sarcinae,  and  torulse  in  great 
numbers.  The  vomitus  undergoes  fermentative  changes  very  rapidly,  is 
ill-smelling,  the  odors  being  mainly  due  to  sulphuretted  and  phosphuretted 
hydrogen.  It  consists  of  acetic,  butyric,  and  lactic  acids  and  partially 
decomposed  food  (HCl  being  usually  absent),  and  on  standing  separates 
into  three  layers — an  upper  layer  of  brownish  froth,  a  middle  one  of 
grayish-brown  fluid,  and  a  lower  one  composed  of  remnants  of  food.  The 
acid  contents  of  the  stomach  are  not  infrequently  regurgitated,  causing 
pyrosis.  Eructations  of  foul  gases  are  also  common.  A  dragging  pain 
is  often  present  in  the  upper  abdomen,  most  intense  after  eating. 

Certain  general  symptoms  almost  invariably  ensue.  Progressive 
emaciation  naturally  follows,  sometimes  becoming  extreme.  A  charac- 
teristic symptom  is  muscular  cramp  affecting  the  calves  of  the  legs  and 
sometimes  spreading  to  the  flexors  of  the  arms  and  the  abdominal  muscles. 
Owing  to  the  fact  that  but  a  small  amount  of  liquid  reaches  the  intestines, 
and  also  to  the  impaired  absorption  of  the  stomach,  there  are  co7istip)ation 
iand  scanty  urine,  usually  alkaline  in  reaction.  The  nervous  phenomena 
of  gastritis  are  in  evidence  and  insomnia  is  often  pronounced.  Loss  of 
consciousness  has  been  met  with.  Tetany,  with  which  indicanuria  may 
be  associated,  particularly  after  lavage,  has  also  been  observed.  A 
striking  instance  is  reported  by  J.  T.  Whitcomb,  in  which  nearly  all  the 
muscles  of  the  body  appeared  to  be  in  a  tetanic  condition.  Cardiac  pal- 
pitation and  arrhythmia  are  often  present  and  are  induced  principally  by 
the  effects  of  the  dilatation.     Nocturnal  dyspnea  (asthma  ?)  may  develop. 

Physical  Signs. — Inspectio7i  may  reveal  a  rounded  prominence  just 
above  the  umbilicus,  patient  in  the  supine  posture,  and  just  below  the 
umbilicus  when  standing.  In  the  epigastric  region  there  is  sometimes  a 
noticeable  depression.  The  outline  of  the  stomach  may  be  made  dis- 
tinct by  the  patient  taking  an  effervescing  draught,  and  may  sometimes 
be  readily  seen.  The  outline  of  the  greater  curvature  is  at  times  visible, 
•'passing  obliquely  from  the  tip  of  the  tenth  rib  on  the  left  side  toward 
^Jour.  Arner.  Med.  Assoc,  Nov.  10,  1906. 


788  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  pubes,  and  theu  curving  upwani  to  the  right  costal  margin.'"  Some- 
times peristalsis  is  visible  through  the  abdominal  walls,  and  rarely  the 
peristaltic  waves  are  seen  passing  from  right  to  left.  These  movements 
may  be  excited  mechanically  by  various  manipulations.  Palpation. — 
The  increased  resistance  of  the  walls  of  the  stomach  and  their  peculiar 
elasticity  aid  us  in  mapping  out  the  contour  of  the  stomach  with  more 
precision  by  palpation  than  by  inspection  alone.  The  movements  of  the 
organ  can  be  plainly  felt.  A  sign  of  considerable  value  is  the  loud 
splashing  sound  obtained  by  tapping  the  region  of  the  stomach  with 
the  finger-tips  of  both  hands  alternately,  or  by  shaking  the  body  while 
the  hand  is  placed  over  the  epigastrium,  though  this  should  be  dis- 
tinguished from  a  similar  sound  produced  in  the  colon.  The  patient  may 
produce  and  maintain  similar  splashing  sounds  by  voluntary  efforts. 
l\nx'ussion  furnishes  subsidiary  evidence  as  compared  with  palpation. 
The  examiner  should  first  percuss  the  empty,  and  then  the  filled  stom- 
ach, if  he  would  obtain  reliable  aid  from  this  sign.  When  empty, 
an  increased  area  of  tympanitic  resonance  will  be  obtained,  extend- 
ing from  above  downward  to  a  point  several  inches  below  the  um- 
bilicus. If  now  water  amounting  to  1  quart  (1  liter)  be  introduced 
into  the  organ,  and,  in  consequence,  a  line  of  dulness  at  or  below 
the  navel  be  noted  where  tympanitic  resonance  had  been  found,  we  have 
good  evidence  of  the  existence  of  dilatation.  The  posture  of  the  patient 
should  next  be  changed,  when  it  will  be  found  that  the  line  of  dulness 
has  also  altered.  The  stomach  may  be  inflated  by  gas  or  air  (vide 
Physical  Examination)  :uid  its  limits  mapped  out  by  auscultatory  percus- 
sion. Auscultation  reveals  little  that  is  of  diagnostic  value.  The  transmit- 
ted sounds  heard  over  the  stomach  have  a  metallic  ring.  I  have  confirmed 
the  observation  by  Franck  and  others,  who  claimed  to  have  heard  pecu- 
liar gurgling  sounds  produced  by  the  heart's  action  and  systolic  in 
rhythm.  Fluids  swallowed  by  the  patient  may  be  heard  dropping  into 
the  dilated  stomach,  and  euccussion-sounds  may  be  elicited  by  shaking 
his  body.  Measurements  made  by  introducing  a  probang  into  the  stom- 
ach until  it  reaches  the  greater  curvature  are  valuable  only  when  tha 
degree  of  dilatation  is  considerable.  In  health  the  instrument  passes 
about  60  cm.  (24  inches),  reaching  a  point  more  or  less  nearly  on  a  level 
with  the  umbilicus,  while  in  extreme  dilatation  it  may  be  introduced  70 
cm.  (28  inches).  Dilatation  can  also  be  determined  by  an  2;-ray  ex- 
amination. 

Diagnosis. — The  diagnosis  embraces,  first  and  foremost,  the  recog- 
nition of  the  special  causes.  The  unmistakable  clinical  manifestations 
are  the  characters  of  the  vomitus  and  the  peculiar  manner  of  recurrence 
of  the  vomiting.  The  foregoing  points,  together  with  the  physical  signs, 
are  adequate  for  a  positive  diagnosis. 

Differential  Diagnosis. — The  condition  is  apt  to  be  confounded  with 
ascites  or  ovcrdistention  of  the  bowel,  and  in  the  female  with  ovarian 
cyst.  In  dilatation  of  the  intestines  the  gastric  symptoms  of  dilatation 
of  the  stomach  are  wanting ;  moreover,  the  physical  signs  are  dissimilar. 
The  splashing  sounds  on  manipulation,  the  line  of  dulness  below  the 
umbilicus  after  filling  the  stomach,  and  other  signs  of  gastric  dilatation 
are  absent  in  ovcrdistention  of  the  intestines.  In  addition,  we  may 
try  the  salol  test,  though   this   is  now  considered  of  little  value  (vide 


DILATATION  OF   THE  STOMACH.  789 

Chemical  Examination).  From  dilatation  of  tlic;  stomach  wc  may  dis- 
criminate ascites  by  the  history  and  by  the  characteristic  gastric  symp- 
toms belonsin";  to  the  former  affection.  In  dilatation  the  al)domen  is 
asymmetric,  the  projecting  prominence  being  in  the  vicinity  of  or  just 
below  the  umbilicus.  In  ascites  the  lower  portion  of  the  belly  is  chiefly 
distended,  and  on  assuming  the  recumbent  posture  the  abdominal  area 
becomes  broadened  and  flattened.  On  [)alpation  fluctuation  may  be 
elicited  in  the  hypogastric  and  iliac  regions.  Mcjjalogastria.,  or  simple 
"big  stomach,"  is  distinguished  by  its  absence  of  symptoms,  and  the  fact 
that  the  food  is  passed  into  the  intestines  as  quickly  as  in  healtli.  Gan- 
troptonis  may  be  distinguished  by  absence  of  decided  motor  insufficiency 
and  by  finding,  on  inflation,  the  lesser  curvature  lowered. 

Acute  Gastric  Dilatation. — Acute  dilatation  of  the  stomach  has  a 
sudden  onset ;  the  first  symptom  is  violent  vomiting,  accompanied  by 
more  or  less  intense  pain  in  various  parts  of  the  distended  abdomen. 
The  pulse  is  small  and  rapid,  but  the  temperature  is  normal.  "  The 
absence  of  a  rise  of  temperature  allows  peritonitis  to  be  excluded " 
(Neck).  Vomiting  is  more  frequent  and  severe  than  in  the  chronic  form. 
Cyanosis  is  a  common  symptom,  and  pain  often  a  prominent  one.  The 
patient  frequently  passes  into  a  condition  of  collapse  that  may  prove 
speedily  fatal.  Acute  dilatation  may  arise  in  the  course  of  chronic  gas- 
trectasis.  Some  cases  represent  a  mere  episode  in  the  course  of  the 
chronic  disease  (Veeder,  Todd). 

Prognosis. — The  prognosis  in  the  acute  form  is  uncertain,  though 
the  majority  of  cases  recover;  the  condition  may,  however,  tend  to  merge 
into  the  chronic  form. 

Chronic  dilatation  offers  a  bad  prognosis,  most  instances  being  utterly 
incurable.  Obviously,  it  depends  greatly  upon  the  causal  conditions.  A 
resort  to  surgical  interference  sometimes  gives  promise  of  a  more  favor- 
able subsequent  course  in  cases  of  cicatricial  stenosis.  Cases  of  dilata- 
tion that  are  not  secondary  to  pyloric  obstruction,  however,  give  a  more 
favorable  prognosis  on  the  whole. 

Treatment. — One  of  the  chief  aims  of  the  physician  should  be  to 
lessen  the  labor  of  the  muscular  coat  and  to  prevent  the  continual  neces- 
sity of  passing  the  usual  contents  of  the  stomach  into  the  intestines.  This 
is  to  be  accomplished  by  careful  attention  to  the  character  and  amount  of 
food  taken  and  by  frequent  cleansing  of  the  stomach.  It  is  necessary  to 
thoroughly  empty  the  organ  by  lavage,  repeated  daily.  Perhaps  the  best 
way  in  which  to  thoroughly  empty  the  stomach  is  by  the  use  of  the  stom- 
ach-tube, as  will  be  detailed  under  Chronic  Gastritis.  Recently  this  has 
been  replaced  by  the  siphon  apparatus  as  a  simpler  and  more  con- 
venient mechanism  than  the  former,  and  one  not  so  likely  to  be  at- 
tended with  harmful  effects,  though  perhaps  less  efficacious.  The  long 
course  of  these  conditions  renders  it  desirable  that  the  patient  should, 
whenever  possible,  be  taught  to  wash  out  his  own  stomach.  On  account 
of  the  fermentative  and  putrefactive  changes  going  on  in  the  ingesta 
it  is  necessary  to  use  weak  antiseptic  solutions  for  this  purpose,  suita- 
ble ones  being  a  3  per  cent,  solution  of  boracic  acid  or  a  1  per  cent, 
solution  of  salicylic  acid.  Subsequently  warm  water  alone  may  be  em- 
ployed. Lying  on  the  right  side  for  an  hour  after  meals,  so  that  the 
opening  in  the  pylorus  is  on  a  lower  level  Avith  the  rest  of  the  stomach, 


790  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

is  worthy  of  trial,  'i'lie  diet  should  be  composed  chiefly  of  fluids,  given 
in  small  quantities  and  at  stated  intervals.  If  the  pyloric  obstruction  be 
not  too  far  advanced,  tender  meats,  eggs,  and  other  easily  digested  albu- 
minous articles  of  food  may  be  allowed  in  moderate  (juantities.  Since 
gastric  digestion  and  absorption  are  very  often  markedly  impaired,  it  is 
well  to  include  those  substances  that  are  digested  and  assimilated  after 
leaving  the  stomach,  though  they  must  be  given  in  a  fluid  state.  In  no 
other  manner  can  we  bring  such  marked  relief  from  gastric  symptoms  as 
by  a  suitable  dietary,  and  in  no  other  manner  can  the  nutrition  of  the 
patient  be  so  markedly  improved.  The  weakened  condition  of  the 
muscle-walls  is  due  to  overstrain  and  to  degenerative  processes ;  hence, 
after  having  minimized  the  labor  thrown  upon  it,  we  should  attempt  to 
overcome  its  paretic  state  by  the  employment  of  such  agents  as  strychnin 
and  electricity.  Stockton,  Reed,  and  others  have  obtained  good  results 
from  direct  electrization  of  the  stomach  by  the  use  of  special  electrodes; 
it  improves  motility  and  lessens  the  size  of  the  organ.  Exercises  to 
develop  the  muscles,  abdominal  massage,  and  suitable  bandages  are  also 
useful.  For  the  associated  catarrhal  state  the  remedies  recommended 
under  Chronic  Gastric  Catarrh  may   be  employed. 

The  deficiency  of  intestinal  fluid  is  to  be  met  by  rectal  injections  of  a 
weak  solution  (gr.  v  to  .5J — 0.324-32.0)  of  sodium  chlorid,  not  less  than 
one  pint  of  this  solution  being  injected  twice  daily.  In  addition,  nutri- 
ent enemata  should  be  employed  when,  despite  proper  regulation  of  tiie 
dietary,  loss  of  flesh  and  strength  continue.  For  the  anemia  and  debility 
tonics  are  indicated,  particulai'ly  iron.  Finally,  surgical  intervention 
often  becomes  necessary,  and  should  not  be  too  long  delayed. 

For  acute  dilatation,  lavage  of  the  stomach  every  hour  or  two  if  nec- 
essary, followed  by  complete  rest  and  stimulation,  Avith  strychnin,  eserine 
salicylate  (dose,  gr.  ^1^),  and  especially  saline  infusion,  are  the  chief  items 
of  treatment.  Place  the  patient  upon  the  stomach  Avith  slight  inclina- 
tion to  the  right  side  so  as  to  mechanically  compress  the  dilated  stomach 
and  possibly  unkink  the  duodenum  (Morris). 


mFLAMMATORY  DISEASES  OF  THE  STOMACH. 

ACUTE    CATARRHAL   GASTRITIS. 
[Acute  Gastric  Catarrh.) 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  stomach,  attended  with  more  or  less  severe  local  and  con- 
stitutional symptoms. 

Pathology. — The  postmortem  evidences  of  an  acute  inflammation 
of  the  gastric  mucosa  are  distinctive  only  of  the  graver,  fatal  forms. 
Observations  upon  cases  of  gastric  fistula,  however,  have  shown  that 
in  milder  grades  the  morbid  appearances  are  similar  to  those  charac- 
teristics of  acute  catarrhal  inflammations  of  the  mucous  membranes 
normally  exposed  to  view.  Thus,  at  first  there  are  small  irregular 
patches  of  redness,  dryness,  and  ecchymosis.  Later,  serum  eff"used  from 
the  congested  vessels,  and  mixed  with  an  increased  quantity  of  mucus, 
escaped   leukocytes,  and   desquamated  epithelium,    is   present.      Hem- 


ACUTE  CATARRHAL   GASTRITIS.  791 

orrhagic  erosions  may  bo  seen;  the  mucous  membrane  is  now  thickly 
swollen,  softened,  ari'cb  covered  with  a  tenacious  mucopns.  Infiltration 
and  swelling  of  the  solitary  lymph-follicles  are  frequent;  these  some- 
times form  minute  abscesses  that  rupture  and  result  in  follicular  ulcers. 
The  gastric  tubules  may  be  filled  with  a  granular  d(ibris  of  epithelial 
cells.  The  above-described  changes  are  more  pronounced  near  the 
pylorus. 

etiology. — The  predisposing  causes  of  acute  gastric  catarrh  em- 
brace those  various  impairments  of  the  system  in  which  the  normal  func- 
tional activity  of  the  stomach  is  altered  or  diminished.  These  are  seen 
as  the  result  of  (a)  improper  hygienic  surroundings ;  (h)  malnutrition ; 
{c)  the  various  anemias ;  (d)  in  gouty  and  rheumatic  subjects ;  (e)  in  the 
tuberculous,  cancerous,  and  malarial  dyscrasise ;  (/)  associated  with 
chronic  passive  hyperemia  of  the  stomach  due  to  emphysema  of  the 
lungs,  cirrhosis  of  the  liver,  and  renal  and  cardiac  diseases  ;  (^)  in  sickly 
and  delicate  children,  in  convalescents  from  acute  diseases,  and  in  ener- 
vated chronic  invalids.  (A)  Persons  having  chronic  gastric  catarrh  are 
predisposed  to  superadded  attacks  of  the  acute  disorder. 

The  excitants  are  mainly  (1)  dietetic.  These  include  the  ingestion 
of  much  indigestible  food ;  food  or  drink  that  is  too  hot  or  too  cold 
(thermal)  ;  sour  and  highly-seasoned  articles  ;  the  too  free  use  of  condi- 
ments ;  and  especially  the  eating  of  decomposed  canned  goods  and 
tainted  meats.  In  cases  due  to  the  latter  the  fermentative  and  putre- 
factive agents  (acetic,  lactic,  and  butyric  acids,  and  the  ptoma'ins)  are 
the  immediate  causes  of  the  catarrhal  inflammation  and  tend  to  produce 
the  constitutional  disturbances,  sometimes  typhoid  or  septic  in  nature, 
that  give  rise  to  the  so-called  "gastric  fever."  The  term  ^'■crapulous 
gastritis  "  has  been  applied  to  those  cases  due  to  gluttonous  meals.  (2) 
Toxic  gastritis.  Excessive  indulgence  in  spirituous  liquors  is  a  common 
cause.  Certain  drugs,  as  the  salicylates,  iodids,  bromids,  arsenic,  and 
mercury.  (For  the  intense  form  of  toxic  gastritis,  vide  p.  793).  (3) 
Acute  infectious  fevers,  as  measles,  typhus  fever,  and  scarlatina,  pro- 
voke the  disorder  ('' infectious  gastritis"),  as  do  also  malarial  fevers, 
especially  when  of  the  pernicious  variety.  (4)  The  influence  of  cold  as 
an  excitant  of  this  disease  has  very  probably  been  overestimated.  (5) 
The  mycotic  origin  of  the  condition  cannot  any  longer  be  doubted. 
Among  the  microorganisms  incriminated  are  the  anthrax  bacillus, 
the  favus  fungus,  the  Oidium  albicans,  and  the  yeast  fungus.  (6) 
Animal  parasites  {e.  g.^  ascarides,  taenia,  oxyurides,  etc.)  may  cause 
gastritis. 

Clinical  History. — The  symptoms  of  the  ordinary  or  milder  vari- 
ety of  .-icute  gastric  catarrh  are  embraced  in  the  description  of  the  "  sub- 
acute gastritis ''  or  "  acute  dyspepsia  "  of  some  writers.  Soon  after  eat- 
ing there  are  uneasiness,  fulness,  pressure,  distress,  and,  perhaps,  a  dull 
pain  referred  to  the  epigastrium.  Thirst  is  common,  also  nausea,  eruc- 
tations of  gas  or  liquid,  and,  less  often,  vomiting.  The  vomitus  con- 
sists of  undigested  food,  considerable  mucus,  and  fluid  constituents  that 
are  sometimes  bile-stained.  The  percentage  of  HCl  in  the  stomach- 
contents  is  variable,  although  either  absent  or  greatly  diminished  as  a 
rule.  The  tongue  is  coated.  The  general  condition  of  the  patient 
remains^unimpaired,  and  the  average  duration  is, Jess  than  twenty-four 


792  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

hours.  In  i^evtrer  cases  the  symptoms  before  stated  are  intensified,  and 
particularly  the  nausea  and  vomiting.  Physica4  exploration  discloses 
slight  prominence  of  the  epigastric  area,  with  more  or  less  tenderness 
on  palpation.  The  tompie  is  dry  and  heavily  coated,  the  breath  unpleas- 
ant as  a  rule,  the  patient  complaining  of  a  Hat  or  bitter  taste  in  the 
mouth.  Oonstitutional  sj/)nptonis  appear  early,  and  the  onset  is  often 
marked  by  rigor  and  a  febrile  reaction,  the  temperature  rising  to  102° 
or  even  103°  F.  (38.8°-39.4°  C).  Herpes  may  appear  on  the  lips  and 
skin — a  fact  that  points  to  the  infectious  nature  of  this  complaint.  The 
pulse  is  usually  accelerated,  and  there  are  indisposition  to  exertion, 
headache,  dulness,  and  other  nervous  symptoms.  An  erythematous 
cutaneous  eruption  is  often  present,  particularly  in  febrile  cases  in  chil- 
dren. The  marked  general  disturbance  is  due  to  the  toxic  effects  of  the 
products  of  fermentation  and  decomposition. 

Complications. — Constipation  is  a  comparatively  frequent  compli- 
cation, and  diarrhea  a  comparatively  infrequent  one.  Either  coinci- 
dently  or  by  direct  extension  the  duodenum  is  similarly  affected,  and 
in  some  instances  jaundice  becomes  an  accompanying  feature.  The 
duration  of  this  variety  of  the  disease  rarely  exceeds  four  or  five  days. 

Diagfnosis. — The  diagnosis  of  the  lighter,  afebrile  forms  of  the  dis- 
order is  not  attended  with  the  slightest  difficulty.  A  logical  diagnosis 
in  cases  in  which  well-marked  local  and  general  symptoms  appear  is  not 
easy.  The  definite  etiology,  the  vomiting  (affording  temporary  relief), 
the  pain  or  tenderness,  the  sudden  rise  of  temperature,  and  the  equally 
sudden  fall  at  the  end  of  a  few  days,  however,  are  almost  une(iuivocal. 

Differential  Diagnosis. — The  absence  of  prodromata,  of  rose  spots,  of 
the  peculiar  temperature-range,  and  of  enlargment  of  the  spleen  serve 
to  distinguish  this  complaint  from  ti/phoid  fever.  The  instances  of  in- 
determinate etiology  may  present  a  clinical  picture  not  to  be  diff'eren- 
tiated  from  certain  infectious  diseases.  Here  a  careful  analysis  of  the 
local  symptoms  and  signs  will  usually  lead  to  a  correct  conclusion,  despite 
the  apparently  complete  identity  of  the  general  disturbances.  Close 
observation  of  the  behavior  of  any  obscure  case  for  two  or  three  days 
will  usually  enable  the  physician  to  arrive  at  a  correct  diagnosis.  In 
children  headache  and  vomiting  are  symptoms  often  so  well  marked  as 
to  create  a  striking  resemblance  to  tubercular  meningitis,  but  the  latter 
can  be  discriminated  by  the  history  and  longer  duration.  In  children 
acute  gastritis  with  an  erythematous  rash  is  often  mistaken  for  scarlet 
fever.  The  final  elimination  of  the  latter  disease  is  usually  easy,  how- 
ever, in  consequence  of  the  absence  of  angina,  of  the  typical  tongue,  the 
hard  and  very  rapid  pulse,  and  the  peculiar  desquamation  aff'ecting  the 
hair  and  the  nails. 

Prognosis. — Quite  generally  the  prognosis  is  good.  When,  as 
sometimes  happens,  however,  the  disease  is  purely  secondary,  the  prog- 
nosis must  depend  largely  upon  the  primary  aff'ection.  Many  persons 
suff'er  from  repeated  attacks  of  gastric  catarrh,  each  increasing  the  liability 
to  subsequent  attacks. 

Treatment. — Our  chief  aim  should  be  to  remove  the  cause  and  then 
to  give  the  stomach  complete  rest.  Hence,  whenever  the  disease  is  dis- 
tinctly traceable  to  errors  of  diet,  emetics  of  the  blandest  sort  should  be 
employed :  large  draughts  of  warm  water  usually  suffice,  but  lavage  is 


TOXIC  GASTIIITIS.  793 

to  be  preferred  in  some  cases.      This  should  1)o  followed  by  a  purge  made 
up  as  follows : 

I^.   Ilydrarg.  chlorid.  mit.,  gr.  j  (0.0648); 

Sodii  bicarb.,  gr.  xviij  (1.10); 

Sacchari  lactis,  gr.  xij      (0.777). 

M.  et  ft.  chart.  No.  vj. 
Sig.   One,  dry  on  the  tongue,  every  hour;   the  last  to  be  followed 
in  two  hours  by  a  wineglassful  of  Hunyadi  Janos  or  other 
saline  laxative. 

The  stomach  must  now  have  absolute  rest  for  about  twenty-four 
hours,  when  pancreatized  milk  or  milk  boiled  with  lime-water  may  be 
given  at  stated  intervals.  If  nausea  and  continued  vomiting  prohibit 
the  use  of  milk  by  the  mouth,  I  resort  to  rectal  alimentation  early,  and 
particularly  in  children.  Certain  symptoms,  as  nausea,  pain,  and  rest- 
lessness, demand  as  early  relief  as  possible,  and  can  be  most  success- 
fully met  by  the  use  of  morphin  in  small  doses  hypodermically  at  inter- 
vals of  twelve  hours.  When  constant  nausea  is  the  symptom  chiefly 
complained  of,  I  have  found  creasote  combined  with  bismuth  or  cocain 
in  small  doses  to  be  highly  serviceable.  Convalescence  is  usually  unin- 
terrupted, and  is  soon  complete.  When  protracted  it  is  often  on  account 
of  the  too  early  return  to  solid  articles  of  diet  or  the  too  early  use  of 
bitter  tonics.  The  mineral  acids  should  first  be  administered,  well  di- 
luted, after  the  local  symptoms  have  in  a  great  measure  subsided,  and  to 
these  the  bitter  vegetable  tonics  are  later  to  be  gradually  added.  Locally, 
I  employ  sinapisms  at  the  beginning  of  severe  types  of  the  affection, 
and  follow  these  with  warm  linseed  poultices  lightly  applied  to  the  entire 
epigastric  and  hypochondriac  regions. 

TOXIC   GASTRITIS. 

Pathology  and  l^tiology. — This  is  an  intense  form  of  acute  gas- 
tritis, produced  by  the  ingestion  of  irritant  and  corrosive  poisons,  among 
the  former  being  such  agents  as  phosphorus,  antimony,  and  arsenic,  and 
among  the  latter  concentrated  mineral  acids  and  strong  alkalies.  When 
caused  by  the  non-corrosive  poisons,  intense  hyperemia  and  tumefaction, 
leading  to  desquamative  changes  in  the  glandular  structure,  ensue. 
When  excited  by  corrosive  substances  necrosis  of  the  mucous  membrane 
may  occur,  leading  even  to  an  involvement  of  all  the  coats,  and  termi- 
nating in  perforative  peritonitis.  Injurious  retention  substances,  as  in 
uremia,  cholemia,  and  diabetes,  may  cause  an  autotoxic  variety  of  gas- 
tritis.    The  lesions  are  either  localized  or  general. 

Symptoms. — The  symptoms  vary  somewhat  with  the  nature  of  the 
special  poison,  though  they  are  usually  quite  violent.  Incessant  vomit- 
ing, great  pain  in  the  epigastric  region,  and,  later,  diarrhea,  and  exces- 
sive thirst,  together  with  such  symptoms  as  intense  burni^ig  pains  in  the 
mouth  and  throat  and  dysphagia,  are  the  most  characteristic  signs. 
The  vomitus  contains  mucus,  sometimes  blood,  and.  rarely,  shreds  of 
mucous  membrane.  The  physical  examination  reveals  a  marked  disten- 
tion of  the  abdomen,  which  is  also,  as  a  rule,  very  painful  on  pressure 
over  the  epigastric  region.      The  general  condition  of  the  patient  soon 


794  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

becomes  one  of  profound  ]n-(istr;ition ;  the  skiii-surfaee  is  cold  and 
clammy,  and  the  pulse  and  respiration  are  hurried,  terminating  at  times 
in  fatal  collapse  within  a  few  hours.  Sometimes  there  is  a  febrile  move- 
ment :  the  temperature  may  reach  10i°  F.  (40°  C.) ;  the  pulse  ranges 
from  100  to  130  :  and  if  life  be  spared  long  enough  toxic  nephritis,  with 
or  without  hematuria,  develops.  The  nervous  symptoms  (convulsions, 
stupor,  sometimes  ending  in  coma)  may  be  due  in  part  to  the  renal 
lesions,  though  mainly  to  the  diminished  alkalinity  of  the  blood.  Symp- 
toms of  gastric  ulcer  or  of  esophageal  stricture  may  be  sequelae. 

Diagnosis. — The  diagnosis  rests  upon  the  history  of  the  ingestion 
of  some  poison,  upon  the  character  of  the  symptoms  (referable  not  only 
to  the  stomach,  but  also  to  the  mouth  and  pharynx),  and  upon  the 
results  of  an  inspection  of  the  mouth,  pharynx,  and  the  vomitus.  A 
chemical -examination  of  the  stomach-contents  and  urine  may  be  neces- 
sary. 

Prognosis. — This  depends  upon  the  nature  of  the  poison  and  its 
dose.  When  free  emesis  occurs  early  the  prognosis  is  thereby  rendered 
more  favorable,  since  both  the  local  and  constitutional  effects  are  thereby 
mitigated.  Among  unfavorable  symptoms  may  be  mentioned  signs  of 
collapse  or  of  peritonitis.  Among  sequelae  (due  to  scar-formation)  are 
pyloric  stenosis  and  hour-glass  contractions. 

Treatment. — To  ascertain,  in  the  first  place,  the  special  cause  of 
the  gastritis,  and  when  this  is  found  to  administer  the  proper  antidote 
to  that  poison,  are  measures  of  prime  importance.  The  stomach  should 
be  cautiously  washed  out  with  warm  water  containing  some  demulcent 
substance  and  a  small  proportion  of  the  appropriate  antidote.  Subsequently 
measures  should  be  employed  to  combat  the  active  local  inflammation. 
Externally,  leeches,  followed  by  the  ice-bag,  have  proved  to  be  the  best 
agents  in"  my  own  hands  ;  internally,  opium,  bismuth,  and  demulcents, 
with  bits  of  ice,  are  most  useful.  Rectal  alimentation  should  form  the 
sole  method  of  feeding  so  long  as  the  signs  of  severe  inflammation  along 
the  upper  alimentary  tract  are  present.  The  indications  presented  by 
the  general  conditions  will  vary  with  the  general  effects  of  the  peculiar 
poison  in  each  case. 

DIPHTHERITIC    GASTRITIS. 

This  form  of  gastritis  is  always  a  secondary  condition,  though  it  is 
not,  as  has  often  been  stated,  always  caused  by  a  direct  extension  of 
the  diphtheritic  process  from  the  pharynx  down  through  the  esopha- 
gus to  the  stomach.  It  arises  more  frequently  in  the  course  of  some 
other  acute  infectious  malady,  as  pneumonia,  scarlet  fever,  or  small-pox. 
Though  it  is  regarded  as  a  rare  disease,  the  fact  that  it  is  unrecognizable 
during  life  renders  it  certain  that  the  affection  is  sometimes  overlooked. 
I  have  seen  two  instances  associated  with  croupous  inflammation  of  the 
intestines,  both  occurring  in  greatly  debilitated  children.  Osier  saw  a 
case  which  occurred  as  a  secondary  process  in  pneumonia. 

ACUTE    SUPPURATIVE   GASTRITIS- 
{Phlegmonous  Gastritis.) 

Definition. — An  acute  suppurative  inflammation  of  the  submucosa. 


ACUTK  NUri'URATJVK  (lASTIlITIS.  705 

Pathology  and  Btiology. — I*hlegrnonou.s  gastritis  is  confessedly 
a.  rare,  and  almost  invaiiably  a  secondary,  disease.  I  have  observed 
pathologic  evidences  of  its  presence,  however,  in  two  cases  that  came  to 
autopsy,  both  patients  having  died  of  sepsis.  It  is  excited  by  invasion 
with  bacteria  or  fungi.  The  male  sex  is  the  more  commonly  affected. 
It  may  originate  spontaneously  or  follow  an  injury;  more  commonly  it  is 
a  symptom  of  a  general  septic  process  or  a  complication  of  an  acute 
infectious  malady.  Two  forms  are  described — namely,  a  diffuse  purulent 
infiltration  and  a  circumscribed  form  [stomach-abscess).  The  morbid 
process  begins  in  the  submucous  layer,  and  then  spreads  in  various  direc- 
tions, involving  soon  all  of  the  coats.  The  limited  variety  results  in  the 
formation  of  abscesses  that  may  attain  considerable  size  and  rupture 
either  into  the  peritoneal  cavity  or  into  the  stomach. 

Symptoms. — There  may  or  may  not  be  an  initial  rigor.  Whether 
the  attack  is  ushered  in  by  a  chill  or  not,  the  temperature  rapidly 
rises  to  103°  or  104°  F.  (40°  C),  and  subsequently  pursues  an  irreg- 
ular course.  The  symptoms  of  the  typhoid  state  supervene,  and  are 
usually  associated  with  the  symptoms  of  the  primary  affection.  Hence 
the  clinical  picture  is  greatly  diversified.  For  a  variable  period  prior  to 
the  fatal  issue  the  patient  passes  into  coma.  The  local  symj)toms  and 
physical  signs  are  rarely  diagnostic.  There  is  a  constantly  increasing 
epigastric  pain,  which  is  not  aggravated  by  movement ;  emesis  also 
appears,  the  vomita  often  containing  a  notable  quantity  of  pus-cells. 
Leukocytosis  is  generally  found. 

The  physical  signs  reveal  but  little  in  most  instances,  and  vary  with 
the  form  of  the  complaint.  Inspection  shows  in  the  diffuse  form  a  con- 
siderably distended  abdomen.  On  pressure  the  stomach  is  found  to  be 
quite  tender.  In  the  limited  variety  the  gastric  abscess  sometimes 
gives  rise  to  the  physical  signs  of  a  tumor,  and  a  localized  prominence 
may  be  seen  over  the  seat  of  the  abscess ;  the  tenderness  to  the  pressing 
finger  may  be  confined  to  the  same  area.  Palpation  has  served  to  elicit 
fluctuation  and  to  define  the  limits  of  the  tumor,  the  latter  sometimes 
attaining  the  size  of  a  cocoanut ;  on  percussion  either  dulness  or  a  muffled 
tympanitic  resonance  is  elicited,  varying  according  to  the  size  of  the  mass. 

Diagnosis. — The  diffuse  variety  cannot,  a-s  a  rule,  be  positively 
distinguished  from  certain  other  gastric  affections.  The  detection  of 
pus-cells  is,  however,  of  the  utmost  diagnostic  value.  Gastric  abscess, 
on  the  other  hand,  is  often  recognizable,  since  the  physician  has  not 
only  the  history  to  aid  him,  but  also  the  physical  signs,  which  may 
demonstrate  the  presence  of  a  fluctuating  tumor. 

Course  and  Prognosis. — The  majority  of  cases  reach  a  fatal  ter- 
mination within  one  week,  and  those  that  do  not  terminate  in  death  thus 
early  pursue  a  subacute  or  even  chronic  course.  They  present  such 
symptoms  as  local  pain,  chills,  and  fever,  and  death  results,  sooner  or 
later,  either  from  exhaustion  or  such  complications  as  peritonitis  and 
metastatic  abscess  with  jaundice. 

Treatment. — The  treatment  in  the  diffuse  form  is,  at  best,  only 
palliative.  In  the  circumscribed  variety  the  aid  of  the  surgeon  should 
be  invoked  as  soon  as  a  probable  diagnosis  has  been  made. 


796  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHRONIC    CATARRHAL   GASTRITIS. 
(  C?ironic  Catarrh  of  the  Stomach;   Chronic  Catarrhal  Dyspepsia.) 

Definition. — A  cbronic  catarrhal  inflammation  of  the  gastric  mu- 
cous nu'inlirane,  presenting  various  degrees  of  intensity  and  embracing 
the  sym})toras  that  are  more  or  less  characteristic  of  widely  different 
clinical  forms  of  gastric  derangement. 

Pathology. — The  anatomic  changes  are  most  marked  near  the  py- 
lorus, where  the  mucous  membrane  often  presents  a  distinctly  wrinkled, 
mammillated  appearance.  The  mucous  membrane  looks  either  red  or 
gray  (the  latter  hue  being  due  to  pigmentation),  and  is  pretty  generally 
covered  by  tenacious  mucus,  mingled  with  detached  epithelium.  Ewald 
describes  the  histologic  changes  thus:  "  The  minute  anatomy  shows  the 
picture  of  a  parenchymatous  and  an  interstitial  inflammation.  The 
gland-cells  are  in  part  eroded  or  show  cloudy,  granular  swelling  or  atro- 
phy. The  distinction  between  the  '  haupt '  and  'beleg'  cells  cannot  be 
recognized,  and  in  many  places,  particularly  in  the  pyloric  region,  the 
tubes  have  lost  their  regular  form  and  show  in  many  places  an  atypical 
branchino;  like  the  fingers  of  a  glove.  Individual  glands  are  cut  off  to- 
ward  the  fundus,  but  appear  at  the  border  of  the  submucosa  as  cysts, 
with  a  smooth  membrane,  partly  filled  with  remnants  of  hyaline  and 
refractile  epithelium.  An  abundant  small-celled  infiltration  presses  apart 
the  tubules,  and  is  particularly  marked  toward  the  surface  of  the  mucosa, 
and  from  the  submucosa  extensions  of  the  connective  tissue  may  be  seen 
passing  between  the  glands.  The  mucoid  transformation  of  the  cells  of 
the  tubules  is  a  striking  feature  in  the  process  and  may  extend  to  the 
very  fundus  of  the  glands."  Hemorrhagic  abrasions  may  be  found  in 
cases  due  to  cardiac  disease  or  to  portal  engorgement.  Superficial  ulcers 
may  form,  usually  in  the  pyloric  region,  varying  in  size  from  a  few  lines 
to  an  inch  or  more  in  diameter,  and  nearly  circular  in  shape.  Long- 
standing cases  also  present  sclerotic  changes  of  the  mucous  membrane. 
Of  these,  two  forms  are  distinguished.  In  the  one  variety  the  mucous 
membrane  is  perfectly  smooth  and  atrophied ;  the  glands  are  displaced, 
narrowed,  and  shortened,  while  the  gap  thus  formed  is  more  or  less  filled 
with  connective  tissue  There  is  a  thinning  of  the  stomach-wall,  with 
enlargement  of  its  cavity.  The  other  form  presents  a  h^'perplasia  of  the 
mucous  membrane,  the  glandular  structure,  and  the  submucous  layer, 
sometimes  resulting  in  enormous  thickening  of  the  stomach  walls,  with 
great  diminution  in  the  size  of  its  cavity  {gastrophthisis).  The  contrac- 
tion of  the  new-formed  connective  tissue  may  cause  polypoid  projections. 

Ktiology. — It  is  evident  that  the  factors  which  produce  acute  gastric 
catarrh  will,  if  long  continued,  produce  a  chronic  condition.  The  causes 
of  chronic  gastritis  act  either  as  mechanical,  chemical,  thermic,  or  bio- 
logic  irritants,  and  fall  naturally  into  the  following  classes :  {a)  Errors 
of  diet  (referring  more  particularly  to  important  articles  of  food),  its 
varietv,  and  preparation  ;  excessive  alimentation  ;  the  habit  of  eating 
at  irregular  intervals  or  with  undue  haste,  and  thus  not  allowing  time 
for  perfect  mastication  of  the  food.  The  too  free  use  of  ice-water,  tea. 
and  coffee  during  meals  plays  an  important  role  in  the  causation  of 
dyspepsia  in  America,     [li)  The  immoderate  use  of  alcohol,  more  particu- 


CHRONIC  CATARRHAL   GASTRfTfS.  797 

larly  spirituous  liquors,  stands  second  in  order  of  importance.  ^J'hose 
persons  wlio  habitually  indulge  in  alcoholic  beverages  to  excess  are  prone 
to  an  irregular  mode  of  life,  which  leads  to  digestive  disturbances.  Such 
patients  are  apt  to  suffer  from  the  more  active  forms  of  the  complaint, 
and,  at  intervals  of  time,  from  genuine  acute  gastritis.  In  the  same 
category  should  be  mentioned  certain  toxic  irritants,  as  the  overuse  of 
tobacco  and  the  prolonged  use  of  tonics  and  purgatives,  (c)  Functional 
derangements  of  the  stomach  sometimes  merge  into  the  disease  under 
consideration.  This  is  true  of  that  form  in  which  there  is  a  deficiency 
in  the  gastric  juice.  Under  these  circumstances,  as  also  in  gastric 
ectasy,  fermentative  and  putrefactive  changes  develop  in  the  retained 
stomach-contents.  Stockton  holds  that  the  majority  of  cases  of  chronic 
dyspepsia  are  of  nervous  origin,  (d)  Local  mechanical  influences  (portal 
congestion)  may  offer  resistance  or  obstruction  to  the  outflow  of  venous 
blood  from  the  stomach  to  the  right  heart.  In  this  way  chronic  gastric 
catarrh  is  a  secondary  process  in  chronic  affections  of  the  liver,  heart, 
and  lungs,  (e)  Such  constitutional  conditions  as  gout,  chronic  rheu- 
matism, chronic  tuberculosis,  Bright's  disease,  diabetes,  anemia,  chlorosis, 
chronic  malaria,  syphilis,  and  chronic  forms  of  skin  disease.  The  ex- 
planation of  the  peculiar  liability  of  these  conditions  to  catarrh  of  the 
stomach  lies  in  the  obstruction  offered  to  the  passage  of  blood  through 
the  hepatic  and  cardiopulmonary  circulation.  This  is  true  in  an  especial 
degree  in  chlorosis,  anemia,  chronic  tuberculosis,  and  malaria ;  in  gout, 
chronic  Bright's  disease,  and  syphilis  it  is  probably  due  largely  to  the 
action  of  chemico vital  irritants  in  the  circulating  medium.  (/)  Gastric 
carcinoma. 

Clinical  History. — The  local  symptoms  bear  a  striking  resemblance 
to  those  of  other  forms  of  gastric  disturbance.  They  vary  greatly  in 
severity,  though  never  entirely  absent,  as  in  the  case  of  purely  functional 
disorders.  Deficient  secretion  of  the  gastric  juice,  due  to  the  anatomic 
changes  in  the  gastric  tubules,  is  a  potent  factor  in  the  production  of 
the  symptoms  directly  referable  to  the  stomach.  It  is  the  function  of 
hydrochloric  acid,  normally  present  in  the  gastric  secretions,  to  destroy 
the  ferment-producing  spores ;  hence  when,  owing  to  lack  of  free  HCl, 
the  latter  are  not  destroyed,  deleterious  products  of  fermentation  are 
the  result,  these  in  turn  aggravating  and  prolonging  the  course  of  the 
affection.  Recent  investigations  go  to  show  that  deficient  motor  power 
is  more  important  than  a  deficiency  in  the  secretions  in  bringing  about 
the  clinical  phenomena  of  the  disease.  The  presence  of  an  inordinate 
amount  of  mucus  which  is  alkaline  in  reaction  neutralizes  in  part  the 
HCl ;  it  may  also  more  or  less  completely  cover  the  ingesta,  thus  pre- 
venting the  gastric  secretions  from  reaching  them,  and  lengthening,  at 
the  same  time,  the  period  of  digestion. 

Among  the  earlier  symptoms  directly  attributable  to  the  gastric 
lesions  are  anorexia  (though  at  times  the  appetite  may  be  moderately 
good  or  even  keen) ;  fulness  and  distress ;  burning  sensations  and  dull 
pain  in  the  epigastric  region ;  eructations  of  gas,  which  may  be  either 
offensive  or  odorless,  during  and  immediately  after  meals ;  regurgitation 
of  fluid,  either  acid  (heartburn),  due  to  the  presence  of  organic  or  hydro- 
chloric acid,  or  a  bitter  form  of  peptones.  These  symptoms  are  usually 
increased  in  intensity  after  meals.     The  tongue  frequently  appears  broad 


798  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  flabby,  ami  almost  constantly  the  edges  and  tip  are  somewhat  red- 
dened, uhilst  the  j)apilliv  are  enlarged.  Occasionally  it  is  small,  \>ith 
enlarged  and  red  papilh«,  or  it  may  look  healthy.  A  bad  or  a  persist- 
ently bitter  taste  and  great  thirst  may  be  complained  of.  There  may  be 
a  profuse  secretion  of  saliva  or  the  month  may  be  dry.  ^^aitsro  is  com- 
mon, and  is  most  marked  in  the  morning  hours  ;  it  is  fret|Uent  before  or 
after  meals,  and  often  vomitiiuj  occurs  either  immediately  after  meals  or 
a  couple  of  hours  later.  The  vomitus  wiil  vary  somewhat  with  the  time  of 
the  occurrence  of  emesis.  Usually  it  consists  of  food  in  the  first  stages 
of  digestion,  mixed  with  large  (juantities  of  mucus.  In  alcoholic  catarrh 
mornin;^  voinitin<r  occurs.  an<l  consists  mostly  of  saliva  and  mucus.  This 
class  of  sufferers  may  exhibit  well-marked  evidences  of  salivation.  In 
Kelson's  experience,  aching  throat  is  often  associated  Avith  flatulent  dys- 
pepsia. I  have  repeatedly  found  the  material  vomited  in  chronic  gastric 
catarrh  to  be  acid  in  reaction,  unless,  as  occasionally  happens,  the  vom- 
iting takes  place  several  hours  after  eating,  Avhen  it  is  sometimes  faintly 
alkaline  or  neutral.  The  acidity  of  the  vomitus  is  not  due  to  the  pres- 
ence of  free  HCl,  but  possibly  in  small  measure  to  combined  HCl.  and 
partly  and  sometimes  largely  to  acid  salts  (lactic,  butyi'ic)  or  resulting 
from  the  abnormal  processes  of  fermentation. 

Microscopic  examination  sometimes  reveals  the  presence  of  sarcinae 
ventriculi,  yeast  fungi,  and  numerous  bacteria.  The  relations  of  these 
low  forms  of  vegetable  life  to  the  pathologic  processes  going  on  in  the 
stomach  are  not  well  understood.  It  is  to  be  borne  in  mind  that 
many  of  these  bacteria  are  introduced  Avith  the  food,  and  that  cer- 
tain of  them  contribute  toAvard  the  production  of  gases,  and  of  the 
organic  acids  of  the  stomach.  Hydrochloric  acid  inhibits  the  develop- 
ment of  bacteria. 

A  chemical  examination  of  the  contents  of  the  stomach  for  purposes  of 
diagnosis  according  to  the  methods  laid  doAvn  in  the  preliminary  section 
{vide  p.  778)  should  not  be  neglected.  In  simple  chronic  gastric  catarrh 
the  hydrochloric  acid  is  found  to  be  diminished,  and  lactic,  butyric,  and 
acetic  acids  are  rarely  present.  In  many  cases  of  chronic  catarrhal 
gastritis  there  is  an  abundance  of  mucus  (gastritis  mucipara — Boas) ; 
and  in  other  cases  there  is  present  a  normal  amount  of  acid  or  even 
hyperacidity — the  gastritis  acida  of  Boas.  In  protracted  forms  free 
HCl  is  sometimes  greatly  diminished  or  entirely  absent — gastritis 
anacida.  According  to  Boas  the  diff'erence  betAveen  this  and  the 
atrophic  form  is  but  one  of  degree,  all  secretion  being  lost  in  the  lat- 
ter. In  atrophic  gastritis  then  there  is  little  or  no  mucus  in  the  gastric 
contents,  and  in  established  cases  an  absence  of  HCl  and  of  the  gastric 
ferments  (gastritis  atrophicans).  EAvald  has  subdivided  all  cases  into 
three  varieties:  ((/)  Simple  gastritis,  in  Avhich  the  fasting  stomach  con- 
tains only  a  small  ([uantity  of  slimy  fluid,  while  after  the  test-breakfast 
the  HCl  is  diminished  in  quantity,  and  lactic  acid  and  the  fatty  acids 
are  usually  present,  (b)  Mucous  gastritis,  in  Avhich  class  the  acidity  is 
ahvays  slight  and  the  condition  is  distinguished  from  simple  gastritis  by 
the  large  amount  of  mucus  present,  (c)  Atrophy.  Here  the  fasting 
stomach  is  always  empty,  Avhile  after  the  test-breakfast  HCl,  pepsin^ 
and  the  curdling  ferments  are  Avholly  Avanting. 

The  absorbent  and  motor  powers  of  the  stomach  are  both  diminished 
in  proportion  to  the  degree  of  damage  received  by  the  stomach. 


CHRONIC  CATARRHAL   GASTRITIS.  799 

Physical  Signs. — Sonietimes  tlicrc  may  be  observed  an  undue  disten- 
tion of  the  stomach,  the  prominence  being  more  marked  toward  tlie  left. 
On  making  j/?'rw  pressure  over  the  epigastric  )-egion  tenderness  is  often 
elicited.  This  is  not  present  in  the  early  stages,  nor  constantly  later, 
since  the  degree  of  inflammatory  action  is  subject  to  great  oscillation. 
Diffuse  tenderness  in  the  absence  of  a  new  growth  is  of  great  diagnostic 
value.  It  is  to  be  recollected,  however,  that  resistance  may  be  felt  when 
the  stomach  is  thickened  in  chronic  interstitial  gastritis.  Dilatation 
of  the  organ  may  be  indicated  by  splashing-sounds  {vide  Physical  Signs, 
p.  787),  and  these  are  not  suggestive  of  gastritis  if  detected  at  a  time 
when  the  stomach  should  be  empty. 

On  percussion  we  may  note  alterations  in  the  size  of  the  organ. 

Among  the  general  or  indirect  symptoms  manifested  the  nervous  phe- 
nomena are  of  first  importance.  So  prominent  are  they  in  the  clinical 
picture  that  the  physician  may  suspect  his  patient  to  be  suffering  from 
some  primary  disease  of  nervous  origin.  The  nervous  derangements 
have  been  by  many  writers  attributed  solely  to  morbid  sympathetic  dis- 
turbances. It  is  altogether  probable,  however,  that  we  should  ascribe 
a  share  of  the  morbid  influence  to  the  absorption  of  toxic  materials  from 
the  stomach  and  intestines.  Headache  is  frequently  complained  of;  it  is 
generally  frontal,  though  also  occipital,  and  tends  to  appear  before  meals. 
The  so-called  sick  headache  more  rarely  occurs.  Indisposition  to  mental 
or  physical  exertion,  vertigo,  depression  of  spirits,  and  Avell-marked  hypo- 
chondriasis are  common  concomitants.  Patients  complain  of  wakeful- 
ness and  disturbed  dreams,  though  drowsy  after  ■  meal-time.  There  is  a 
sympathetic  disturbance  of  the  cardiac  rhythm,  and  sometimes  dyspnea, 
owing  to  the  same  cause.  The  urine  is  often  highly  colored,  scanty,  and 
deposits  an  abundant  uratic  sediment;  occasionally  (e.  g..,  in  neurotic 
subjects),  it  is  of  low  specific  gravity,  rather  copious  in  amount  and  pale 
in  color,  owing  to  the  influence  of  phosphates. 

Complications. — The  intestines  often  become  involved,  and  usually 
by  direct  extension.  Implication  of  the  duodenum  may  lead  to  jaundice 
and  to  obstinate  constipation,  though  only  moderate  constipation  is  the 
rule  in  catarrh  of  the  stomach.  When  the  process  extends  to  the  large 
intestines  diarrhea  develops.  Alternating  constipation  and  diarrhea  are 
often  observed.  The  nutritive  system  is,  in  confirmed  cases,  seriously 
implicated,  as  shown  by  the  anemia,  emaciation,  and  general  debility 
present.  It  is  particularly  in  examples  of  combined  intestinal  and 
gastric  catarrh  that  we  observe  the  most  notable  impairment  of  the  gen- 
eral health,  the  reason  being  that  under  these  circumstances  all  the  diges- 
tive fluids  are  lessened  in  amount.  The  gases  generated  in  the  stomach 
often  find  their  way  into  the  intestinal  canal,  giving  rise  to  distention, 
and  sometimes  to  colicky  pain.  Perhaps  many  reflex  sympathetic  dis- 
turbances are  of  intestinal  origin.  The  gastric  catarrh  may  extend  up- 
ward to  the  oral  cavity.  Under  such  circumstances  the  tongue  is  large 
and  heavily  coated,  with  impressions  of  the  teeth  upon  its  edges.  The 
abnormal  condition  of  the  secretions  renders  the  breath  foul  and  causes 
thirst.  Certain  skin-eruptions,  as  eczema,  lichen,  and  urticaria,  are  com- 
mon. These  disorders  of  the  skin  are  probably  due  to  an  auto-intoxica- 
tion from  the  intestinal  tract.  I  have  frequently  observed,  however, 
that  when  present  their  improvement  has  been  followed  by  an  aggrava- 


800  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tion  of  the  gastric  symptoms,  and  vice  versa.  A  seqnel  of  the  disease  is 
dilatation  of  the  stomach.  The  course  of  chronic  gastric  catarrh  is  long, 
the  average  duration  being  considerably  more  than  one  year.  Its  dura- 
tion may  be  much  abridged  by  early  recognition  and  proper  treatment. 
The  svmptoras  at  first  intermit  and  are  mild,  but  later  are  persistent. 

Diagnosis. — A  positive  diagnosis  may  be  based  on  a  clear  etiology, 
the  presence  of  persistent  symptoms  and  signs  of  digestive  disturbance, 
diminished  {u»ualh/),  normal,  or  even  increased,  amount  of  IICl  (the 
atrophic  form  apart,  vide  supra),  an  abundance  of  mucus  in  the  gas- 
tric contents,  and  deficient  absorptive  and  motor  power.  The  finding  of 
mucus  in  the  wash-water  of  the  fasting  stomach  is  truly  diagnostic 
(Riegel).  The  points  of  difference  between  the  more  serious  affections  of 
the  stomach  (carcinoma,  ulcer,  and  dilatation)  and  chronic  gastric  catarrh 
v^all  be  detailed  when  the  former  diseases  are  considered.  As  I  have 
said,  Ewald  makes  three  leading  forms  of  the  complaint,  based  on  the 
results  obtained  from  an  analysis  of  the  stomach-contents,  but  transitional 
types  are  constantly  met  with. 

Prognosis. — Chronic  catarrh  of  the  stomach  may  be  said  not  to 
manifest  an  innate  lethal  tendency.  It,  however,  aggravates  the  symp- 
toms of  existing  forms  of  acute  and  serious  forms  of  chronic  diseases, 
especially  other  organic  affections  of  the  stomach.  The  prognosis  de- 
pends considerably  upon  the  stage  that  has  been  reached  when  first  met 
with,  since  the  condition  is  amenable  to  treatment  only  Avhen  not  too  far 
advanced.  The  prognosis  is  rendered  somewhat  more  grave  by  the  pres- 
ence of  certain  complications,  particularly  intestinal  involvement.  I  have 
seen  one  case  that  proved  fatal  in  conseijuence  of  stricture  of  the  pylorus. 
Treatment. — It  must  never  be  forgotten  as  far  as  possible  to  search 
for  and  remove  the  causal  affections  in  every  case.  When  associated  with 
grave  forms  of  cardiac,  hepatic,  or  renal  disease  these  must  receive  care- 
ful attention  primarily. 

The  masticating  apparatus  must  be  looked  after  by  the  physician,  who 
must  also  instruct  his  patient  in  the  art  of  eating  slowly,  so  that  insaliva- 
tion  of  the  food  is  thoroughly  effected.  Too  often  the  quantity  of  ali- 
ment consumed  is  beyond  the  need  of  the  bodily  functions,  and  the 
method  of  preparing  the  same  faulty.  All  food  eaten  should  be  fresh 
and  pure.  Such  patients  should  eat  oftener  than  in  health,  taking  four 
or  five  meals  in  the  twenty-four  hours.  The  physician  must  with  untir- 
ing diligence  attend  to  every  dietetic,  sanitary,  and  therapeutic  detail. 
The  major  portion  of  the  treatment  has  relation  to — 

(1)  The  Diet. — In  the  matter  of  arranging  the  dietary  in  separate 
cases  the  general  condition  and  peculiarities  of  the  individual  must  be 
taken  into  account.  The  wise  physican  will  be  guided  to  some  extent  by 
the  dictates  of  his  patient's  experience,  and  will  not  fail  to  avail  himself 
of  any  information  obtainable  upon  this  head.  The  teachings  of  phys- 
iology direct  that  animal  food  should  be  allowed  with  a  view  to  stimu- 
lating the  secretion  of  IICl  when  found  to  be  deficient  in  the  gastric  con- 
tents. We  must,  however,  select  the  special  articles  of  diet  according  to 
the  severity  and  nature  of  the  morbid  process.  In  severe  cases  an  exclu- 
sive milk  diet  for  a  period  of  two  to  four  weeks  often  gives  the  best 
results.  The  daily  amount  requisite  to  meet  the  demands  of  the  vital 
functions  is  4  to  8  pints.     Of  this,  5  to  8  ounces  are  to  be  taken  slowly 


\ 


CHRONIO  CATARRHAL   GASTRITIS.  XOl 

fevery  two  hours  during  the  day.  The  beginning  amount,  however,  must 
occasionally  be  smaller — 2  to  3  ounces — to  be  gradually  increased.  A 
pinch  of  salt  or  from  ^  to  1  ounce  of  lime-water  may  be  added  to  each 
feeding,  or  the  milk  may  be  diluted  with  Vichy.  The  milk  shoidd  not 
be  taken  iced,  but  warmed  or  at  the  temperature  of  the  room.  Boiled 
milk  is  objectionable.  The  stools  are  to  be  watched  for  curds,  and  when 
the  digestive  capacity  is  exceeded  the  amount  of  the  nutrient  should  be 
lessened  and  other  articles  cautiously  added. 

When  wliole  milk  cannot  be  digested  on  account  of  an  actual  loathing 
for  it,  skimmed  or  partly  skimmed  milk  or  buttermilk  should  be  substi- 
tuted. If  the  latter  cannot  be  utilized  in  proper  amount,  animal  broths, 
together  with  some  of  the  artificial  foods  (panopeptone,  liquid  peptonoids), 
may  be  added.  As  tolerance  for  a  liberal  amount  of  milk  becomes  estab- 
lished the  appetite  is  no  longer  satisfied,  and  then  I  begin  to  add  the 
light  solids  in  a  gradual  manner  ;  for  example,  white  meat  of  chicken  or 
game  (except  tame  ducks  and  turkey),  stale  or  twice-baked  bread,  milk 
or  dry-toast  or  zwieback,  soft-boiled  eggs,  oysters,  fish,  and,  later,  Ham- 
burg steaks,  stewed  sweetbread,  and  the  like.  For  dessert,  junket  or  cus- 
tards, sweetened  with  saccharin,  are  well  borne  as  a  rule.  Subsequently, 
farinaceous  articles,  if  thoroughly  cooked  (except  oatmeal),  and  certain 
plain  vegetables,  may  be  allowed,  but  their  effects  must  be  minutely  ob- 
served. The  former  are  to  be  eschewed  in  cases  in  which  acid-fermenta- 
tion or  flatulency  is  a  prominent  feature.  Among  the  latter,  rice,  spin- 
ach, lettuce,  and  macaroni  (stewed  in  milk)  are  to  be  selected.  Peas  and 
beans,  if  green  and  succulent,  may  be  tried,  but  if  ripe  are  to  be  dis- 
carded. The  only  form  of  fat  permissible  is  good  butter.  Stewed 
fruits,  Graham  bread,  and  soft,  green  vegetables  are  often  well  borne 
and  tend  to  overcome  constipation.  -Pig's-  and  calf's-foot  jelly  may  be 
allowed. 

In  light  cases  and  in  those  of  moderate  severity,  particularly  if  the 
cause  of  the  complaint  is  removable,  the  dietary  need  not  be  rigid  at  the 
start.  Indeed,  to  minimize  the  saccharine  articles  and  starches  and  to 
avoid  the  coarser  vegetables,  hot  bread,  pastries,  and  the  like,  is  all  that 
is  required.  In  the  case  of  confirmed  dyspeptics  the  following  articles 
are  to  be  scrupulously  avoided :  very  fat  meats,  fat  fish-foods,  condiments, 
certain  fruits  (strawberries,  bananas),  hot  bread,  saccharine  articles  of 
diet  and  farinacea,  potatoes,  and  coarser  vegetables.  Fermentable  foods, 
as  milk,  eggs,  and  rare  meats,  should  be  avoided  in  selected  cases. 

The  best  drink  during  meal-time  is  simple  hot  water,  to  which  a  little 
milk  may  be  added,  or  a  single  coffee-cup  of  weak  tea.  Occasionally 
cocoa  is  allowable,  but  ordinary  chocolate,  coffee,  and  strong  tea  are 
harmful.  Too  much  liquid  should  not  be  taken  during  a  meal,  since  it 
dilutes  the  gastric  secretion  to  a  deleterious  extent,  and  cold  drinks  are 
to  be  interdicted  during  the  same  period.  Alcohol,  and  particularly  con- 
centrated spirituous  liquors,  exert  an  irritating  effect,  and  hence  should 
be  forbidden.  In  cases  in  which  there  is  no  gastric  fermentation  certain 
wines  may  be  allowed  (Oporto,  Malaga,  imported  Hungarian  Tokay). 

(2)  Hygienic  7neasures  are  of  signal  value  in  this  disease.  Of  these 
the  most  important  are  forms  of  fresh-air  exercise,  as  bicycling,  walking, 
boating,  and  horseback-riding.  Suitable  indoor  apparatus  for  physical 
exercise  is  now  easily  obtainable  at  little  cost,  and  therefore  open-air 

51 


802  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

exercise  may  be  supplemented  by  the  latter.  Physical  exercise  must  be 
carefully  supervised,  so  as  to  avoid  the  deleterious  effects  of  over-exertion. 
I  am  convinced  of  the  superior  advantage  of  travel,  including  a  sea- 
voyage,  and  an  appropriate  change  of  air — for  example,  to  the  seaside 
or  mountains-r— particularly  for  the  large  class  of  self-centered  and  low- 
spirited  dyspeptic  patients.  A  cold  sponge-bath,  followed  by  brisk  fric- 
tion of  the  skin,  is  to  be  advised.  An  abdominal  bandage,  made  of  wool- 
len or  silk  material  and  constantly  worn,  tends  to  increase  the  patient's 
comfort. 

(3)  Medicinal  Treatment. — k^aline  laxatives,  as  sodium  phosphate, 
Rochelle  salts  or  Carlsbad  salts,  taken  fasting  in  hot  water,  are  advan- 
tageous, since  they  serve  to  regulate  the  bowels,  to  deplete  the  engorged 
gastro-intestinal  vessels,  as  Avell  as  to  rinse  the  stomach.  Hunyadi  Janos 
or  Carlsbad  waters  may  be  substituted.  Their  ellic-u-y  is  much  enhanced 
when  the  alkaline  carbonates  are  administered  sinmltaneously.  Patients 
may  be  advised  to  seek  suitable  watering-places,  but  the  course  should 
not  be  for  too  long  a  period.  The  use  internally  of  antiseptics,  com- 
bined with  alteratives  and  mild  astringents,  is  often  beneficial.  I  can 
speak  most  positively  in  favor  of  the  following  pill : 

'B^.  Argenti  uitratis,  gr.  iv     (0.259)  ; 

Ext.  hyoscyami,  gr.  viij  (0.518). 

M.  et  ft.  pil.  No.  xvj. 
Sig.  One  about  one  hour  before  each  meal,  the  stomach  being 
first  prepared  by  washing  with  one  or  more  pints  of  a  2 
per  cent,  solution  of  borax  in  Avater, 

Hemmeter  recommends  silver  nitrate,  in  the  form  of  lavage  (1  :  2000), 
or  in  the  form  of  solution  0.3  to  120  of  peppermint-water;  of  this  one 
tablespoonful  three  times  daily  on  an  empty  stomach. 

In  ihe  fermentative  form  of  chronic  gastric  catarrh  the  hyperacidity  is, 
in  reality,  often  dependent  upon  the  lack  of  free  HCl ;  hence  this  agent 
should  be  supplied.  It  is  best  administered  immediately  after  meals,  the 
dose  being  not  less  than  10  minims  (0.666),  well  diluted,  and  this  may  be 
repeated  in  the  course  of  ten  or  fifteen  minutes  in  obstinate  cases ;  it  may 
be  combined  advantageously  with  pepsin  (gr.  v-x — 0.324-0.648)  or  pan- 
creatin  (gr.  x — 0.648).  Pancreatin  is  better  associated  with  sodium  bi- 
carbonate in  the  form  of  a  tablet  containing  each  gr.  ij  (0.129).  Of 
these  two  or  three  may  be  administered  fifteen  to  thirty  minutes  after 
meal-time.  Care  is  to  be  taken  to  use  only  the  best  articles  of  pepsin 
and  pancreatin.  When  hyperacidity  exists,  diastase  and  ptyalin  may  be 
exhibited,  but  I  have  failed  to  obtain  encouraging  results  from  their 
employ.  This  class  of  cases  represents  an  aggravated  or  advanced  form 
of  the  disease  (atrophic  stage),  and  demands  prolonged  and  varied  treat- 
ment. At  the  end  of  the  digestive  process  it  is  Avell  to  thoroughly  irri- 
gate the  stomach  (lavage),  and  more  particularly  if  evidences  of  dilatation 
be  present.  The  stomach  may  also  be  cleansed  and  prepared  for  the  re- 
ception of  the  next  meal  in  a  very  agreeable  manner  by  having  the 
patient  sip  a  2  per  cent,  solution  of  borax  in  warm  water  or  a  2  per  cent, 
solution  of  sodium  chlorid  half  an  hour  before  meals ;  indeed,  the  con- 
tinued use  of  simple  hot  water  for  the  same  purpose  has,  in  my  hands, 
often  given  excellent  results.     AVith  it  must,  of  course,  be  combined  the 


CHRONIC  CATARRHAL   GASTRITIS.  803 

saline  laxatives  and  the  restricted  diet.  Not  lesH  than  1  pint  of  water, 
hot  as  it  can  be  taken  by  the  patient,  should  be  sippcid  at  each  sitting. 
Boas  considers  magnesium  salicylate  (gr.  xv-xxx — 1.0-2.0,  t.  i.  d.)  the 
best  antifermentative  remedy. 

To  assist  the  appetites  of  these  patients  and  to  stimulate  the  secretory 
function  a  few  drops  (not  more  than  5)  of  the  tincture  of  nux  vomica  may 
be  given  fifteen  minutes  before  meals,  with  gr.  ii— iij  (0.129-0.194)  of 
sodium  bicarbonate.  These  indications  are  also  fulfilled  by  lavage  once 
daily  or  bi-daily  (if  the  patient  be  feeble).  If  hyperacidity,  due  to  the 
organic  acids,  tends  to  persist,  we  may  combine  bismuth  subnitrate  with 
magnesia  and  a  few  grains  of  charcoal,  this  being  administered  when  the 
stomach  is  empty.  We  may  also  check  fermentation  by  the  exhibition 
of  salicylic  acid  (gr.  v — 0.324)  thrice  daily  or  creasote  (gr.  | — 0.0324) 
thrice  daily.  Germain  S^e  has  recently  found  strontium  bromid  (.^ss  to 
3j — 2.0—4.0)  to  be  of  great  value  in  cases  in  which  gaseous  fermentation 
with  hyperacidity  is  combined  with  permanent  tenderness.  Happy  re- 
sults often  follow  a  course  at  some  spa  if  the  patient  be  under  the  charge 
of  a  competent  physician  during  his  sojourn.  The  robust  or  plethoric 
should  go  to  Carlsbad,  Ems,  and  Kissingen  abroad,  and  to  Saratoga  at 
home,  using  more  especially  the  Hawthorne  water.  The  anemic  should 
go  to  Franzenbad  and  to  the  iron  springs  at  Bedford,  Pennsylvania.  A 
course  of  the  alkaline  mineral  waters  may  be  successfully  taken  at  home 
in  many  instances,  though  patients  are  much  more  apt  to  obey  the  phy- 
sician's injunctions  as  to  diet,  exercise,  and  the  like  when  at  a  spa  than 
when  at  home.  These  waters  do  not  simply  act  as  purgatives,  but  also 
as  antacids.  It  has  been  experimentally  shown  that  sodium  chlorid,  so- 
dium carbonate,  as  well  as  carbon  dioxid,  promote  the  secretion  of  the 
gastric  juice.  In  the  more  chronic  cases  belonging  to  this  class  or  those 
that  have  resisted  other  forms  of  treatment  intestinal  complications  are 
usually  found.  Here  the  alkaline  waters  are  to  be  alternated  with  calomel 
in  small  doses,  prescribed  thus  : 

^.  Hydrarg.  chloridi  mitis,  gr.  ij  (0.129) ; 

Sodii  bicarb.,  3j        (4.0) ; 

Sacchari  lactis,  3ss      (2.0). 

M.  et  ft.  chart.  No.  xij. 
Sig.  One,  dry  on  the  tongue,  four  times  daily, 

I  have  been  in  the  habit  of  continuing  the  use  of  these  powders  for 
several  days  to  one  week,  then  returning  to  the  alkaline  waters  for  a 
period  of  two  weeks. 

In  the  mucous  variety  of  gastric  catarrh  additional  indications  for 
treatment  are  presented.  The  chief  aim  should  be  to  limit,  as  far  as 
possible,  the  production  of  mucus  and  to  cleanse  thoroughly  the  stomach 
prior  to  each  meal,  thus  preparing  the  organ  for  the  reception  and  better 
digestion  of  food.  Here,  again,  at  least  one  pint  of  hot  water,  contain- 
ing the  substances  before  mentioned,  should  be  sipped  half  an  hour  before 
each  meal.  This  mode  of  cleansing  the  stomach  is  usually  successful ;  if 
unsuccessful,  however,  it  should  be  supplemented  by  lavage  once  daily, 
employing  two  or  more  pints  of  warm  water.  The  siphon  is  also  quite 
useful  in  cases  of  this  sort  in  which  stricture  of  the  pylorus  is  suspected 
and  when  the  food  is  retained  in  the  stomach  much  longer  than  the 


804  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

normal  period  of  digestion ;  a  condition  ■which  is  enhanced  by  the 
mucus  collecting  upon  tiie  food  and  thus  preventing  it  t'roni  being  acted 
upon  by  the  gastric  juice.  For  the  same  reason  absorption  is  greatly 
retarded.  Tlic  therapy  of  tliis  form  of  clironic  gastritis  requires  the  more 
potent  astringents  for  the  purpose  of  arresting  liypersecretion  of  mucus. 
The  best  way  to  use  these  agents  is  topically.  The  stomach  may  be 
washed  (at  bed-time  or  early  in  the  morning)  with  a  1^  per  cent,  solution 
of  alum  or  a  1  per  cent,  solution  of  tannic  acid ;  antiseptic  sidutions  are 
employed  in  like  manner,  a  2  per  cent,  solution  of  salicylic  acid  being 
especially  efficacious.  If  lavage  cannot  be  practised,  such  astringents  as 
catechu,  cerium  oxalate,  and  silver  nitrate,  with  small  doses  of  opium 
{vide  si(pra).  should  be  tried.  For  use  internally,  one  of  the  best  reme- 
dies is  atropin  sulphate. 

Certain  symptoms  belonging  to  all  varieties  of  the  affection  may  demand 
relief.  These  must  be  met  in  accordance  with  general  principles.  Vom- 
itinor,  which  is  at  times  a  distressing  symptom,  is  best  allayed  by  small 
doses  of  resorcin  or  creasote  in  combination  with  cerium  oxalate. 

As  soon  as  the  morbid  irritability  of  the  stomach  has  been  reduced 
mild  forms  of  bitter  tonics,  with  a  view  to  imparting  vigor  to  the. digestive 
organs,  may  be  cautiously  employed.  Their  too  early  use  is  very  apt  to 
aggravate  existing  symptoms,  or  even  to  reproduce  such  as  have  already 
disappeared.     Iron  is  often  indicated  during  convalescence. 


GASTRIC  ULCER. 

{Swiple  or  Bound   Ulcer  of  the  Stomach.) 

Definition. — An  ulcer  presenting  sharp  borders,  with  a  tendency  to 
extend  in  depth,  generally  without  collateral  inflammation,  giving  rise, 
usually,  to  one  or  more  characteristic  symptoms,  as  pain,  vomiting,  and 
hemat*emesis.     Peptic  ulcers  may  be  single,  but  are  oftener  multiple. 

Pathology. — The  gross  anatomic  characteristics  and  peculiarities 
may  be  briefly  considered  seriatim,  (a)  In  shape  it  is  usually  round  or 
oval.  Frequently  there  are  several  ulcers,  and  these  may  unite  to  form 
larger  ones  having  irregular  borders.  They  are  at  first  superficial, 
though  their  floor  (when  seen  at  autopsy)  is  below  the  mucous  meiubrane. 
Tlius,  the  ulcer  has  for  its  base  frei^uently  the  muscular  or  serous  coats, 
but  sometimes  the  ulcerative  process  extends  through  the  walls  of  the 
stomach  (••perforating  ulcer"),  in  which  case  adhesions  form  between 
the  st.Knich  and  the  adjacent  viscera,  one  or  other  of  the  latter  organs 
occupying  the  base  of  the  ulcer.  The  walls  usually  slope  inward,  giving 
rise  to  the  characteristic  funnel-shape.  The  edges  may,  however,  be 
sharp  and  abrupt.  The  floor  of  the  ulcer  is  quite  generally  clean.  A 
recent  ulcer  presents  clean-cut  edges  that  are  not  the  seat  of  collateral 
indamraatory  edema,  though  an  old  ulcer  often  presents  thickeneil  mar- 
gins, {h)  The  size  is  quite  variable.  The  majority  of  the  ulcers  are  not 
larger  than  a  dime ;  others  may  measure  as  much  as  10  cm.  (4  inches) 
in  their  greatest  diameter.  The  edges  are  almost  invariably  formed 
from  the  coalescence  of  two  or  more  smaller  ones,     (c)  The  position  is 


GASTRIC  ULCER.  805 

most  frequently  near  the  pylorus  on  the  posterior  wall,  and  particulurly 
in  the  vicinity  of  the  lesser  curvature.^  "^rhis  is  the  point  of  greatest 
irritation  from  the  moving  mass  of  gastric  contents  which  the  disturbed 
muscular  mechanism  ejects  before  they  have  become  reduced  to  a  li((uid 
(Barker).     Fortunately  the^'^  rarely  occupy  the  anterior  surface. 

The  deeper  ulcers  heal  by  cicatrization.  The  resulting  scar  is  pale 
and  stellate,  and  there  is  puckering  of  the  surrounding  mucous  mem- 
brane. If  the  ulcer  has  not  extended  deeper  than  the  mucous  mem- 
brane, granulation-tissue  develops  from  the  edges  and  base;  this  tissue 
slowly  contracts,  uniting  the  margins  without  a  distinct  scar.  On  the 
other  hand,  if  the  ulcer  be  large  and  involve  the  muscular  and  serous 
coats,  stricture  of  the  pylorus,  followed  by  dilatation,  may  result.  The 
stomach  may  present  an  hour-glass  shape,  due  to  the  contraction  of  a 
girdle  ulcer  in  the  central  part  of  the  organ.  Nearly  all  gastric 
ulcers  would  perforate  the  coats  were  it  not  for  the  development  of 
a  localized  peritonitis  with  the  establishment  of  protective  adhesions. 
The  ulcers  being  usually  situated  on  the  posterior  wall,  the  surface  of 
the  pancreas  forms  the  point  of  attachment  most  frequently,  though  the 
stomach  may  also  become  adherent  to  the  left  lobe  of  the  liver,  the 
spleen,  omentum,  diaphragm,  or  the  transverse  colon.  The  organs  Avith 
Avhich  the  stomach  becomes  agglutinated  may  be  penetrated  by  the 
ulcerative  process,  resulting  in  suppurative  inflammation  (abscess) ;  or, 
guided  by  the  limiting  adhesions,  fistulous  connections  of  the  stomach 
with  the  transverse  colon,  the  pleura,  the  pericardium,  lungs,  gall- 
bladder, and  the  duodenum  may  be  established.  Of  these,  gastrocolic 
fistulse  are  the  most  common.  The  ulcer  has  perforated  the  left  ventricle. 
Penetration  of  the  ulcer  through  the  posterior  gastric  wall  opens  the 
lesser  peritoneal  cavity,  in  which  case  the  base  remains  limited,  pro- 
ducing a  condition  known  as  subphrenic  pyo-pneumothorax.  When  the 
anterior  surface  of  the  stomach,  which  has  no  anatomic  relations  with 
other  organs  favorable  for  the  establishment  of  protective  adhesions  is 
perforated,  general  infectious  peritonitis  rapidly  supervenes.  Intense 
hyperemia  or  the  erosion  of  small  vessels  gives  rise  to  small  or  moderate 
hemorrhages.  If  the  ulcer  penetrate  one  of  the  larger  vessels,  then  fatal 
hematemesis  is  the  usual  result.  The  development  of  a  "protective  throm- 
bosis "  may  prevent  this  accident.  In  several  instances  small  aneurysms 
have  been  found  at  the  bases  of  the  ulcers  (Douglas,  Powell,  Welch). 

Frequency  and  etiology. — The  prevalence  of  gastric  ulcer  in 
the  various  countries  is  shown  by  the  statistics  of  C.  P.  Howard ;  he 
analyzed  the  records  of  161,599  cases  treated  in  American  hospitals,  and 
found  930  instances  in  which  gastric  ulcer  was  present  (0.57  per  cent.) ; 
Bromwell,  of  Edinburgh,  in  43,357  cases,  found  2.02  per  cent,  to  suffer 
from  gastric  ulcer.  The  percentage  for  London  is  1.21  per  cent,  lower 
than  that  given  for  Edinburgh  ;  Breslau  0.66  per  cent.  ;  Berlin  1.33 
per  cent.  Concerning  its  pathogenesis,  there  are  two  points  that  are 
generally  accepted :  (a)  that  the  ulcer  is  due  to  a  self-digestion  of  a  cir- 
cumscribed  portion  of  the  stomach ;  (5)  that  the  resistance  of  the  part 

'  Of  793  cases  collected  by  Welch  from  hospital  statistics,  288  were  on  the  lesser 
curvature,  235  on  the  posterior  wall,  95  at  the  pylorus,  69  on  the  anterior  wall,  50  at  the 
cardia,  29  at  the  fundus,  27  on  the  greater  curvature.  MacNevin  and  Herrick  noted  the 
location  of  the  lesion  in  97  fatal  cases,  as  follows :  lesser  curve  47,  posterior  wall  30, 
anterior  wall  17,  and  greater  curve  3. 


806  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

digested  has  been  previously  reduced  or  even  lost.  Diminished  or  lost 
resistance  may  be  due  to  a  lessening  of  the  supply  of  alkaline  arterial 
blood,  ^vhich  prevents  the  stomach  from  being  digested  in  health  ;  also,  to 
eoibolisf/i  and  t/iroinhosii)  of  the  nutrient  artery  of  the  part,  the  infarct  thus 
produced  being  annihilated  by  the  gastric  secretions  (Virchow).  Bassler 
thinks  the  lack  of  gastric  mucus,  which  protects  the  glandular  elements  in 
hyperchlorhydria,  is  a  faetor.  The  experiments  by  I'anum  and  Cohnheim 
show  that  ulcers  produced  artificially  tend  to  heal  rapidly.  Stockton  holds 
that  the  disease  is  a  neurosis.  Traumatic  injuries  have  been  suggested.  It 
is  probable  that  microbic  invasion  has  not  received  sufficient  attention  in 
the  past  as  an  etiologic  factor.  The  gastric  juice,  while  bactericidal,  does 
not  aft'ord  universal  protection.  Turck  claims  that  round  ulcer  of  the  stom- 
ach and  duodenum  can  be  produced  in  dogs  by  feeding  the  colon  bacillus. 

Predisposing  Causes. — Hyperacidity  of  the  gastric  juice  is  doubtless 
most  influential — a  condition  almost  universally  present  in  this  disease ; 
although  the  ulcers  may  not  result  primarily  from  the  presence  of  an  ex- 
cess of  acid,  it  is  quite  probable  that  further  extension  of  the  ulcerative 
process  may  be  due  to  this  factor.  Peter  assumes  the  cause  of  simple 
ulcer  to  be  gastritis.  It  rarely  follows  cutaneous  burns  and  also  wounds 
of  the  bladder.  The  aft'ection  is  often  secondary  in  chlorosis,  anemia, 
and  amenorrhea.  The  fact  that  in  all  the  difi"erent  forms  of  anemia  there 
is  a  diminished  alkalinity  of  the  blood  is  of  great  interest  in  this  connec- 
tion. Obviously,  then,  ulcer  occurs  more  frequently  in  females  than  in 
males.  It  is  most  common  between  seventeen  and  thirty-five  years ;  it 
is  rare  in  young  children,  though  Gorgart  saw  an  instance  in  a  child 
thirty  hours  after  birth,  and  less  rare  in  those  past  middle  life.  Cackovic 
states  that  the  age  was  under  ten  years  in  2.32  per  cent,  of  172  operative 
cases.  It  is  more  frequent  in  the  poor  than  in  the  rich ;  occupation  has 
also  a  noticeable  influence,  and  I  have  personally  seen  instances  in 
weavers.  It  is  also  prone  to  attack  servants,  cooks,  and  needlewomen 
among  females,  and  shoemakers,  tailors,  saddlers,  and  carpenters  among 
males.     Exner  has  discovered  that  gastric  ulcers  are  fre(iuent  in  tabetics. 

Clinical  History. — In  topical  cases  of  gastric  ulcer  the  clinical 
symptoms  are  almost  positively  diagnostic.  The  earliest  manifestations 
commonly  point  to  chronic  or  subacute  gastric  catarrh,  these  being  fol- 
lowed, soon  or  late,  by  those  that  are  characteristic,  as  pain,  vomiting, 
and  hematemesis.  Of  these,  pain  is  most  constantly  present,  and  pre- 
sents certain  peculiarities  that  demand  rather  elaborate  mention.  It  is 
commonly  dull,  at  times  burning,  and  is  associated  usually  with  great 
oppression.  The  character  of  pain  that  is  most  diagnostic  is  an  intense 
gnawing,  burning  or  boring  in  the  epigastrium,  more  or  less  periodic  and 
strictly  localized  in  a  circumscribed  area.  These  paroxysms  usually  come 
on  almost  immediately  after  eating,  occasionally  one  or  two  hours  later, 
and  disappear  quite  promptly  when  the  stomach  is  emptied  either  by 
vomiting  or  by  its  contents  passing  into  the  duodenum.  From  the  time 
of  its  development,  the  quality,  and  strict  localization  of  the  pain,  it  may 
safely  be  assumed  that  it  is  due  to  direct  irritation,  set  up  by  the  food, 
of  the  sensory  fibers  occupying  the  base  of  the  ulcer.  In  addition,  there 
are  paroxysms  of  diffuse  pain  (gasfralgia)  there  are  often  strictly  inter- 
mittent, though  not  necessarily  excited  by  the  partaking  of  food.  This 
pain  is  due  to  a  sympathetic  nervous  disturbance  or  reflected  irritation. 


GASTRIC   ULCER.  807 

Finally,  sharp,  intense,  lancinating  pains,  that  are  caused  by  local  or 
general  peritonitis,  may  appear  suddenly.  The  pain  in  round  gastric 
ulcer  is  greatly  modified  by  numerous  conditions.  The  effect  of  taking 
food  has  been  already  referred  to,  and  it  should  be  added  that  indigestible, 
imperfectly  masticated,  and  highly  spiced  food,  sweet  and  hot  substances, 
cause  the  paroxysms  to  be  more  intense  than  do  less  irritating  articles  of 
diet.  Rest  diminishes  the  pain  by  preventing  traction  on  the  ulcer.  (Jertain 
postures  may  aggravate  it,  and,  while  not  a  trustworthy  guide,  we  may 
often  determine  the  situation  of  the  ulcer  by  the  effect  of  posture  after 
taking  solid  food.  The  severity  of  the  pain  is  often  increased  by  bodily 
fatigue  or  even  moderate  exercise  and  emotional  influences.  The  situation 
of  the  pain,  when  strictly  localized,  is  of  the  utmost  importance  in  diag- 
nosis. I  have  found  it  almost  invariably  from  one  to  two  inches  below 
the  ensiform  cartilage,  yet  it  has  rarely  been  observed  in  the  umbilical 
and  hypochondriac  regions.  It  is  absent  in  one-half  of  all  cases.  There 
is  a  pain-point  in  the  dorsal  region  (often  at  a  level  with  the  tenth  to  the 
twelfth  thoracic  vertebra)  on  the  left  side.  Says  Moullin  :  One  special 
symptom  that  indicates  the  spread  of  ulceration  is  persistent  cutaneous 
hyperesthesia  in  Head's  epigastric  triangle  and  at  the  dorsal  pain-point. 

Vomiting^  next  to  pain,  is  the  most  frequent  symptom,  but  unless  the 
vomitus  contains  macroscopic  blood,  which  is  present  in  less  than  50  per 
cent,  of  all  the  cases,  or  occult  blood  (vide  p.  832),  it  has  little  diagnos- 
tic importance.  Nausea  and  eructations  of  acid  or  food  often  precede  or 
accompany  the  emesis.  Vomiting  usually  occurs  about  two  hours  after 
eating,  often  at  the  height  of  the  paroxysm  of  pain,  which  the  vomiting 
relieves  as  a  rule.  The  vomitus  and  gastric  contents^  as  first  shown  by 
Riegel,  commonly  contains  an  increased  proportion  of  HCl  (hyperacidity). 
The  total  acidity  is  abnormally  high.  The  withdrawn  test-meal  usually 
contains  blood,  either  macroscopic  or  occult.  The  acidity  is  reduced  with 
the  age  of  the  patient  and  chronicity.  Kemp  confirms  Rubow's  assertion 
that  the  amount  of  residue  is  large  and  extremely  acid. 

Hematemesis  is  a  symptom  of  unequalled  clinical  significance,  and  on 
it  alone  frequently  rests  a  positive  diagnosis.  When  the  hemorrhage  is 
considerable,  pure  blood,  more  or  less  clotted,  may  be  ejected,  this  being 
highly  characteristic  of  gastric  ulcer.  Frequently,  however,  the  blood 
oozes  gradually  into  the  stomach  and  mingles  with  the  gastric  juice,  and 
in  consequence  the  oxyhemoglobin  of  the  blood  is  converted  into  hematin, 
the  vomitus  presenting  the  appearance  of  coffee-grounds.  On  microscopic 
examination  large  and  small  granules  of  blood-pigment  are  seen,  but  the 
red  cells  are  incapable  of  recognition.^  Vomiting  of  blood  may  occur  at 
intervals  of  a  few  hours  or  on  each  successive  day.  The  amount  also 
varies  within  the  widest  limits  according  to  the  size  of  the  vessel  eroded. 
Some  of  the  effused  blood  passes  through  the  pylorus,  escaping  with  the 
feces  and  giving  to  the  latter  a  tarry,  black  appearance.  A  few  cases 
have  been  reported  in  which  all  the  blood  was  evacuated  with  the  stools 
except  that  which  was  absorbed  from  the  alimentary  tract.  Steele 
claims  that  gastric  ulcers  do  not  bleed  as  often  as  might  be  expected, 
and  that  in  dubious  cases  the  stools  must  be  examined  for  several  weeks 
before  chronic  ulcer  could  be  excluded.     Intermitterit  hemorrhages,  how- 

*  The  blood,  however,  can  be  identified  by  the  euaiacum  and  other  chemical  tests  and 
through  its  spectroscopic  appearance. 


808  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ever,  point  stron<:;ly  toward  ulcer.  Either  as  the  result  of  a  single  copious 
hemorrhage  or  of  repeated  smaller  bleedings  a  pronounced  anemia  is  pro- 
duced. As  a  rule,  however,  the  evidences  of  anemia  are  only  moderately 
uell  marked,  and  to  assume  that  the  anemia  is  due  solely  to  the  hemor- 
rhages would  be  an  error.  A  slight  rise  of  temperature  is  often  observed 
under  these  circumstances  ;  this  is  the  so-called  aneuiic  fever.  The  pain 
and  the  most  unpleasant  local  synijitoms  have  been  freiiuently  observed 
to  disappear  after  its  cessation.  Both  cardiospasm  and  ])ylorospasm,  as 
shown  by  radioscopy,  are  not  infrecjuent  accompaniments.  The  appetite 
mav  be  good,  but  the  patient  is  disinclined  to  cat.  owing  to  the  pain  re- 
sulting therefrom.      Not  infre(iuently  convalescence  sets  in  immediately. 

Physical  signs  are  few  and  sliglit.  On  palpation  tenderness  is  found, 
though  not  in  all  cases.  The  spot  of  localized  agonizing  pain  before 
alluded  to  is  often  excessively  tender  on  pressure — a  valuable  sign.  The 
true  gastralgic  attacks  arc  at  times  relieved  by  making  firm  pressure  with 
the  broad  hand  over  the  ei)igastrium.  Near  the  pyloric  end  of  the  stomach 
palpable  tumors  may  be  felt,  due  to  the  thickened  floor  of  the  ulcer. 
When  these  indurated  masses  become  adherent  to  adjacent  organs — the 
pancreas,  for  example — epigastric  tumors  of  considerable  size  may  be 
felt,  suggesting  the  presence  of  carcinoma.  General  sjimptomH  often  do 
not  appear  until  late  in  the  disease.  Anemia  is  usually  noted  first,  to  be 
followed  by  debility  and  emaciation  ;  the  degree  of  the  general  disturb- 
ances is  in  direct  proportion  to  the  severity  and  duration  of  the  coexist- 
ing catarrh,  hemorrhages,  pain,  and  vomiting.  The  cachexia  may  be 
pronounced,  and  the  face,  on  account  of  the  prolonged  suffering,  assumes 
a  gaunt  appearance. 

Other  Clinical  Forms. — These  have  been  subdivided  into  numerous 
types,  some  of  which  merge  into  one  another  and  cannot  be  separated- 
clinically.  The  following  atypical  forms  should  be  distinguished :  (a) 
Latent  ulcers,  whose  existence  is  not  suspected  during  life,  but  which  are 
revealed,  should  they  come  to  autopsy,  as  open  ulcers  or  cicatrices,  {b) 
An  explosive  form,  in  which  the  ulcer  mayor  may  not  give  rise  to  gastric 
disturbances  prior  to  the  occurrence  of  perforative  peritonitis,  (c)  A  re- 
current form,  described  by  Welch  thus  :  "  In  this  the  symptoms  of  gastric 
ulcer  disappear,  and  then  follow  intervals,  often  of  considerable  duration, 
in  which  there  is  apparent  cure,  but  the  symptoms  return,  especially 
after  some  indiscretion  in  the  mode  of  living.  This  intermittent  course 
may  continue  for  many  years.  In  these  cases  it  is  probable  either  that 
fresh  ulcers  form  or  that  the  cicatrix  of  an  old  ulcer  becomes  ulcerated." 

Complications  and  Sequelae. — Perforation  of  the  ulcer  (most 
common  when  it  is  situated  in  the  anterior  wall)  leads  to  peritonitis, 
which  almost  always  ends  fatally.  Rarely  a  localized  peritonitis  is  the 
result,  owing  to  rapidly  formed  limiting  adhesions  or  perforation  into  the 
lesser  peritoneal  cavity.  The  symptoms  of  this  complication  will  be  given 
in  their  proper  place  (see  also  Pain,  p.  806).  Hemorrhage  ma,y  prove  a 
serious  complicating  accident,  being  in  not  rare  instances  an  immediate 
cause  of  death.  Severe  hemorrhage  may  also  cause  a  diminution  of  free 
HCl,  with  an  amelioration  of  the  symptoms.  Parotitis,  due  to  oral  star- 
vation and  multiple  neuritis,  have  been  noted. 

The  cicatrization  of  an  ulcer  may  lead  to  hour-r/lass  stomach,  which 
presents  features  as  follows  .   "(1)  In  washing  out  the  stomach  part  of  the 


GASTRIC   ULCKIl.  809 

fluid  is  lost.  (2)  If  the  stotnacli  is  washed  clean,  a  sudden  reappearance 
of  stomach-contents  may  take  place.  (3)  'Paradoxical  dilatation  '  when 
tlie  stomach  has  apparently  been  emptied,  a  splashing  sound  may  be 
elicited  by  palpation  of  the  pyloric  segment.  (4)  After  dist,(;nding  the 
stomach  a  change  in  the  position  of  the  distention  tumor  may  be  seen  in 
some  cases.  (5)  Gushing,  bubbling,  or  sizzling  sounds  are  heard  on 
dilatation  with  carbon  dioxid  at  a  point  distinct  from  the  pylorus.  (6) 
In  some  cases,  when  botli  parts  are  dilated,  two  tumors  with  a  notch  or 
sulcus  between  are  apparent  to  sight  or  touch  "  (Moynihan). 

Diagnosis. — The  typical  cases  in  which  the  characteristic  symp- 
toms above  mentioned  are  conspicuous  are  easy  of  diagnosis.  Hemor- 
rhages occurring  with  gastralgic  attacks  are  almost  pathognomonic.  A 
considerable  proportion,  however,  offer  formidable  difficulties.  Without 
the  presence  of  hematemesis,  visible  or  occult,  for  example,  a  positive 
diagnosis  should  not  be  made,  and  yet  this  symptom  does  not  appear  in 
50  per  cent,  of  all  cases.  In  the  absence  of  hemorrhage  we  may,  how- 
ever, infer  the  altogether  probable  existence  of  ulcer  if  there  be  a  history 
of  the  more  important  etiologic  factors ;  if  there  be  gastralgia,  hyper- 
acidity, local  pain  and  tenderness,  a  dorsal  pain-point ;  and,  particularly, 
if  the  latter  symptoms  be  aggravated  by  the  taking  of  food.  The  long 
course  and  liability  to  remission  are  strongly  confirmatory. 

Differential  Diagnosis. — This  disease  may  be  mistaken  for  gastralgia^ 
chronic  gastritis,  the  passage  of  gall-stones,  cirrhosis  of  the  liver,  and 
carcinoma  of  the  stomach.  The  differentiation  of  the  latter  complaint 
will  be  given  later,  (a)  In  certain  cases  of  cirrhosis  of  the  liver  hema- 
temesis is  met  with,  but  here  there  is  absence  of  all  the  other  character- 
istic symptoms  of  ulcer,  and  the  presence  of  a  group  of  symptoms  and 
physical  signs  pointing  to  disease  of  the  liver,  (h)  Hepatic  colic  simu- 
lates ulcer  of  the  stomach  without  hemorrhage.  The  sudden  onset,  the 
longer  duration  of  the  attack  of  pain,  its  sudden  complete  cessation,  the 
presence  of  jaundice  and  certain  .physical  signs  presented  by  the  liver, 
often  suffice  to  distinguish  this  affection  from  gastric  ulcer.  The  urine 
may  contain  pepsin  in  ulcer,  and  the  administration  of  orthoform  (Hem- 
meter)  will  relieve  the  gastric  pain  but  not  that  of  cholelithiasis,  (e) 
Chronic  gastric  catarrh  with  hematemesis  resembles  ulcer  of  the  stomach 
in  many  particulars.  The  great  diminution  in  the  proportionate  amount 
of  hydrochloric  acid  found  in  chronic  gastric  catarrh  and  the  increased 
amount  in  gastric  ulcer  help  materially  in  discriminating  these  two  dis- 
eases. When  associated  with  one  another  my  observation  teaches  that 
there  is  an  excess  of  HCl  present;  hence  a  proportionately  diminished 
amount  of  HCl  probably  argues  against  the  presence  of  ulcor.  The 
vomiting  in  ulcer  is  combined  with  severe  paroxysms  of  pain ;  not  so  in 
chronic  gastritis,  and  the  vomit  in  the  former  contains  larger  quantities 
of  blood  than  in  the  latter  disease,  (d)  Doubtless  ulcer  of  the  stomach 
has  often  been  mistaken  for  neurotic  gastralgia,  and  the  discrimination 
cannot  always  be  accomplished  to  a  certainty. 

Gastric  Ulcer.  Gastralgia. 

History  of  certain  occupations,  taking  of      History  of  neurasthenia,  neuralgia,  and 
hot  drinks  or  irritants,  as  acids  or  al-  hysteria  the  rule, 

kalies,  chlorosis,  amenorrhea,  tubercu- 
losis, and  heart  diseases  common. 


810  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Gastric  Ulcer.  Gastralgia. 

Most  frequent  from   fifteen   to   thirty-tive  Most  frequent  before  or   near   the   iweno- 

years  of  age.  pau.se  (in  the  female). 

The  paroxysms  of  pain  usually  come  oa  Paroxysms   more   frequent  when  stomach 

at  a  definite  period  after  eating.  is  empty  and  show  less  poriodicitv. 

Eating  rarely  relieves  pain.  Eating  usually  brings  relief. 

Position  of  patient  may  relieve  pain.  No  decided  relief. 

Tenderness   on   pressure  over   a  certain  Tender  spot  absent.     General   hyperes- 

limited  area  in  the  epigastrium.  thesia  of  the  skin  of  epigastrium  often 

present. 

Pressure   usually   aggravates,  and   only  Pressure  almost  always  relieves  the  pain. 

occasionally    relieves    patient    during 

paroxysm  of  pain — not  during  the  in- 
tervals between  seizures. 

In  the  intervals  gastric  disturbances^  more  In  the  intervals  between  attacks  no  gas- 

or  less  severe,  are  present.  trie  disturbances  present,  as  a  rule. 

Hematemesis  present  in  nearly  one-half  Hematemesis  absent. 

of  the  cases. 

General  health  often  much  impaired,  par-  General  health  less  affected  than  in  ulcer. 

ticularly  late  in  the  affection. 

Physical  signs  of  a  mass  may  be  present.  Signs  of  tumor  always  absent. 

Dilatation  may  coexist  in  the  late  stage.  Dilatation  never  present. 

Hyperacidity  of    gastric    juice    usually  Hyperacidity    present    only    in    certain 

present.  forms  (supTo). 

Improvement  follows  rest  and  regulation  Regulation  of  diet  has  no  effect. 

of  diet. 

The  prognosis  is  obviously  uncertain.  The  average  mortality  is 
about  15  per  cent.  Such  grave  complications  as  free  bleedings  and  peri- 
tonitis have  been  discussed  suflficiently  in  the  Clinical  History.  Among 
serious  thoracic  complications,  pneumonia,  tuberculosis,  and  left-sided 
perforative  empyema  are  those  most  frequently  encountered.  The  more 
recent  the  case  the  better  the  prospect  of  recovery.  The  possibility  that 
the  resulting  scar  may  cause  persistent  gastralgia,  and  the  probability 
that  a  cicatrix  surrounding  the  whole  or  any  part  of  the  pylorus  may 
cause  obstruction,  followed  by  ectasy,  must  be  remembered.  Carcinoma 
often  develops  in  the  floor  of  an  old  ulcer  (vide  p.  813).  Innately,  the 
disease  is  an  exceedingly  chronic  one,  often  lasting  several,  and  some- 
times ten  or  fifteen,  years. 

Treatment. — ;The  treatment  of  simple  gastric  ulcer  embraces  three 
leading  objects:  (1)  Of  paramount  importance  is  absolute  rest  for  the 
stomach.  This  is  to  be  accomplished  by  maintaining  the  recumbent  posture 
in  bed,  on  the  one  hand,  and  by  rectal  feeding,  wholly  or  partly,  on  the 
other.  This  mode  of  alimentation  will  be  discussed  presently.  Perfect 
rest  constitutes  the  best-known  safeguard  against  those  serious  accidents 
that  intervene  suddenly  in  the  course  of  this  aflFection.  It  also  ensures 
more  rapid  cicatrization  than  any  other  single  agent.  The  process  of 
repair  is  very  slow  under  the  most  fiivorable  circumstances ;  hence  the 
patient  should  be  informed  at  the  outset  that  from  six  to  eight  weeks, 
at  least,  must  be  spent  in  bed.  (2)  The  careful  regiilation  of  the  diet. 
It  is  not  possible  fur  the  stomach,  when  the  seat  of  ulcer,  to  digest  the 
normal  amount  of  nitrogenous  food  without  being  injuriously  aflfected 
thereby.  Those  articles  of  diet  should  be  employed  that  are  digested 
and  assimilated  chiefly  in  the  intestinal  tract.  But,  though  the  patient 
is  fed  by  the  mouth,  this  should  be  supplemented  by  rectal  feeding 
almost  from  the  beginning.  By  pursuing  this  combined  method  and 
giving  per  rectum  but  a  limited  amount  of  albuminous  food  the  vital 


GASTRIC   ULCER.  811 

forces  can  be  more  effectually  supported.  Failure  to  cure  cases  of  gjfstric 
ulcer  is  often  due  to  the  fact  that  the  patient's  general  strength  early 
becomes  exhausted.  Frequently  the  stomach  is  so  irritable  as  to  render 
it  exceedingly  difficult  to  introduce  into  it  even  a  fractional  part  of  the 
amount  of  food  necessary  to  support  life  properly;  in  such  cases  "a 
period  of  absolute  abstention  from  food  by  tlie  stomach  should  be  inaugu- 
rated" (Lambert).  Nothing  but  water  and  pieces  of  ice  should  be  allowed. 
Exclusive  rectal  feeding  during  the  first  week  is  a  method  quite  commonly 
adopted.  The  following  dietary  will  be  found  useful:  At  7  a.  m.  give 
100  c.cm.  (5iij)  of  Leube's  beef-solution  ;  at  11  A.  M.,  200  c.cm.  (.5vj)  of 
pancreatized  milk-gruel  ;'^  at  3  P.  M.,  200  c.cm.  (,lvj)  of  peptonized 
milk  or  skimmed  milk  or  buttermilk  ;  at  7  P.  M.,  200  c.cm.  (.Ivj)  of 
pancreatized  milk-gruel;  in  addition,  the  following  by  rectal  injection: 
at  8  A.  M.,  6  ounces  of  pancreatized  milk-gruel,  with  |  ounce  of  bovinin, 
and,  if  necessary  to  overcome  rectal  irritability,  5  to  10  drops  of  tinc- 
ture of  opium,  this  to  be  repeated  at  2  and  8  P.  M.  If  the  nutrient 
enemata  must  be  discontinued  for  a  time,  the  regular  diet  must  be  in- 
creased proportionately.  If,  on  the  other  hand,  the  stomach  rejects  the 
above-mentioned  food,  then  the  feeding  must  be,  for  a  time,  exclusively 
rectal ;  this  is  quite  practicable  if  the  proper  choice  be  made  of  nutrient 
preparations.  In  addition  to  the  substances  before  mentioned  we  may 
employ  from  4  to  6  ounces  (150—200  c.cm.)  of  Leube's  beef-solution,  or 
the  same  amount  of  defibrinated  blood  or  pancreatized  milk  with  brandy. 

Lenhartz  treated  295  cases  of  gastric  ulcer  with  a  more  nourishing 
diet  than  that  allowed  by  von  Leube,  with  a  mortality  of  2.3  per  cent. 
Da  Costa  reported  recently  a  number  of  instances  that  were  cured  by  a 
diet  of  ice  cream.  Senator  advises  the  use  of  gelatine  as  food  in  gastric 
ulcer.  Owing  to  the  abnormally  free  secretion  of  HCl  in  this  disease, 
the  proteins  should  be  limited  in  the  dietary,  while  carbohydrates  are  in- 
dicated, physiological  investigations  having  shown  that  the  latter  (also 
fats)  diminish  the  secretion  of  the  normal  acid.  It  has  been  recom- 
mended to  employ  lavage  when  the  stomach  is  exceedingly  irritable, 
but  the  use  of  the  stomach-tube  is  liable  to  damage  the  ulcer  even  in  the 
most  careful  hands.  The  good  effects  from  washing  out  the  stomach  for 
uncontrollable  vomiting  and  pain  have,  however,  been  frequently  wit- 
nessed. It  may  often  be  accomplished  by  the  use  of  1  pint  (J  liter)  of 
warm  water  containing  a  few  grains  of  sodium  bicarbonate,  sipped  slowly 
when  the  stomach  is  empty.  If  at  the  expiration  of  two  months  the 
condition  of  the  patient  indicates  that  the  reparative  process  is  far  ad- 
vanced, then  well-boiled  rice,  stale  bread,  and  potatoes  may  be  allowed ; 
and  later  eggs,  oysters,  fish,  and  sago,  while  an  ordinary  solid  diet  should 
not  be  resumed  for  at  least  six  months. 

(3)  The  medicinal  treatment^  which  is  altogether  subsidiary  to  the 
dietetic,  has  reference  to  two  ends :  (a)  Promotion  of  the  healing  proc- 
ess. We  cannot  be  certain  that  any  known  remedial  agents  can 
accomplish  this  object,  yet  it  is  our  duty  to  attempt  it.  Of  the  efficacy 
of  alkaline  remedies  we  are  thoroughly  convinced ;  in  neutralizing 
the  hyperacidity  of  the  gastric  secretions  they  fulfil  an  important 
indication,   since  the   excess   of  HCl   must   have   an   unfavorable  effect 

1  The  milk-gruel  is  prepared  with  wheaten  flour  or  arrowroot,  mixed  with  an  equal 
quantity  of  milk. 


812  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

upon  the  ulcer.  Of  these,  sodium  learbonate  (in  full  doses)  or  the 
alkaline  purgative  mineral  waters,  as  Carlsbad,  Kissingen,  liunyadi 
Jdnos,  are  most  useful.  The  Carlsbad  salts  are  beneficial,  and  may  be 
prepared  artificially  as  follows:  sodium  sulphate,  50  parts;  sodium 
bicarbonate,  0  parts  ;  sodium  chloride,  8  parts — of  which  a  teaspoonful 
may  be  taken  in  hot  w;iter.  fasting,  in  the  morning.  The  alkaline  waters 
must  not  be  allowed  while  the  stomach  is  at  perfect  rest.  The  prepara- 
tions of  bismuth  may  be  given  in  combination  with  antiseptics,  which 
latter  are  especially  to  be  recommended.  Fleiner's  method  of  giving  10 
gm.  of  bismuth  in  2(>0  gm.  of  warm  water  on  an  empty  stomach,  then 
allowing  the  patient  to  drink  several  swallows  of  water,  and  afterward 
placing  him  in  the  horizontal  position  with  the  hi])S  elevated  for  about 
an  hour,  has  yielded  gratifNMng  results.  About  200  gm.  of  bismuth 
administered  in  the  above  manner  usually  suffice  to  effect  a  cure 
(Savelieff).  For  the  chronic  gastric  catarrh  which  may  be  associated 
with  ulcer,  silver  nitrate  is  efficient,  and  may  be  combined  Avith  small 
doses  of  opium  or  hyoscyamus.  Tlie  previous  general  condition  of  the 
patient  is  frequently  unfavorable  to  the  successful  healing  of  the  ulcers, 
and  to  combat  the  anemia  and  chlorosis  that  are  often  present  we  may 
employ  iron  and  arsenic.  Small  doses  of  Fowler's  solution  of  arsenic 
are  generally  well  borne  by  the  stomach  ;  the  former  may  also  be  given 
hypodermically.  When  organic  cardiac  diseases  are  concomitants  they 
should  receive  careful  attention,  and  also  any  other  associated  conditions. 

(b)  The  relief  of  symptoms.  The  extract  of  ojiium,  combined  with 
silver  nitrate,  often  relieves  the  pain.  Mild  counter-irritation  is  also  of 
service,  but  not  warm  poultices.  The  application  of  the  ice-bag  some- 
times alleviates  the  pain,  but  Hemmeter  advises  orthoform.  For  the  gas- 
tralgic  attacks  morphin  may  be  required.  For  vo7nitmg,  bismuth,  cre- 
asote,  silver  nitrate,  and  opium  are  useful ;  chipped  ice,  with  a  small 
amount  of  brandy  thrown  over  it,  is  also  of  value.  When  obstinate,  the 
following  remedies  may  be  tried  separately  :  cerium  oxalate,  potassium 
bromid,  tincture  of  iodin,  cocain,  chloral,  and  hydrocyanic  acid. 

For  the  heynatemesis,  rest,  rectal  feeding,  the  application  of  a  broad, 
flat  ice-bag,  and  the  use  of  morphin  or  ergot  hypodermically,  will  usually 
suffice.  For  exhaustive  hemorrhages  infusion  into  the  veins  or  into  the 
subcutaneous  tissue  of  normal  salt  solution  is  an  important  measure.  For 
stopping  a  hemorrhage,  lavage  followed  by  bismuth  is  highly  recommended. 
Operative  intervention  in  gastric  ulcer  is  demanded:  1.  In  recurring 
hematemesis,  W.  L.  Rodman  advises  operation  between  attacks — always 
after  the  third  bleeding ;  2.  In  perforation,  so  soon  as  the  diagnosis  is 
clearly  established.  In  the  cases  of  perforation  which  have  been  oper- 
ated upon  within  the  first  twelve  hours  during  the  past  three  years,  83.78 
per  cent,  have  been  saved  (Tinker).  3.  Most  of  the  cases  not  cured  by 
medical  treatment  are  savable  by  timely  surgical  intervention,  but  in 
simple  ulcer  of  the  stomach  operation  is  not  advised,  "  the  medical 
treatment  of  which  should  be  more  careful  and  more  prolonged  than  was 
formerly  deemed  necessary  "  (Robson^).  4.  If  gastrectasis  due  to  pyloric 
obstruction  or  if  adhesions  form  and  persist,  operation  is  indicated.  The 
treatment  of  callous  ulcer  is  purely  surgical. 

^British  Medical  Journal,  Nov.  17,  1906. 


CARCINOMA    OF  THE  STOMACH.  813 


CARCINOMA  OF  THE  STOMACH. 

Pathology. — Next  to  the  uterus,  the  stomach  is  the  most  favored 
seat  of  carcinoma.      In  a  total  of  over  80,000  cases  studied   by  Welch, 

21.4  per  cent,  showed  involvement  of  tliis  organ.  With  reference  to  the 
parts  of  the  organ  attacked,  Welch  analyzed  1200  cases  with  the  follow- 
ing results:  pyloric  region,  791;  lesser  curvature,  148;  cardia,  104; 
posterior  wall,  68;  greater  curvature,  34;  anterior  wall,  30;  fundus,  19. 
The  forms  of  gastric  carcinoma  noted  are  columnar  epitlielial  (including 
colloid)  and  the  glandular  carcinomata  (embracing  encephaloid  and  scir- 
rhous). The  epitheliomata  grow  from  the  lining  opitbelinm,  while  the 
encephaloid  and  scirrhous  are  new  growths  from  the  glandular  epithelium. 
The  last  two  forms  are,  therefore,  similar  in  structure,  but  differ  in  the 
rapidity  of  their  growth  ;  the  encephaloid  cancers  are  soft,  and  readily 
break  down  on  their  surface,  forming  large  ulcers  that  have  a  clean  floor, 
while  the  scirrhous  cancers  are  hard  and  firm.  Columnar  epitheliomata 
are  frequent,  and  are  situated  at  the  pyloric  end  of  the  stomach.  They 
are  often  the  seat  of  colloid  degeneration.  Squamous  epitheliomata  occur 
at  the  cardiac  end.  Secondary  new  growths  in  adjacent  organs  occur, 
the  scirrhous,  however,  manifesting  the  least  tendency  to  metastasis. 
Perforation  of  the  stomach-walls  occurs  in  3.3  per  cent.  (Brinton). 
Welch  collected  37  cases  of  secondary  gastric  carcinoma ;  17  were  sec- 
ondary to  mammary  carcinoma.      Atrophic  gastritis  ensues. 

Ktiology. — The  factors  bearing  upon  the  etiology  of  gastric  carci- 
noma may  all  be  regarded  as  predisposing  causes.  Of  these  age  is  the 
most  potent.  Of  2038  cases  examined  by  Welch  with  reference  to  this 
point,  75  per  cent,  occurred   between   the  fortieth  and  seventieth  years, 

24.5  per  cent,  between  forty  and  fifty  years,  30.4  per  cent,  between  fifty 
and  sixty  years,  and  2.8  per  cent,  before  the  thirtieth  year.  The  maxi- 
mum liability  lies  between  the  forty-fifth  and  sixtieth  years  (Lebert).  In 
1069  cases  collected  by  Osier  and  McCrae,^  2.5  per  cent,  developed 
before  thirty  years  of  age.  There  are  records  of  6  cases  before  the 
tenth  year.  Collingsworth  reports  the  case  of  a  child  at  ten  days  and 
death  at  twenty-ninth  day  ;  and  Widerhofer  1  at  sixteen  days.  I  find 
records  of  13  cases  between  ten  and  twenty  years.  Heredity  stands  next 
to  age  as  a  causal  factor,  though  it  is  far  less  influential.  W^elch  analyzed 
1744  cases,  and  found  that  a  family  history  of  carcinoma  was  present  in 
about  14  per  cent.  Sex  has  little  if  any  influence.  The  colored  race 
enjoys  comparative  immunity.  Gastric  carcinoma  may  follow  a  pre- 
existing chronic  catarrh.  More  commonly,  however,  chronic  ulcer  pre- 
cedes. In  Haberfeld's  series  of  662  autopsies  in  cases  of  gastric  carci- 
noma, 106,  or  16  per  cent.,  showed  macroscopic  evidence  of  having 
originated  in  round  ulcer.  Sonnichsen,  quoted  by  Rodman,  found  that 
out  of  156  cases  of  gastric  carcinoma  which  came  to  autopsy,  22,  or  14 
per  cent.,  developed  in  the  scars  of  ulcers,  while  the  statistics  of  Klausa 
(126  cases)  give  more  than  26  per  cent,  that  grow  from  either  ulcers  or 
cicatrices.  The  disease  is  most  probably  of  bacterial  origin.^  The  dis- 
ease is  rare  in  the  tropics. 

1  New  York  Medical.  Journal,  April  21,  1900,  p.  581. 

2  "The  Nature  of  Carcinoma,"  by  the  writer,  New  York  Medical  Jounial,  Nov.  21, 
1908. 


814  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Clinical  History. — Prior  to  the  development  of  gastric  carcinoma 
the  j^yuiptuius  of  catarrhal  dyspepsia  may  be  present  for  a  variable  period 
of  time.  The  onset,  however,  is  oftener  abrupt.  Again,  it  may  be  in- 
sidious, and  be  marked  more  by  the  evidences  of  failing  general  health 
and  strength  than  by  distinct  local  subjective  symptoms.  Osier  and 
McCrae^  have  reported  cases  of  latent  carcinoma  of  the  stomach.  A 
progressive  decline  of  th-e  appetite  is  generally  observed,  thougli  occa- 
sionally it  remains  unimpaired.  A  sense  of  oppression,  rarely  true 
eardialgia,  and  eructations  {pyrosis)  come  on  soon  after  eating.  In 
many  cases  but  little  pain  is  complained  of,  while  in  a  lesser  number 
pain  is  a  prominent  symptom  throughout  the  entire  course.  Its  char- 
acter is  very  often  described  as  lancinating,  less  often  as  burning  or 
gnawing ;  the  latter  form  of  pain  is  due,  most  probably,  to  associated 
secondary  ulcers.  The  pain  is  often  referred  to  the  shoulders  and  the 
back  or  loins.  Vomiting  is  infrequent,  except  in  the  more  advanced 
stages  of  the  disease,  when  it  is  almost  constantly  present  to  a  greater  or 
less  degree.  During  the  earlv  staorcs  it  is  due  to  the  catarrhal  irritation, 
later  to  obstruction.  When  the  latter  is  at  the  cardiac  orifice,  the  pain 
occurs  at  once  after  eating ;  wlien  at  the  pylorus,  it  appears  .several  hours 
after  meals.  Vomiting  may  also  be  caused  by  the  occurrence  of  fermen- 
tation in  large  accumulations.  The  vomitus  has  few,  if  any,  of  the 
physical  characteristics  noted  in  simple  ulcer  of  the  stomach.  Free 
hematemesis  is  very  rare  ;  when,  however,  the  surface  of  the  new  growth 
ulcerates,  there  is  almost  invariably  an  occasional  slow  oozing  of  blood 
into  the  stomach.  It  is  here  acted  upon  by  the  altered  gastric  juice,  and 
the  black  hematin  resulting  from  the  transformation  of  the  red  hemo- 
globin gives  rise  to  the  well-known  "  coifee-ground  "  vomit  of  carcinoma 
of  the  stomach.^  The  chocolate-colored  appearance  of  the  vomitus  is  not 
found  alone  in  carcinoma  of  the  stomach.  Small  hemorrhages  are  more 
common  in  ulcerated  carcinoma  than  in  gastric  ulcer. 

The  che/nieal  examination  of  tlie  aspirated  stomach-contents  is  of 
prime  diagnostic  importance,  showing  as  it  does  the  almost  constant  ab- 
sence of  free  IICl  after  the  test-meal  (see  p.  778).  The  presence  of  free 
HCl,  supposing  the  examinations  to  be  properly  made  (by  the  use  of  the 
color-test)  and  sufficiently  often  repeated,  speaks  almost  positively  against 
carcinoma.  In  not  one  of  154  artificial  digestive  experiments  was  albu- 
min digested  in  this  disease.  Cases  do  occur,  however,  in  which  free 
HCl  is  present,  as  when  carcinoma  of  the  stomach  is  secondary  to  an 
ulcer.  Moreover,  in  the  incipient  stage  of  gastric  carcinoma  a  small  per- 
centage of  HCl  is  occasionally  found.  Free  HCl  is  also  absent  in  carci- 
noma of  the  esophagus,  duodenum,  extensive  amyloid  disease,  advanced 
cases  of  renal  disease,  and  the  febrile  state. 

The  leading  view  as  to  the  cause  of  the  absence  of  IICl  is  that 
the  inflammatory  degeneration  of  the  mucous  membrane,  commencing 
as  a  catarrhal  inflammation  and  advancing  to  interstitial  change  and 
atrophy  {Rosenheim'' b  view),  diminishes  and  finally  arrests  hydrochloric 
acid  secretion.     Moore  ^  believes  that  the  non-production  of  IICl  is  due 

'  Philadelphia  Medical  Journal,  Feb.  3,  1900. 

2  Teichnuinn'H  tfst  for  lieniatin  crystals  may  be  employed  a.x  follows :  Place  a  drop  of 
the  "  coHee-ground  "  material  upon  the  slide  and  add  a  few  crystals  of  sodium  chlorid. 
Then  introduce  a  few  drops  of  acetic  acid  beneath  the  cover-glass  and  warm. 

3  27/e  Lancet,  l,  1120,  1905. 


CARCINOMA    OF  THE  STOMACH.  815 

to  the  relative  (limirmtioii  of  11.  ions  and  an  increase  in  the  Oil.  ions 
and  alkalinity  of  tlie  blood.  Lactic  acid  in  excess  occurs  in  the  stomach- 
contents  after  a  test-meal  in  carcinoma.  Sick '  concludes  that  the  most 
important  factor  for  lactic  acid  fermentation  is  the  soluble  albuminoids 
produced  by  the  carcinoma  (autolysis).  The  microscopic  appearanccn 
of  the  vomitus  and  wash-water  are  in  some  ways  identical  witli  those 
observed  in  gastric  ulcer,  and  if  they  be  examined  speedily,  red  blood- 
corpuscles  may  rarely  be  seen.  The  constant  finding  of  occult  blood  with 
the  guaiac  test  has  great  significance.  Invisible  hemorrhage  in  the  stool 
is  a  fairly  constant  finding.  The  microscope,  also,  very  seldom  reveals 
pieces  and  bits  of  cancer-tissue,  and  Kaufmann  and  Ilerameter  emphasize 
the  frequency  of  long  bacilli,  the  latter  observer  finding  the  Boas-Oppler 
bacillus  in  94  per  cent,  of  cases.  Riegel  states  that  sarcinae  are  infre- 
quent. Both  the  proteolytic  and  amylolytic  power  of  the  stomach  are 
greatly  diminished.  The  presence  of  pus  in  the  gastric  contents  is  con- 
firmatory of  carcinoma.  The  working  power  of  the  stomach  is  defective 
at  an  early  stage — an  important  diagnostic  feature.  Kemp  found  a  small 
amount  of  relics  of  food  in  the  fasting  stomach  twelve  hours  after  eating 
as  a  constant  sign. 

Physical  Examination. — Inspection  may  reveal  an  irregular  tumor  in 
patients  much  emaciated.  When  dilatation  exists,  the  outlines  of  the 
organ  may  be  seen.  On  palpation  the  new  growth,  in  a  majority  of 
cases,  may  be  felt  through  the  abdominal  walls,  though  often  not  clearly, 
as  a  hard,  nodular,  and  sometimes  movable  mass.  Though  this  gener- 
ally appears  in  the  epigastrium,  it  must  be  recollected  that  it  depends 
upon  the  part  involved ;  also  that  a  tumor  united  with  the  Avail  of  the 
stomach,  particularly  if  situated  at  the  pylorus,  sags  downward,  even  to 
a  point  below  the  umbilicus.  Less  frequently  it  is  discovered  in  such 
unlooked-for  situations  as  the  right  or  left  hypochondriac  region.  Vary- 
ing degrees  of  fulness  of  the  stomach  will  alter  the  position  of  the  tumor. 
When  situated  at  the  cardia  if  is  beyond  reach  ;  when  attached  to  the 
lesser  curvature  of  the  stomach  or  the  posterior  wall,  it  is  rarely  to  be 
felt  unless  of  large  size.  The  new  growth  cannot  be  definitely  made  out 
when  it  assumes  the  form  of  a  diffuse  infiltration,  though  it  offers  in- 
creased resistance  and  exhibits  tenderness  on  pressure.  Usually  the 
patient  lies  in  the  dorsal  position  during  the  examination,  with  the  limbs 
drawn  up,  breathing  regularly,  while  the  mouth  is  kept  open.  The  detec- 
tion of  a  tumor  when  in  an  unfavorable  situation  may  be  facilitated  by 
shifting  the  patient's  position  from  the  dorsal  to  the  lateral,  the  standing, 
or  the  knee-elbow  position  respectively  ;  at  the  same  time  one  or  two 
tumblers  of  some  carbonated  water  should  be  given  with  a  view  to  dis- 
tending the  stomach  and  carrying  the  tumor  downward.  Pulsations  are 
frequently  communicated  from  the  aorta  to  the  palpating  hand  through 
the  tumor.  If  the  growth  is  situated  at  the  lesser  curvature,  a  deep  in- 
spiration will  often  cause  it  to  fall  lower  and  become  accessible  to  palpa- 
tion. Percussion  over  the  growth  causes  a  muffled  tympanitic  resonance ; 
superficial  percussion,  however,  may  give  dulness. 

The  presence  of  metastatic  new  growths  in  the  liver  and  enlargements 
of  the  supraclavicular  or  inguinal  lymph-glands  are  of  value  in  the  diag- 
nosis. In  one  instance  that  I  saw  in  the  Philadelphia  Hospital  a  nodule 
^  De^dttch.  Archivf.  Uin.  Med.,  Berlin,  vol.  Ixxxvi.j  Xos.  4  and  o,  1906. 


816  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  size  of  a  walnut  protruded  from  the  umbilicus,  leading  to  the  suspi- 
cion of  gastric  carcinoma.  Subsciiucntly  a  nodulated  pyloric  neoj)lasni 
could  be  readilv  held  in  the  grasi).  Boas  contends  that  enlarjjcnient  of 
the  supraclavicular  glands  has  no  value  as  an  early  indication,  since  he 
has  never  observed  this  symptom  in  the  early  stages. 

General  Si/rnvtoms. — Quite  early  in  the  disease  such  evidences  of  gen- 
eral nutritional  disturbance  as  loss  of  flesh  and  anemia  may  be  observed, 
and,  obviously,  cases  attended  with  constant  anore.xia  and  vomiting  will 
earliest  manifest  the  wasting  process.  Almost  from  the  beginning  the 
face  gradually  assumes  the  cachectic  appearance  which,  in  the  advanced 
stages,  becomes  so  characteristic  of  gastric  carcinoma.  Anemia  soon 
becomes  a  prominent  feature.  There  is  a  waxy  pallor  of  countenance, 
and  the  cerebral  symptoms  as  well  as  the  peculiar  cardiac  murmurs  of 
anemia  appear.  The  blood  frequently  presents  peculiarities  that  bear  a 
resemblance  to  those  seen  in  pernicious  anemia,  and  at  times  such  bloods 
are  indistinguishable  from  those  of  true  pernicious  anemia.  I  have 
observed  leukocytosis  late  during  the  course  of  this  malady.  A  difter- 
ential  study  of  the  leukocytes  is  of  no  value,  and  the  presence  or  absence 
of  digestive  leukocytosis  is  too  uncertain  to  be  of  diagnostic  importance. 
The  blood-count  is  usually  that  of  secondary  anemia.  Nucleated  red 
cells  (normoblasts)  are  not  uncommon,  and  myelocytes  are  occasional 
findings.  The  anemia  of  cancer  is  accompanied  by  loss  of  flesh,  while  in 
pernicious  anemia  the  superficial  fat  is  preserved.  The  causes  of  the 
profound  anemia  met  with  in  this  aff"ection  are  not  quite  plain,  since  fre- 
quently it  becomes  pronounced  before  the  nutritional  disturbances  (shown 
by  a  loss  of  flesh)  have  become  marked.  The  f;ict  that  metastatic 
carcinoma  has  been  found  to  be  abundant  in  the  marrow  of  the  bones  is 
significant  in  this  connection,  as  pointing  to  the  probable  interference, 
in  some  instances,  with  the  blood-producing  function  of  the  bone- 
marrow.  In  advanced  cases  moderate  edema  of  the  ankles  and  of  the 
backs  of  the  hands  is  frequently  observed,  and  is  probably  dependent 
upon  excessive  anemia.  The  temperature  at  first  shows  no  abnormali- 
ties, as  a  rule,  though  after  the  cachexia  has  become  decided  it  is  often 
subnormal.  Sudden  elevations  of  temperature  (103°  to  104°  F. — 40°  C.), 
preceded  by  rigors  and  followed  by  profuse  sweating,  are  rarelv  observed. 
The  explanation  of  their  occurrence  is  to  be  found  in  the  fact  that  sup- 
puration sometimes  takes  place  in  the  bases  of  the  cancerous  ulcers. 
The  mind  almost  invariably  remains  clear  to  the  last,  though  delirium 
may  be  a  late-appearing  symptom. 

Complications. — Intestinal  symptoms  are  freciuently  observed,  and 
constipation  in  particular  is  quite  common.  It  is  apt  to  alternate  with 
diarrhea  toward  the  close  of  the  disease,  or  diarrhea  may  in  the  later 
stages  become  a  persistent  and  obstinate  symptom.  Some  of  the  com- 
plicating conditions  have  reference  to  the  secondary  new  growths. 
When,  as  frequently  happens,  the  liver  is  implicated,  jaundice  is  rather 
common,  being  associated  with  signs  of  hepatic  enlargement.  Indeed, 
80  prominent  may  be  the  symptoms  and  physical  signs  referable  to 
secondary  carcinoma  of  the  liver  as  entirely  to  mask  the  more  or  less 
hidden  forms  of  carcinoma  of  the  stomach.  The  mesenteric  and  retro- 
peritoneal lymph-glands  or  the  lungs  may  be  the  seat  of  secondary  car- 
cinoma, which,  however,   rarely   gives   rise   to   characteristic   symptoms. 


CARCINOMA   OF  THE  STOMACH.  817 

Occasionally  the  new  growths  spread  to  the  peritoneutn  (and  excite  exu- 
dation) or  to  the  rectum.  Perforation  may  rarely  occur,  and  we  then 
have  the  pronounced  and  rapidly  supervening  symptoms  of  difluse  peri- 
tonitis.— Fistulous  communications  between  the  stomach  and  the  trans- 
verse colon  or  the  suiall  intestine — the  latter  rarely — may  also  occur. 
Nervous  symptoms  mny  be  regarded  as  complicating  conditions,  and  some- 
times hasten  the  fatal  termination  ;  the  patient  becomes  somnolent  or, 
rarely,  even  comatose  ;  the  breathing  is  difficult  and  the  respiration  deep 
and  labored.  This  mode  of  termination  I  noted  in  one  case.  Traces  of 
albumin,  and  in  the  later  stages  tube-casts,  may  be  present  in  the  urine. 
Indicanuria  is  a  rather  common  symptom,  while  acetonuria  is  seldom 
seen.     Diacetic  acid  is  present  in  rare  instances. 

I/atent  Forms. — The  disease  may  be  latent,  most  often  in  feeble 
persons  and  in  the  aged,  and  accidentlv  discovered  on  physical  examina- 
tion.    In  some  cases  the  cachexia  furnishes  ground  for  suspicion. 

General  Course  and  Duration. — The  course  of  gastric  carcinoma 
is  invariably  toward  a  fatal  issue,  death  usually  taking  place  before  the 
expiration  of  two  years.  The  average  duration  of  the  disease  is  about 
one  year.  When  it  occurs  in  emaciated  persons  it  pursues  a  slower 
course  than  when  occurring  in  fleshy  individuals.  Cases  develop  only 
slowly  in  old  ulcer  cases.  The  younger  the  individual  the  more  rapid  the 
course  of  the  disease.  The  symptoms  are  far  less  intense  in  the  cases  in 
which  food  stagnation  is  absent. 

Diagnosis. — A  positive  diagnosis  of  gastric  carcinoma  is  easily 
made  when  a  tumor  is  demonstrable.  The  history,  the  presence  of  char- 
acteristic symptoms,  such  as  pain,  ectasy,  coffee-ground  vomit,  deficient 
motor  power  {early).,  the  constant  absence  of  free  hydrochloric  acid,  es- 
pecially the  almost  constant  presence  of  lactic  acid  after  the  Boas  test- 
meal  (unfortunately  not  an  early  feature)  and  a  constant  positive  blood 
reaction  in  the  stools,  all  occurring  in  persons  beyond  middle  life,  together 
with  the  existence  of  progressive  cachexia,  are  sufficient  to  warrant  a 
diagnosis  in  the  absence  of  a  palpable  new  growth.  A  putrid  smelling 
tube  and  putrid  eructations  have  diagnostic  importance,  and  Hemmeter 
states  that  the  early  diagnosis  of  carcinoma  of  the  stomach  is  possible  in  a 
certain  number  of  cases  from  histologic  examination  of  small  fragments  of 
gastric  mucosa,  if  a  direct  invasion  of  the  gland-substance"  by  epithelial 
cells  is  observed.  Exploratory  laparotomy  may  be  advised  if  improve- 
ment does  not  follow  rnedical  treatment  in  suspicious  cases  within  a  few 
weeks  at  most.  Moullin  has  emphasized  the  diagnostic  value  of  direct 
inspection  through  an  incision.  Kelling's  method,^  or  the  hemolytic 
serum  test,  was  applied  by  Rosenbaum^  in  70  patients,  including  26  of 
carcinoma ;  he  obtained  favorable  results.  If  the  reaction  be  negative, 
however,  cancer  cannot  be  excluded  (Gorham  and  Lisser).  The  results  of 
recent  experiments  tend  to  discredit  the  reliability  of  this  test.  The 
meiostagmin  reaction  (Ascoli)  has  been  found  to  be  reliable  by  certain 
observers.  The  glycyltryptophan  test  is  valuable  for  diagnosis  (Wein- 
stein).  Goodman's  ^  modification  of  the  Salomon  test,  which  shows  the 
percentage  of  phosphates  (over  10  mg.  per  100  c.c.)  in  the  wash-water,  is 
corroborative  in  ulcerative  cases.     Falk  and  Salomon's  salicylate  method 

^Arch.f.  Min.  Chir.,  Ixxx.,  No.  1,  Berlin.  '  Miinch.  med.  Woehen.,  March  3,  1908. 

3  Arch.  f.  Verdauung$kr.,  B.  xv.,  H.  4. 

52 


818 


DISEASES   OF  THE  DIGESTIVE  SYSTEM. 


is  of  material  aid'.  Salomon  and  SaxP  have  found  a  reaction  of  neutral 
sulphur  very  constant  in  carcinomatous  patients.  Smithies^  found  in 
1175  cases  this  test  less  constant  than  the  glycyltryptophan  reaction. 
A  positive  skin  reaction  is  strong  presumptive  evitlence  of  carcinoma 
(Lisser  and  Blooinficld).''  B.  K.  Brown  found  the  stools  uniformly 
Gram-positive  in  a  series  of  cases.  An  expert  x-i-dy  examination  is  an 
important  aid  in  the  diagnosis. 

When  malignant  degeneration  of  an  ulcer  sets  in,  pain  increases  in 
intensity  and  may  radiate  to  the  thorax  and  back,  anorexia  develops, 
hyperacidity  often  gives  way  to  achlorhydria,  and  hematemesis  may 
occur  early  and  recur  at  frequent  intervals. 

Differential  Diagnosis. — A  gastric  carcinoma  presenting  a  discernible 
mass  is  liable  to  be  mistaken  for  a  cicatrized  ulcer,  for  C((rciiiovia  of  the 
pancreas,  of  the  transverse  colon,  duodenum,  omentum,  and  the  left  lobe 
of  the  liver,  as  well  as  for  aneurysm  of  the  abdominal  aorta.  The  aneu- 
rysmal tumor,  however,  is  smooth,  and  is  not  nodular,  like  the  cancer- 
ous growth,  moreover,  it  gives  rise  to  an  expansile  impulse.  In  aneu- 
rysm the  characteristic  cachexia  is  wanting.  In  pancreatic  carcinoma 
the  tumor  is  fixed  {vide  infra,  p.  956).  Carcinoma  of  the  transverse  colon 
and  omentum  will  be  excluded  by  the  presence  in  malignant  disease  of 
the  stomach  of  a  chocolate-colored  appearance  of  the  vomitus,  deficient  mo- 
tility of  the  organ,  the  permanent  absence  of  HCl,  and  persistent  pres- 
ence of  lactic  acid  in  the  gastric  contents.  For  the  recognition  of  hidden 
gastric  carcinoma  with  grave  anemia  the  reader  is  referred  to  p.  47'). 

Chronic  ulcer  may  in  cicatrizing  give  rise  to  a  small  tumor,  followed 
by  pyloric  stenosis  and  secondary  dilatation — an  exact  counterpart  of 
the  course  of  gastric  carcinoma.  Great  reliance  should  be  placed  on 
the  age  of  the  patient,  the  presence  of  HCl  in  the  gastric  secretions, 
the  points  of  pain  (dorsal  epigastric)  and  localized  tenderness  with 
hematemesis,  and  the  longer  duration  of  ulcer.  Ulcer  with  tumor-like 
thickening  may  show  an  excess  of  lactic  acid,  due  to  associated  motor 
insufficiency,  rendering  a  differential  diagnosis  exceedingly  difficult. 
Hypertrophic  stenosis  of  the  pylorus  is  also  simulated  {vide  p.  819). 

Simple  gastric  ulcer  and  chronic  gastritis  are  often  confounded  with 
carcinoma  of  the  stomach  without  palpable  tumor  {vide  parallel  differen- 
tial tables  below,  modified  slightly  from  DaCosta). 


Chronic  Gastritis. 
Not  confined   to  any   age. 
More  cominon  in  middle- 
aged  or  elderly  people. 

Pain  at  the  epigastrium 
somewhat  augmented  by 
food ;  soreness  is  also 
present.  Both  are  con- 
stant, although  compar- 
atively slight. 


Gastric  Ulcer. 

May  occur  in  middle-aged 
persons,  but  is  most  fre- 
quent in  young  adults, 
especially  women. 

Pain  at  the  epigastrium 
much  augmented  by 
food  ;  subsides  when  this 
is   digested :    paroxysms 


of  pain,  not  lancinating  ; 
strictly  localized  soreness 
to  touch  in  epigastrium  ; 
sometimes  a  painful  spot 
over  lower  dorsal  verte- 
brae. Intermissions  in 
the  pain  are  frequent. 

^  Deutsche  med.   IVochen.,  Jan.  11,1912.         ^Archives  of  Internal  Medicine,  Oct.,  1012 
3  C'eiUralblntt  fiir  die  Grenzijebiete  der  med.  und  Chir.,  Jena,  Aug.  30,  1911. 
*  Bull,  of  Johns  Hopkins  Hosp.,  Dec,  1912. 


Gastric  Carcinoma. 

Most  common  in  elderly 
people  ;  rarely  occurs  in 
persons  under  thirty 
years  of  age. 

Pain  frequently  of  a  radi- 
ating kind,  often  parox- 
ysmal, not  infrequently 
severe  and  lancinating, 
but  not  of  necessity  asso- 
ciated with  soreness.  Lit- 
tle or  not  at  all  affected 
by  food.  Pain  rarely 
remits ;  never  intermits 
for  any  considerable 
time. 


CARCINOMA    OF  THE  STOMACH. 


810 


Chronic  Gastritis. 


Symptoms 
marked. 


of    indigestion 


Sometimes  vomiting. 

No  hemorrhage,  or  but  tri- 
fling hemorrhage  ;  at 
most  blood-streaks  in 
vomited  matter. 

Bowels  constipated. 


No  fever. 


Not  so. 

Not  much  emaciation  ;  no 
cachectic  appearance. 


Disease  may  be  relieved  or 
cured  ;  is  often  of  very 
long  duration. 

No  tumor. 

Contents  of  stomach  al- 
most alvrays  contain  free 
hydrochloric  acid. 

No  lactic  or  fatty  acids  after 
the  rigid  Boas  test-meal. 

Slight  motor  disturbance. 

No  dropsy, 


Gastrh;  Ui-cer. 

Symptoms    of    indigestion 

sometimes  very  slight. 

Vomiting  may  be  present 
or  absent. 

Abundant  hemorrhage 
from  the  stomach  com- 
mon. Stools  may  con- 
tain blood  (tarry). 

Bovrels  usually  constipa- 
ted ;  intermittent  occult 
blood  in  stools. 

No  fever. 


Acids  taken  increase  pain. 

Frequently  extreme  pallor 
and  debility,  especially 
if  preceded  by  anemia. 


Duration  uncertain :  may 
get  vcell,  may  run  on 
rapidly  to  perforation  ; 
or  may  last  for  years. 

Rarely  a  tumor. 

Hydrochloric  acid  in  excess 
in  contents  of  stomach. 

No  lactic  or  fatty  acido  after 
the  rigid  Boas  test-meal. 
Motor  function  fair. 
No  dropsy 


Gastric  Carcinoma. 

Symfjtoms  of  indigestion 
marked.  Anorexia;  ex- 
treme acidity  of  stomach. 

Vomiting  a  very  frequent 
symptom. 

Hemorrhage  not  very  abun- 
dant, but  frequently  oc- 
casioning coflee-ground- 
looking  vomit. 

Bowels  obstinately  consti- 
pated. Occult  blood  in 
feces ;  more  constant. 

Attacks  of  slight  fever  occur; 
temperature  often  subnor- 
mal. 

Not  so. 

Progressive  loss  of  flesh, 
and  cachexia ;  and  at 
times  hypertrophy /)ftlie 
lymphatic  plands,  especi- 
ally cervical. 

Average  duration  one  year; 
may  be  shorter,  but  sel- 
dom longer. 

Generally  a  tumor. 
No   hydrochloric    acid    in 
contents  of  stomach. 

Lactic   acid    present   after 

Boas's  test-meal. 
Early  marked  disturbance. 
Edema  of  ankles  common. 


Treatment. — The  diet  should  be  adapted  to  the  peculiarities  of  the 
individual  case.  Physiology  indicates  that  meat  and  meat-extracts  stim- 
ulate the  secretion  of  HCl,  hence  they  deserve  a  careful  trial  in  the 
earlier  stages.  If  these  fail  of  their  physiologic  eifect,  however,  then  ar- 
ticles of  food  that  are  digested  and  assimilated  in  the  intestines  should  be 
employed.  After  well-marked  evidences  of  pyloric  obstruction  appear  we 
may  add  greatly  to  the  comfort  of  the  patient  by  limiting  the  dietary  to 
liquids,  and  by  predigesting  them  if  they  are  not  otherwise  well  borne. 
Should  the  stomach  reject  all  food,  rectal  alimentation  should  be  promptly 
instituted.  The  more  troublesome  symptoms — namely,  pain,  vomiting, 
hematemesis,  and  constipation — are  to  be  met  on  general  principles.  The 
claims  that  have  been  advanced  in  favor  of  arsenic  and  other  preparations 
as  possessing  power  to  control  the  progress  of  gastric  carcinoma  aAvait 
confirmation.  Coca  and  Gilman  ^  have  used  a  vaccine  in  the  specific 
treatment  of  carcinoma.  Neoformans  vaccine  is  also  recommended.  If 
dilatation  coexists,  it  is  to  be  managed  in  accordance  with  the  recom- 
mendations found  under  Dilatation  of  the  Stomach  (p.  790).  Gastric  car- 
cinoma is  usually  primary  and  for  some  length  of  time  it  is  a  local 
disease.  Early  surgical  intervention,  therefore,  oiFers  promise  of  relief 
and  even  cure. 

Hypertrophic  Stenosis  of  the  Pylorus. — By  this  term  is  meant 
pyloric  obstruction  due  to  hypertrophy,  principally  of  the  circular  layer 
^Philippine  Jour,  of  Scienee,  1910,  iv.,  391. 


820  I)ISEASJ!:S   OF  THE  DIGESTIVE  SYSTEM. 

of  the  muscularis  with  hyperphisia  leading  to  secondary  dihitation  of  the 
stomach.  This  may  be  ((»)  congenital;  [b)  accjuired  (f. //.,  tuberculosis). 
Tiie  etiology  is  unknown,  although  spasm  of  the  })ylorus  has  been  sug- 
gested. The  si/mpto))is  are  those  of  dilatation  of  the  stomach  and  a 
pyloric  tumor  may  be  pali)able.  The  resemblance  to  ulcer  with  tumor- 
like thickening  and  to  ulcus  oarcinoinatoauin  may  be  striking  (vide  also 
p.  818).  Medical  treatment — massage,  electricity,  and  strychnin  inter- 
nally— should  be  tried,  this  failing;  pyloric  stretching  or  other  form  of 
operation  is  indicated. 

Benign  Cirrhosis  of  Stomach. — This  is  a  rare  condition  and 
difficult  of  diagnosis.  Sheldon  states  that  it  may  be  suspected  in  patients 
presenting  symptoms  of  benign  stenosis  of  the  pylorus  with  contracted 
stomach.  The  symptoms  pointing  to  it  are  long-standing  disease, 
absence  of  hematemesis,  contraction  of  the  stomach,  absence  of  tumor  on 
jialpation,  absence  of  glandular  or  hepatic  involvement,  and  general  im- 
provenient  and  relief  of  the  stomach  symptoms  for  a  period  of  time  when 
rectal  feeding  is  resorted  to.      The  treatment  is  necessarily  surgical. 

Congenital  atresia  proves  rapidly  fatal,  while  the  adult  form  may  run 
a  long  course.  Exceptionally  other  forms  of  gastric  tumor  occur — 
lipomafa,  sarcomata  (a  total  of  56  cases — von  Graft"),  fibromata,  and  cysts. 


HEMATEMESIS. 


Hematemesis  is  a  symptom,  hence  it  is  hardly  to  be  properly  classed 
among  gastric  affections. 

Ktiology. — Among  the  causes  of  hematemesis  are — 1.  Traumatic 
injury  to  the  stomach;  2.  Diseases  of  its  coats  (carcinoma,  ulcer,  miliary 
aneurysms,  acute  congestion) ;  3.  A  mechanical  impediment  to  the 
portal  circulation  ;  4.  Vicarious  menstruation  ;  5.  Alterations  in  the 
blood ;  6.  A  disease  of  some  neighboring  organ,  such  as  carcinoma  of 
the  pancreas,  may  perforate  the  gastric  coats  and  open  its  vessels. 

Symptoms  and  Diagnosis. — If  the  fact  that  it  is  always  a  symp- 
tom, and  not  a  disease,  be  recollected,  the  importance  of  recognizing  its 
causal  condition  in  each  instance  will  be  greatly  facilitated.  The  manner 
of  its  occurrence  and  the  characteristics  piesented  by  the  blood  often 
give  a  clue  to  its  nature  and  origin.  Thus,  we  have  seen  that  the  clinical 
signs  in  hematemesis  due  to  carcinoma  and  ulcer  of  the  stomach  vary 
greatly,  being  almost  peculiar  to  each.  This  fact  must,  however,  be 
weighed  with  the  history  and  symptoms  of  the  case  in  which  it  may 
occur;  in  this  manner,  and  in  this  manner  only,  can  errors  be  avoided. 
A  process  of  exclusion  is  the  best  way  to  reach  a  decision.  If  a  careful 
inquiry  determines  the  absence  of  morbid  lesions  of  the  stomach,  such  as 
carcinoma,  ulcer,  or  chronic  gastritis,  then  the  other  organs  of  the  abdo- 
men, and  more  particularly  the  liver,  must  be  examined.  If  this  and 
the  heart  be  found  to  be  healthy,  attention  should  then  be  turned  toward 
the  state  of  the  blood,  as  in  the  specific  fevers.  It  may  also  be  found 
that  the  menstrual  or  other  habitual  discharge  has  become  suppressed. 

Differential  Diagnosis. — It  is  to  be  recollected  that  the  source  of  the 
blood  may  be  other  than  the  stomach.      Rarely,  an  abdominal  aneurysm 


NEUROSES  OF  THE  STOMA  OH.  821 

bursts  into  the  stomach  ;  occasionally,  too,  a  thoracic  aneurysm  opens  into 
the  esophagus,  whence  the  blood  speedily  finds  its  way  into  the  stomach. 
A  careful  consideration  of  the  history  and  of  the  attending  symptoms, 
together  with  a  thorough  physical  examination,  will,  after  excluding  the 
various  conditions  causing  true  gastric  hemorrhage,  lead  to  a  correct  inter- 
pretation of  the  phenomena.  Blood  coming  from  the  throat.,  tonsils, 
mouth,  or  the  respiratory  organs,  including  the  nose,  is  sometimes  swal- 
lowed, and  afterward  ejected  by  vomiting.  To  discriminate  from  this 
condition  it  is  only  necessary  to  make  an  examination  of  the  lungs  and 
elicit  most  carefully  the  history.  It  must  also  be  recollected  that  hys- 
teric females  and  malingerers  have  been  known  to  swallow  the  blood  of 
animals  and  other  dark  fluids,  and  vomit  them  subsequently.  The  vom- 
itus  may  resemble  dark  blood  in  appearance  when  stained  by  bile  or  iron 
or  after  a  free  indulgence  in  wipe.  The  points  of  contrast  between 
hematemesis  and  hemoptysis  are  correlatively  considered  below  : 

Hematemesis.  Hemoptysis. 

The   history  points   to   gastric,   splenic,  History  of  cough   and   other  symptoms 

hepatic,  or  cardiac  disease,  or  anemia.  points  to  pulmonary  or  cardiac  disease. 

A  feeling  of  uneasiness,  and  sometimes  A  feeling  of  weight  and   uneasiness   in 

of  nausea   or   faintness,  precedes   the  the  chest,  a  saline  taste,  and  a  tickling 

hemorrhage.  in  the  throat  precede  the  hemorrhage. 

The  blood  is  ejected  by  vomiting  ;  violent  The  blood  is  raised  by  coughing  or  clearing 

vomiting  may  excite  cough.  of  the  throat,  though,  if  it  be  swallowed, 

vomiting  may  follow. 

The  blood  is  either  clotted  or  fluid  and  The  blood  is  bright-red,  frothy,  in  small 

dark ;  it  may  be   mingled  with   rem-  coagula,  sometimes  mixed  with  muco- 

nants  of  food,  and  is  acid  in  reaction.  pus,  and  alkaline  in  reaction. 

Prognosis. — Hematemesis,  except  it  be  due  to  rupture  of  an  aneur- 
ysm, rarely  presents  a  hopeless  prognosis.  In  cases  of  splenic  enlarge- 
ment, hepatic  cirrhosis,  or  gastric  ulcer,  it  may  prove  fatal. 

The  treatment  has  been  detailed  in  the  discussion  of  Gastric  Ulcer. 
The  suprarenal  extract  has  given  specially  favorable  results. 


NEUROSES  OF  THE  STOMACH. 

NERVOUS   DYSPEPSIA. 

{Neurasthenia   Gastrica.) 

Definition. — A  functional  disorder  of  the  stomach,  usually  charac- 
terized by  regularly  (and  sometimes  irregularly)  recurring  attacks  of 
gastric  disturbance,  followed  by  almost  complete  freedom  from  symptoms. 
Sensory  disturbances  of  the  stomach  are  constantly  present,  and  with 
these  either  motor  or  secretory  disturbances  or  both  may  be  associated. 

Ktiology. — The  majority  of  cases  occur  in  highly  emotional  and 
hysteric  persons,  under  such  exciting  conditions  as  great  anxiety,  violent 
passion,  dissipation,  social  excesses,  mental  overexertion  in  business 
life,  grievances,  and  any  startling  neAvs.  The  condition  is  most  com- 
monly met  with  in  healthy-looking,  ruddy-cheeked  adults.  It  is  more 
common  in  females.  Persons  living  amid  luxurious  surroundings  suffer 
most.      Gastric  neuroses  may  be  of  reflex  origin,  arising  from  derange- 


822  DISEASES  OE  THE  DKlESTlVE  SYSTEM. 

uient  of  tlie  nervous  system.  Doavev'  states  tliat  tliey  may  be  manifes- 
tations of  disease  in  tlie  liver,  gall-bladder,  bile-ducts,  or  appendix,  Avhich 
uill  ileiiiand  sui^ieal  interference. 

Symptoms. — The  symptoms  follow  immediately  upon  the  action  of 
the  e.xciting  cause  and  are  largely  under  the  influence  of  the  emotions. 
In  the  ordinary  form  the  gastric  secretions  are  often  normal,  and  the 
stomach  is  found  empty  after  a  test-meal  within  the  physiologic  time- 
limit.  There  is  anorexia,  which  occasionally  alternates  with  a  voracious 
appetite.  After  meals  the  patient  complains  of  distress  and  oppression 
in  the  epigastrium ;  eructations,  and  an  occasional  regurgitation  of  the 
acid  liquid  or  solid  contents  of  the  stomach,  with  heartburn,  will  also  be 
noted.  Vomiting  is  not  rare,  and  occurs  independently  both  of  the  time 
of  eating  and  of  the  character  of  the  food.  Gastric  peristahis  is  some- 
times so  well  marked  as  to  be  readily  felt  and  even  visible  through  the 
stomach-Mall.  Kussmaul  has  called  special  attention  to  this  symptom, 
{vide  peri-'<taltic  luircst,  ]).  826).  The  increased  ])eristaltic  waves  excite 
cooinir,  gurgling  sounds  that  are  a  source  of  annoyance. 

The  physical  examination  sometimes  reveals  abdominal  distention  and 
hyperesthesia  of  the  surface,  but  no  localized  tenderness,  pressure  with 
the  broad  hand  usually  affording  relief  from  pain.  Nervous  phenomena 
always  exist,  and  their  correct  interpretation  is  of  the  utmost  importance 
in  the  diaf^nosis.  Neurasthenic  and  hysteric  manifestations  are  com- 
monly associated.  The  mental  condition  is  unstable  and  illy  regulated, 
and  this  fact  furnishes  a  satisfactory  explanation  of  the  operation  of 
the  etiologic  factors.  The  general  health  is  in  many  instances  not 
noticeably  impaired  ;  but  in  those  subject  to  fre(iuent  vomiting  and 
complete  aiKjrexia,  the  general  nutrition  suffers  considerably. 

Complications. — The  bowels  are  of'teu  constipated,  distended  with 
gas,  and  may  be  the  seat  of  an  abnormal  peristalsis.  The  course  of 
nervous  dyspepsia  is  chronic,  and  it  may  terminate  in  catarrh  of  the 
stomach. 

Nervous  dyspepsia  with  hypochondriasis  forms  a  group  of  cases  in 
which  the  hypochondriasis  may  sustain  a  causal  relation  ;  it  may,  how- 
ever, be  secondary  to  the  gastric  disturbances.  It  is  apt  to  be  marked 
after  the  gastric  symptoms  have  lasted  a  long  time.  The  symptoms  other 
than  the  nervous  are  similar  to  those  described  above. 

Diagnosis. — The  diagnosis  is  based  on  the  following  points :  {a) 
The  etiol')gic  factors.  Here  it  is  important  to  ascertain  the  particular 
causative  influence  that  produces  the  gastric  symptoms,  taking  also  into 
consideration  any  well-recognized  predisposing  causes.  (5)  The  course 
of  the  complaint  and  the  absence  of  some  of  the  physical  signs  and 
symptoms  that  would  point  positively  to  anatomic  lesions  of  the  stomach. 
When  there  is  a  catarrhal  process,  the  symptoms  become  more  pro- 
nounced immediately  after  taking  food  than  in  neurasthenia  gastrica.  The 
influence  of  the  ingestion  of  indigestible  substances  upon  sympathetic 
dyspepsia  is  often  to  relieve,  or  is  of  neutral  effect,  whereas  in  catarrhal 
indigestion  it  decidedly  aggravates  the  condition.  The  dull  pain  after 
eating  and  the  tenderness  on  pressure  are  more  marked  in  the  catarrhal 
variety,  and  the  stomach  contains  large  amounts  of  mucus.  The  symp- 
toms of  the  latter  do  not  intermit,  as  in  nervous  dyspepsia,  but  are  more 
^  Amer.  Jour.  Med.  Sciemces,  Feb.,  1909. 


NEUROSES  OF  THE  STOMAC'/I.  82'} 

constant.  The  analysis  of  the  stornacli-contcnts  obtained  after  a  test- 
breakfast  shows  digestion  to  be  normal  as  to  time  and  ciieinisrn,  although 
rarely  any  secretory  abnormality  may  be  present.  The  motor  function 
may  be  either  reduced  or  increased,  but,  as  a  rule,  it  is  normal. 

Prognosis. — If  there  be  an  absence  of  an  inherited  predisposition, 
and  if  the  cause  is  removable,  complete  recovery  may  be  prognosticated. 
In  a  neurotic  constitution,  however,  the  tendency  to  recurrence  is  very 
strong.  The  most  unpromising  cases  are  those  in  which  the  cause  is 
irremovable,  though  as  to  life  the  prognosis  is  favorable. 

Treatment. — Every  causal  factor  must  be  recognized  and  mitigated 
or  removed.  The  dietary  should  be  generous  and  composed  of  highly 
nutritious  articles  of  food,  and  to  convince  the  patient  that  his  stomach 
is  capable  of  digesting  a  full  meal  is  the  physician's  first  duty.  So  soon 
as  the  patient  realizes  the  truth  in  reference  to  his  digestive  capacity  liis 
sufferings  are  largely  at  an  end.  The  nervous  system  demands  especial 
attention,  and  the  internal  treatment  of  the  stomach  is  merely  placeboic. 
Nerve-tonics  combined  with  nerve-stimulants  are  serviceable. 

A  change  of  air  from  the  city  to  the  country,  the  mountains,  or  the 
sea-coast  is  usually  folloAved  by  improvement.  In  some  manner  the 
patient  must  be  extricated  from  the  old  surroundings  under  the  influence 
of  which  the  disease  was  started  and  has  continued.  Sea  air  has  seemed 
to  me  to  be  more  serviceable  than  mountain  air  in  these  cases,  though  I 
believe  it  to  be  an  axiom  in  climatic  therapeutics  that  the  latter  confers 
more  lasting  benefits  than  the  former.  These  patients  are  often  averse 
to  taking  exercise,  but  this  sanitary  measure  should  be  insisted  upon. 
Cold  sponging  of  the  surface,  followed  by  friction  to  the  skin,  should  be 
practised  daily  for  its  effect  upon  the  nervous  system.  Occasional  lavage, 
hot  and  cold  douches,  electricity  (intra-  and  extra-gastric),  and  gastric 
massage  may  all  be  tried.  In  highly  neurotic  and  hysteric  females  the 
S.  Weir  Mitchell  treatment  is  often  attended  with  good  results.  The 
hypochondriac  form  is  often  intractable.  Strychnin,  however,  if  perse- 
veringly  used,  and  if  coupled  with  a  change  of  air,  often  proves  bene- 
ficial. One  of  the  most  obstinate  examples  of  this  nature  that  I  have 
seen  occurred  in  a  retired  merchant  living  in  Philadelphia.  This  man 
was  finally  cured  in  consequence  of  his  own  suggestion,  resulting  in  his 
removal  to  the  country  and  engaging  in  farming.  In  neurasthenia  gas- 
trica  lupulin  finds  a  special  indication  (Stern  ). 

SPECIAL  FORMS  OF  GASTRIC  NEUROSES,  CHARAC- 
TERIZED BY  MARKED  AND  PECULIAR  ANOMALIES 
OF  SENSATION,  MOTILITY,  AND  SECRETION. 

NEUROSES   OP   SECRETION. 

HYPERCHLORHYDBIA. 
( Hyperacidity. ) 
Definition. — An    augmentation    of  the   secretory   function   of  the 
stomach  during  the  digestive  period,  resulting  in  excess  of  HCl. 

i^tiology. — Hyperacidity  is  common  during  digestion,  and  is  usually 
due  to  the  causative  influences  mentioned  under  Nervous  Dyspepsia  (grief. 


824  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

great  anxiety,  mental  overtaxation).  The  disease  is  common  among  the 
professional  chisses  (male  sex)  and  in  the  young.  Highly  seasoned  foods 
and  alcoholic  intoxicants  may  occasion  the  condition.  Lichty  empha- 
sizes organic  disease  of  the  gall-hladder  and  ducts  as  a  cause. 

Symptoms. — llyperchlorhydria  may  be  continuou)i,  though  more 
often  it  is  disconiuucoiis  and  lasts  from  a  few  hours  to  several  days. 
After  the  periodic  form  has  lasted  a  long  time  it  may  gradually  become 
a  permanent  condition.  The  patient  first  complains  of  uneasiness  in  the 
epigastrium  one  or  two  hours  after  meals.  Later,  this  amounts  to  painy 
and  follows  every  meal  after  a  like  interval.  The  dunition  of  the  pain  is 
from  one  to  three  hours.  Acid  eructations  are  frecjuently  noted.  The 
increase  of  hydrochloric  acid  interferes  with  the  digestion  of  starches,  and 
thus  tends  to  increase  the  pain.  On  the  other  hand,  however,  a  diet 
composed  of  albuminoids  often  affords  relief,  and  the  salts  of  the  alkalies 
also  ease  the  pain.  Associated  nervous  symptoms  (headache,  dizziness) 
are  often  observed,  though  the  bodily  nutrition  is  usually  well  main- 
tained. Palpation  of  the  epigastrium  may  show  a  diffused  tenderness. 
Evidences  of  moderate  gastrectasis  may  be  detectable.  The  amylolytic 
power  of  the  stomach  is  uninfluenced  as  a  rule.  If  amylacea  are  taken 
in  large  amounts,  stagnation  of  stomach-contents  and  even  permanent 
hvpersecretion  may  be  produced.      The  amidulin  reaction  is  intensified. 

Diagnosis. — Though  the  diagnosis  of  hyperacidity  is  made  probable 
by  the  above  symptoms,  it  is  rendered  certain  only  by  a  repeated  analy- 
sis of  the  gastric  contents.      The  findings,  according  to  Einhorn,  are: 

(1)  On  examination  of  the  stomach  in  the  fasting  condition,  the  organ 
either  is  found  empty  or  contains  only  a  few  cubic  centimeters  of  juice; 

(2)  one  hour  after  Ewald's  test-breakfast  the  hyperacidity  is  increased, 
owing  to  the  great  amount  of  free  HCl  present.  To  make  a  decisive 
diagnosis  the  examination   must  be  made  during  the  height  of  digestion. 

Gastric  ulcer  must  be  eliminated.  In  this  disease  hyperacidity  occurs, 
but  the  pain  is  aggravated  immediately  after  eating,  and  is  not  relieved 
by  albuminous  food  nor  by  large  doses  of  alkalies,  as  in  hyperchlorhydria 
of  nervous  genesis.  In  ulcer,  moreover,  the  pain  often  leads  to  vomiting, 
and  severe,  painful  attacks  frequently  occur  at  night. 

Gastro-succorrlioea  {Beichmann) ;  Gastroxynsis  (Bossbach). — In  this 
affection  there  is  an  increase  of  hydrochloric  acid,  either  constantly  or 
intermittently,  when  no  food  is  present.  An  epigastric  gnawing  pain 
and  nausea  appear  in  the  full  bloom  of  health.  The  nausea  soon 
results  in  the  vomitiny  of  enormous  quantities  of  gastric  contents.  The 
appetite  is  lost,  but  the  thirst  is  excessive,  and  the  amount  of  drink 
taken  and  of  liquid  vomited  are  proportional.  During  the  night  or 
in  the  early  morning  hours  the  patient  commonly  vomits  large  amounts 
of  a  clear  or  bile-tinted  liquid  containing  hydrochloric  acid  and  the 
gastric  ferments  in  excess.  This  may  be  followed  by  persistent  vom- 
iting, attended  with  much  retching.  After  a  lapse  of  a  few  hours  the 
ejection  of  a  large  quantity  of  highly  acid  liquid  may  be  repeated.  The 
paiyi  often  becomes  intense,  headache  is  common,  and  a  tendency  to  col- 
lapse is  usually  marked.  The  attacks  last,  as  a  rule,  about  two  or  three 
days,  when  they  quite  abruptly  give  place  to  apparent  good  health. 
Recurrence  at  the  end  of  periods  ranging  from  a  few  months  to  a  year 
or  more  are  common.      A  physiologic  form  has  been  advanced. 


NEUROSES  OF  SECRETION.  825 

The  diagnosiH  is  made  upon  the  presence  of  the  cause  (a  violent 
psychic  shock),  the  clinical  symptoms  and  course,  as  well  as  upon  the 
results  of  oft-repeated  analyses  of  the  vomitus.  Gastric  ulcer  and  Cf;rtain 
organic  spinal  and  cerebral  nervous  affections,  in  which  there  is  excessive 
gastric  secretion,  must  be  excluded  before  diagnosis  can  be  made. 

Gastro-succorrhoea  Continua  Ohronica. — Rcichmann  first  described  a 
condition  characterized  by  a  <;o7ista')d  secretion  of  gastric  juice  either  in 
the  absence  or  presence  of  food.  The  st/mptoms  are  much  the  same  as 
those  in  hyperacidity,  but  tend  to  become  continuous,  so  that  the  vomit- 
ing finally  becomes  a  daily  occurrence.  In  the  fasting  state  a  highly 
acid  secretion  that  contains  no  food-particles  flows  through  the  stomach- 
tube.  Albuminoids  are  rapidly  and  starches  slowly  digested.  The  dis- 
ease is  quite  rare,  and  must  not  be  confounded  with  the  organic  diseases 
to  which  continuous  gastric  succorrhea  may  be  secondary  and  upon  which 
it  is  dependent.  Schreiber,  Boas,  and  others  believe  that  this  is  almost 
always  a  symptom  of  gastric  atony  or  gastric  ulcer. 

Larval  Superacidity. — This  variety  arises  early  in  the  period  of  diges- 
tion ;  the  amount  of  gastric  contents  after  the  test-meal  is  large,  and  con- 
sists mainly  of  a  watery  secretion  with  low  specific  gravity  and  with  a 
normal  acidity  and  presenting  the  amidulin  reaction. 

Leube  has  described  a  neurosis  in  which  there  is  a  constant  sub- 
acidity  of  the  secretion. 

Gastromyxorrhoea. — The  fasting  stomach  often  contains  small  quanti- 
ties of  mucus  (5  cm.),  but  when  above  25  cm.  Cuttuer  considers  it  patho- 
logic and  terms  the  condition  gastromyxorrhoea.  It  seems  to  be  largely 
of  nervous  origin.  There  are  two  forms  of  the  disease,  the  intermittent 
and  the  continuous.  In  the  first,  the  attacks  develop  suddenly  with 
severe  headache,  pain,  and  vomiting,  and  after  a  period  varying  from  one 
to  five  days  the  attack  suddenly  ceases  (Friedenwald).  The  other  type 
is  usually  discovered  in  examination  for  chronic  catarrh.  The  treatment 
is  symptomatic,  although  lavage  is  of  service  in  the  acute  form.  The 
neurotic  tendency  must  be  combated  during  the  intervals. 

Achylia  Gastrica  (Mhhorn). — The  suspension  of  the  gastric  secretions 
may  result  either  from  gastric  atrophy  (common)  or  from  a  nervous  de- 
rangement of  secretion.  The  condition  has  been  mistaken  for  carcinoma 
of  the  stomach.  Lactic  acid,  however,  is  not  present  in  excess.  Eosino- 
phile  cells  generally  occur  in  the  gastric  juice.  Achylia  gastrica  may 
cause  chronic  lienteric  diarrhea  (A.  A.  Jones). 

The  prognosis  in  the  foregoing  affections  is  not  bad  as  to  life,  and 
not  infrequently  a  cure,  even,  can  be  effected. 

Treatment. — The  dietetic  treatment  differs  according  to  different 
observers.  Einhorn  advises  three  large  and  two  small  meals  composed 
principally  of  nitrogenous  articles,  daily.  Physiology,  however,  teaches 
that  when  milk,  bread,  fats,  and  starchy  substances  are  taken,  the  amount 
of  HCl  secreted  is  small,  hence  the  proper  causal  treatment  is  to  limit  the 
amount  of  proteids.  Acids,  tobacco,  and  spirits — substances  that  excite 
the  glands  of  the  stomach — must  be  excluded.  The  medicinal  treatment 
should,  in  addition  to  meeting  the  general  neurotic  condition,  consist  of 
full  doses  of  sodium  bicarbonate  or  sodium  citrate.  In  some  cases  more 
active  alkalies  than  sodium  bicarbonate  may  be  needful — e.  g.,  magne- 
sium and  sodium  salicylate,  aluminum  silicate  (sss-j   ad  aqua  5iij  a.  c), 


826  DISEASES   OF  THE  DIUESTIVE  SYSTEM. 

either  separately  or  in  combination.  Lavage  daily,  before  the  chief  meal, 
is  beneficial  and  may  be  combined  uith  a  salt-free  diet.  Lemoine  advises 
hydrotherapy  and  rest  to  strengthen  the  nervous  system. 

NEUROSES   OF   MOTILITY. 
INCREASED   PERISTALSIS    OF   THE    STOMACH. 

Gastric  peristalsis  is  increased  in  various  conditions,  which  will  be 
considered  seriatim,  though  brietly. 

(<?)  Belching  and  Eructations. — These  may  be  of  nervous  oru/in  and 
are  met  witii  generally  in  Jiysteric  subjects,  and  less  frequently  in 
neurasthenics.  The  air  is  swallowed,  and  then  e.xpelled  with  more  or 
less  noise,  owing  to  an  increased  contractility  of  the  stomach.  Q'he  gas  is 
odorless,  and  diflers  in  this  point  from  the  gases  of  fermentative  dys- 
pepsia. Epigastric  distress  and  distention  often  arise,  and  certain  nervous 
phenomena,  as  anxiety  or  palpitation,  may  coexist.  In  hysteric  subjects 
the  belching  may  be  from  the  esophagus  alone. 

(h)  Pyrosis  means  regurgitation  of  the  acid  contents  of  the  stomach. 

(r)  Rumination  (.^feri/cisni). — A  rare  affection  in  which  the  food  is  re- 
gurgitated into  the  mouth,  the  cud  chewed,  and  again  swallowed  after  the 
fashion  of  ruminants. 

(d)  Nervous  Vomiting. — This  is  a  rejiex  neurosis  that  may  affect 
persons  of  any  age,  though  most  frequently  it  is  seen  in  adult  females 
with  an  hysteric  tendency.  Without  previous  nausea,  and  independ- 
ently of  the  character  of  the  food  taken,  the  contents  of  the  stomach 
are  readily  expelled  or,  more  correctly  speaking,  regurgitated  into  the 
mouth,  and  then  expectorated.  Though  this  usually  takes  place  after 
meals,  it  may  occur  without  reference  to  meal-time — a  feature  that  indi- 
cates its  nervous  origin.  The  attacks  of  vomiting  are  separated  by 
longer  or  shorter  intervals  of  excellent  health.  Periodic  vomiting  may 
also  occur  independently  of  hysteria  or  other  nervous  affections,  as  pointed 
out   by  Leu  be.     The   course  is  rarely   unfavorable. 

(r)  Peristaltic  unrest  (Kussmaul).  or  spasm  of  the  stomach,  has  been 
referred  to  under  Nervous  Dyspepsia.  It  has  also  been  observed  in 
compensatory  hypertrophy  of  the  stomach-wall  following  pyloric  strict- 
ure. In  a  case  of  gastric  carcinoma  in  my  own  care  the  supermotility 
of  the  stomach  caused  an  almost  immediate  expulsion  of  the  gastric 
contents,  and  even  of  the  rigid  test-meal  at  certain  times. 

(/)  Cardiospasm. — By  this  term  is  meant  a  painful  cramp  of  the 
cardia.  Two  forms  are  distinguished  :  (a)  acute  cramp  ;  {b)  chronic  cramp 
(exceeding!}'  rare).  Among  causes  are  neurasthenia,  hysteria,  and  local 
irritation  (thermal,  mechanical).  Bassler  found,  post-mortem,  firm  adhe- 
sions of  the  pleura,  particularly  at  the  base,  in  association.  Chronic 
spasm  may  lead  to  complete  atresia  of  the  cardia,  and  is  a  distressing 
affection.      Li  acute  cardiospasm  the  attacks  may  recur. 

[g)  Pylorospasm. — Cramp  of  the  ring-musculature  of  the  pylorus  may 
be  inimary  or  secondary.  The  latter  is  due  to  intense  local  irritation 
(superacidity,  hypersecretion,  excess  of  organic  acids).  The  painful 
spasm  in  the  pyloric  region  induces  stagnation  of  the  ingesta,  followed 
by  atony  of  the  stomach  and  consequent  dilatation. 

Treattnent. — To  the  regimenal  management  the  attention  of  the 
physician  should  be  primarily  directed.      The  medicinal  treatment  is  to 


GARDfALGIA.  827 

be  aimed  at  tlie  causal  nervous  affection.  The  valerianates  and  the  bro- 
inids  often  do  good  service.  For  the  cramp  of  the  cardia  and  pyloius 
belladonna  or  codeine  are  efficient;  these  failing,  stretching  of  the  cardia 
is  indicated.  If  internal  treatment  fails  in  functional  motor  insufficiency, 
operative  intervention  may  be  indicated. 

DIMINISHED   PERISTALSIS    OF    THE   STOMACH. 
{Atony. ) 

[a)  Pyloric  Relaxation  or  Incompetency. —  Tbis  is  a  rare  neurosis  that 
allows  the  partially  digested  gastric  contents  to  pass  the  portals  of  the 
stomach  prematurely.  It  likewise  permits  the  regurgitation  of  the  in- 
testinal contents  into  the  stomach.  Its  recognition  is  possible  upon  in- 
flating the  stomach,  when  gas  may  be  seen  to  pass  into  the  intestines, 
and  also  upon  tbe  regurgitation  of  intestinal  contents  into  the  stomach. 

{h)  Insufficiency  of  the  Cardia. — This  condition  leads  to  eructations 
and  regurgitations,  and  when  these  are  of  aggravated  form  they  impair 
the  general  nutrition.      Ordinarily  no  ill-effects  follow. 

[c)  Atonic  Dyspepsia  {Atony). — This  may  occur  either  as  a  neurosis 
or  secondary  to  chronic  gastritis  and  reflexly  in  chronic  appendicitis,  car- 
cinoma, and  tuberculosis  of  the  intestines.  It  ini[)lies  Itypomotiliiij. 
The  chyme  is  retained  in  the  stomach  beyond  the  natural  time-limit. 
There  is  an  epigastric  oppressioii  with  a  distention  of  the  organ  during 
digestion  that  tends  to  become  permanent.  There  are  eructations  of  gas, 
an  impaired  appetite,  and  often  constipation.  The  stomach  is  found 
empty  in  the  morning,  and  six  or  seven  hours  after  Leube's  test-meal  it 
contains  some  chyme.  In  the  absence  of  pyloric  stricture  tbe  hypo- 
motility  may  be  shown  by  the  administration  of  salol. 

Treatment. — The  diet  is  to  be  regulated  as  in  chronic  gastritis 
with  dilatation.  It  is  rarely  necessary  to  restrict  the  solids  to  any 
marked  extent,  but  the  quantity  of  fluids  should  be  lessened.  The 
patient  must  be  taught  to  eat  slowly  and  masticate  thoroughly.  His 
hygienic  standard  of  living  must  be  high,  and  he  must  not  be  allowed 
to  over-use  his  mental  faculties.  Exercise  in  the  open  air  and  cold 
baths,  properly  regulated,  are  potent  for  good.  Of  medicines,  strychnin 
stands  first,  and  I  have  found  the  following  formula  of  great  service : 

I^.  Tr.  nuc.  vomicae,  fgiiss  (10.0)  ; 

Inf.  cascarillae,  q.  s.  ad  f§iv    (128.0). — M. 

Sig.  sij  (8.0)  three  times  daily. 

Electricity  is  indicated,  and  intragastric  faradization  has  given  ex- 
cellent results.  The  constipation  is  to  be  overcome  by  an  appropriate 
dietary  (green  vegetables,  Graham  bread,  an  abundance  of  fruit).  There 
is  an  advantage  in  assuming  the  right  lateral  position,  which  hastens 
evacuation.     Lavage  deserves  a  prudent  trial. 

NEUROSES  OF  SENSATION. 

OABDIALGIA. 

( Gastralgia  ;    Gastrodynia.) 

Definition. — Severe  paroxysmal  pain  in  the  epigastrium  in  the  ab- 
sence of  gastric  lesions.      There  are  two  other  forms  of  this  disease  that 


828  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

are  clinically  identical  "witli  nervous  gastralgia,  the  one  occurring  in  ulcer 
and  carcinoma  of  the  stomach,  and  the  other  in  certain  chronic  nervous 
diseases,  t'orniincj  the  so-called  <rastric  crises. 

Ktiology. — The  subjects  are  often  hereditarily  predisposed  to  neu- 
roses of  other  types.  Such  conditions  as  anemia,  exhaustion  from  re- 
peated hemorrhages,  and  syphilis  exert  a  predisposhig  influence.  The 
female  sex  is  more  liable  than  the  male,  and  in  the  former  it  appears  to 
be  dependent  upon  disturbances  of  the  menstrual  function  or  quite  fre- 
quently upon  hysteric  conditions.  It  is  sometimes  excited  by  reflex 
irritation,  by  deep  grief,  woir^',  and  great  anxiety.  Hypochondriasis 
and  hyperacidity  are  also  among  its  freijuent  causes. 

Symptoms. — These  are  sudden  in  their  onset  as  a  rule,  and  quite 
characteristic.  Occasionally  the  attack  is  preceded  by  anorexia,  or  it 
may  begin  with  a  sense  of  oppression  and  distention  in  the  epigastrium, 
lasting  for  a  few  minutes.  In  any  event,  the  onset  of  the  attack  proper 
is  marked  by  agonizing  pains  in  the  epigastrium,  that  dart  through  to 
the  back,  and  at  times  also  pass  around  the  lower  ribs.  The  seizure  lasts 
from  a  few  minutes  to  an  hour  or  two,  and  terminates  with  eructations  of 
gas,  or,  less  frequently,  with  vomiting.  From  the  nature  of  the  causative 
factors  it  is  obvious  that  the  gastralgic  seizures  are  in  no  wise  dependent 
upon  the  character  of  the  food  taken  ;  hence  the  fact  that  they  occur  more 
frequently  when  the  stomach  is  empty  need  occasion  no  surprise.  Firm 
pressure  over  the  epigastrium  relieves  the  pain.  Nervous  phenomena, 
varying  with  the  etiology  of  individual  cases,  are  constant  attendants,  but 
cannot  be  detailed  here.  A  distinct  clinical  variety  is  found  associated 
with  that  form  of  nervous  dyspepsia  in  which  an  excess  of  HCl  is 
secreted  {vide  Hyperacidity) ;  this  occurs  at  varying  intervals.  Many 
functional  nervous  disturbances  are  thus  subject  to  the  law  of  periodicity. 
I  believe  that  a  very  small  percentage  of  cases  are  caused  by  malaria, 
since  I  have  met  witii  two  such  cases  in  a  malarial  district,  both  of  which 
yielded  readily  to  quinin.  The  disease  took  on  a  desultory,  periodic 
character,  and  was  associated  with  other  malarial  symptoms. 

Diagnosis. — The  history,  the  absence  of  any  local  causes,  the  vio- 
lent, spasmodic  attacks  of  pain,  that  cease  abruptly,  and  their  occurrence 
at  irregular  intervals,  will  enable  the  clinician  to  render  a  positive  diag- 
nosis in  most  instances.  The  gastric  crises  that  occur  in  locomotor 
ataxia  closely  resemble  gastralgia  and  must  be  excluded.  Gastralgia 
may  be  simulated  by  cholelithiasis  {q.  v.).  To  discriminate  this  condi- 
tion from  gxfifric  ulcer  is  difficult,  but  stress  has  been  laid  upon  the  dif- 
ferential points  in  the  description  of  the  latter  disease  {vide  p.  809). 

Prognosis. — Tliis  depends  entirely  upon  the  causal  condition.  The 
disease  itself  has  no  intrinsic  fatal  tendency. 

Treatment. — This  is  to  be  subdivided  into  {a)  the  treatment  of  the 
attack;  {h)  the  management  of  the  intervals  between  the  seizures.  The 
pain  is,  as  a  rule,  sufficiently  intense  to  demand  morphin,  which  is  best 
administered  hypodermically  in  combination  Avith  atropin.  This  should 
not,  however,  be  given  if  an  idiosyncrasy  exist.  In  mild  attacks  the 
constant  or  the  faradic  current  often  affords  prompt  relief.  Under  these 
circumstances  counter-irritation,  together  with  the  internal  use  of 
Hoffman's  anodyne  or  chloroform  in  small  doses,  may  relieve  the  pain. 

(6)   The  Management  of  the  Intervals.— Here  the  physician's  efforts 


ANOREXIA.  829 

should  be  directed  to  the  detection  of  tlie  causes  and  their  removal  by  ap- 
propriate means.  In  hysteric  females  I  have  obtained  good  results  from 
the  prolonged  use  of  the  valerianates,  combining  with  them  iron  and 
arsenic,   thus : 

^.  Zinci  valerianat.,  gr.  xviij   (1.16); 

Quininse  valerianat.,  gr.  xxvij  (1.74) ; 


Ferri  arseniat.,  gr.  ij         (0.129). 

M.  et  ft.  pil.  No.  xviij. 
Sig.  One  after  each  meal. 

A  change  of  air  is  often  highly  serviceable,  and  should  be  advised 
whenever  financial  considerations  permit.  These  patients  are  constantly 
in  a  more  or  less  exhausted,  anemic,  and  run-down  condition,  and  a  tonic 
plan  of  treatment  is  always  indicated  to  overcome  the  primary  cause. 
In  the  intervals  between  the  attacks  digestion,  as  before  stated,  proceeds 
normally,  and  the  stomach,  therefore,  requires  no  treatment.  Constipa- 
tion, if  present,  is  a  condition  demanding  relief,  not,  however,  by  the 
use  of  purgatives,  but  by  such  means  as  massage,  a  suitable  diet,  enemata, 
or  laxative  suppositories.  The  physician  must  carefully  regulate  the 
sanitary  particulars  of  the  patient's  daily  life. 

HYPERESTHESIA   OP   THE   STOMACH. 

This  is  met  with  in  functional  and  organic  diseases,  as  well  as  in 
chronic  gastric  catarrh  and  other  affections  of  the  stomach.  Again,  it 
may  occur  as  a  neurosis,  most  frequently  in  chlorotic  girls  and  women. 
There  is  an  increased  gastric  sensibility,  so  that  the  mildest  irritant  pro- 
duces painful  sensations  that  may  be  either  gnawing  or  burninor  in  cha- 
racter. A  feeling  of  fulness  and  nausea  are  among  the  common  features 
of  the  complaint.  Food  and  certain  articles  that  are  not  easily  digestible 
may  afford  relief,  and,  oppositely,  fasting  or  restriction  of  diet  may  aggra- 
vate the  condition.  The  complaint,  however,  is  often  aggravated  during 
digestion,  particularly  after  excessive  indulgence  in  certain  kinds  of 
food  (crabs,  lobsters,  oysters,  strawberries).  Cutaneous  symptoms,  as 
erythema  and  urticaria,  may  appear.  Hypochondriasis,  neurasthenia, 
and  hysteria  are  often  associated.  The  above  symptoms  are  dependent 
upon  an  individual  idiosyncrasy. 

Treatment. — At  first  a  restriction  of  the  diet  to  soft  and  liquid  arti- 
cles should  be  tried,  and  later  a  cautious  return  to  solid  food  is  to  be  made. 
Of  medicaments,  the  bromids,  given  for  a  period  of  two  or  three  months, 
liave  given  the  best  results  in  my  own  hands.  For  the  chlorotic  type 
iron  in  the  form  of  Blaud's  pill,  in  ascending  doses,  is  the  best  treatment, 

ANOREXIA. 

This  consists  merely  in  a  loss  of  appetite,  and  occurs  in  many  organic 
gastric  disorders.  It  may  also  be  a  primary  gastric  neurosis,  the  latter 
being  often  associated  with  gastric  hyperesthesia.  Anorexia  sometimes 
leads  to  a  repugnance  to  food  and  a  degree  of  abstinence  that  may  induce 
grave  nutritional  disturbance.  Among  exciting  causes  mental  shock  of 
any  sort  ranks  first.  The  recognition  of  anorexia  as  a  neurosis  of  the 
stomach  is  difficult  after  the  general  nutrition  has  become  seriously  im- 


830  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

paired.  Chronic  dyspepsia,  phthisis,  and  other  diseases  associated  with 
emaciation  and  debility  must  be  excluded  before  the  dia<;nosis  is  estab- 
lished. 

HYPEROREXIA. 
[Excessive  Appetite.) 

This  may  either  be  symptomatic  of  other  affections  [c.  g.  diabetes 
mellitus)  or  it  may  be  a  gastric  neurosis.  It  may  also  be  paroxysmal 
(bulimia).  The  patient  complains  of  burning  sensations  in  the  epigas- 
tric region  and  of  an  insatiable  hunger.  The  symptoms  of  neurasthenia 
and  hysteria  are  often  in  association.  The  local  and  general  symptoms 
are  volicveil  by  food.  It  may  also  accompany  affections  of  tlie  brain, 
exophthalmos,  and  migraine.  In  bulimia  the  abnormal  sensation  of 
hunger  may  come  on  at  any  hour,  even  immediately  after  abundant  food 
has  been  taken.  When  the  morbid  sensation  of  hunger  develops  more 
gradually  and  some  time  after  meals  it  is  spoken  of  -a^  ijolyphayia. 

Pica  is  the  term  applied  to  the  craving  for  substances  not  used  as 
food  (slate-])enci]s,  dirt,  chalk). 

Malacia  represents  the  desire  for  highly  spiced  dishes  (mustard, 
salads,  pickles,  fruits). 

The  above  conditions  are  met  with  in  neurasthenia,  chronic  gastric 
affections,  and  chlorosis. 


VIII.    DISEASES  OF  THE  INTESTINES. 

METHODS  OF  DIAGNOSIS. 

Examination  of  the  Feces.— Although  the  results  are  in  most 
cases  unsatisfactory,  an  examination  of  the  feces  should  not  be  neg- 
lected, especially  in  the  more  serious  affections  of  the  intestine.  This 
embraces — {a)  a  macroscopic  ;  (b)  a  microscopic ;  [c)  a  chemical ;  and 
(c?)  a  bacteriologic  examination. 

{a)  The  macroscopic  appearances  often  suffice.  A  thorough  inspec- 
tion of  the  stools  furnishes  valuable  points  in  regard  to  the  presence  or 
absence  of  coarse  parasites,  fragments  of  tumor,  foreign  bodies,  concre- 
tions, blood,  bile,  fat,  pus,  mucus,  undigested  meat,  and  the  like. 

The  shape,  color,  and  consistence  of  tlie  stools  must  be  noted,  and  it 
is  to  be  remembered  that  in  these  particulars,  as  well  as  regards  their 
frequency,  they  exhibit  a  considerable  range  of  normal  variations, 
according  to  individual  peculiarities,  the  character  of  food  taken,  and 
so  on.  It  is  to  be  recollected  that  normal  stools  contain  fat  in  varying 
amounts,  for  the  reason  that  only  a  limited  quantity  can  be  emulsified 
and  taken  up  from  the  intestine.  The  naked  eye  may,  at  times,  detect 
its  presence  from  the  "peculiar  silvery  appearance"  of  the  feces.  Fat 
in  the  stools  {steatorrhea)  is  often  pathologic,  and  the  separate  affec- 
tions in  which  it  is  met  with  will  be  considered  hereafter.  The  dejecta 
present  a  shining,  tallowy  appearance,  either  throughout  or  in  circum- 
scribed spots.  Again,  the  fat  may  occur  in  the  form  of  oil  floating  on 
the  surface  of  liquid  stools.  Mucus  is  also  visible,  either  as  slimy  or 
jelly-like  masses,  or  as  shreds  and  granules  (sago-grains).      Diarrheal 


METHODS  OF  DIAGNOSIS.  H.'il 

stools  sliould  be   examined  iniici'oscopieally  witli  great  eare  foi-  gross  ad- 
mixtures (flakes  of  casein,  bits  of  meat,  etc.).      Constipational  dejections 
often  assume  a  rounded  form  {sheep's  dumj)  on  account  of  their  delay  in 
the  large  bowel.      They  may  attain  to  the  size  of  an  orange,  and  may 
be,  though  rarely,  enveloped  in  mucus  or  blood-streaked.      Their  color 
is  dark.      On  the  other  hand,  the  stools  may  be  colorless  in  cases  in 
which  the  bile-ducts  are  occluded ;  these  usually  contain  a  large  pro- 
portion of  fat,  though  not  invariably.      The  effect  of  certain  drugs  upon 
the  color  of  the  stools  is  to  be  borne  in  mind.     When  blood  is  inti- 
mately mingled  with  the  feces,  they  have  a  reddish,  dark-  or  blackish- 
brown  (tarry)  color,  according  to  the  quantity  and  the  time  allowed  for 
decomposition  in  the  intestine.     Blood,  either  clotted  or  fluid,  may  also 
be  passed  in  a  pure  state.     Its  source  is  usually  the  lower  bowel,  though 
when  peristalsis  is  augmented,  it  may  come  from  the  small  intestine,  as 
in  typhoid  fever.      Pus  may  occasionally  be  recognized  macroscopically. 
From  a  diagnostic  point  of  view,  it  is  most  important  to  examine  for 
biliary  concretions  in  doubtful  abdominal  colic.      "For  the  detection  of 
small  concretions  the  stools  should  be  passed  through  a  sieve  "  (Ewald). 
(6)  Microscopic  Examination. — Diarrheal  stools  can  be  examined  as 
discharged,  but  to  solid  and  mushy  dejections  a  solution  of  common 
salt  (J  per  cent.)   should  be    added    and  all  hard    masses  thoroughly 
broken    up.     Different  portions   of  the  stools   are   to  be    selected    for 
microscopic  examination.     Microscopically  we  are  enabled  to  detect  the 
eggs  of  parasites,  pus,  blood,  protozoa,  mucus  in  the  form  of  shining, 
vitreous,  homogeneous,  or  whitish  masses ;  and  in  the  interior  of  the 
latter  certain  pathogenic  bacteria,  various  crystals,  and  intestinal  epi- 
thelium   may    be    seen.      Remnants    of    vegetable    food    may    simulate 
mucous   islets,  but  the  former  strike  a  blue  color  on  the  application  of 
Lugol's    solution.     Microscopically,    diarrheal    stools    show    undigested 
muscle-fibers,  fat-crystals,  vegetable  cells,  starchy  granules,  and  innum- 
erable bacteria.    Von  Leersum^  advocates  the  sedimentation  process  until 
the  sediment  finally  contains  most  of  the  meat-fiber,  and  that  the  nuclei 
be  then  stained  and  examined  to  estimate  the  degree  of  pancreatic  di- 
gestion.       Undissolved    starch    in    even    moderate    quantity    points    to 
catarrhal   enteritis   of  the    small   intestine.       On   microscopic   examina- 
tion   of  the  dejections  in  constipation  we  find  "a  copious  detritus  of 
brown   or  black   color,    usually   numerous   colorless    or    slightly   tingeo 
triple    phosphates    (phosphate    of    ammonium    and    magnesium    crystal- 
lizing in  the  form  of  a  coffin-lid),  or,  more  sparse,   crystals  of  neutral 
phosphate  of  lirae."      Seldom  do  we  meet  with  the  rhomboid  plates  of 
cholesterin,  which  are  recognized  in  that  they  are  colored  from  a  red^ 
dish-brown  to  violet  by  dilute  sulphuric  acid  (1  :  5),   and  become  blue 
or  green  on  the  further  addition  of  a  solution  of  iodin.     Needle-shaped 
crystals  of  fat,  single  and  also  in  the  forms  of  tufts,  are  frequently  met 
in  obstruction  of  the  biliary  ducts.     Bile-pigment  cannot  be  detected. 
Remnants  of  food  are  sparsely  present  in  normal  feces.     Epithelium  from 
the  mucous  membrane,  pus-cells,  and  blood-corpsucles,  unless  they  come 
from  the  passage  of  the  fecal  mass  through  the  anus  (in  Avhich  case  they 
are  simply  adherent  to  the  external  surface  of  the  scybala  and  are  but 
little    changed),    are    greatly    altered ;     they    are    fatty,     degenerated, 
1  Munchener  Med.  Woeh.,  February  6,  1912. 


832  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

shrunken,  and  hardly  recognizable.  Rhomboid  crystals  of  hematoidin 
may  be  at  times  observed.  The  microscopic  examination  for  animal 
parasites  will  be  referred  to  in  appropriate  sections  of  this  work. 

((■)  Cheinical  I^xammatiou. — The  presence  of  bile-pigment  is  easily 
detected  by  the  Gmelin  reaction.  The  stools  must,  if  needful,  be  ren- 
dered iiuid  by  the  addition  of  water,  then  filtered,  and  the  filtrate 
allowed  to  dry.  At  the  margin  of  the  drop  the  characteristic  green 
color  will  appear.  Urobilin  strikes  a  red  color.  The  stools  in  diarrhea 
may  contain  ferments  capable  of  digesting  albuminoids.  The  fatty  acids 
are  distinguished  from  fatty  soaps  by  the  solubility  of  the  former  in  ether. 

For  the  detection  of  occult  blood,  to  an  ethereal  extract  of  2  to  5  cc.  of 
litjuid  feces  or  solid  stool  reduced  by  Avater,  2  cc.  of  a  10  per  cent,  solu- 
tion of  guaiac  in  glacial  acetic  acid  is  added,  followed  by  2  cc.  of  hydro- 
gen dioxid,  the  mixture  is  thoroughly  shaken  and  in  the  presence  of 
blood  turns  blue.  A  dilution  of  blood,  1  in  250,000,  is  recognized  by 
the  Adler  technique,  in  which  to  feces  prepared  as  above  add  1  cc.  glacial 
acetic  acid  and  2  cc.  of  fresh  concentrated  solution  of  benzidin  in  pure 
alcohol,  and  an  equal  volume  of  hydrogen  dioxid;  if  positive,  a  dirty 
green  or  deep  blue  develops.  Boas'  phenol phthalein  test  may  also  be 
employed.^  In  bleeding  from  the  stomach  and  intestines,  from  the 
mouth,  pharynx,  rectum,  or  vagina,  the  ingestion  of  meat,  watermelon, 
or  medicinal  iron  must  always  be  excluded.  The  indol-reaction  may  be 
increased,  pointing  to  increased  intestinal  putrefaction. 

(d)  A  bacterial  examination  of  the  intestinal  contents,  and  particu- 
larly of  any  mucus  or  mucopus  that  may  be  discharged,  may  decide 
the  diagnosis  of  certain  intestinal  disorders  (tuberculosis,  amebic  dysen- 
tery). For  the  method  of  carrying  on  these  investigations  the  reader  is 
referred  to  special  works  on  diagnosis  and  bacteriology. 

{e)  The  a--rays  have  been  shown  to  be  of  diagnostic  value  in  many 
intestinal  conditions  {vide  Enteroptosis,  Appendicitis,  Enteroliths). 

Physical  or  External  Bxamination. — Inspection. — This  should 
be  made  with  tiie  patient  in  the  dorsal  position  and  with  proper  illumi- 
nation. Localized  prominences  are  to  be  noted  (sometimes  simulated  by 
localized  contractions  of  the  abdominal  muscles).  The  influence  of  respi- 
ration on  these  circumscribed  bulgings  is  also  to  be  observed.  In  the 
absence  of  unusual  distention  of  the  abdominal  walls  it  is  of  great  value 
to  inflate  the  large  intestine  with  air  per  rectum,  and  to  note  the  pro- 
gressive distention  of  the  intestinal  coils  as  a  means  of  detecting  obstruct- 
ing lesions  in  the  bowel ;  the  position  and  mobility  of  a  tumor  should  also 
be  noted.  It  is  often  of  markeil  aid  to  inspect  the  mucosa  of  the  rectum 
by  the  use  of  approved  specula.  The  volume  of  the  abdomen  may  be 
diminished  or  even  '"scaphoid."  Abnormal  peristalsis  may  rarely  be 
noted  (important  if  associated  with  distention). 

Palpation. — This  is  of  first  importance.  The  patient  should  occupy 
the  dorsal  decubitus,  with  the  head  raised,  the  thighs  drawn  up,  and 
the  mouth  open,  so  as  to  relax  the  abdominal  muscles.  Something  may 
be  gained  in  this  direction  by  distracting  the  patient's  attention.  I 
have  found  that  placing  the  patient  in  the  lateral  decubitus,  with  the 
thighs  flexed  on  the  abdomen,  to  be  the  most  satisfactory  way  of  deter- 
mining the  degree  of  mobility  of  certain  tumors.  The  examiner  should 
^  Avier.  Jour,  of  Gasiro-enterology,  September,  1911,  p.  48. 


METHODS  OF  DIAONOSIS.  833 

not  fail  to  remember  the  knee-elbow  position  in  cases  in  which  it  is 
desired  to  palpate  the  parts  occupying  the  bottom  of  the  pelvic  cavity 
and  all  deep-seated,  movable  growths.  In  certain  cases  relaxation  of 
the  abdominal  muscles  is  only  obtainable  by  anesthetizing  the  patient, 
and  I  do  not  hesitate  to  do  this  in  cases  in  which  the  diagnosis  is 
important.  In  palpating  the  abdomen  for  abnormal  conditions  we  must 
keep  in  mind  steadily  the  relations  of  the  different  parts  of  the  intes- 
tines, and  also  that  the  latter  may  vary  considerably  in  position — a  fact 
particularly  true  of  the  transverse  colon  {tnde  Enteroptosis).  In  this 
connection  Ewald's  statement  "  that  abnormally  situated  organs  or 
neoplasms  of  parts  other  than  the  intestines  will,  under  the  pressure  of 
the  intestines  filled  with  air  or  water,  return  to  the  position  that  the 
organ  normally  occupies,"  should  be  emphasized.  New  growths  of  the 
pancreas,  of  the  spinal  column,  or  of  the  pelvis,  and  retroperitoneal 
tumors  will  remain  fixed.  Palpation  may  detect  pathologic  peristalsis, 
and  increased  resistance  if  the  coats  are  thickened.  Tenderness,  localized 
or  diffuse,  as  well  as  peritoneal  friction,  is  noted.  The  rectum  may  be 
palpated  if  the  symptoms  point  to  disease  of  that  organ. 

The  palpation  of  pathologic  conditions  of  the  intestines  will  be  con- 
sidered in  connection  with  the  separate  intestinal  affections. 

Percussion  detects  a  fluid  effusion  either  in  the  general  peritoneal 
cavity,  the  position  varying  with  the  patient's  posture,  or  in  circumscribed 
localities ;  the  latter  must  not  be  confounded  with  areas  of  dulness  that 
are  occasioned  by  splenic  and  hepatic  enlargements,  solid  new-growths, 
or  abscesses.  Air  in  the  peritoneal  cavity  {meteor{s7nus  peritonei)  gen- 
erally gives  a  pure  tympanitic  note,  though  if  the  tension  be  very  strong, 
a  non-tympanitic  tone  may  be  elicited.  These  sounds  are  general,  even 
extending  up  to  the  fifth  or  fourth  rib,  and  hence  they  cover  the  regions 
of  the  spleen  and  liver.  The  best  results  when  the  abdomen  is  not 
tense  are  obtained  after  inflation  of  the  large  intestine  with  air.  The 
pitch  of  the  tympanitic  note  becomes  elevated  with  increase  in  the  tension 
of  the  gut ;  it  falls  with  relaxation  of  the  bowel.  Hence  the  large  can- 
not always  be  told  from  the  small  intestine  by  percussion. 

Auscultation. — Noises  are  often  audible  either  at  a  distance  or  by 
means  of  a  stethoscope  applied  to  the  abdomen.  They  are  sometimes  oc- 
casioned by  the  natural  peristaltic  movements  or  by  certain  voluntary  or 
involuntary  spasms  of  the  abdominal  muscle.  I  have  repeatedly  confirmed 
the  observation  of  Ewald,  who  frequently  found  in  those  suffering  with 
chronic  intestinal  indigestion  a  swashing  or  splashing  noise,  sounding 
as  though  air  and  water  were  being  forced  through  a  narrow  space  in 
the  ileo-cecal  region.  These  sounds  may  rarely  be  found  in  healthy 
persons.  Similar  noises  sometimes  have  their  seat  in  the  descending 
colon,  particularly  if  the  bowel  is  unnaturally  dilated  by  air  or  fluid. 
They  are  often  audible  prior  to  an  evacuation  in  cases  of  colitis.  Noises 
mav  also  originate  in  the  transverse  colon,  and  to  discriminate  these  it  is 
necessary  to  empty  the  stomach  if  we  would  avoid  confusion  with  iden- 
tical gastric  sounds.  Direct  auscultation  of  the  intestines  renders  aud- 
ible the  peristaltic  movements,  and  the  absence  of  the  latter  indicates 
paralysis  of  the  intestine,  which  may  be  local  or  general.  Friction- 
sounds  may  be  audible  when  inflammatory  exudates  are  present.  When 
obstruction  of  the  large  intestine  is  suspected,  auscultation  should  be 

53 


834  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

practised  ■while  air  is  being  forced  into  tlie  rectum,  inasniudi  as  the 
degree  of  permeability  can  be  thus  determined.  Metallic  tinkling  and 
amphoric  noises  may  be  audible,  particularly  on  making  auscultatory 
pecussion,  but  these  are  without  real  diagnostic  value. 


ENTEROPTOSIS. 


Definition. — The  descent  of  the  intestines  from  their  normal 
position.  The  condition  occurs  coincidently  with  gastroptosis,  neph- 
roptosis, and  prolapse  of  other  viscera,  constituting  splanchnoptosis 
(Glenard's  disease). 

Ktiology. — It  is  linked  with  gastroptosis  and  other  forms  of  ptosis 
by  common  etiologic  influences,  such  as  sex  (being  most  common  in 
females),  tight  lacing,  traumatism,  muscular  strain,  numerous  pregnan- 
cies, rapid  emaciation,  and  probably  the  wrong  use  of  cathartics.  Either 
the  small  intestine  alone  or  the  large,  or  both,  may  be  involved.  Pro- 
lapse of  the  colon  (coloptosis)  is  the  more  common  ;  it  is  more  frequent 
than  gastroptosis  (C.  Meinert).  Lying  immediately  above  the  symphy- 
sis pubis,  it  is  sometimes  elongated  and  tortuous — "  S-  or  M-shaped." 

Symptoms. — The  condition,  even  when  pronounced,  may  exist 
without  symptoms.  On  the  other  hand,  in  the  majority  of  instances  the 
intestinal,  gastric,  and  other  bodily  functions  are  disturbed,  and  yet 
enteroptosis  is  usually  overlooked.  Chief  among  the  intestinal  symp- 
toms is  excessive  flatulence ;  not  rarely,  also,  there  is  membranous 
enteritis,  the  latter  probably  being  due  to  the  flexures  that  produce  an 
arrest  of  fecal  masses,  and  this  in  turn  causing  inflammation  (Boas). 
Constipation  generally  prevails,  and  sometimes  alternates  with  diarrhea. 
The  symptoms  of  gastroptosis  and  nephroptosis  are  often  associated ; 
they  are  loss  of  flesh  and  nervous  symptoms,  and  the  latter  may  simu- 
late those  of  neurasthenia  or  hysteria. 

The  diagnosis  is  made  upon  the  afore-mentioned  points  and  upon 
the  results  of  a  physical  examination.  The  position  of  the  colon  may 
be  determined  by  inflation  with  air  or  gas.  Again,  after  the  injection  of 
■water  (fsviss-ixss — 200-300  c.cm.)  a  splashing  sound  is  audible;  this  is 
double  the  amount  of  water  required  in  the  normal  condition.  Glenard 
lias  pointed  out  that  a  transverse  cord  (which  he  believes  to  be  the  colon) 
can  be  felt  in  the  upper  part  of  the  abdomen.  Boas  and  Ziemssen  assert 
that  this  cord  is  the  pancreas,  rendered  palpable  by  the  sinking  of  the 
stomach.  Movable  tenth  rib  is  common,  but  not  a  distinctive  sign,  since 
it  is  just  as  frequent  in  nervous  gastric  disturbances  in  general.  The 
x-raj/ft  are  of  diagnostic  value  (vide  Plate  VII.). 

Treatment. — The  bowels  must  be  moved  regularly,  the  tonicity  of 
the  abdominal  walls  must  be  increased  by  electricity,  massage,  and  hydro- 
therapy, and  in  strongly  nervous  cases  the  treatment  of  neurasthenia, 
including  the  AVeir  Mitchell  rest-cure,  must  be  instituted.  Supporting 
bandages  have  been  found  serviceable.  The  medicinal  treatment  aims 
at  meeting  symptomatic  indications,  such  as  flatulence  and  fermentation. 


Pl.ATK    Vll. 


Skiageaph  of  Enteroptosis  (Pfahler). 


INTESTINAL    (JATAJilill.  835 

INTESTINAL  CATARRH. 

{Catarrhal  Enteritis;  Muw-erderilis.) 

Definition. — A  catarrhal  inflammation  of  the  mucous  membrane  of 
the  whole  or  of  any  anatomic  division  of  the  intestinal  tract.  It  may  be 
either  acute  or  chronic,  primary  or  secondary.  Tiie  chronic  variety  oc- 
curs less  frequently  than  its  counterpart,  chronic  gastritis,  particularly  in 
adult  life. 

Pathology. — The  morbid  lesions  of  the  acute  variety  do  not  differ 
essentially  from  those  met  with  in  catarrhal  inflammation  of  any  other 
mucous  membrane.  The  first  stage  is  characterized  by  swelling  and  dry- 
ness of  the  mucosa ;  this  is  soon  followed  by  a  copious  exudation  of 
mucus,  and  more  rarely  of  pus,  Avhich  bathes  the  membrane  more  or  less 
completely.  After  an  abundant  secretion  is  poured  out  the  membrane 
appears  rather  pale,  though  the  tips  of  the  valvulae  conniventes  in  the 
small  intestines  may  appear  reddened.  The  solitary  and  agminated 
glands,  as  well  as  Peyer's  patches,  may  stand  out  prominently,  owing  to 
their  corrugated  condition  {follicular  enteritis).  The  apices  of  the  soli- 
tary glands  often  undergo  a  necrotic  change,  thus  forming  follicular  ulcers. 
The  remainder  of  the  mucosa  may  also  be  the  seat  of  rather  extensive 
areas  of  superficial  erosion,  though  this  must  not  be  confounded  with 
postmortem  softening  of  the  epithelium.  In  some  cases  the  desquama- 
tion of  epithelium  is  more  pronounced  than  the  abnormal  mucous  secre- 
tion. In  chronic  intestinal  catarrh  the  mucosa  presents  a  slaty  hue, 
with  a  more  or  less  dark  pigmentation  of  the  villi  and  follicles ;  it  is  in 
most  instances  thickened,  owing  to  an  increase  in  its  connective-tissue 
elements.  In  a  smaller  number  of  cases  it  is  thinned,  particularly^  in  the 
intestinal  catarrh  of  children,  on  account  of  atrophic  changes  affecting 
chiefly  the  glandular  and  muscular  layers.  Roughening  of  the  inner 
surface  of  the  bowel,  due  to  projecting  glands,  is  frequent  in  those  forms 
of  chronic  intestinal  cataiTh  that  are  attended  with  thickening  of  the 
coats.     Polypoid  cysts  may  develop  in  long-standing  cases. 

!^tiology. — The  primary  form  is  produced  by  (a)  local  irritants, 
either  mechanical  or  toxemic,  that  find  their  way  into  the  intestinal  canal. 
The  chief  source  of  these  excitants  is  an  unsuitable  dietary,  and  especially 
is  this  the  case  in  children.  It  is  readily  seen  from  this  fact  why  the 
stomach  and  the  intestines  are  often  simultaneously  involved  in  a  catarrhal 
process.  (5)  Over-eating  may  be  productive  of  the  disease,  though  this 
often  excites  diarrhea  by  merely  increasing  intestinal  peristalsis,  (c) 
Idiosyncrasy  has  a  positive  influence,  the  ingestion  of  certain  substances 
not  difficult  of  digestion  being  invariably  followed  by  this  affection  in 
individuals  thus  predisposed,  {d)  Toxic  substances,  whether  in  the 
form  of  tainted  food-stuffs  (spoiled  meats,  ice-cream,  beer)  or  inorganic 
poisons  (mineral  acids,  caustic  alkalies,  mercury,  arsenic)  or  irritating 
cathartics,  often  produce  intestinal  catarrh,  {e)  Impure  water,  or  water 
to  which  individuals  are  unaccustomed.  (/)  Atmospheric  changes, 
particularly  a  prolonged  high  or  a  sudden  fall  of  temperature,  the  latter 
being  especially  apt  to  cause  it  in  children.  ((7)  An  excess  or  a  lack 
of  biliary  secretion.     Two  functions  of  the  bile  (its  antiseptic  properties 


836  DISEASES  OF  Til  J-:  DldF.STIVE  SYSTEM. 

and  its  power  to  stimulate  peristalsis)  must  not  be  forgotten  :  the  one 
explains  how  a  paucity  of  this  secretion  favors  the  abnormal  processes 
of  fermentation  that  are  c'a])al)le  of  exciting  catarrh,  and  the  other  makes 
plain  the  possibility  of  a  bilious  diarrhea  being  due  to  an  excessive 
hepatic  secretion.  It  is  not  clear,  however,  that  the  latter  condition  is 
attended  with  an  actual  catarrhal  process.  The  same  is  true  of  diarrhea 
due  to  fright,  excitement,  or  other  nervous  influence.  (A)  Bacteria  are, 
doubtless,  among  the  excitants — e.  g.  the  normal  colon-bacillus,  under 
conditions  favorable  to  its  growth  and  development.  The  small  intes- 
tinal diphciicci  probably  operate  to  ))roduce  catarrh,  particularly  fer- 
mentative dyspepsia  (Schmidt  and  Strasburger). 

Secondary  or  complicating  forms  are  caused — {a)  By  direct  extension 
from  adjacent  organs  (ulcers,  gastritis,  peritonitis,  hernia,  and  invagina- 
tion) ;  (h)  By  general  infectious  processes  (septicemia,  pyemia,  typhoid 
fever,  (lysentery,  cholera,  tul)erculnsis,  pneumonia). 

The  chronic  forms  are  met  with — (a)  In  certain  cachectic  states  (car- 
cinoma, chronic  malaria,  chronic  Bright's  disease,  Addison's  disease,  and 
profound  anemia) ;  {b)  In  connection  with  disturbances  of  the  circulation, 
particularly  such  as  produce  stasis  in  the  terminal  branches  of  the  portal 
system  of  vessels :  among  the  chief  diseases  that  tend  to  prevent  the 
return  of  venous  blood  from  the  intestines  are  chronic  heart-affections, 
diseases  of  the  liver  (especially  cirrhosis),  and  emphysema ;  (c)  Severe 
cases  of  chronic  diarrhea,  probably  due  to  the  protozoan  balantidium, 
have  been  reported  recently. 

Among  predisposing  causes  is  the  age,  children  being  particularly 
liable  to  the  disease.  Unfavorable  hygienic  surroundings,  especially 
when  a  high  temperature  prevails,  and  epidemic  and  endemic  conditions 
also  strongly  predispose  to  the  affection. 

Clinical  History. — From  a  clinical  standpoint  we  recognize  acute 
and  chronic  forms  of  enteritis  ;  also  special  varieties  {vide  infra). 

The  simple  acute  form  of  general  catarrh  of  the  intestines  (muco- 
enteritis)  has  for  its  two  most  characteristic  symptoms  slight  griping  or 
colicky  pains  in  the  abdomen  (sometimes  absent),  that  are  followed  soon 
by  diarrheal  stools.  The  discharges  consist,  at  first,  of  feculent  masses, 
and  later  of  a  watery,  highly  irritating  fluid.  Diarrhea  is  due  partly  to 
increased  peristalsis  and  partly  to  the  abnormal  irritability  of  the  intes- 
tinal mucous  membrane.  Active  peristalsis  of  the  intestines  may  (vide 
ante)  be  of  purely  nervous  origin  (e.  g.,  in  neurasthenia),  and  produce  a 
diarrhea  that  is  to  be  distinguished  from  that  due  to  catarrh,  although 
an  exceedingly  difficult  task  in  some  cases.  Again,  steatorrhoea  may  be 
present  in  cases  in  which  the  pancreatic  secretion  is  absent.  The  causes 
that  produce  the  catarrh  abso  produce  the  undue  peristaltic  movements. 
If  it  be  true,  as  physiology  teaches,  that  the  stools,  owing  to  the  absorp- 
tion of  the  watery  portions  of  the  food,  are  normally  formed  in  the  large 
intestines,  then  catarrh  of  the  small  intestines  alone  does  not  excite  diar- 
rhea, though  both  large  and  small  are  involved  in  the  majority  of  the 
cases.  On  tlie  other  hand,  in  acute  colitis  diarrhea  is  conspicuous,  and 
forms  the  most  important  clinical  symptom.  The  vigorous  peristalsis  also 
accounts  for  the  gurgling  and  rumbling  sounds  [borborygmi)  that  are 
often  felt  and  heard  by  the  patient  himself.  These  peculiar  noises,  if 
pronounced,  point  to  isolated  catarrh  of  the  small  intestines.     The  stools 


INTESTINAL   (JATAIlliH.  837 

vary  in  number  from  two  to  ton  or  more,  boinf^  incr(;aso<l  in  fre'juency 
after  taking  food  ;  gases  are  also  formed,  causing  tympanites.  The  tbin 
or  mushy  stools  either  present  a  bright-yellow  or  a  yellowish-brown 
color  and  emit  offensive  odors.  Occasionally  they  are  greenish  in  color 
from  the  presence  of  considerable  quantities  of  bile-pigment  or  from 
bacterial  action.  In  advanced  cases  of  considerable  severity  there  is 
painfid  tenesmus ;  the  stools  are  often  small  and  contain  mucus  and 
blood,  becoming  dysenteric  in  chiiracter,  especially  in  colonic  catarrh. 
Nausea,  impairment  of  appetite,  and  great  thirst  are  commonly  present. 

A  microscopic  examination  reveals  large  masses  of  epithelium  and 
mucus,  as  well  as  countless  microorganisms  and  isolated  leukocytes, 
crystals  of  calcium  phosphate,  oxalates,  remnants  of  food  (^starch- 
granules,  fat,  and  muscular  fibers).  Flakes  of  yellowish-brown  mucus, 
of  epithelium,  and  grayish-white  masses  of  fat  may  often  be  seen  macro- 
scopically.     The  stools  give  an  alkaline  reaction  as  a  rule. 

The  pliysical  examination  reveals  on  inspection  slight  tympanitic  dis- 
tention as  a  rule.  The  tongue  is  dry  and  furred.  Paljyation  elicits  con- 
siderable sensitiveness  in  the  majority  of  cases,  though  during  the  colicky 
pains  pressure  with  the  palm  of  the  hand  often  aifords  relief.  Fluctua- 
tion may  be  detected  if  the  intestines  contain  much  fluid.  Percussion 
gives  an  exaggerated  tympanitic  resonance,  varying,  however,  with 
the  tension  of  the  bowel.  Splenic  enlargement  has  been  described  by 
Fischl. 

The  general  symptoms  are  often  entirely  wanting,  save  for  a  slight 
feeling  of  weakness  due  to  the  diarrheal  discharges.  Severe  forms  of 
infectious  origin  often  disturb  the  general  health  considerably.  The 
patient  is  languid,  and  prostration  is  prominent ;  he  suflFers  much  from 
headache,  and  pyrexia  is  common,  the  temperature  often  reaching  100°— 
103°  F.  (37.7°-39.4°  C).  The  higher  temperatures  are  seen  among 
children.  Additional  evidences  of  a  systemic  infection  are  sometimes 
observed,  such  as  painful  enlargements  of  certain  joints,  severe  muscular 
pains,  and  albuminuria. 

Complications. — The  symptoms  of  gastric  catarrh  (vomiting,  nausea, 
and  pain  immediately  after  feeding)  are  often  associated  with  those  of 
enteric  catarrh ;  the  combination  is  then  spoken  of  as  g astro- enteritis. 
Acute  nephritis  has  been  noted  as  a  sequel. 

Special  F'orms. — Though  the  anatomic  limits  in  the  more  or  less 
local  forms  of  intestinal  catarrh  cannot  be  made  out  definitely,  yet  the 
diiferent  clinical  pictures  observed  often  enable  us  to  fix  the  location  of 
the  disease  with  considerable  accuracy ;  it  is  important,  moreover,  from 
the  standpoint  of  the  treatment,  to  accomplish  this  whenever  possible. 
The  following  may  be  briefly  described : 

(a)  Duodenal  catarrh  {duodenitis),  in  which  form  constipation,  often 
obstinate,  is  present  in  the  place  of  diarrhea,  the  colon  not  being  aff'ected; 
merely  local  pain,  tenderness  on  palpation,  and  uneasiness  are  complained 

•  of.  These  symptoms  may  frequently  be  overshadowed  by  those  referable 
to  the  stomach  when  gastric  catarrh  coexists  (gasfro-duodeniiis).  With- 
out jaundice  (usually  present)  due  to  the  occlusion  of  the  common  bile- 
duct  in  consequence  of  the  swelling  of  the  duodenal  mucous  membrane, 
we  cannot  render  a  positive  diagnosis. 

(b)  Localized    catarrh    of    the  jejunum    and   ileum    cannot    always 


838  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

be  distinguished.  The  condition  is  often  found  to  be  a  more  or 
less  prominent  feature  in  general  enteric  catarrh,  in  which  complaint 
diarrhea  is  a  prominent  symptom.  The  existence  of  this  special  variety 
may  be  safely  inferred  when  certain  enteric  symptoms  are  combined  with 
marked  gastric  disturbance.  Under  these  circumstances  the  symptoms 
indicative  of  inflammation  of  the  small  intestines  are  rumbling  noises 
(borborygmi),  colicky  pain,  swelling,  and  slight  tenderness  over  the 
abdomen  in  the  vicinity  of  the  umbilicus  or  over  other  regions  occupied 
by  the  small  intestines.  Finally,  an  examination  of  the  stools  furnishes 
valuable  points  for  differential  diagnosis.  It  must  be  kept  in  remem- 
brance that  in  catarrh  of  the  small  intestines  the  stools  may  be  quite 
solid,  despite  the  increased  peristalsis  caused  by  the  catarrhal  process 
{vide  ante).  More  frequently,  when  the  ileum  is  the  seat  of  catarrh 
the  colon  is  also  implicated,  this  combination  being  attended  with  diar- 
rhea, even  if  it  be  of  minor  severity.  The  thin  stools  "contain  food- 
remnants,  that  point  indubitably  to  implication  of  the  small  intestine." 
As  the  result  of  increased  peristalsis  of  the  small  intestines  their  con- 
tents are  passed  into  the  large  bowel  with  undue  rapidity ;  hence  the 
latter  contains  undigested  food-constituents  and  other  substances  that 
are  normally  found  in  the  small  intestines.  These  pass  from  the  rec- 
tum unchanged.  They  are  mainly  starch,  fat,  and  masses  of  meat-fiber, 
the  latter  of  which  may  be  of  sufficient  size  to  be  seen  by  the  naked  eye. 
This  would  be  pathognomonic  evidence  of  the  form  of  catarrh  in  ques- 
tion if  it  were  not  true  that  increased  peristalsis  of  the  small  intestines, 
due  to  other  conditions,  as  anemia,  extreme  nervousness,  and  fever-con- 
ditions, that  are  not  seen  in  ileo-jejunal  catarrh,  causes  the  same  fecal 
peculiarities.  An  acid  reaction  of  the  dejecta  points  to  catarrh  of  the 
small  intestines.  MirroscopieaUy  the  stools  show  hyaline  particles  of 
mucus,  giving  rise  to  a  speckled  appearance. 

In  health  the  contents  of  the  small  intestines  give  the  characteristic 
color-reaction  for  bile-pigment,  whilst  the  contents  of  the  large  bowel 
and  the  stools  do  not.  There  is  quite  often  a  large  admixture  of  unde- 
composed  bile-pigment  (Striimpell)  that  responds  to  Gmelin's  test,*  a 
fact  of  considerable  value  in  diagnosis.  Nothnagel  has  called  forcible 
attention  to  the  fact  that  hile-stained  stools  and  small  pigmented  masses 
of  mucus  are  met  with,  and  are  highly  characteristic  of  the  diarrhea  that 
marks  catarrh  of  the  small  intestines. 

(c)  Colitis. — The  joint  appearance  of  abdominal  pain  and  diarrhea  is 
almost  pathognomonic  of  this  condition.  These  symptoms,  in  the  ab- 
sence of  the  more  prominent  and  above-mentioned  clinical  features  that 
have  special  reference  to  inflammation  of  the  small  intestines,  point  to 
the  fact  that  the  large  intestines  are  the  chief  seat  of  the  disease. 

Physical  examination  is  only  partially  confirmatory  of  the  rational 
symptoms.  The  chief  sign  is  tenderness  on  palpation  over  the  track  of 
the  colon.  An  ocular  examination  of  the  stools  furnishes  important  prac- 
tical results.  They  may  contain  blood  and  mucus,  and  the  latter  often 
in  masses  large  enough  to  be  readily  visible  to  the  naked  eye ;  it  is  not 

'  This  consists  in  bringing  a  few  drops  of  nitric  acid  in  contact  with  the  intestinal 
contents,  when  the  characteristic  play  of  colors  appears.  (See  also  Methods  of  Diagnosis, 
pp.  830-834.) 


INTESTINAL   CATARRH.  839 

intimately  mixed  with  the  feces,  as  in  catarrh  of  tiic  sinull  intestines, 
but  forms  separate  masses.  The  feces  are  often  of  the  consistence  of 
soup.  "  If  the  catarrh  aifects  the  lower  portion  of  the  large  intestine 
chiefly,  it  may  be  that  the  intestinal  contents  are  already  formed  "  in 
firm  lumps,  which  may  sometimes  be  wholly  or  partly  enclosed  in  a 
layer  of  mucus  (Striimpell). 

Such  general  symptomH  as  loss  of  flesh,  weakness,  and  sallowness  of 
the  skin  are  often  observed.  Simple  diarrhea,  lasting  but  a  few  days,  as 
a  rule,  is  to  be  classed  with  catarrh  of  the  large  intestines,  since  these 
affections  imply  increased  peristalsis  of  the  large  bowel.  It  is  not 
always  easy,  however,  to  discriminate  diarrhea  due  either  to  purely  func- 
tional influences  or  to  catarrh  of  the  rest  of  the  intestinal  tract. 

{d)  ProctitUj  or  inflammation  of  the  rectum,  is  characterized  by 
painful  tenesmus  and  by  the  presence  of  large  quantities  of  mucus  and 
pus,  particularly  in  the  dejections.  The  disease  may  be  primary,  though 
more  often  it  is  secondary  to  morbid  lesions  either  in  organs  that  are 
adjacent  to  or  in  the  rectum  itself. 

Chronic  intestinal  catarrh  may,  comparatively  rarely,  be  a  immary 
disease,  developing  gradually.  It  may  also  be  secondary  (vide  Pathol- 
ogy) at  times  to  one  or  more  attacks  of  acute  intestinal  catarrh.  Gen- 
erally there  are  no  other  local  symptoms  to  call  attention  to  the  condi- 
tion than  chronic  diarrhea.  More  rarely  there  are  in  addition  colicky 
pain  and  tenderness  over  the  abdomen.  The  diarrhea  often  alternates 
with  constipation,  and  this  is  most  apt  to  be  the  case  when  the  disease 
is  of  idiopathic  origin  and  aff"ects  only  the  large  intestine  (Nothnagel). 
Constipation  is  constant  in  those  cases  in  which  atrophic  alterations 
occur  in  the  glandular  and  muscular  coats,  as  well  as  in  those  in  which 
the  lesions  are  in  the  small  intestines.  When  constipation  is  not  pres- 
ent the  stools  are  thin,  pale,  sometimes  fermented,  emitting  off'ensive 
odors,  and  vary  greatly  in  number  and  quantity.  There  is  com- 
monly present  visible  mucus.  When  the  small  bowels  are  also  impli- 
cated, food-remnants  are  found  in  the  dejections  (lienteric  diarrhea). 
Microscopically,  the  picture  does  not  diff'er  from  that  of  the  acute  form. 
That  form  of  diarrhea  occurring  in  organic  diseases  of  the  heart,  liver, 
and  lungs  demands  brief  special  mention.  Here  the  serum  of  the  blood 
is  made  to  exude  into  the  intestines,  owing  to  mechanical  obstruction 
to  the  return  of  the  venous  blood,  and  this  results  in  a  liquefaction  of 
the  feces.  The  stools  are  apt  to  be  most  copious  and  numerous  during 
the  morning  hours.  Sometimes  an  irresistible  desire  to  evacuate  the 
bowels  seizes  the  patient  as  soon  as  his  feet  strike  the  floor  on  rising  in 
the  morning ;  two  or  more  serous  discharges  follow  each  other  at  short 
intervals.  Subsequently,  all  discharges  cease  until  the  following  morn- 
ing, when  the  same  symptoms  are  repeated.  The  general  nutrition 
sufi"ers  visibly  in  chronic  enteritis,  and  emaciation  eventually  becomes 
pronounced.     I  have  also  noticed  slight  pyrexia  in  the  evening  hours. 

DiflFerential  Diagnosis. — Among  the  diseases  likely  to  be  con- 
founded with  acute  catarrh  of  the  intestines  are  typhoid  fever,  dysentery 
(diseases  in  which  diarrhea  is  a  cardinal  symptom),  peritonitis,  and  colic. 
The  chief  differential  features  between  simple  colic  and  enteric  catarrh 
may  be  contrasted  thus  : 


840  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


KXTKRIC    (.ATARRH.  CoLlC". 

Diarrhea  is  penorally  present.  Constipation  is  present. 

Fever  may  Ite  sliifht  or  marked.  No  fever. 

Pain  is  griping,  and  followed  by  diarrheal  Pain  is  colicky,  more  severe,  and  is  not 

stools.  followed  by  diarrheal  discharges. 

Tenderness  in  the  iijtervals  between  pains.  No  sensitiveness  on  palpation. 

From  peritomti><  we  may  readily  distinjiuish  catarrh  of  the  intestines 
by  the  more  intense  ])ain  and  tenderness,  by  the  constipation,  the 
greater  tympany,  the  constitutional  disturbance,  the  anxious  face,  thoracic 
respiration,  and  immobility  of  the  patient,  all  of  which  characterize  the 
former  disease.  The  characteristic  symptoms  of  ti/phoid  fever  (the  typical 
temperature-curve,  swelling  of  the  spleen,  eruption,  AVidal  test)  and  of 
dysentery  (scanty,  freijueut  stools,  tenesmus)  are  easily  separable  from 
enteric  catarrh.  In  children,  however,  the  diagnosis  between  typhoid 
fever  and  sim]>le  catarrh  of  the  bowels  offers  considerable  difficulty  ;  but 
the  temperature-record,  the  enlargement  of  the  spleen,  the  characteristic 
eruption,  and  the  Widal  reaction,  taken  unitedly,  will  warrant  the  diag- 
nosis of  typhoid  fever  and  exclude  acute  enteritis. 

In  diagnosticating  chronic  intestinal  catarrh  we  may  have  difficulty  in 
eliminating  lardaceous  disease  of  the  bowels  and  ulcerations.  The  latter 
condition  will  be  excluded  hereafter.  Boas  recommends  lavage  in  the 
diagnosis  (about  one  liter  of  lukewarm  water  through  a  rectal  tube) :  the 
funnel  is  then  lowered  and  the  dejecta  siphoned  off.  If  the  recovered  fluid 
contain  mucus,  catarrh  is  present.  Amyloid  degeneration  is  a  general 
disease,  affecting  primarily  other  organs  than  the  bowel,  and  hence  lar- 
daceous diarrhea  is  always  preceded  by  the  clinical  indications  of  disease 
(enlarged  viscera,  albuminuria)  elsewhere.  The  condition  also  gives  a 
definite  etiolor/y  as  a  rule. 

Prognosis. — The  prognosis  in  uncomplicated  cases  is  favorable, 
though  the  possibility  of  a  merging  into  the  chronic  form  must  be  borne 
in  mind.  Occurring  in  weakly  subjects  and  in  the  course  of  debilitating 
affections,  acute  catarrh  of  the  intestines  may  endanger  life.  Its  dura- 
tion varies  much — from  three  to  ten  days  or  more — according  as  the  type 
of  the  individual  case  is  mild  or  severe. 

The  prognosis  in  the  chronic  forms  is  moderately  good  as  to  life, 
though  as  to  cure  it  is  not  so,  the  disease  often  enduring  for  many  years 
too^ether,  or  as  long  as  the  chronic  conditions  producing  it  remain  un- 
removed.  It  sometimes  exhausts  the  system  of  those  suffering  from 
serious  causal  affections  of  a  chronic  nature,  and  occasionally  it  ulti- 
mately proves  fatal.  The  prognosis  will  depend  largely  upon  the  charac- 
ter of  the  etiologic  affection,  but  intestinal  catarrh  invariably  renders 
the  prospects  of  life  more  gloomy. 

Treatment. — Kespecting  the  treatment  of  this  affection  the  views 
of  the  profession  have  undergone  many  changes,  even  within  recent 
years  ;  hence  it  may  be  reasonably  inferred  that  our  present  therapeutic 
methods  are  by  no  means  satisfactory. 

Hygienic  and  Dietetic  Management. — In  the  not  uncommon  mild 
cases,  due  to  errors  in  diet,  a  mild  purgative,  followed  by  proper  dietetic 
treatment,  is  all  that  is  required.     Albuminous  food  in  li(juid  form,  such 


INTESTINAL   CATARRH.  841 

as  skimmcid  inilk,  weak  brotlis,  and  even  Henii-auimal  articles  of 
diet,  as  eggs,  oysters,  sweet  milk  with  seltzer,  are  usually  well  borne.  In 
the  severe  forms  predigested  liquid  foods  only  should  be  allowed.  When 
the  chief  seat  of  the  disease  is  in  the  large  intestine,  we  may  allow 
easily  digested  starches  and  certain  green  vegetables  (arrow-root,  sago, 
lettuce,  water-cress) ;  the  coarser  vegetables,  all  fats,  and  most  fruits 
should  be  withdrawn  absolutely.  Rest  in  bed  is  especially  beneficial  in 
that  it  serves  to  keep  the  abdomen  warm  and  mitigates  the  pain  and 
diarrhea,  and,  in  short,  cures  the  disease.  Sinapisms  should  be  ap- 
plied at  the  outset  until  the  skin  is  reddened,  succeeded  by  light  linseed 
poultices  until  the  local  sensitiveness  has,  in  a  great  measure,  subsided; 
after  this  a  flannel  band  may  be  applied.  The  local  abstraction  of  blood 
by  a  few  leeches,  applied  to  the  abdomen  or  anus,  is  beneficial  in  the 
early  stages  in  severe  types  of  enteric  catarrh,  provided  the  patient's 
strength  is  good. 

Medicinal  Treatment. — It  is  sound  practice  to  prescribe  a  mild  ca- 
thartic (castor  oil,  calomel,  or  rhubarb,  followed  by  a  saline)  with  a  view  to 
getting  rid  of  decomposable  intestinal  contents.  Combined  gastric  lavage 
and  high  intestinal  irrigation  has  recently  yielded  excellent  results  in 
my  hands ;  it  is  an  appropriate  method  of  overcoming  the  fermentative 
processes  that  tend  to  excite  and  maintain  the  condition. 

If  the  chief  tenderness  be  localized  in  the  right  iliac  fossa,  corre- 
sponding to  the  course  of  the  colon,  a  simple  enema,  slowly  given,  will 
stimulate  the  bowel  sufficiently  and  cleanse  it  more  eff"ectually  than  a 
cathartic.  Subsequently,  chief  reliance  is  to  be  placed  on  intestinal 
antiseptics  and  astringents,  though  it  must  be  recollected  that  the  selec- 
tion of  internal  remedies  must,  in  part,  be  influenced  by  the  etiologic 
indications.  For  instance,  if  the  cause  has  been  exposure  to  cold  or 
wet,  besides  the  efforts  directed  at  the  local  condition  diaphoretics  and 
febrifuge  mixtures  are  serviceable.  I  have  found  the  following  com- 
bination to  be  of  benefit  in  controlling  the  local  inflammatory  action  : 

I^.  Salol,  3SS   (2.0); 

Creasoti,  '     mx  (0.666)  ; 

Bismuthi  salicylat.,  .^j     (4.0). 

M.  et  ft.  capsules  No.  xx. 
Sig.   One  every  three  hours. 

If  pain  be  troublesome,  opium  or  phenacetin  may  be  combined  with 
the  above  formula. 

In  many  instances  the  secretions  of  the  intestinal  tube  are  decreased 
for  a  considerable  period  after  the  most  active  symptoms  have  been 
subdued.  Here  we  must  supplement  the  natural  juices  of  the  bowel : 
this  may  be  satisfactorily  accomplished  by  the  following  agents  : 

^.  Pancreatin,  3j    (4.0); 

Sodii  bicarb.,  3ij  (8.0). 

M.  et  ft.  chart.  No.  xij. 
Sig.   One  an  hour  after  meals. 

In  cases  in  which  the  large  intestine  is  chiefly  affected,  and  when  the 
condition   does  not  yield   to  internal  medicines,  treatment  by  medicated 


842  DISEASKS   OF  THE  DIGESTIVE  SYSTEM. 

colonic  irrigations  are  useful.  When  tiiere  is  reason  to  suspect  that  the 
main  lesion  is  in  the  large  bowel,  small  enemas  of  starch-water  (^ij — 
64.0),  with  laudanum  (TH.  xx-xxx — 1.8^^2.0),  every  four  to  six  hours, 
are  also  efficacious.  If  colicky  pain  be  severe,  morphin  (gr.  ^ — 0.008) 
should  be  given  hypodermically  in  addition  to  the  measures  before  sug- 
gested. If  the  diarrhea  shows  no  tendency  to  abate  after  forty-eight 
hours  of  the  general  treatment  above  outlined,  large  doses  of  bismuth 
(gr.  xxx-lx — 2.0-4.0)  every  three  or  four  hours  should  be  tried.  In  my 
own  hands  load  acetate  (gr.  ij — 0.120),  with  the  extract  of  opium  (gr.  \— 
0.008)  in  pill-form,  has  proved  a  most  efficient  combination.  The  thirst 
is  best  relieved  by  chipped  ice  in  small  quantities  or  by  carbonic  acid  and 
Apollinaris  waters.  For  distressing  flatulence  we  may  prescribe  the 
alkaline  carbonates,  or  spirits  of  ammonia,  and  some  carminative.  The 
oil  of  cajeput  is  a  most  valuable  drug  in  the  treatment  of  excessive  fer- 
mentation (Murrell). 

In  chronic  catarrh  of  the  intestines  the  local  treatment  is  of  para- 
mount importance.  Daily  irrigation  of  the  bowel  with  a  weak  solution 
of  some  antiseptic  agent,  as  salicvlic  acid  (gr.  v-5J — 0.324-32.0), 
boracic  acid  (gr.  x-sj— 0.648-32.0),  "creolin  (iTl  v-sj— 0.324-32.0),  or 
with  some  such  astringent  as  tannin  (gr.  v— 5J — 0.324 — 32.0),  or  finally 
with  an  alterative,  such  as  silver  nitrate  (gr.  ^.?j — 0.016-32.0),  will  be 
found  to  be  serviceable.  The  latter  solution  is  a  most  excellent  remedy, 
but  sometimes  excites  pain  if  too  concentrated.  I  often  use  a  mild  anti- 
septic or  astringent  with  the  foregoing,  giving  each  on  alternate  days, 
and  thus  obtain  happy  results.  The  only  appliance  needful  is  a  fountain 
syringe  with  a  soft-rubber  end-piece,  which  should  be  gently  introduced 
for  a  considerable  distance  into  the  bowel.  The  fluid  used  should  be 
warmed  to  90°  F.  (32.2°  C),  and  the  quantity  administered  at  each  sit- 
ting should  be  not  less  than  2  to  3  pints  (1-1.5  liters)  ;  this  should  be 
allowed  to  flow  into  the  bowel  slowly.  The  patient  should,  as  a  rule, 
assume  the  dorsal  decubitus,  though  if  the  fluid  is  to  be  carried  as  high 
up  as  possible,  the  knee-elbow  position  may  be  assumed  or  the  patient 
may  be  placed  on  the  left  side  with  the  hips  elevated.  Again,  tui-ning 
him  from  side  to  side  during  the  irrigating  process  may  be  warmly  rec- 
ommended. 

The  same  careful  attention  must  be  paid  to  hygienic  details,  and 
especially  to  the  diet,  as  is  directed  in  the  acute  form.  In  addition,  flan- 
nel should  be  worn  next  the  skin  both  in  winter  and  summer.  If  the 
strength  will  admit  of  it,  cold  baths  are  useful. 

A  stay  at  a  suitable  spa  (Saratoga,  Bedford,  Virginia  Springs,  Carls- 
bad, Kissingen)  often  produces  most  satisfactory  results. 

Among  internal  agents,  zinc  oxid  (gr.  v  to  x — 0.324—0.648 — t.  i.  d.), 
silver  nitrate,  lead  acetate,  and  alum,  given  with  tonics,  such  as  strych- 
nia, arsenic,  and  iron,  are  especially  to  be  recommended. 

The  management  of  this  troublesome  malady  depends  upon  the  in- 
dications furnished  by  the  causative  aff'ections.  No  method  of  treatment, 
however,  can  succeed  that  is  not  carried  out  patiently,  systematically, 
and  over  long  periods  of  time. 


DIARRHEAS  OF  CHILDRKN.  843 

DIARRHEAS  OP  CHILDREN. 

ACUTE   GASTRO-INTESTINAL    CATARRH. 

(Acute  Gastro-enteric  Infection;  Summer  Diarrhea ;  Gastru-enteritis  ;  Cholera  Infan- 
tum ;  Mycotic  Diarrhea. ) 

Definition. — This  is  the  usual  intestinal  trouble  that  prevails  during 
the  warra  summer  months.  It  usually  takes  the  form  of  an  epidemic, 
and  its  course  is  manifested  by  a  sudden  onset,  high  fever,  irritability  of 
tlie  stomach,  frequent  watery  evacuations,  and  symptoms  of  nerve-in- 
volvement. This  form  of  diarrhea  usually  follows  an  attack  of  acute 
indigestion,  in  which  it  rery  frequently  has  its  origin  {acute  dyspejAie 
diarrhea).  Acute  gastro-intestinal  catarrh  {cholera  infantum)  stands 
midway  between  acute  indigestion  and  ileo-colitis. 

l^tiology. — Two  important  conditions  seem  to  be  necessary  to  influ- 
ence the  disease — temperature  and  diet.  A  general  and  well-recognized 
belief  associates  special  danger  with  the  second  summer  of  children. 
Out  of  nearly  2000  fatal  cases  collected  by  Holt,  only  3  per  cent,  were 
exclusively  breast-fed.  Generally  speaking,  the  disease  has  its  origin 
in  some  irregularities  in  artificial  feeding.  Heat  and  season  are  im- 
portant elements  in  the  continuation  of  the  disorder  when  once  com- 
menced. 

It  is  seen  from  May  to  September,  the  greatest  prevalence  occurring 
in  July.     The  pauper  element  of  large  cities  furnishes  most  instances. 

Flexner  and  Holt '  assert  that  the  bacillus  dysenterise  may  be  isolated 
from  the  intestinal  discharges,  and  from  the  intestinal  mucosas  in  a  large 
percentage  of  cases  developing  along  the  Atlantic  coast  of  the  United 
States,  during  the  summer  months.  Holt  found  bacillus  dysenteriae 
in  50  per  cent,  of  cases  at  the  Babies'  Hospital  of  New  York.  The 
Flexner-Harris  type  of  bacillus  is  most  often  encountered,  while  the 
"  Shiga  "  type  is  but  occasionally  recovered.  It  is  common  for  cultures 
to  develop  streptococci  in  connection  with  the  bacillus  dysenterice,  and 
both  organisms  appear  to  grow  luxuriantly  together,  which  renders  it 
impracticable  to  decide  whether  the  lesions  of  the  intestine  and  the 
general  symptoms  depend  upon  one  or  both  of  these  organisms. 

Booker,  Jeffris,  Baginsky,  and  Metschnikoff  affirm  that  the  proteus  class 
of  bacteria  are  commonly  present,  and  that  they  are  pathogenic.  The 
"  bacillus  dysenterias  "  reacts  with  the  serum  of  infected  children. 

Pathology. — A  catarrhal  swelling  of  the  mucosa  of  the  large  and 
small  bowel  is  present ;  the  mucosa  itself  is  pink  in  color  from  capillary 
congestion.  Beyer's  patches  are  enlarged.  The  whole  intestinal  tube 
shows  an  early  stage  of  inflammation  (ileo-colitis).  In  addition  there 
is  most  likely  some  involvement  of  the  sympathetic  nerves,  leading  to 
dilatation  of  the  capillaries  and  transudation  of  serum  into  the  intestine, 
and  to  alterations  of  the  pulse,  temperature,  and  respiration.  Its  nature 
is  paralytic,  and  closely  resembles  in  its  results  experimental  sections 
of  the  sympathetic  nerves.  The  changes  in  the  other  organs  are  slight. 
Broncho-pneumonia  frequently  occurs.  The  spleen  is  often  swollen,  the 
brain  is  anemic,  and  the  kidneys  are  congested. 

^  Rockefeller  Institute  for  Medical  Research,  1904.  > 


S44  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symptoms. — Clinically,  there  are  three  forms  of  acute  enteric  infec- 
tion :  (1)  acute  dyspeptic  diarrhea ;  (2)  cholera  infantum  ;  and  (3)  ileo- 
colitis. 

(1)  Acute  Bi/speptir  Diarrlica. — There  may  be  merely  an  increase 
in  the  number  of  stools,  with  or  -without  fever;  restlessness  is  usual  at 
niji;ht.  Tiiis  condition  may  continue  for  two  or  three  days,  when  the 
stools  become  more  frequent  and  offensive,  containing  undigested  food 
and  curds.  The  odor  by  this  time  is  very  pronounced.  Frequently  the 
disease  has  a  sudden  onset,  with  vomiting,  griping  pains,  and  fever, 
which  may  quickly  rise  to  104°,  105°,  or  106°  F.  (40°-41°  C).  Con- 
viih/'ons  may  be  the  commencement  of  the  attack.  The  abdomen  is 
sensitive  and  swollen,  and  the  child  lies  with  its  legs  flexed  on  the 
stomach.  The  stools  consist  of  grayish  or  greenish-yellow  feces  (mixed 
with  curds,  portions  of  undigested  food)  and  some  fluid.  In  children 
two  years  of  age  and  older  the  stools  may  contain  unripe  fruit  or  large 
curds  from  excessive  drinking  of  milk.  Relapses  are  frequent,  and 
during  hot  weather  the  frequency  of  the  attacks  may  lead  to  a  persistent 
entero-colitis. 

In  delicate  children  a  severe  attack,  especially  if  it  is  accompanied  by 
convulsions,  may  prove  fatal. 

(2)  Cholera  Infantum. — The  initial  symptoms  are  sudden.  The 
child  voids  immense  stools,  at  first  fecal,  if  no  preceding  diarrhea  have 
been  present.  Soon  they  become  w\atery,  light  yellow  or  greenish  in 
color  ;  frequently  they  are  so  thin  and  colorless  as  to  pass  through  the 
napkin  without  leaving  a  stain.  At  times  they  contain  a  few  yellow 
or  greenish  flocculi  or  a  mass  of  mucus,  and  in  all  cases  they  are  odor- 
less. Very  often  the  stools  are  brown  and  liquid,  Avith  a  small  quan- 
tity of  fecal  matter,  having  a  peculiar  musty  odor  that  clings  to  the 
napkin  and  child  for  days.  The  number  of  stools  per  diem  may  vary 
from  six  to  thirty,  and  a  most  remarkable  feature  is  the  fact  that  they 
are  evacuated  with  considerable  force. 

The  stomach  becomes  irritable,  refusing  everything  ;  even  ice  is  re- 
jected as  soon  as  swallowed.  The  vomitus  at  first  contains  bile,  while 
later  it  becomes  serous.  The  appetite  is,  of  course,  entirely  lost ; 
intense  thirst  prevails,  the  little  patient  drinking  at  every  chance  and 
following  the  receding  glass  with  eager  eyes.  The  tongue.,  moist  at 
first,  soon  becomes  dry  and  pasty ;  the  abdomen  is  collapsed.  The 
temperature  is  always  high— 105°  or  even  108°  F.  (40.5°-42.2°  C); 
and  the  pulse  small  and  very  frequent — 130  to  180  beats  per  minute. 
The  hreatliing  is  shallow  and  irregular,  and  the  expression  anxious  and 
staring,  but  soon  ])econies  dull.      The  urine  becomes  dark  and  scanty. 

With  this  array  of  symptoms  there  is  a  striking  and  appalling  change 
in  the  child's  general  apj)earance.  Within  a  few  hours  it  can  scarcely 
be  recognized ;  the  face  has  become  pale  and  pinched,  the  eyes  and 
cheeks  sunken,  the  eyelids  and  lips  wide  apart  from  loss  of  muscular 
control,  the  muscles  flabby,  the  bones  prominent,  and  the  skin  greenish 
or  cadaverous,  hanging  in  loose  folds  from  the  wasted  frame. 

Collapse  comes  on  soon  :  the  hands,  feet,  nose,  and  breath  become 
cool,  the  respirations  more  unefjual,  and  there  are  drowsiness  and  utter 
apathy.  When  life  is  near  its  close,  vomiting  stops,  the  whole  surface  be- 
coming cool  and  clammy  as  the  patient  sinks  into  a  state  of  coma,  with 


DIARRHEAS  OF  CHILDREN.  84r) 

injected  eyes  and  contracted  pupils.  At  last  the  end  is  reached  quickly, 
preceded  perhaps  by  a  slight  convulsion.  The  duration  of  the  disease  is 
short ;  it  may  prove  fatal  in  from  one  to  four  days. 

(3)  Ileo-colitiH. — This  may  follow  acute  dyspeptic  diarrhea,  cholera 
infantum,  or  complicate  the  acute  infections  of  childhood.  The  Hymp- 
tonis  develop  acutely.  At  the  outset  there  may  be  vomiting,  but  it  is 
not  persistent,  and  the  stools  are  greenish,  feculent,  often  showing  masses 
of  casein.  Later  the  discharges  are  increased  in  frequency,  are  small, 
and  contain  also  blood  and  mucus.  In  severe  cases  pain  and  straining 
are  distressing  features.  The  abdomen  is  prominent  and  there  is  ten- 
derness along  the  course  of  the  colon.      The  disease  presents  high  fever. 

The  course  is  variable.  It  may  be  acute — three  to  six  days — terminat- 
ing either  in  convalescence  or  death  due  to  exhaustion.  In  other  instances 
the  acute  symptoms  subside,  particularly  the  fever,  while  moderate  diar- 
rhea continues  and  is  attended  with  wasting  and  debility.  Gradual  re- 
covery may  ensue,  though  more  commonly  relapses  occur  and  death  follows 
from  broncho-pneumonia  or  an  intercurrent  acute  attack. 

Treatment. — The  treatment  of  acute  gastro-mtestinal  catarrh  di- 
vides itself  into  hygienic,  dietetic,  and  medicinal  measures.  If  a  child 
is  attacked  in  the  city  during  the  summer  and  does  not  yield  to  treat- 
ment in  two  or  three  days,  it  should  be  sent  to  the  country  or  seashore. 
In  the  case  of  a  child  under  two  years  this  is  absolutely  imperative. 
Fresh  air  is  important  in  all  diarrheal  disorders,  and  all  cases  should  be 
kept  out  of  doors  as  much  of  the  time  as  possible.  Children  should  be 
kept  quiet.  Bathing  is  soothing,  insures  cleanliness,  and,  what  is  very 
important,  reduces  the  temperature. 

Dietetic  treatment  is  of  great  importance.  It  should  be  remembered 
that  digestion  is  arrested  in  the  early  stage,  hence  to  give  food  at  this 
stage  is  to  do  harm.  Thirst  may  be  controlled  by  ice-  or  albumin-water, 
toast-water,  or  gum-water,  with  a  little  brandy.  Buttermilk  twice  daily 
tias  given  excellent  results. 

Medicinal  Treatment. — The  first  step  is  directed  against  the  acute 
indigestion  and  the  active  putrefaction  going  on  in  the  intestine.  The 
indication,  therefore,  is  to  empty  thoroughly  the  alimentary  tract  as  soon 
as  possible,  and  no  other  treatment  should  be  considered  until  this  end 
has  been  accomplished.  Whenever  vomiting  persists  the  stomach  should 
be  washed.  In  older  children  emetics  will  favor  complete  emptying  of 
the  stomach,  but  are  never  to  be  given  to  infants  under  two  years.  For 
the  intestine  calomel  and  soda  may  be  used ;  for  the  colon  irrigation : 
this  is  advisable  in  all  cases,  as  it  hastens  the  eifect  of  the  calomel,  and 
removes  at  once  much  irritating  and  offensive  material.  Opium  should 
not  be  used  until  the  whole  intestinal  tube  is  cleansed,  and  then  cau- 
tiously. Spirits  of  chloroform,  or  camphor,  is  a  better  remedy  for  the 
pain  than  opium  in  any  form.  In  older  children  the  hypodei'mic  injec- 
tion of  morphin  and  atropin  in  appropriate  doses  frequently  controls 
the  symptoms.  Bowles  has  used  lactic  acid  in  the  maximum  dose  of  IJ 
grains  every  hour,  and  found  it  to  control  the  symptoms  in  from  twenty- 
four  to  forty-eight  hours.  Thus  far  the  results  of  serum  treatment  have 
been  disappointing. 

Treatment  of  Cholera  Infantum. — In  this  form  of  infection  of  the 


846  DISKASES  OF  THE  DIGESTIVE  SYSTEM. 

intestiniil  tract  we  are  likely  to  forget  that  we  are  called  upon  to  treat 
a  case  of  acute  poisoning.  The  toxic  material  acts  both  powerfully  and 
quickly  as  a  cardiac  and  systemic  depressant.  It  also  acts  toxically 
upon  the  nerve-centers,  and  ))aralyzes  the  vaso-motor  nerves.  According 
to  Holt,  the  leading  indications  are — {a)  to  empty  the  stomach  and  intes- 
tines ;  {h)  to  supply  the  body  with  Huid  to  offset  the  great  loss  by  vomit- 
ing and  purging ;  (c)  to  counteract  the  effect  of  the  poison  on  the  heart 
and  the  nervous  system  ;  {d)  to  reduce  temperature  ;  and  (e)  to  treat  the 
symptoms  as  they  arise.  In  the  first  condition  thorough  stomach  and 
intestinal  cleansing  is  absolutely  necessary.  Moreover,  we  cannot  depend 
on  emetics  or  purgatives  to  arrest  pain  and  to  limit  the  effect  of  the  poison 
on  the  nervous  system;  a  hypodermic  injection  of  atropin  and  morphin 
is  essential.  Morphin  must  be  given  with  discrimination  to  young  chil- 
dren, especially  when  the  vomiting  and  purging  are  slight;  it  is  espe- 
cially contraindicated  when  stupor  or  collapse  seems  near.  Small  doses 
repeated  are  better  than  larger  single  doses.  Holt  gives  gr.  yottt  (0.0006) 
of  morphin,  with  gr.  -g-J-g-  (0.00008)  of  atropin,  as  the  first  dose  in  a  child 
one  year  old.  In  supplying  fluid  to  the  exhausted  tissues  it  is  useless  to 
attempt  to  give  them  by  the  mouth,  or  even  by  the  rectum,  as  by  both 
avenues  it  would  be  rejected.  An  injection  into  the  cellular  tissues  of 
the  buttocks,  back,  or  thighs  of  a  saline  solution  (40  gi-ains — 2.59 — of 
common  salt  to  a  pint  of  sterilized  water)  is  the  best  way  to  meet  the 
drain.  One  pint  (half  liter)  may  be  used  every  twenty-four  hours,  and 
larger  quantities  may  often  be  used  Avith  advantage.  Baths  must  be 
given  to  control  temperature,  and  ice-bags  should  be  placed  to  the  head. 
Ice-water  injections  will  aid  in  the  control  of  temperature,  and  ice-sup- 
positories act  efficiently  when  the  water  is  not  retained.  Stimulants 
may  be  given  hypodermically.  During  the  active  stage  nothing  should 
be  allowed  by  the  mouth  except  iced  brandy  or  champagne. 

The  dietetic  management  and  internal  treatment  of  ileo-colitu  are 
similar  to  that  of  the  preceding  variety.  A  dose  of  castor  oil  or  of 
calomel  is  to  be  promptly  administered  and  followed  in  a  few  hours  by 
copious  irrigations  of  the  colon,  preferably  with  tepid  saline  solution 
(strength  7  :  1000).  Later  a  small  quantity  of  a  thin  starch  solution, 
to  which  tnj  to  iij  of  laudanum  has  been  added,  may  be  gently  thrown 
into  the  rectum,  to  be  repeated  once  or  twice  daily.  After  the  acute 
stage  is  over  a  weak  silver  nitrate  solution  may  be  employed. 

CELIAC   DISEASE. 
{Diarrhoea  Alba ;  Diarrhoea  Chj/losa.) 

Definition. — A  form  of  intestinal  catarrh  marked  by  copious  fetid 
and  frothy  discharges  resembling  gruel. 

Pathology. — Although  ulcers  have  been  noted  in  the  intestine,  the 
pathology  of  the  disease  is  not  known.  Says  Osier :  This  affection  re- 
sembles somewhat  the  disease  in  adults  known  as  "  hill  diarrhea  "  or  the 
"white  nux"  of  India. 

Ktiology. — The  disease  is  limited  chiefly  to  children  from  one  to 
five  years  old.  The  filaria  sanguinis  hominis  has  been  found  in  the  feces 
in  cases  of  diarrhoea  chylosa. 

Symptoms. — The  disease  is  of  slow  development,  and  the  character- 


CROUPOUS  OR   DTJ'JITJJERrnC  ENTERITIS.  847 

istic  feature  consists  of  copious  diarrlieal  (tliouj^li  not  watery)  ntooh,  re- 
sembling gruel  or  oatmeal-porridge,  '^fljese  are  also  frothy  {frofj-Hjxnvn) 
and  horribly  fetid.  The  physical  niyns  consist  of  a  moderate  distention 
of  the  abdomen  and  a  boggy  sensation  that  is  imparted  to  the  palpating 
finger.  The  general  features  may  be  summated  in  gradually  increasing 
emaciation,  debility,  and  pallor.  The  disease  terminates  fatally  as  a  rule. 
The  treatment  is  purely  symptomatic,  unless  the  presence  of  para- 
sites be  suspected,  when  large  antiseptic  enemata  should  be  given. 


PHLEGMONOUS  ENTERITIS. 

This  is  a  suppurative  inflammation  of  the  submucous  layer  of  the 
intestines.  It  is  among  the  rarest  of  grave  maladies,  especially  as  an 
irrelative  disease.  It  may  be  diffuse  or  take  the  form  of  a  circumscribed 
abscess.  Rarely  it  occurs  as  a  complicating  condition  in  septico-pyemia 
and  in  malignant  types  of  the  exanthemata,  resulting  in  the  formation 
of  abscesses  that  usually  have  their  seat  in  the  duodenum.  Phlegmon- 
ous enteritis  may  be  secondary  to  strangulated  hernia  or  intussusception. 

Symptoms. — The  local  signs  simulate  closely  those  of  peritonitis. 
Among  the  symptoms  vomiting  is  prominent,  though  not  diagnostic  ;  it  is 
always  severe,  and  may  become  stercoraceous.  Pain  and  tenesmus^  when 
due  to  obstruction,  are  intense.  Rigors  more  or  less  severe  have  been 
observed.  The  temperature  is  high,  and  its  curve  is  somewhat  typical 
of  the  fever  of  suppuration.  The  disease  is  very  fatal,  the  patient 
passing  from  a  condition  of  extreme  prostration  to  one  of  utter  collapse. 

Treatment. — The  physician's  task  is  confined  to  an  attempt  to  sup- 
port the  powers  of  the  patient  and  to  relieve  his  inordinate  suifering. 
The  surgeon's  aid  should  be  invoked  early  in  cases  of  obstruction. 


CROUPOUS  OR  DIPHTHERITIC  ENTERITIS. 

Definition. — An  intense  inflammation  of  the  intestinal  mucosa,  ac- 
companied by  a  croupous  exudate ;  it  occurs  in  connection  with  a  variety 
of  conditions.  If  from  any  cause  the  epithelial  covering  is  destroyed, 
agents  that  set  up  local  inflammation  may  excite  a  croupous  exudate. 

Pathologfy. — There  are  two  sets  of  morbid  lesions  to  be  distin- 
guished:  (1)  The  first  and  most  important  class  exhibits  a  croupous 
deposit  varying  greatly  in  thickness  and  in  area.  Its  color  is  variable, 
being  sometimes  of  a  grayish  or  grayish-ivhite  hue,  frequently  grayish- 
yellow,  and  rarely  blackish.  I  have  almost  invariably  seen  these  lesions 
in  the  colon.  (2)  In  the  second  group  the  solitary  follicles  alone  are 
inflamed,  and  covered  with  diphtheritic  deposit. 

The  etiologic  factors  may  be  (a)  mechanical  irritants  (impacted  feces,  in- 
testinal sand,  gall-stones);  (6)  chemical  irritants  (ammonia,  acids,  mercury, 
arsenic) ;  (c)  secondary  to  acute  infectious  and  certain  chronic  complaints 
(Bright's  disease,  pyemia,  carcinoma,  diabetes,  tuberculosis,  and  anemias). 

Symptoms. — When  mechanical  irritants  give  rise  to  symptoms, 
they  do  not  differ  from  those  due  to  stercoral  ulcers,  and  there  is  no  way 
of  reoognizing  the  croupous  deposits  unless  they  be  discharged  per  rectum 
and  are  detected  in  the  stools.     In  cases  that  ai-ise  from  the  action  of  irri- 


848  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tant  poisons  vomiting  and  purging  are  well  marked  and  the  dejections 
contain  blood-stained  mucus.  We  cannot  be  certain  about  the  presence 
of  croupous  deposits  in  toxic  cases  unless  they  be  found  in  the  dis- 
charges. When  phlegmonous  enteritis  occurs  as  a  complicating  condi- 
tion in  infectious  diseases,  the  symptoms  are  almost  completely  veiled. 
The  symptomatology  of  the  follicular  variety  cannot  be  separated  clini- 
cally from  that  of  follicular  ulceration. 

The  treatment  is  that  of  the  causal  conditions  or  affections. 


SPRUE. 

{Fnilosiii. ) 

This  has  been  defined  as  "  an  insidious,  chronic,  remitting  inflamma- 
tion of  the  whole  or  part  of  the  mucous  membrane  of  the  alimentary 
canal,  occurring  principally  in  Europeans  who  are  residing  or  have 
resided  in  tropical  or  subtropical  climates  "  (Manson). 

The  principal  morbid  changes  consist  in  patchy  or  general  destruc- 
tion of  "  the  surface  of  the  mucosa  in  all  degrees,  from  slight  erosions 
to  complete  disintegration  of  the  villi,  glands,  and  follicles."  Conges- 
tive, catarrhal,  ulcerative,  and  cirrhotic  changes  may  be  all  combined  in 
one  and  the  same  case. 

The  etiology  is  unknown,  although  the  disease  is  probably  of  micro- 
organismal  nature.  Residence  in  hot  climates  and  previous  aff'ections 
of  the  alimentary  tract  are  the  main  predisposing  causes. 

The  leading  symptoms  are,  according  to  Manson,  irregular  action  of 
the  bowels,  and  the  passage  of  copious,  pale,  drab-colored,  yeasty-looking, 
sickly-smelling  stools.  The  complexion  is  dark  or  muddy  ;  there  is  emacia- 
tion and  the  abdomen  is  distended.  Weakness,  loss  of  memory,  and 
irritability  of  temper  are  common.  The  oro-cavity  is  inflamed  and  the 
seat  of  erosions,  cracks,  and  superficial  ulcerations.  Brunton  has  pointed 
out  that  Indian  Hill  diarrhea  diff"ers  from  sprue  in  that  soreness  of  the 
mouth  and  anus  is  absent  in  the  former. 

Early  appropriate  treatment,  which  is  principally  dietetic  (milk- 
diet)  and  hygienic,  checks  the  progress  of  the  disease. 


CHOLERA  MORBUS. 

{Cholera  Nostras  ;  Sporadic  Cholera.) 

Definition. — A  self-limiting  disease,  characterized  by  serous  vomit- 
ing and  purging,  colicky  pains,  and  often  muscular  cramps. 

Pathology. — No  constant  anatomic  changes  have  been  noted.  They 
are  analogous  to  those  seen  in  acute  gastro-enteritis,  though  cases  have 
terminated  fatally  in  which  no  morbid  lesions  were  found  postmortem. 

Ktiology. — Among  predisposing  causes,  the  age  and  the  season 
exert  tlie  most  prominent  influence.  The  condition  may  appear  in  sub- 
jects under  two  years,  when  the  term  "cholera  infantum"  is  employed; 
but  it  is  oftener  met  witli  in  older  children  and  adults.  It  is  almost  in- 
variably seen  during  the  heated  term  in  temperate  zones,  from  the  latter 
part  of  June  to    September,  and  it   is  especially  prevalent  during   the 


CHOLERA   MORBUS.  849 

months  of  July  and  August.  Bad  liygienic  environment,  foul  air  in 
particular,  has  a  noticeable  effect,  and,  though  not  as  yet  uh.solutely 
proved,  it  may  be  safely  inferred  from  the  symptomatology  and  general 
clinical  course  of  the  affection  that  it  is  of  microbic  origin.  Among 
other  factors  are  improper  food,  particularly  unripe  fruit,  cucum- 
bers, egg-plant,  and  exposure  to  cold  and  wet.  Various  organumi) 
(especially  the  Finkler  and  Prior  spirillum)  have  been  found  present. 
No  one  variety,  however,  has  been  definitely  found  to  be  the  cause  of 
the  condition.  Virulent  specimens  of  the  bacillus  coli  commune,  and 
even  of  the  streptococcus,  have  been  noted. 

Clinical  History. — The  onset  is  often  sudden,  and  is  marked  by 
abdominal  pain,  vomiting,  and  diarrhea.  At  first  the  vomitus  consists 
of  food,  and  later  of  bile  and  mucus.  The  dejections  are  fecal  in  char- 
acter at  the  onset ;  though  they  soon  become  watery,  and  may  resemble 
the  rice-water  stools  of  Asiatic  cholera. 

Physical  examination  reveals  only  tenderness  on  pressure  over  the 
abdomen,  and  particularly  over  the  epigastric  region. 

General  Symptoms. — Cramps  in  the  calf  muscles  are  common.  The 
temperature  varies  greatly,  ranging  from  100°  to  106°  F.  (37.7°  to  41.1° 
C).  The  skin-surface,  however,  and  more  particularly  that  of  the  ex- 
tremities, feels  cool,  and  owing  to  this  fact  the  rectal  temperature  should 
be  recorded.  The  pulse  becomes  rapid  and  feeble  as  the  case  progresses. 
The  face  is  pale  or  even  cyanotic,  and  the  features  look  pinched.  The 
extremities  lose  their  plumpness,  and  the  patient  usually  appears  pros- 
trated and  mentally  dull.  The  urine  is  scanty,  high-colored,  and  some- 
times albuminous,  and  thirst  is  extreme.  There  is  a  group  of  cases  that 
develop  subacutely,  and  in  these  the  symptoms  tend  to  persist. 

Differential  Diagnosis. — The  symptoms  of  cholera  morbus  re- 
semble so  closel}'^  those  of  Asiatic  cholera  as  to  preclude  the  possibility 
of  a  differential  diagnosis  from  the  symptoms.  A  bacteriologic  examina- 
tion of  the  stools,  however,  permits  a  certain  discrimination ;  and  during 
a  cholera  epidemic  the  distinction  between  these  affections  is  thus  made. 
The  effects  of  certain  direct  irritants,  as  in  poisoning  by  ptomains  and 
toxic  doses  of  arsenic,  must  be  excluded  by  the  history. 

Prognosis  and  Duration. — The  duration  of  the  disease  varies 
from  three  to  four  hours  to  two  days.  It  is  rarely  fatal,  though  in  per- 
sons suffering  from  such  chronic  affections  as  Bright's  or  cardiac  disease, 
and  also  in  the  aged,  the  prognosis  is  only  guardedly  favorable.  An  ele- 
ment of  danger  is  profound  collapse.  Otitis  media  is  occasionally  seen, 
although  most  cases  without  sequelae  recover. 

Treatment. — The  diet  must  be  rigorously  restricted,  and  predi- 
gested  milk  and  animal  broths  are  to  be  prepared  as  lightly  as  possible 
until  convalescence  has  been  faiirly  established.  The  comfort  of  the 
patient  is  much  enhanced  by  keeping  him  at  absolute  rest.  Local 
measures  are  useful  in  combating  pain  and  vomiting.  A  large  mustard- 
paste  applied  to  the  stomach  and  abdomen,  followed  by  linseed-poultices 
that  are  to  be  worn  constantly,  has  a  strong  influence  in  accomplishino- 
the  relief  of  the  symptoms  before  mentioned.  If  indigestible  substances 
have  been  taken  prior  to  the  attack,  prompt  though  mild  laxatives  are  to 
be  given  at  the  beginning  of  the  treatment.  For  the  excessive  thirst 
chipped  ice,  over  which  a  little  brandy  has  been  sprinkled,  is  effective. 

54 


850  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

For  controlling  the  morbid  sensitiveness,  on  which  the  pain,  nausea,  and 
the  diarrhea  depend,  we  have  a  remedy  j.Hir  excellence  in  the  hypodermic 
administration  of  morpliin.  The  dose  should  vary  (gr.  \  to  h — 0.016 
to  0.032)  according  to  the  severity  of  the  symptoms,  and  I  have  rarely 
found  it  necessary  to  give  a  second  dose.  Not  only  are  the  pain  and 
diarrhea  subdued,  but  the  circulation  is  re-established.  It  has  also  been 
recommended  to  administer  opium  by  the  mouth  for  these  symptoms, 
but  the  results  are  less  satisfactory.  The  other  points  in  the  treatment 
of  this  affection  are  identical  witli  those  discussed  under  the  treatment 
of  Gastric  and  Enteric  Catarrh. 


INTESTINAL  INFARCTION. 

A  FEW  instances  of  occlusion  of  the  suj)erior  mesenteric  artery  by  an 
embolus  have  been  recorded  recently.  The  condition  produces  hemor- 
rhagic infarction  of  the  small  intestines,  and  is  marked  by  grave  and 
usually  fatal  symptoms.  Its  causes  are  sometimes  obscure.  The  cases 
that  have  come  to  autopsy  have  shown  intense  congestion,  with  a  swollen, 
blood-infiltrated  state  of  the  jejunum  and  ileum.  Osier  has  seen  three 
instances  :  in  one  there  were  numerous  vegetations  on  the  mitral  valves 
from  which  the  embolus  was  probably  derived ;  in  another  the  superior 
mesentery  was  plugged  at  its  orifice ;  and  in  the  third  the  artery 
was  blocked  by  a  portion  of  the  fibrous  clot  of  an  aneurysm  of  the 
aorta  near  the  diaphragm.  The  symptoms  are  urgent.  Quite  often 
diarrhea  is  present  from  the  first,  the  dejections  sometimes  becoming 
blood-tinged.  Soon  the  characteristically  grave  symptoms  of  intestinal 
obstruction  supervene — viz.,  <ireat  pain,  vomiting,  and  constipation  (less 
commonly  diarrhea),  with  tijmpanitie  distention  of  the  abdomen  (gener- 
ally). The  condition  cannot  be  i-ecognized  from  the  symptoms  on  account 
of  their  resemblance  to  the  various  forms  of  obstruction,  yet  its  probable 
existence  may  be  inferred  from  the  presence  of  the  known  causes. 


INTESTINAL  ULCERS. 

DUODENAL   ULCER. 

Definition. — A  small,  round  perforating  ulcer  of  the  duodenum 
(vide  p.  804).      It  may  be  primary  or  secondary. 

Pathology. — The  morbid  characteristics  are  so  nearly  identical  in 
appearance  and  nature  with  those  of  peptic  ulcer  of  the  stomach  that 
they  scarcely  demand  a  separate  presentation.  The  seat  of  the  ulcer  is 
with  few  exceptions  above  the  orifice  of  the  common  bile-duct.  When 
these  ulcers  heal  the  resulting  cicatrix  produces  stenosis,  which  in  turn 
leads  to  dilatation  of  that  portion  of  the  duodenum  back  of  it,  and  finally 
of  the  stomach  also.  Progressive  cicatricial  contraction  may  completely 
close  the  ductus  communis  and  the  pancreatic  duct  or  portal  vein.  Pro- 
tective adhesive  inflammation  between  the  duodenum  and  the  adjacent 
parts  (pancreas,  gall-bladder,  liver)  often  prevents  complete  perforation 
of  the  duodenal  wall:  when  perforation  does  occur,  the  peritoneal  cavity 
may  be  opened,  causing  peritonitis,  or  a  fistulous  communication  may  be 
established  with  the  gall-bladder,  liver,  or  pancreas. 


INTESTINAL    ULCERS.  80 1 

!^tiology. — Though  tlio  duodenal  ulcer  has,  as  a  rule,  tho  same  mode 
of  origin  or  pathology  as  the  g;i,stric  ulcer,  it  is  a  remarkable  fact  that 
extensive  burns  of  tlu;  skin-suj'face  of  tlie  body  are  (juite  prone  to  be  fol- 
lowed by  a  perforating  ulcer  of  the  duodenum  (6.2  per  cent,  of  fatal 
burns,  Fenwick's),  while  gastric  ulcers  are  seldom  caused  in  this  manner. 
As  in  other  forms  of  duodenal  and  gastric  ulcers,  the  circulation  is  arrested 
by  an  embolus  (from  decomposing  masses  of  blood)  at  some  point  in  the 
mucous  membrane,  the  acid  gastric  juices  subsequently  digesting  the  part 
thus  deprived  of  its  blood-supply.  The  disease  is  met  with  in  chronic 
Bright's  disease,  in  pneumonia,  and  in  association  witli  gall-stones. 

The  influence  of  sex  and  age  as  causal  factors  is  notable  and  in  strik- 
ing contrast  with  their  import  in  gastric  ulcer.  In  the  latter  disease 
most  instances  occur  among  young  females,  while  in  duodenal  ulceration 
they  occur,  as  a  rule,  in  males  between  the  twentieth  and  fortieth  years. 
These  diiferences  respecting  their  etiology  are  inexplicable.  W.  J.  Mayo 
met  74  cases  in  a  total  of  231  gastric  and  duodenal  ulcers;  he  found  most 
of  the  latter  situated  close  to  the  pylorus.  They  are  commonly  mistaken 
for  gastric  ulcers  just  within  this  aperture.  In  duodenal  ulcer,  gastric 
ulceration  is  associated  in  50  per  cent.  (Mayo,  Moynihan).  Codman  ^ 
holds  that  ulcer  is  more  common  below  than  above  the  pyloric  orifice.  In 
the  necropsy  records  of  3000  cases,  Paus  found  duodenal  ulcer  in  0.73 
per  cent,  and  gastric  ulcer  in  2.77  per  cent. 

Clinical  History. — Perhaps  no  real  distinction  between  thfe  symp- 
toms of  gastric  ulcer  and  those  of  its  homologue  affecting  the  duodenum 
can  be  said  to  exist  in  most  instances.  For  example,  Kemp  found  gastric 
hypersecretion  in  his  10  operative  cases.  A  probable  diagnosis  of  ulcer- 
ation of  the  duodenum  has,  however,  been  repeatedly  made,  and  some- 
times verified  by  the  subsequent  autopsy.  Griinzburg^  noted  a  tym- 
panitic zone  in  the  region  of  the  quadrate  lobe  of  the  liver,  presumably  due 
to  the  dilated  duodenum  passing  behind  this  lobe.  If  duodenal  ulcer  be 
classed  with  gastric  ulcer,  there  is  great  danger  that  the  true  nature  of 
many  cases  will  be  overlooked.  The  difference  in  the  symptomatology 
in  the  two  forms  of  ulceration  is  owing  solely  to  the  difference  in  locality. 

The  distinctive  features  of  this  disease  may  be  shown  by  presenting 
its  leading  symptoms  by  the  side  of  those  characteristic  of  gastric  ulcer : 

Duodenal  Ulcee.  Gastric  Ulcer. 

Usually  occurs  between  20  and  40  years,  May  occur  at  any  age  after  childhood. 

except  when  due  to  external  burns. 

Males  are  more  frequent  sufferers  than  Females  are  the  chief  sufferers. 

females,  in  the  proportion  of  10  to  1. 

Onset  marked  by  intestinal  hemorrhage,  Hematemesis  often  occurs,  preceded  by 

which  may  recur  at  intervals.  other  gastric  symptoms,  as  a  rule. 

The  melena  may  be  preceded,  or  accom-  Blood  may  appear  in  the  stools,  usually 

panied,  by  hematemesis,  though  not  after  hematemesis. 

generally. 

Blood  in  the  discharges  often  is  bright  The  blood  in  the  dejections  is  dark  and 

red,  profuse,  but  not   marked  as  in  tarry  from  the  action  of  the  gastric 

gastrorrhagia ;  dark  and  tarry  from  juices. 

the  action  of  acid  chyme  when  slight. 

Pain,  due  to  acid,  may  come  on  late,  two  Pain  paroxysmal,  greatly  influenced  by 

to  four  hours  after  meals  ;   more  often  taking  food.    Pain  sharply  localized  in 

absent.     It  is  localized   a  little  above  the  epigastric  region,  about  two  inches 

and  to  the  right  of  the  umbilicus.    Pain  below   the    ensiform    cartilage.      Usu- 

relieved  by  eating,  owing  to  absorption  ally  pain  is  aggravated  by  taking  food. 

of  acid  and  closure  of  pylorus. 

1  Boston  Med.  and  Surg.  Jour.,  November  25,  1909. 

2  Deulnche  medizinische  Wochenschrift,  Berlin,  July  14,  1910. 


^;52  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

DroDEXAL  Ulcer.  (Jastric  I'iaek. 

Hyperclilorhydria  with  hypenuotility.  Hyperchlorliydria  without  hyperinotility. 

CJuslric  crises  occur  without  reference  to  Gastric  crises  come   on   soon   after  taking 

time  of  taking  foi>d.  food. 

\'omiting   inconstant   without   relation   to  Vomiting   more   common   (during  painful 

ingestion  of  food,  and  affords  no  relief.  crisis)  and  atibitls  relief. 

Jaundice  occasionally  pi-esent.  Jaundice  absent. 

No   niarketi   improvement   after   diet    has  Usually   a    marked    improvement   follows 

been  regulated.  regulation  of  diet. 

Dorsal  pain-point  absent.  Pain-point  (tenth  to  twelfth  dorsal  vertebrae 

on  left  side)  usually  present. 

Motor  insufficiency,  due  to  pyloric  spasm,  Less  common. 

may  occur. 

Finally,  '*  whenever  a  young  man  in  apparently  good  health  is  at- 
tacked by  melena,  with  or  without  heniatemesis,  it  is  probable  that  the 
ulcer  is  located  in  the  first  part  of  the  duodenum  rather  than  in  the  stom- 
ach, the  converse  being  the  case  in  young  women  "  (Fenwick). 

Diagnosis. — Of  the  symptoms  mentioned  under  Duodenal  Ulcer, 
the  inte.'itinal  bleedings  and  violent  pains  in  the  right  hypochondrium, 
coming  on  from  one  to  four  hours  after  meals,  are  the  most  diagnostic. 
Attacks  of  pain  before  meals  (hunger  pains),  with  vomiting,  may  warrant 
a  provisional  diagnosis  (Codman).  The  diagnosis  is  rendered  more  posi- 
tive if  the  thread-test  shows  a  distinct  blood-spot — 58  to  QQ  cm.  from  the 
teeth  (Einhorn^).  An  a--ray  examination  after  a  meal  of  bismuth,  in 
uncomplicated  cases,  shows  the  fluid  passing  into  the  duodenum  at  once 
with  great  rapidity,  so  that  the  stomach  is  empty  before  the  pain  begins. 
While  hemorrhage  is  the  leading  single  symptom,  we  must  not,  in 
attempting  to  estimate  its  significance  in  any  case,  neglect  to  eliminate 
hemorrhoids,  carcinoma,  tuberculosis,  dysentery,  and  hemorrhagic  dia- 
thesis— all  conditions  in  which  melena  may  occur.  There  may  be  an 
absence  of  symptoms  until  perforation  occurs  (latoit  duodenal  ulcer). 
Moynihan  speaks  of  fluid  passing  down  in  perforation,  causing  symptoms 
simulating  those  of  appendicitis. 

Sequelae. — Dilatation  of  the  stoiiiach  from  pyloric  spasm  or  follow- 
ing the  healing  of  these  ulcers,  associated  usually  with  chronic  gastro- 
duodenal  catarrh,  is  not  uncommon.  Rarely,  stenosis  of  the  ductus  com- 
munis is  a  sequel ;  more  frequently  tumors  either  compress  or  occlude 
the  lumen  of  the  bowel  below  the  mouth  of  the  duct.  The  symptoms 
presented  diifer  from  those  due  to  stenosis  above  the  duct,  the  most  char- 
acteristic being  the  continual  backward  flow  of  bile  into  the  stomach, 
sometimes  attended  by  constant  vomiting  of  biliary  secretions. 

Complications. — As  in  the  case  of  gastric  ulcer,  so  in  the  duodenal 
form,  there  is  at  times  so  much  thickening  about  the  base  of  the  ulcer  as 
to  give  rise  to  the  signs  of  malignant  tumor.  This  is  especially  true  of 
those  instances  in  which  the  base  of  the  ulcer  becomes  attached  to  adja- 
cent organs.  Under  these  circumstances  infection  of  the  head  of  the 
pancreas  with  tumor-like  swelling  may  occur  and  produce  obstruction  to 
the  outflow  of  bile,  with  accompanying  jaundice. 

Prognosis. — The  risk  to  life  is  greater  than  in  gastric  ulcer.  Per- 
haps 50  per  cent,  of  the  fatal  cases  are  due  to  perforation. 

Treatment. — The  treatment  of  duodenal  ulcer  is  similar  to  that  of 
gastric  ulcer.     Medical  measures  are  to  be  tried,  but  when  the  diagnosis 
1  Medkal  Record,  1909,  p.  549. 


INTESTINAL   ULCERS.  853 

is  no  longer  in  dispute,  timely  operative  intervention  Ih  to  be  advised. 
Pyloric  spasm  may  be  prevented  by  the  use  of  atropin  and  alkalies. 

Follicular  ulcers  have  already  been  described  under  Catarrlial  Enteritis 
(vide  p.  835),  and  they  have  a  similar  pathology  and  etiology.  When 
present  in  goodly  numbers  they  give  rise  to  a  symptom  peculiarly  their 
own,  and  hence  may  be  dignified  by  a  separate  though  brief"  mention. 
The  symptoms  of  the  condition  arising  in  the  course  of  chronic  enteritis 
often  escape  observation  for  a  long  time.  The  most  characteristic  man- 
ifestation is  the  appearance  in  the  stools  of  conical-shaped  masses  of 
mucus  resembling  "boiled  sago."  Marked  weakness  and  emaciation 
rapidly  ensue.  Among  children  the  disease  is  common  and  assumes  an 
aggravated  form,  the  little  sufferers  quite  frequently  reaching  their  end 
as  the  result  of  inanition.  An  unfavorable  termination  may  be  due  to 
perforation  followed  by  suppurative  peritonitis.  The  treatmeiit  coin- 
cides with  that  of  chronic  enteritis. 

Stercoral  ulcers  are  the  result  of  the  mechanical  effect  of  hard  fecal 
scybala  (often  enteroliths,  due  to  a  deposit  of  lime-salts)  upon  the  intes- 
tinal mucous  membrane.  They  occupy  the  sides  or  tops  of  the  normal 
folds  in  the  colon. 

Symptoms. — There  is,  as  a  rule,  a  clear  history  of  chronic  constipa- 
tion, though  the  physician  is  often  called  on  account  of  the  presence  of 
diarrhea;  this  is  caused  by  the  retained  hardened  feces  finding  their 
way  into  the  rectum.  A  digital  exploration  will  now  clear  up  the  diag- 
nosis. There  are  tenesmus  and  colicky  pain  in  the  abdomen,  the  latter 
symptom  being  also  complained  of  when  diarrhea  is  absent.  The  pain 
often  occurs  in  severe  paroxysms  that  may  be  attended  with  the  discharge 
of  flaky  mucus,  pus,  and  sometimes  blood.  Enteroliths  may  lie  in  the 
intestines  for  years  together,  or  they  may  finally  be  discharged  with  the 
stools.     The  ulceration  that  is  thus  caused  often  passes  unrecognized. 

Physical  Examination. — Palpation  may  in  rare  instances  reveal  the 
presence  of  a  sausage-shaped  tumor  and  sharply  localized  tenderness  over 
the  seats  of  ulcers. 

The  prognosis  is  good  if  the  condition  be  not  overlooked. 

The  treatment  consists  in  thoroughly  evacuating  the  bowels  by  salines 
and  simple  enemata,  persistently  used.  Subsequently  these  cases  are  to 
be  treated  as  other  non-specific  ulcers  of  the  bowels. 

Simple  ulcerative  colitis  is  a  not  uncommon  complaint,  and  one  that 
is  frequently  associated  with  chronic  intestinal  catarrh.  The  ulcers 
may  be  quite  extensive,  removing  the  greater  portion  of  the  mucous 
membrane,  though  in  several  instances  I  have  observed  cases  at  the 
Episcopal  Hospital  that  were  superficial ;  these  were  confined  almost 
solely  to  the  mucosa.  The  muscular  layer  of  the  gut  was  greatly  hyper- 
trophied  and  its  lumen  increased  in  every  instance.  The  non-ulcerated 
portions  of  the  mucosa  looked,  in  part,  quite  pale,  and  in  part  quite  dark. 
Polypoid  growths  have  been  observed  situated  between  the  ulcers. 

The  etiology  is  obscure.  The  disease  is  met  with  most  frequently 
in  persons  past  middle  life,  and  it  is  quite  probable  that  chronic  enteritis 


854  DISEASES  OF  THE  DKiESTIVE  SYSTEM. 

sustains  a  causal  relation.  Those  Nvliose  constitutions  have  been  enfee- 
bled by  previous  disease  or  an  improvident  hygienic  environment  are 
the  fhiet"  sutVerors. 

Symptoms. — The  clinical  features  are  ill  defined  at  the  onset,  and 
are  often  erroneously  ascribed  to  indigestion.  Diarrhea  (lienteric  in 
character)  is  its  most  prominent  symptom,  and  with  it  constipation  may 
alternate.  Pus  and  blood  are  absent  Avith  the  rarest  exceptions.  The 
general  health  soon  suffers  greatly,  the  patient  becoming  weak  and 
emaciated. 

The  course  of  the  disease  is  subacute,  tending  to  become  chronic. 

The  diagnosis,  apart  from  a  consideration  of  the  symptoms  above  men- 
tioned, re(iuires  the  elimination  of  dysentery — an  easy  task  as  a  rule. 
The  disease  resembles  most  closely  the  amebic  form  of  dysentery,  hence 
in  dubious  cases  a  microscopic  examination  of  the  feces  should  not  be 
neglected. 

Prognosis. — This  is  unfavorable  during  the  earlier  stages  in  the  aged. 
The  tendency  to  chronicity  of  the  disease  must  be  considered. 

The  treatment  embraces  {a)  a  careful  regulation  of  the  diet,  consist- 
ing in  a  restriction  of  the  patient  to  liquids  and  semi-solids  during  the 
acute  stage;  {h)  the  administration  of  a  gentle  laxative,  followed  by 
antiseptics  and  astringents  (bismuth  gr.  xxx — 2.0 — combined  with  salol 
gr.  V — 0.824 — every  four  hours);  {<•)  the  more  serviceable  local  measures 
in  the  form  of  enemata,  among  the  best  being  silver  nitrate  (gr.  \  ad  |j 
— 0.016  to  32.0)  or  creolin  (2  per  cent.). 

Solitary  Ulcers. — "  Two  instances  of  ulcer  of  the  cecum,  both  with 
perforation,  have  come  under  my  observation,  and  in  one  instance  a 
simple  ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis  "  (Osier). 

The  diffuse  catarrhal  ulcer  is  inseparable  from  acute  enteritis ;  the 
cancerous  ulcer,  tuberculous  ulcer,  and  amebic  ulcer  are  alluded  to  under 
their  respective  heads. 


APPENDICITIS. 


Definition. — A  catarrhal,  ulcerative,  or  interstitial  inflammation 
of  the  appendix  vermiformis.  It  must  be  confessed  that,  according  to 
our  present  views,  appendicitis  is  a  surgical  rather  than  a  medical  affec- 
tion, particularly  from  the  standpoint  of  treatment.  Knowing  from 
personal  experience  and  observation,  however,  that  general  practitioners 
are  constantly  meeting  with  cases  of  appendicitis,  its  prompt  clinical  rec- 
ognition by  the  latter  is  not  only  a  matter  of  interest,  but  also  of  great 
practical  importance  for  two  reasons:  First,  in  order  that  surgical  inter- 
vention can  be  instituted  at  the  proper  moment ;  and  secondly,  because 
appendicitis  is  the  leading  serious  disease  of  the  intestinal  tract. 

The  term  '*  appendicitis  "  includes  the  affections  typhlitis  (inflamma- 
tion of  the  cecum)  and  perityphlitis  (a  similar  involvment  of  the  connec- 
live  tissue  behind  the  cecum)  by  reason  of  the  fact  that  with  few  excep- 
tions when  the  symptoms  of  the  latter  affection  are  presented  the  ap- 
pendix vermiformis  is  the  part  primarily  affected.      To  the  physicians 


APPENDICITIS.  855 

and  surgeons  of  America  belongs  the  credit  of  having  first  estahlislied 
the  truly  important  rank  of  appendicitis.' 

Anatomic. — Without  any  known  function  the,  human  appendix 
vermiformis  represents  the  remains  of  the  enormous  cecum  of  inferior 
animals,  especially  rodents  and  herbivora.  Clado  asserts  that  the  ver- 
miform appendix  is  kept  in  position  by  two  folds  of  peritoneum,  a 
'  meso-appendix,  which  is  attached  to  the  iliac  fossa,  and  a  second  fold, 
perpendicular  to  the  first,  which  is  attached  to  the  posterior  portion  of 
the  small  intestine.^  A  lymphatic  gland  generally  occupies  tlie  angle 
formed  by  the  appendix,  cecum,  and  the  small  gut;  this  receives  all 
the  lymphatic  vessels  of  the  appendix.  In  the  female  a  lymphatic  con- 
nection may  exist  between  the  appendix  and  the  right  ovary.  The  size 
of  the  appendix  varies  greatly.  Ferguson,^  after  measuring  200  appen- 
dices, gave  as  the  average  length  4^  inches  (11.4  cm.),  and  as  the  diam- 
eter, that  of  a  No.  9  English  sound — about  a  quarter  of  an  inch  (0.62 
cm.).  Berry's  studies,  which  are  partly  based  upon  personal  examina- 
tion of  100  bodies,  and  partly  upon  comparison  of  his  own  results  with 
those  obtained  by  other  investigators,  gives  the  average  length  in  all  the 
observations  as  9.2  centimeters  (3.6  inches).  The  caliber  is  ordinarily 
of  the  size  of  a  goose-quill.  Very  exceptionally,  as  in  a  case  reported  by 
Swan,  there  is  a  congenital  absence  of  the  appendix.  Its  two  fibro- 
muscular  coats  (external  longitudinal  and  internal  circular)  are  thick  ; 
its  mucous  membrane  contains  lymphoid  elements  in  abundance.  The 
blood-supply  is  derived  from  the  ileo-colic  artery  at  the  valve,  a  single 
branch  running  to  the  end  of  the  appendix,  while  the  nerves  are  derived 
from  the  superior  mesenteric  plexus  of  the  sympathetic.  Shortly  after 
middle  life  the  cavity  of  the  appendix  becomes  obliterated.  Its  blind 
extremity  points  mo?t  frequently  toward  the  spleen.  The  appendix  may 
lie  behind  the  cecum,  and  sometimes  partly  to  its  inner  side,  its  tip 
almost  touching  the  liver  or  the  gall-bladder.  In  not  a  few  instances  it 
dips  downward,  passing  over  the  brim  of  the  pelvis.  There  is  no  adjacent 
organ  to  which  it  may  not  become  adherent,  and  in  rare  instances  it  is 
twisted  like  a  loop  around  the  small  gut,  causing  constriction  or  even 
strangulation. 

Pathology. — Three  pathologic  varieties  are  recognized  : 
(1)  Catarrhal  or  Obliterative  Appendicitis. — This  may  be  acute  or 
chronic.  The  term  "catarrhal  inflammation"  is  still  retained,  though 
scarcely  applicable,  since,  as  a  rule,  appendicular  inflammation  tends  to 
spread  quickly  to  all  the  coats,  including  the  serosa.  Obliterative  ap- 
pendicitis is  descriptive  and  in  every  way  preferable.  The  mechanism 
of  the  inflammation  is  briefly  as  follows :  The  mesentery  being  too 
short,  the  exit  is  too  small,  and  in  consequence  of  swelling  of  the  coats 
(especially  the  mucous)  the  venous  return  is  greatly  impeded,  then  the 
arterial,  followed  often  by  abscess-formation.  In  the  female  a  branch  is 
supposed  to  be  furnished  by  the  ovarian  artery,  making  a  more  perfect 
blood-supply.  The  appearances  are,  in  the  beginning,  identical  with  those 
of  catarrhal  inflammations  elsewhere  in  the  bowel.     Within  twenty-four 

^  The  following  names  will  long  be  connected  with  this  disease:  Pepper,  Fitz,  McBur- 
ney,  Porter,  Willard  Parker,  Weir,  Sand,  Bull,  Warren,  Keen,  Morton,  White,  Price, 
Deaver.  Senn,  and  many  others.  2  ^fyo,j^,>  Annual,  vol.  i.,  1893. 

"  "  Some  Points  regarding  the  Appendix  Vermiformis,"  American  Jow-ncd  of  Medical 
Sciences,  Jan.,  1891. 


856  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

hours  all  the  layers  are  swollen,  with  marked  cellular  infiltration,  causing 
the  appendix  to  become  firm  and  often  rigid.  The  mucosa  may  be  de- 
nuded of  its  epithelium  and  present  a  granular  surface.  The  external 
coat  (serosa)  is  usually  hyperemic,  and  not  uncommonly  the  seat  of  fresh 
or  old  adhesions.  The  tube  may  become  completely  obliterated  by 
pressure,  resulting  in  a  union  between  the  granular  surfaces,  in  this 
manner  rendering  subseijuent  attacks  impossible  (Hawkins).  It  is  in 
cases  in  which  this  fortunate  result  is  not  reached,  however,  that  acute 
appendicitis  leads  to  the  chronic  form  with  relapses.  Two  additional 
terminations  may  be  observed :  First,  an  obliteration  of  the  lumen  may 
occur  near  the  valve,  in  which  case  the  appendix  becomes  dilated,  and 
sometimes  enormously  so  (cystic).  The  contained  liquid  may  be  either 
serous  or  purulent.  Second,  obliterative  appendicitis  may  lead  directly 
to  ulceration  of  the  mucous  membrane,  and  often  in  the  absence  of  a 
fecal  concretion  or  foreign  body.  Again,  the  cystic  appendix  may 
ulcerate,  with  or  without  perforation.  Obviously,  the  more  marked  the 
stenosis  of  the  appendix  the  less  favorable  the  conditions  for  natural 
drainage,  and  the  greater  the  liability  to  recurrences  of  attacks  of 
appendicitis.  This  variety  then  may  end  in  resolution,  complete  oblit- 
eration, stenosis,  or  ulceration,  and  the  latter  sometimes  in  perforation. 

(2)  Ulcerative  Inflammation. — Like  the  preceding,  this  variety  may 
be  acute  or  chronic.  It  may  be  a  sequel  of  the  obliterative  form,  and 
often  accompanies  chronic  obliterative  appendicitis.  More  commonly, 
however,  it  is  seen  in  connection  with  concretions,  and  sometimes  with 
foreign  bodies  also.  By  no  means  invariably,  however,  does  the  pres- 
ence of  these  substances  excite  ulceration  of  the  appendix.  Micro- 
organisms play  an  important  role  in  this  variety  {vide  Etiology).  The 
submucosa  or  muscularis  usually  forms  the  base  of  the  ulcer.  The  ter- 
mination may  be  in  healing,  with  tendency  to  stricture.  Again,  the 
ulcer  may  extend  in  depth  until  perforation  occurs. 

(3)  Interstitial  or  Parietal  Inflammation. — This  may  be  preceded  by 
the  obliterative  or  the  ulcerative  form,  which  maybe  followed  by  anemic 
necrosis  and  sloughing.  Concretions  or  foreign  bodies  are  often  found, 
though  specific  bacteria  are  of  greater  etiologic  importance.  The  gravest, 
most  common,  and  hence  the  most  important  lesions  are  the  gangrenous, 
which  are  usually  limited  to  a  circumscribed  part  of  the  tube.  Interstitial 
inflammation  has  a  single  termination — perforation — and  leads  to  appen- 
dicular peritonitis  of  a  virulent  and  infectious  type. 

It  may  be  that  neither  necrosis  nor  gangrene  may  supervene.  When 
perforation  occurs,  one  or  more  openings,  ranging  in  size  from  one  to 
several  millimeters,  may  be  observed,  while  the  remainder  of  the  appen- 
dix may  present  no  abnormalities;  more  often,  however,  it  is  blood- 
injected  and  swollen.  The  appendix  may  slough  en  masse.  The  histo- 
pathologic changes  may  be  characterized  by  intense  cellular  exudation, 
necrosis,  or  purulent  inflammation.  Pathologically  considered  nearly  all 
cases  are  suppurative.  The  muscular  coat  is  hypertrophied,  and  chronic 
thickening  of  the  appendix  may  result. 

Consequences  of  Perforation. — A  common  result  of  all  forms  of  appen- 
dicitis is  a  localized  peritonitis,  and  this  is  a  constant  eff'ect  of  the  severer 
forms,  either  leading  to  (a)  circumscribed  peritonitis  or  to  an  (h)  acute 
diffuse  peritonitis. 


APPENDICITIS.  857 

(a)  CircumHcrihed  PeritoniiiH. — At  first  the  .surface  of  the  peritoneurii 
is  opaque  and  velvety.  Soon  a  fibrinous  exudation  covers  the  appendic- 
ular peritoneum,  and  quickly  establishes  adhesions  between  the  appendix 
and  the  adjacent  parts  (abdominal  wall,  intestinal  coils).  The  process 
may  not  proceed  any  further.  Generally,  however,  it  is  soon  followed  by 
a  serous  or  sero-fibrinous  exudation,  which  becomes  sero-  or  fibrino-puru- 
lent,  and  often  forms  the  so-called  perityphlitic  abscess.  The  seat  of  the 
abscess  is  always  near  the  tube,  and  is  as  varying  as  the  position  of  the 
appendix  ;  its  size  is  also  extremely  variable,  as  it  sometimes  contains 
enormous  amounts  of  pus.  Among  the  most  common  locations  are — 
McBurney's  point,  the  vicinity  of  the  cecum,  the  coils  of  the  small  in- 
testines (near  the  umbilicus),  and,  more  rarely,  in  the  pelvis  below. 
The  pus  contained  in  the  abscess  is  rarely  thick,  grayish-yellow  in  color, 
and  emits  a  fecal  odor ;  more  commonly  it  is  thin,  turbid,  dark -gray  or 
greenish  in  color,  and  has  an  extremely  fetid  or  even  gangrenous  odor. 
The  process  of  gangrenous  sphacelation  en  masse  is  often  completed  after 
the  limiting  wall  of  adhesion  has  formed,  when  the  entire  appendix  is 
found  free  in  the  pus-cavity. 

The  abscess  may  be  subperitoneal,  as  when  perforation  occurs  into 
the  retro-cecal  connective  tissue,  and  the  term  "  iliac  abscess  "  was 
formerly  applied  to  these  extra-peritoneal  purulent  collections.  They 
are  rare,  however,  since  the  early  operation  has  been  employed.  Their 
situation  and  dimensions  depend  upon  the  direction  taken  by  the  ap- 
pendix. The  latter  may  pass  downward,  and  the  pus  is  then  apt  to 
accumulate  in  the  lower  part  of  the  iliac  fossa,  and  may  point  and 
finally  burst  in  the  neighborhood  of  Poupart's  ligament,  with  subse- 
quent recovery.  Occasionally  under  these  circumstances  a  fistula 
remains  for  an  indefinite  period  of  time.  The  appendix  may  touch 
various  abdominal  structures,  and  the  pus  in  following  the  line  of  least 
resistance  may  cause  spontaneous  rupture  into  the  rectum,  bladder,  or 
the  vagina  when  it  points  inward ;  and  into  the  perinephric  region  or 
into  the  pleural  cavity  (through  the  diaphragm)  when  it  points  upward ; 
or  even  into  the  cecum  or  colon.  The  contents  of  the  abscess  may  also 
find  their  way  through  the  abdominal  wall  in  the' vicinity  of  the  umbil- 
icus. The  psoas  muscle  may  conduct  the  abscess  downward,  and  it 
may  then  point  at  the  hip-joint  or  gain  the  gluteal  regions  or  the  scro- 
tum, producing  the  so-called  "scrotal  appendicitis."  The  appendix  has 
also  been  found  in  a  hernial  sac.  Among  the  rare  lesions  to  be  noted 
are  erosion  of  one  of  the  arteries  of  the  iliac  region  (causing  fatal 
hemorrhage)  and  pylephlebitis.  From  the  thrombi  in  the  mesenteric 
veins  in  the  latter  condition  infectious  emboli  may  be  conveyed  to  the 
liver,  giving  rise  to  hepatic  abscess ;  this  occurred  in  a  case  of  my  own 
at  the  Episcopal  Hospital,  Philadelphia.  The  abscess  may  also  be  due 
to  an  extension  of  the  thrombo-phlebitis  of  the  mesenteric  veins  that 
lead  from  the  appendix  to  the  portal  vein.  Thrombosis  of  the  iliac 
veins  with  edema  of  the  corresponding  leg  may  also  arise,  and  these 
veins  may,  during  the  process  of  healing,  become  compressed,  with 
a  resulting  edema  of  the  leg,  as  in  two  of  my  cases.  It  rarely  happens 
that  suppurative  processes  are  both  extra-  and  intra-peritoneal. 

{h)  Acute  Diffuse  Peritonitis. — This   follows   perforation  when  pre- 
vious adhesions  have  not  taken  place,  or  when,  having  formed,  they  yield. 


858  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Generalized  peritonitis  may  also  follow  the  eircumscribed  lorni,  the  lesions 
being  propagated  to  the  entire  membrane  by  extension.  The  morbid 
chaniies  are  described  under  Acute  Peritonitis  (q.  v.).  Since  the  early 
o])eration  has  been  eui))loyed  peritonitis  has  been  the  result,  usually,  of 
direet  perforation  bi'lbre  protective  adliesions  have  been  formed. 

Ktiology. — Predisposing  Causes. — (a)  Doubtless  certain  covgenital 
strndnral  defects  aid  in  the  producton  of  appendicitis.  Among  them 
are  unnatural  length,  location,  and  arrangement  of  the  organ ;  also 
the  shape  of  the  meso-appendix  and  Gerlach's  valve.  These  factors 
tend  to  obliterate  the  lumen  of  the  eanal  by  ])roducing  kinks  and  twists, 
thus  favoring  the  collection  of  material  within  the  ap])ei)dix.  (h)  Stric- 
tures, particularly  near  the  cecal  end  of  the  tube,  and  old  adhesions, 
especially  peritonitis,  operate  in  the  same  manner  as  (a),  only  with  greater 
power.  (c)  Fecal  eoncretions  are  the  main  cause  in  nearly  one-half, 
while /orc^V/w  bodies  play  a  small  role,  having  been  present  in  7  per  cent, 
only  of  1400  cases  (J,  F.  Mitchell).  The  calculi  form  in  the  appendix 
itself  (Rochaz).  The  foreign  bodies  are  very  various,  and  consist  of  seeds, 
worms,  gall-stones,  pills,  bristles,  and,  more  rarely,  pointed  bodies,  as 
fish-bones  or  pins.  The  presence  of  fecal  concretions  and  foreign  bodies 
is  often  tolerated  by  the  appendix  without  symptoms  or  local  pathologic 
changes;  hence  they  are  looked  upon  rather  as  a  predisposing  than  as  an 
exciting  cause.  (<7)  Ulcers  (tuberculous,  typhoid,  and,  rarely,  actinomy- 
cotic) may  also  produce  this  affection,  (e)  Straining  Efforts  and  Trauma- 
tism.— Not  uncommonly  excessive  muscular  exertion,  traumatism,  or  jar- 
ring of  the  body,  as  in  jumping,  act  as  favoring  causes.  (/')  A<je. — The  dis- 
ease is  especially  frequent  in  young  adults  between  the  fifteentli  and  thirtieth 
years.  It  is  not  infrequent  in  childhood  after  the  third  year,  and  it  has 
been  seen  in  persons  over  seventy  years  of  age.  (//)  Sex. — Appendicitis 
attacks  males  oftener  than  females  (4  to  1);  this  fact  has  been  explained 
{vide  supra).  In  the  female  it  is  rarely  of  adnexal  origin.  Adhesions 
between  the  tube  and  ovary  and  the  appendix  may  occur,  the  morbid 
process  then  extending  to  the  latter.  (A)  G-astro-intestinal  Disturbance. 
— Indiscretions  in  the  diet  may  precede  a  primary  attack,  and  are  of 
paramount  etiologic  iriiportance  in  the  recurrent  forms  of  the  malady. 
(/)  Heredity. — That  this  plays  a  role  in  cases  of  appendicitis  I  have  long 
felt  convinced.  This  serves  to  explain  cases  in  which  rheumatism  and 
uric-acidemia  seem  to  act  as  causal  agents,  (y)  Evidence  to  show  that 
influenza  and  other  affections  may  cause  appendicitis  is  not  wanting. 
{Ji)  It  is  not  improbable  that  poor  blood-sitpply  and  retrogression  of  the 
organ,  plus  torsion  and  the  like,  are  the  leading  predisposing  factors. 
Any  slight  interference  with  the  circulation  tends  to  block  it,  with  dire 
consequences.  {I)  The  negro  enjoys  comparative  immunity,  {in)  The 
immoderate  use  of  meat  (MacLean). 

Bacteriology. — The  combined  results  of  several  experimentalists  show 
that  no  special  organism  plays  an  exclusive  role  in  this  disease,  but  the 
studies  of  Hodenpyl  indicate  that  the  Bacillus  coli  communis  is  most 
generally  present:  it  is  well  known,  moreover,  that  this  bacillus  becomes 
pathogenic  when  it  escapes  into  tissues  in  Avhich  it  does  not  naturally 
belong.  A.  0.  J.  Kelly  found  this  organism  present  alone  in  73.4  per 
cent,  in  94  instances  of  acute  appendicitis  ;  alone  in  89.71  per  cent,  of  107 
cases  of  chronic  appendicitis.    Barbacci  emphasizes  the  etiologic  importance 


APVENDWITIS.  859 

of  the  passage  of  the  intestinal  contents  into  the  peritoneal  cavity — i.  e., 
the  chemical  factor.  Of  other  specific  bacteria,  those  of  typhmd  and  tu- 
herculosis  are  not  uncommonly  found  to  be  present.  1'he  streptococcus 
pyogenes  may  also  produce  the  most  virulent  infection,  and  the  Htaph/ylococ- 
cus  pyogenes  aureus,  the  proteus,  and  other  organisms  have  been  found. 
The  great  frequency  of  appendicitis  is  rendered  appreciable  by  the 
numerous  favoring  factors  (including  the  congenital  conditions)  acting 
upon  the  appendix,  which  naturally  has  an  exceedingly  low  vitality; 
also  by  the  constant  presence  of  organisms  that  ara  known  to  become 
pathogenic  in  the  presence  of  a  slight  lesion. 

Clinical  History. — Doubtless  many  cases  are  overlooked  because 
of  the  extreme  mildness  of  the  symptoms.  These  are  often  attributed 
to  intestinal  indigestion  or  to  a  "cold,"  to  which  the  patient  pays  little 
attention  unless  he  displays  unusual  susceptibility. 

The  onset  of  acute  appendicitis  may  be  slow  and  gradual,  but  oftener 
it  is  quite  sudden.  A  clear  history  of  some  obvious  cause  (an  error  in 
diet  or  muscular  effort)  may  be  obtainable.  Again,  preceding  the 
onset  of  the  definite  symptoms  and  extending  over  a  day  or  two,  there 
may  have  been  certain  prodromes,  as  impaired  appetite,  nausea,  consti- 
pation, or  diarrhea.  In  slow  cases  the  local  and  general  symptoms  are 
at  first  slight,  but  gradually  increase  in  severity.  Indeed,  in  the  latter 
class  the  patient  may  go  about  his  customary  duties  during  the  attack 
with  ill-defined  rational  symptoms,  while  in  reality  suffering  from  peri- 
appendicular abscess.  These  patients  run  two  serious  dangers — first, 
spontaneous  rupture  of  the  abscess  into  the  peritoneal  cavity  may  occur  ; 
and  secondly,  the  slow  septic  absorption  may  suddenly  overwhelm  the 
system.  As  a  rule  the  sudden  cases  develop  in  seeming  perfect  health, 
and  are  sometimes  heralded  by  a  rigor  or  chilliness. 

The  characteristic  features  of  the  invasion  are  abdominal  jmin,  fever, 
tenderness  over  McBurney's  point,  circumscribed  resistance,  gastric  dis- 
turbances, and,  as  a  rule,  constipation.  The  pain  varies  in  intensity  from 
a  mere  feeling  of  soreness  to  that  of  the  most  agonizing  suffering.  It  may 
be  paroxysmal,  though  oftener  it  is  constant,  with  moderate  exacerba- 
tions. Severe  pain  points  to  an  involvement  of  the  peritoneum  and 
signalizes  a  danger  of  perforation.  At  first  the  pain  may  be  referred 
to  any  point  in  the  abdomen  for  the  reason  that  the  superior  mesenteric 
plexus,  that  furnishes  the  nerve  supply  to  the  appendix,  sends  numerous 
twigs  to  the  small  intestines  ;  later,  within  forty-eight  hours,  it  becomes 
more  distinctly  localized  in  the  ileo-cecal  region. 

Elevation  of  Temperature. — The  exacerbations  may  at  first  touch 
102°,  103°,  or''even  105°  F.  (38.8°-40.5°  C),  and  particularly  in  chil- 
dren ;  more  commonly  they  range  from  100°  to  102°  F.  (37.7°-38.8°  C). 
The  degree  of  fever  is  unreliable,  however,  as  a  criterion  of  the  severity 
of  the  case,  since  the  worst  cases  may  show  a  subnormal  temperature. 

An  elevation  of  temperature,  however  trivial,  is  most  significant, 
pointing  as  it  does  to  inflammation  as  the  cause  of  the  local  symptoms. 
The  pulse-rate  is  somewhat  higher  than  the  elevation  of  temperature 
would  lead  one  to  expect,  and  in  bad  cases  the  pulse  is  usually  much 
quickened.  Sometimes,  however,  it  remains  at  80  to  90  per  minute,  and 
may  be  full  and  soft,  even  thougli  the  patient  be  practically  moribund. 

Fixed  tenderness  is  practically  constant  on  pressure  over  a  limited 


860 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


area,  midway  on  a  line  between  the  anterior  superior  iliac  spine  and 
the  umbilicus  {JIcBurnei/'s  point),  and  is  a  valuable  sign.  The 
seat  of  the  tenderness  may  be  found  at  other  points  rarely,  depend- 
ing upon  the  location  of  the  appendix.  I  have  twice  observed  it  in 
the  lumbar,  once  in  the  right  hypochondriac  region,  and  once  far  below 
the  usual  point,  in  the  right  iliac  fossa.  It  has  been  found  in 
the  umbilical  and  left  iliac  regions,  in  the  pelvis,  and  in  the  groin. 
In  several  instances,  although  I  have  found  it  elsewhere  in  the  early 
stage,  it  has  shifted  to  McBurney's  point  later.  On  the  other  hand, 
it  may  move  from  the  usual  position  in  cases  that  are  allowed  to  drag 
on.  When  the  sensitive  area  is  at  McBurney's  point,  as  is  the  rule, 
the  gentlest  pressure  often  suffices  to  elicit  excjuisite  tenderness,  but 
when   it  is   situated   elsewhere   firmer  pressure   with   the  finger-tips  is 


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Fig.  59.— Temperature-chart  of  a  case  of  appendicitis.    M.  M ,  aged  thirty-five  years;  motor- 
man.    I>aparotomy,  by  Prof.  E.  Laplace,  disclosed  catarrhal  appendicitis  with  adliesions. 

usually  required.  Deep  pressure  always  reveals  localized  tenderness  at 
some  point  in  the  abdomen  if  the  case  is  one  of  appendicitis.  Palpation 
also  detects  an  abnormal  rigidity  of  the  right  rectus  abdominis  muscle. 
On  or  about  the  second  day  a  circumscnhed  induration  manifests  itself, 
followed  soon  by  a  fulness  and  swelling  tending  to  obliterate  the  depres- 
sions above  and  in  front  of  the  anterior  iliac;  spine.  The  position  of  the 
indurated  area  varies  according  to  the  location  of  the  appendix.  Some- 
times a  questionable  mass  the  shape  of  an  enlarged  appendix  is  palpable. 
In  such  cases  peritoneal  exudation  has  not  as  yet  occurred  to  any  great 
extent.  Induration  may  gradually  assume  the  circumscribed  form  ;  it 
may,  moreover,  be  so  deeply  seated  as  not  to  be  appreciable.  The  degree 
of  tenseness  of  the  two  recti  muscles — right  and  left — should  be  com- 
pared, though  an  absence  of  tension  of  the  right  rectu.s  does  not  eliminate 
appendicitis.     The  results  of  percwis/'on  furnish  no  certain  guide. 

Voutitin;/  u.-iually  occurs  at  the  beginning,  unless  there  be  diarrhea, 
and  is  attended  by  more  or  less  nausea ;  it  may  continue  throughout  the 
course  of  the  attack.     In  most  cases,  after  a  few  paroxysms  of  vomiting 


APPENDICITIS.  861 

the  symptom  disappears,  although  it  may  recur  if  errors  in  diet  be  com- 
mitted or  if  peritonitis  supervene.  Constipation  is  the  rule  during  the 
attack,  though  diarrhea,  which  sometimes  precedes  appendicitis,  may 
also  occur  at  a  late  stage  as  a  septic  symptom.  There  is  anorexia  and 
the  tongue  is  coated.  The  decubitus  is  dorsal,  with  the  right  leg  flexed. 
Frequent  micturition  (early)  and  retention  of  urine  (later)  are  not  un- 
common, the  urine  having  a  deep  color-tint,  and  sometimes  contains 
albumin.  Moderate  leukocytosis  \e.  g.^  10,000  to  15,000  per  c.mm.) 
usually  exists,  but  may  be  absent.  Daniells,'  in  120  cases  of  uncompli- 
cated appendicitis,  found  that  a  rapidly  increasing  leukocytosis  mean^ 
that  the  inflammation  is  increasing  and  extending. 

The  case  may  follow  a  mild  course^  terminating  in  resolution  with 
recovery ;  or  it  may  be  of  a  severe  type  and  develop  perforation,  with 
the  formation  of  abscess  or  diffuse  peritonitis.  It  is  impossible  to  obtain 
statistical  evidence  of  the  relative  frequency  of  these  alternatives,  and 
hence  the  frequency  of  treatment  by  abdominal  section.  In  more  than 
one-half  of  the  cases  it  is  probable  that  the  course  is  favorable. 

If  not  operated  upon  early,  the  fever  may  continue  for  three  to  five 
days,  and  then  subside,  with  simultaneous  abatement  of  the  severe  local 
and  general  symptoms  and  with  the  establishment  of  convalescence. 
The  same  amelioration  of  the  symptoms  may  be  brought  about  by  free 
purgation  early,  as  the  result  of  salines  or,  less  often,  spontaneously. 
In  these  instances  resolution  takes  place  even  after  invasion  of  the  peri- 
toneum. Small  abscesses  may  be  absorbed,  and  usually  in  cases  ter- 
minating in  resolution  perforation  has  not  occurred.  Infection  of  the 
peritoneal  membrane  directly  through  the  appendix  is  not  uncommon. 

In  severe  attacks  perforation  may  occur,  with  the  development  of 
localized  peritoneal  abscess  or  generalized  peritonitis  (vide  Pathology), 
and  it  must  be  remembered  that  cases  that  begin  gradually  may  also 
show  a  tendency  toward  perforation.  When  this  event  occurs  during  the 
course  of  appendicitis,  the  symptoms  of  local  or  general  peritonitis  are 
superadded.  If  early,  the  symptoms  pointing  to  peritonitis  are  intense ; 
the  abdomen  swells  quickly,  and  is  exquisitely  tender,  while  the  physical 
signs  of  a  tumor  are  absent.  The  temperature  often  falls,  when  vomiting 
and  circulatory  collapse  appear.  The  generalization  of  the  peritonitis 
is  usually  marked  by  less  violent  symptoms.  Starting  from  the  seat  of 
circumscribed  inflammation,  the  pain  and  tenderness  advance  notice- 
ably from  day  to  day  until  every  portion  of  the  peritoneum  has  been 
invaded.  Besides  progressive  augmentation  in  the  local  features,  in- 
cluding the  pain,  there  is  a  gradual  failure  in  cardiac  power,  as  shown 
by  the  condition  of  the  pulse ;  vomiting  also  returns,  and  at  last  becomes 
fecal.  Death  results  from  asthenia,  and  sometimes  suddenly  when  un- 
anticipated. If  perforation  occurs  later,  suflScient  time  has  been  allowed 
usually  for  the  inflammation  to  become  circumscribed,  in  which  case  the 
localized  abscess  is  generally  intra-peritoneal ;  it  may,  however,  rarely 
be  extra-peritoneal.  The  local  symptoms  intensify,  the  pain  becomes 
excruciating,  and  the  spot  of  tenderness  may  rapidly  extend  itself  in  all 
directions,  particularly  downward.  Vomiting  sets  in,  and  may  become 
troublesome,  and  constipation  is  absolute,  not  even  gas  escaping. 

Physical  Signs  of  Localized  Abscess. — Inspection  shows  distention  of 
1  Columbus  Med.  Jour.,  September,  1906. 


862  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  belly,  the  affected  area  being  prominent,  with  an  obliteration  of  the 
natural  depression  in  the  right  iliac  region.  A  dark  and  swollen  appear- 
ance of  the  subcutaneous  and  deeper  veins  has  been  noted  by  Skinner. 
I^alpation  discovers  induration  and  great  tension  that  soon  yield  to 
pressure  (dougliy).  and  edema  of  the  skin.  If  the  abscess  is  superficially 
seated,  fluctuation  may  be  aj)preciable.  Deep-seated  tumors  are  not  un- 
common, and  then  fluctuation  is  detected  -with  dillieulty.  An  examina- 
tion per  rectum,  with  a  view  to  determining  whether  the  abscess  occupies 
the  pelvis,  is  important,  and  in  doubtful  cases  bimanual  examination 
.'^hould  not  be  neglected.  Fercussion  reveals  dulness  if  the  abscess  be 
superficial.  A  tympanitic  note,  however,  is  often  elicited,  and  is  due  to 
an  intervening  coil  of  intestine. 

If  active  peritonitis  and  septicemia  do  not  develop,  the  constitutional 
as  well  as  the  local  symptoms  may  abate,  and  the  patient  leave  his  bed, 
carrvinor  with  him,  however,  the  abscess.  The  latter  may  point  some- 
where in  the  right  lower  cjuadrant  of  the  abdomen  or  in  the  lumbar 
reiiion.  Spontaneous  rupture  into  the  rectum,  bladder,  vagina,  or  cecum 
may  also  occur.  Often,  preceding  the  discharge  of  pus  into  these  organs, 
the  latter  display  marked  irritability,  particularly  the  rectum  and  bladder. 
There  is  always  the  danger  that  the  contents  of  the  abscess  may  find  its 
wav  into  the  general  peritoneal  cavity.  The  symptoms  of  hepatic  ab- 
scess may  develop.  The  pus  may  traverse  the  abdomen  in  the  upward 
direction  until  it  touches  the  diaphragm,  when  the  symptoms  of  sub- 
phrenic abscess  may  be  manifested.  Extension  through  the  diaphragm, 
causing  pleurisy  or  pericarditis,  and  a  pleuro-fecal  fistula  may  occur. 
The  lung  comjdications  originate,  as  a  rule,  from  emboli.  Sonnenburg 
found  that  out  of  740  cases  of  appendicitis,  28  had  some  lung  complica- 
tion, and  of  these,  14  Avere  cases  of  thrombosis.  The  early  recognition 
of  post-operative  lung-emboli  is  important. 

The  general  symptoms  undergo  a  modification,  due  to  the  suppurative 
process.  Rigors  or  a  decided  chilliness  may  occur.  Diarrhea  often 
succeeds  to  previous  constipation,  and  drenching  sweats  to  a  dry  skin. 
Improvement  and  even  spontaneous  cure  may  ensue  if  spontaneous  rup- 
ture into  one  of  the  outlets  of  the  body  should  occur.  The  fever  (Fig. 
60)  may  be  either  remittent  or  intermittent,  and  if  the  localized  inflam- 
matory process  be  active,  the  usual  pronounced  features  of  septicemia 
are  predominant  in  the  clinical  picture.  The  latter  specially  grave  con- 
dition often  drifts  into  an  extreme  typhoid  state  with  a  hopeless  course. 

Diagnosis. — Typical  cases  of  appendicitis  are  readily  diagnosti- 
cated. Their  recognition  rests  upon  a  few  cardinal  symptoms — viz.,  the 
acute  development  of  severe  pain  in  the  right  iliac  fossa,  coming  on  in 
a  person  previously  healthy  and  usually  under  forty  years  of  age  ; 
appendicular  tenderness,  unilateral  induration,  fever,  vomiting,  and  con- 
stipation, or,  more  rarely,  diarrhea.  Atypical  cases,  however,  may  offer 
difficulty,  although  it  is 'my  belief  that  errors  in  diagnosis  are  less  fre- 
quent than  in  almost  any  other  disease.  The  pain  may  for  a  time  be 
referred  to  a  circumscribed  area  far  removed  from  the  site  of  the  ap- 
pendix, and  rarely  it  continues  Avithout  a  change  of  situation  through- 
out the  attack.  In  the  latter  case  the  morbid  lesions  may  occupy  the 
usual  position,  or  more  often  perhaps  some  quite  unusual  position.  Thus, 
when  the  pain  is  referred   "  due  east,"  or  to  the  left  iliac   fossa,  Avith 


APPENDICITIS. 


8G.'i 


bilateral  induration,  the  appendix  will  be  found  in  the  pelvis  (Deaver). 
In  such  instances  a  rectal  and  a  bimanual  vaginal  examination  are  im- 
perative. It  should  be  an  unvaryin<f  rule  in  all  cases  of  severe  abdom- 
inal pain  to  palpate  with  the  finger-tip  every  scpiare  inch  of  the  abdomen 
if  necessary,  to  find  the  localized  tenderness  when  it  is  not  found  at 
McBurney's  point.  The  degree  of  tenderness  sustains  a  close  relation- 
ship to  the  severity  of  the  local  inflammation  as  long  as  the  condition 
remains  strictly  localized,  but  this  relationship  is  lost  when  generaliza- 
tion occurs.  With  the  appearance  of  a  circumscribed  induration  and 
of  the  intense  local  tenderness  and  pain  it  is  reasonably  sure  that  per- 


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Fig.  60.— Temperature-chart  of  a  case  of  appendicitis.    R.  C ,  aged  nineteen  years ;  carriage- 
builder.    A  peritoneal  abscess  was  found,  while  the  appendix  was  becoming  gangrenous. 

foration  either  has  occurred  or  is  impending.  Perforation  may  occur 
without  local  induration,  however,  and  even  after  subsidence  of  the 
acute  pain  and  excessive  tenderness.  Gangrenous  appendicitis  is  7nost 
deceptive.  The  very  acute  symptoms,  including  the  fever,  may  disap- 
pear, and  unless  the  physician  be  upon  his  guard  the  patient  will  be 
considered  convalescent  and  be  allowed  to  go  about.  Rupture  of  the 
abscess  now  occurs  unexpectedly  into  the  peritoneal  cavity,  intestines,  or 
some  other  direction,  or  a  large-sized  abscess  develops  with  the  usual 
signs  and  symptoms.  In  dubious  cases  the  .-c-rays  should  be  employed 
for  diagnostic  purposes. 

Differential    Diagnosis. —  Typlilitis,   and   especially  the   Classing   of 


864  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Feces  in  the  Cecxun. — These  are  truly  rare  conditions.  According  to 
McBurney,  99  per  cent,  of  all  typhlitic  abscesses  are  of  appendicular 
origin,  and  of  400  autopsies  by  Einhorn  91  per  cent,  had  this  origin. 
Ball  and  others  have  performed  laparotomy  for  ulcerative  cewtis,  but 
this  condition  cannot  be  recognized  during  life.  Stercoral  typhlitis  is 
discriminated  from  true  appendicitis  by  the  precedent  constipation, 
which  may  become  absolute,  by  the  dragging  character  of  the  pain,  the 
late-appearing  fever,  and  the  physical  signs,  which  indicate  the  presence 
of  a  superficial,  sausage-shaped  tumor  that  is  often  doughy  and  extends 
vertically  from  a  j)oint  near  the  right  costal  border  "southward."  Per- 
cussion elicits  dulness  over  the  seat  of  the  tumor.  The  localized  tender- 
ness and  circumscribed  resistance  of  acute  appendicitis  are  wanting. 

Renal  Colic. — There  is  an  absence  of  fever  and  of  a  localized  spot  of 
tenderness  and  induration.  On  the  other  hand,  disturbed  micturition 
followed  by  hematuria  occurs  and  pain  radiates  into  the  groin  and  testicle. 

Indigestion. — Digestive  disturbances,  and  particularly  pain  and  vom- 
iting, accompany  appendicitis.  AVhen  they  occur  independently  of  ap- 
pendicitis, however,  they  can  be  relieved,  and  the  appendicular  region 
remains  free  from  fixed  pain,  tenderness,  or  tumor. 

Cholecystitis  loith  Distention. — This  gives  rise  to  a  superficial, 
mobile,  pear-shaped  tumor  (the  distended  gall-bladder),  with  or  without 
jaundice — features  not  met  with  in  appendicitis.  The  tumor  in  appen- 
dicitis is  generally  below  the  level  of  the  umbilicus,  but  when  the  ap- 
pendix extends  upward  the  tip  may  almost  touch  the  gall-bladder,  in 
which  case  a  diagnosis  cannot  be  rendered. 

Perinephric  Abscess. — Without  a  clear  history  the  differentiation  can- 
not be  made  except  by  exploratory  incision. 

Pneumonia. — The  pain  in  the  earlier  stages  of  pneumonia  may  be 
referred  to  the  appendix.      Physical  examination  will  prevent  error. 

Acute  Peritonitis,  due  to  Ovarian  or  Tubal  Disease. — When  the  ap- 
pendix occupies,  not  its  usual  seat  in  the  iliac  region,  but  the  pelvic 
fossa,  then  the  distinctions  between  salpingitis  and  appendicitis  are  not 
easily  drawn.  Right  ovaritis,  owing  to  the  presence  of  pain,  tenderness 
in  the  right  iliac  fossa,  and  fever,  often  closely  simulates  appendicitis. 
In  the  former  tenderness  is  less  pronounced,  and  the  organs  of  utero- 
gestation  manifest  certain  disturbances  of  function.  A  clear  history, 
coupled  with  a  careful  pelvic  examination,  will  usually  complete  the 
clinical  separation  of  these  two  conditions. 

Extra-uterine  Pregnancy. — In  this  condition  the  menstrual  history 
furnishes  important  information.  There  is,  in  addition,  profound  col- 
lapse, due  to  hemorrhage,  when  rupture  of  the  adhesions  occurs.  Ele- 
vation of  temperature  is  absent.  The  localized  tenderness  and  in- 
creased resistance  are  lower  in  the  pelvis  than   in  appendicitis. 

Acute  Tuberculous  Peritonitis. — As  in  appendicitis,  so  in  tuberculous 
peritonitis,  pain,  tenderness,  and  fever  are  present,  but  in  the  latter  the 
onset  is  more  gradual,  and  the  signs  of  tumor  and  increased  resistance 
in  the  ileo-cecal  reorion  are  absent.  Movable  •lulue^s  may  be  present  in 
the  tuberculous  affection,  but  not  in  appendicitis  until  the  peritonitis  is 
generalized.    The  lungs  generally  show  lesions  in  tuberculous  peritonitis. 

Acute  Intestinal  Obstruction. — Vfhen  tliis  is  due  to  intussusception 
there  may  be  signs  o/  a  tumor,  but  not  at  McBurney  s  point ;  the  ten- 


CHRONIC  APPENlJlCITIh!.  865 

derness  over  the  site  of  the  mass  is  less  intense,  while  the  frequent 
bloodj  discharges  that  are  seen  in  this  condition,  accompanied  by  tenes- 
mus, do  not  characterize  appendicitis.  When  obstruction  is  caused  bv 
strangulation  stercoraceous  vomiting  is  apt  to  occur,  and  is  absent  in 
appendicitis.  Pain,  local  tenderness,  and,  not  uncommonly,  signs  of  a 
tumor  appear,  but  elsewhere  than  at  McBurney's  point. 

Intestinal  Lithiasis. — This  can  be  diagnosticated,  as  a  rule,  by  the 
presence  of  intestinal  sand  in  the  movements  (Bottentuit).  Circum- 
scribed resistance  is  absent  in  this  connection. 

Acute  Hemorrhagic  Pancreatitis. — This  affection  simulates  appendi- 
citis with  generalized  peritonitis.  But  the  deep-seated  epigastric  pain, 
followed  by  circumscribed  resistance  in  the  same  region  (a  grouping 
absent  in  appendicitis),  should  arouse  strong  suspicion  of  pancreatitis. 

Hip-joint  Disease. — In  both  hip-joint  disease  and  appendicitis  the 
dorsal  decubitus  with  flexed  leg  is  noted.  If  the  patient  be  anesthet- 
ized, however,  full  extension  of  the  leg  and  a  normal  condition  of  the 
hip-joint  are  easily  demonstrable  in  appendicitis. 

Typhoid  Fever. — Mild  cases  of  appendicitis  with  accompanying  diar- 
rhea bear  a  close  superficial  resemblance  to  typhoid  fever.  In  typhoid 
fever,  however,  the  onset  is  more  gradual  and  the  fever-type  more 
continuous  than  in  appendicitis.  In  typhoid  the  stools  are  somewhat 
peculiar,  the  spleen  is  swollen,  there  is  dulness  of  intellect,  bronchitis 
and  the  characteristic  eruption  attend, — all  features  that  are  absent  in 
appendicitis.  The  diazo-reaotion  would  strengthen  the  diagnosis  of 
typhoid,  and  a  response  to  Widal's  test  would  be  conclusive.  In  appen- 
dicitis the  local  features,  and  in  typhoid  the  general,  are  predominant. 

HietVs  Crises. — In  a  case  of  movable  kidney  which  I  saw  recently 
all  the  symptoms  pointed  to  appendicitis.  An  operation  was  about  to 
be  performed  when  a  sudden  subsidence  in  the  abdominal  swelling  and 
local  induration  occurred.  The  kidney  was  subsequently  detected  in 
an  abnormal  location  {vide  Mobility  of  the  Kidney). 

CHRONIC    APPENDICITIS. 

(Helapsing  Appendicitis — Recurrent  Appendicitis. ) 

Relapses  occur  in  nearly  one-half  the  total  number  of  persons  who 
have  suffered  from  a  primary  attack  of  appendicitis.  In  most  of  these 
cases  there  is  constantly  present  a  slight  local  discomfort  during  the  in- 
terval. When  successive  attacks  occur  in  the  same  individual  at  inter- 
vals of  considerable  duration  (e.  g.^  a  year  or  more),  each  new  attack  is 
spoken  of  as  a  recurrent  appendicitis.  Severe  attacks  may  succeed  to 
light  ones  and  even  prove  fatal,  or  conversely,  mild  recurrent,  may  fol- 
low severe  primary  attacks.  The  local  symptoms  in  those  having  had  an 
antecedent  peritonitis  are  more  pronounced  than  in  the  first  attack,  but 
after  a  number  of  recurrences  the  symptoms  are  likely  to  be  less  severe 
with  each  ncAv  attack.  The  most  constant  symptom  between  attacks  is 
a  subacute  form  of  pain  that  is  liable  to  manifest  exacerbating  periods 
with  slight  fever.  Physical  fatigue,  a  strain,  and  errors  in  diet,  causing 
gastro-intestinal  disorder  are  very  likely  to  induce  a  relapsing  or  recur- 
rent appendicitis.  Chronic  appendicitis  strongly  favors  the  retention  of 
fecal  matter  in  the  cecum,  thus  forming  so-called  stercoral  typhlitis. 

55 


866  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

In  the  intervals  between  the  attacks  the  appendix  can  be  readily  ap- 
preciated on  paJpafwn,  the  method  employed  by  Edebohls  being  prefer- 
able:  "The  patient  lies  upon  his  back  with  the  examiner  at  his  side; 
the  latter  places  his  right  hand  upon  the  patient's  abdomen  over  the 
right  rectus  muscle,  opposite  the  anterior  superior  spine  of  the  ilium, 
and  presses  the  left  hand  upon  the  right,  so  that  no  force  is  used  by 
the  right  hand  and  the  tactile  sense  of  its  fingers  is  left  undisturbed. 
The  hands  are  drawn  slowly  outward,  allowing  the  contents  of  the  abdo- 
men to  slip  from  underneath  them.  The  coils  of  intestine  can  be  felt 
as  they  escape  from  under  the  hand  as  it  presses  against  the  posterior 
abdominal  wall."'  In  this  way  the  appendix  may  be  felt  as  an  elon- 
gated tumor  of  the  size  and  shape  of  the  little  finger.  If  tliere  be  only 
a  slight  exudation  present,  the  appendix  often  appears  to  be  immediately 
beneath  the  abdominal  Avail.  It  may,  however,  be  deep-seated,  even 
though  the  exudation  with  adliesions  be  absent.  Bastedo's  test  in  sus- 
pects.— the  passing  of  a  colon  tube  10  or  12  inches  into  the  rectum  and 
injecting  air  by  means  of  an  atomizer  bulb.  If  now  pain  and  tender- 
ness to  finger-point  pressure  become  apparent  at  McBurney's  point,  there 
is  chronic  appendicitis.  Both  pain  and  tenderness  are  pronounced,  and 
particularly  if  pus  be  present. 

Here  should  be  mentioned  a  form  of  appendicitis  which  is  chronic 
from  the  start  and  not  preceded  by  acute  attacks.  The  inflammation, 
slowly  developed,  may  be  due  to  various  causes,  such  as  influenza  (rare), 
floating  kidney  (common),  and  errors  of  diet,  which  produce  a  condition 
of  enterocolitis,  to  which  the  chronic  appendicitis  is  secondary.  The 
symptoms  are, — an  unpleasant,  dull  pain  accompanied  by  a  dragging 
sensation,  which  may  aff'ect  the  entire  riglit  side  of  the  abdomen  or  be 
circumscribed  in  the  region  of  the  appendix,  obstinate  constipation,  ema- 
ciation, and  marked  neurasthenic  features.  Attacks  of  appendicular  colic, 
with  or  without  vomiting,  may  arise  from  time  to  time.  A  diff'erential 
leukocyte  count  and  frequent  thevmometric  observations,  which  may  show 
slight  elevations  of  temperature,  are  aids  to  the  diagnosis.  The  jJ^iysicul 
examination  reveals  tenderness  on  deep  pressure  over  the  vermiform 
appendix,  with  which  an  equal  degree  of  tenderness,  however,  up  near 
to  the  costal  arch  (suggesting  gall-bladder  disease)  may  be  associated. 
More  or  less  resistance  may  also  be  noted,  but  seldom  a  tumor. 

In  so-called  appendix  dyspepsia,  in  which  the  appendix  is  the  seat  of 
chronic  inflammation,  the  symptoms  exhibited  may  be  those  of  gastric 
or  duodenal  ulcer.  This  mimicry  is  due  to  an  exaggerated  action  of  the 
pylorus  (Moynihan).  Removal  of  the  inflamed  appendix  is  generally 
followed  by  relief  of  the  foregoing  dyspepsia.  Sailer^  states  that  many 
cases  of  movable  cecum,  due  to  kinks  or  folds  that  give  rise  to  partial  or 
complete  obstruction,  are  wrongly  diagnosticated  chronic  apjjcndicitis. 
The  removal  of  the  appendix  is  not  followed  by  relief  of  the  symptoms. 

The  results  of  chronic  appendicitis  upon  the  general  health  and  nu- 
trition of  the  patient  are  quite  noticeable,  and  tend  to  augment  as  time 
passes,  if  the  attacks  be  fre(|uent  or  the  intervals  between  them  grow 
shorter.  The  chief  symptoms  are  those  of  a  nervous  type ;  emaciation 
and  debility  are  also  observed.      The  associated  nervous  symptoms  are 

'  B.  Farquhar  Curtis:  Tiventieth  Century  Practice  of  Medicine,  vol.  viii. 
*  Amer.  Jour.  Meil.  Sciences,  February,  1912, 157. 


CIIRONia  APPENDICITTS.  f^G7 

those  of  nenrasthoriiii.  These  patients  often  become  introspective  and 
exceedingly  irritable,  the  mental  condition  bcin;^  accounted  for,  to  a 
great  extent,  by  the  consciousness  that  tliere  is  ever  present  the  over- 
hanging danger  of  ji  fresh  attack  with  serious  possibilities. 

Differential  Diagnosis. — Carcinoma  of  the  Appendix  and  Cecum. 
— This  presents  many  points  of  similarity  to  chronic  appendicitis.  I 
have  under  my  care  at  present  a  lady  aged  sixty  years  suflferincr  from 
chronic  appendicitis,  whose  case  had  been  diagnosticated  as  carcinoma  of 
the  cecum,  and  for  a  considerable  time  my  own  view  coincided  with  that 
of  my  predecessor.  The  occurrence,  however,  of  relapses,  during  which 
the  feces  were  massed  in  the  cecum  and  fever  arose,  soon  indicated  the 
correct  diagnosis.  Besides  the  absence  of  periodic  attacks  of  fever,  th'' 
general  features — loss  of  flesh  and  strength,  anemia — are  more  steadily 
and  rapidly  progressive  in  carcinoma  of  the  appendix  or  cecum.  The- 
history  of  the  mode  of  onset  also  aids  in  the  distinction.  Pain,  tender- 
ness, and  a  resistant  tumor  are  common  to  both  affections.  Lane's  kink 
of  the  ileum  may  present  symptoms  simulating  chronic  appendicitis,  es- 
pecially marked  constipation,  colicky  pains,  and  meteorism. 

Hypochondriasis  and  Hysteria. — Hypochondriasis  and  hysteria  may 
lead  to  the  manifestation  of  morbid  feelings  simulating  those  of  appendi- 
citis. Such  cases  may  show  merely  a  greatly  exaggerated  uneasiness. 
or  such  an  increase  of  sensibility  as  to  cause  the  patient  to  complain  of 
pain  in  the  right  iliac  fossa.  In  addition,  there  may  be  localized  ten- 
derness. I  recently  witnessed  the  removal  of  the  normal  appendix  from 
an  hysteric  female  in  whose  family  two  genuine  cases  of  appendicitis 
had  occurred  not  long  previously.  Hypochondriasis  and  hysteria  dis- 
tinguish themselves  by  the  antecedent  history  and  by  the  absence  of  a 
tumor-mass  and  of  increased  resistance  ;  there  is  also  an  absence  of 
localized  tenderness  if  the  patient's  attention  be  withdrawn.  In  such 
subjects  oxaluria  is  not  infrequent,  and  it  is  possible  that  irritation  of 
the  right  ureter  by  the  passage  of  crystals  of  calcic  oxalate,  as  men- 
tioned by  Cabot,  may  explain  the  localizing  of  the  discomfort  (Wood 
and  Fitz).     I  saw  a  case  of  this  sort  in  a  medical  student. 

Prognosis. — Unlike  many  of  the  acute  infectious  diseases,  the 
height  of  the  temperature  and,  to  a  lesser  degree,  the  rate  of  the  pulse 
are  unreliable  guides  in  appendicitis.  Broadly  speaking,  however,  in 
the  severer  forms  the  local  process  exhibits  a  strong  tendency  to  spi'ead ; 
the  temperature  and  pulse  are  relatively  high,  and  there  is  an  intense 
appendicular  intoxication.  These  are  the  cases  that  suppurate  or  result 
in  perforative  peritonitis  (often  rapidly  spreading),  and  in  pericecal  ab- 
scesses. Of  this  fatal  group  of  cases  not  less  than  68  per  cent,  die  before 
the  eighth  day.  The  development  oi  fulminant  peritonitis  or  of  a  peri- 
toneal abscess  after  perforation  is  attended  by  a  falling  temperature, 
though  subsequently  the  latter  may  mount  high  or  become  markedly 
irregular. 

On  the  other  hand,  in  the  mild  forms  that  are  included  in  the  name 
catarrhal  appendicitis  recovery  is  the  unvarying  rule.  These  lighter 
cases  often  lead  to  adhesive  peritonitis — a  circumstance  that  strength- 
ens the  view  that  they  are  of  an  infectious  nature.  The  temperature 
is  only  moderately  elevated  as  a  rule,  and  the  pulse-rate  correspond- 
ingly  quickened.      Both   pulse   and   temperature   indicate    marked    im- 


868  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

provement  on  the  third  or  fourth  <lay,  while  the  pain  and  localized 
tenderness  disappear.  In  this  connection  the  deceptiveness  of  gan- 
grenous cases  must  be  recollected  (vide  supra.  Diagnosis).  The  compli- 
cations and  antecedent  and  associated  conditions  may  dccide<lly  intiuence 
the  issue.  As  to  age,  "the  younger  the  child  the  worse  the  prognosis" 
(Finney).  The" general  mortality  of  appendicitis  is  about  14  per  cent. 
(Fitz).  Improved  methods,  chiefly  surgical,  of  dealing  with  the  disease  have, 
however,  greatly  reduced  its  death-rate.  The  prognosis  in  chronic 
appendicitis  is  most  uncertain  ;  after  the  patient  has  survived  several 
attacks  it  is  on  the  whole  more  favorable. 

Treatment  of  Appendicitis. — Whether  imminent  danger  of  per- 
foration e.xist.s  or  not,  the  physician  who  is  called  to  a  case  of  appendi- 
citis should  at  once  request  the  services  of  a  competent  surgeon.  Few 
surgeons  subscribe  to  the  doctrine  that  all  cases  demand  operation  ;  but, 
since  it  may  become  necessary  to  perform  celiotomy  at  any  hour  there- 
after, the  latter  should  helj)  to  settle  the  important  ([uestion  :  "  When  is 
it  necessary  to  operate  in  the  case?"  The  physician  who  does  not  pur- 
sue the  course  above  recommended  falls  short  of  his  duty,  both  toward 
the  patient  and  toward  the  surgeon  on  whose  skill  he  relies  to  remove 
safely  the  source  of  danger.  Surely,  in  a  disease  that  so  often  baflfles 
botii  physician  and  surgeon,  suddenly  developing,  as  it  sometimes  does, 
a  fatal  virulence  without  previous  unfavorable  symptoms,  they  should 
stand  guard  together  from  the  moment  the  case  is  diagnosticated  or  ap- 
pendicitis is  strongly  suspected.  Unfortunately,  both  the  medical  and 
surgical  treatment  of  appendicitis  have  each  been  recommended  with 
great  earnestness  by  their  respective  advocates. 

With  rare  exceptions,  prompt  surgical  intervention  should  be  recom- 
mended. The  indication  for  an  immediate  operation  is  undoubted  in 
all  cases  of  acute  appendicitis,  whether  marked  by  sudden  and  severe 
or  mild  invasion-symptoms,  if  seen  at  the  beginning  of  the  attack,  and 
free  purgation  at  the  earliest  possible  moment  is  not  followed  by  de- 
cided relief.  A  waiting  policy  and  medical  treatment  are  also  peril- 
ous in  doubtful  cases.  Obviously,  the  conditions  are  less  favorable 
for  opei'ation  after  a  case  has  progressed  to  the  beginning  of  abscess- 
formation — /.  e.  from  the  third  to  the  fifth  day  of  the  illness.  It  is 
at  this  period  that  the  peritoneal  inflammation  tends  to  circumscribe 
itself  by  the  formation  of  adhesions.  Hence,  as  Richardson  states, 
it  is  "too  late  for  an  early  operation,  and  too  early  for  a  safe  late 
operation,"  since  there  is  great  risk  of  infecting  the  general  peri- 
toneal cavity.  Whether  it  is  wise  to  allow  the  appendix  to  remain  after 
adhesions  have  been  formed  in  some  cases,  and  merely  to  drain,  cleanse, 
and  pack  the  cavity,  cannot  be  discussed  here.  The  lightest  grades  of 
appendicitis,  in  which  doubt  may  surround  the  diagnosis  and  all  factors 
possessing  an  unfavorable  prognostic  import  are  absent,  scarcely  require 
immediate  operation.^  The  mild  attacks  that  develop  in  the  course  of 
chronic  appendicitis  after  numerous  previous  seizures  need  not  excite 
alarm.  In  relapsing  and  in  recurrent  appendicitis  operation  should  be 
undertaken  between  attacks,  when  the  mortality  is  practically  nil.  On 
the  other  hand,  in  cases  that  have  been  allowed  to  drag  on  until  general 

*" Factors  Influencing  Mortality  in  Appendicitis,  fiom  a  Medical  Viewpoint,"  /1r- 
ehireso/  DiagnoKix,  .laniiary,  1911,  hy  the  writer. 


TREATMENT  OF  APPENDICITIS.  869 

peritonitis  has  set  in,  treatment  hy  operation  is  not  advisable.  More- 
over, the  most  ardent  advocate  of  immediate  operative  treatment  is  some- 
times compelled  to  rest  satisfied  with  medical  measures.  Such  cases  are 
those  in  which  there  are  associated  chronic  affections  (advanced  diabetes, 
Bright's  disease),  not  to  speak  of  those  in  which  the  patient  declines 
operation.  King  has  obtained  encouraging  results  in  the  treatment  with 
high-frequency  currents.  Appendectomy  alone  does  not  cure  in  pjitietits 
with  chronic  constipation,  a  long  dilated  cecum,  or  enteroptosis. 

General  Management. — The  patient  should  be  kept  in  bed  in  a  quiet, 
well-ventilated  apartment,  and  in  no  affection  is  the  value  of  absolute 
rest  in  the  treatment  of  inflammation  greater  than  in  appendicitis. 
Neither  food  nor  drink  should  be  allowed  from  the  moment  the  patient 
is  first  seen  until  early  convalescence.  At  the  start,  and  particularly  if 
a  sausage-shaped  tumor  be  present,  intestinal  irrigation,  oft-repeated, 
with  a  view  to  removing  the  fecal  matter,  must  be  carried  forward  care- 
fully. I  avoid  the  use  of  high  enemata  in  progressive  cases,  since  they 
are  more  apt  than  salines  to  induce  rupture  of  the  sac.  To  relieve  thirst, 
enteroclysis  by  the  drop  method  may  be  employed,  and  when  stimulants 
are  needful,  whiskey  or  liquid  meat  extracts  may  be  added  to  the  physio- 
logic saline  solution. 

As  regards  the  use  of  opium  professional  opinion  is  not  united, 
though  a  general  tendency  toward  the  limitation  of  its  use  to  the  mini- 
mum amount  necessary  to  alleviate  pain  is  happily  noticeable ;  unless 
demanded  by  excessive  suffering  it  had  better  be  omitted  altogether. 
When  necessary,  it  is  best  administered  hypodermically  in  the  form  of 
morphin  (gr.  ^ — | — 0.0054-0.0081).  The  greatest  objection  to  the  use 
of  opium  is  its  effect  in  veiling  the  symptoms  that  assist  the  physician 
in  forming  a  judgment  as  to  the  prospects  and  progress  of  the  case. 
Gastric  irritability  may  be  sufficiently  marked  to  demand  special  measures, 
such  as  the  swallowing  of  small  pieces  of  ice,  spirits  of  chloroform, 
menthol,  listerine,  and  the  well-known  combination  of  cereum  oxalate 
(gr.  iij — 0.1944)  and  cocaine  (gr.  1 — 0.0081)  every  third  hour  may  be 
used. 

Local  Measures. — The  suspended  ice-bag  is  an  excellent  means  of 
combating  the  pain,  and  often  obviates  the  necessity  of  an  internal  use 
of  opium.  Instead  of  the  ice-bag,  cloths  wet  in  cold  water  may  be 
applied  and  changed  every  few  minutes.  In  the  early  stage  a  few 
leeches  may  be  beneficial  in  their  effect  upon  the  local  inflammation. 
Blisters,  however,  are  rarely  advisable,  and  are  particularly  objection- 
able should  the  patient  afterward  be  submitted  to  an  operation.  Mild 
forms  of  counter-irritants  (mustard-paste)  are  preferable,  though  these 
also  render  the  skin  and  underlying  tissues  hard  and  leathery. 

Management  of  Convalescence. — The  patient  should  not  be  allowed 
to  leave  his  bed  for  several  days  after  the  disappearance  of  all  symp- 
toms ;  even  the  mildest  forms  of  exercise  should  not  be  undertaken  for 
at  least  one  week  subsequent  to  getting  out  of  bed.  During  convales- 
cence the  diet  must  be  carefully  guarded,  and  the  bowels,  at  all  hazards, 
kept  in  a  soluble  condition.  It  is  questionable  whether  drugs  will  aid 
in  the  absorption  of  the  exudate  or  assist  in  resolution. 


870  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 


TYPHLITIS. 

By  typhlitis  is  meant  inflaniniation  of  the  cecum  without  involvement 
of  the  appendix  (rare) ;  and  in  i^ome  cases  ulceration  due  to  pressure  by 
retained  fecal  matter  or  foreign  bodies  ensues.  The  history  of  previous 
constipation  or  of  some  dietetic  error  is  frequently  obtainable. 

The  sj/mptomn  are  ])ain  of  a  dull  character,  nausea,  and  obstinate  con- 
stipation with  moderate  fever.  The  phi/sieal  si(/ns  are,  a  ]iroininence  in 
the  ileocecal  region,  tenderness  to  pressure,  and  those  of  a  doughy,  sau- 
sage-shaped tumor  in  the  cecal  region.  After  two  or  three  days  the 
tumor  gradually  diminishes ;  also  the  active  symptoms,  but  tenderness 
persists  for  a  week  or  longer.  When  ulceration  attacks  the  inflamed 
cecum  a  jiericecal  abscess  is  the  usual  result.  To  this  condition  the 
term  "-perityphlitis,  '  which  is  now  practically  obsolete,  was  formerly 
applied. 

The  treatment  of  typhlitis  is  that  of  obstinate  constipation.  Eserine 
(gr.  -^  every  foui'th  hour)  has  proved  serviceable.  For  this  ])urpose 
enemata  administered  high  in  the  bowel  are  most  eftective.  We  may 
employ  the  so-called  "ox-gall"  enema,  as  follows: 

I|<.  Powdered  ox-gall,  gr.  xx  (1.29); 

Glycerin,  fl.  5j     (32.0); 

Water  and  soapsuds  (105°  F.),  Oj         (1082.08). 

My  own  best  results  have  been  obtained  from  the  use  alternately  of  an 
enema  of  olive  oil  (sviij  at  a  temperature  of  100°  F.)  administered 
through  a  rectal  tube  high  in  the  bowel  while  the  patient  occupies  the 
left  lateral-prone  position,  and  one  composed  as  follows : 


Sulphate  of  magnesia, 

§iss 

(48.0); 

Glycerin, 

fl-5j 

(32.0); 

Spirits  of  turpentine, 

fi-3ij 

(8.0): 

Hot  water  (100°  F.), 

Oj 

(1082.08), 

The  diet  should  be  of  the  blandest  sort,  such  as  albumin-water,  pep- 
tonized milk  and  the  like,  given  at  stated  intervals  in  small,  fixed  quan- 
tities.    Arterial  stimulants  may  be  required  during  the  latter  stages. 


INTESTINAL   CALCULI. 

Intestinal  calculi  are  rarely  passed  with  tlie  feces,  and  may  be  in  the 
form  of  small  concretions,  hepatic  calculi  that  have  entered  the  intestine, 
and  as  sand  which  is  formed  in  the  saccules  of  the  colon  and  folds  of  the 
cecum  and  rectum.  Their  origin  may  depend  upon  the  deposition  of 
calcium  and  magnesium  salts  upon  particles  of  undigested  food. 

A  teaspoonful  or  more  of  gritty  sand  may  escape  with  each  stool.  But 
four  cases  of  true  enterolithiasis  have  been  reported.  The  condition  ia 
likely  to  arise  when  the  diet  is  exclusively  milk.  "  Sand  "  may  be  pro- 
duced through  the  ingestion  of  the  banana  (Myer  and  Cook). 


INTESTINAL   OBSTRUCTION.  871 

INTESTINAL  OBSTRUCTION. 

{Ikus.) 

Definition. — An  acute  or  chronic,  complete  or  partial,  occlusion  of 
the  intestinal  canal. 

Pathology  and  Ktiology. — The  causes  of  intestinal  obstruction 
may  be  divided,  at  once  most  simply  and  practically,  into  the  (1)  acute 
and  (2)  chronic  forms.  In  the  former  variety  the  narrowing  or  closure 
develops  very  suddenly  or  rapidly,  and  usually  in  the  small  bowel ;  in  the 
latter,  the  large  bowel  is  commonly  affected  by  pathologic  conditions 
that  develop  gradually  and  narrow  its  lumen  (usually  in  advanced  years). 

Acute. — {a)  Strangulation. — In  the  order  of  frequency,  this  is  first 
among  the  causes  of  acute  intestinal  obstruction.  It  is  produced  most 
often  by  bands  of  adhesion,  the  result  of  a  former  recent  or  remote  peri- 
tonitis, and  is  most  commonly  situated  in  the  right  iliac  fossa.  Incar- 
ceration of  the  bowel  from  flexions  and  adhesions  not  rarely  follows  upon 
abdominal  section  for  the  treatment  of  pelvic  disease  in  women. 

The  usually  free  end  of  Meckel's  diverticulum  is  sometimes  attached 
to  the  abdominal  wall,  and  may  thus  cause  constriction  of  a  loop  of 
bowel.  This  diverticulum  is  the  remains  of  the  fetal  omphalo-mesen- 
teric  duct,  and  arises  from  the  ileum  about  half  a  meter  (1.64  ft.)  from 
the  ileo-cecal  valve.  A  similar  constricting  band  is  formed  by  a  cord 
representing  one  or  more  of  the  obliterated  omphalo-mesenteric  vessels. 
The  adhesive  attachment  of  the  free  end  of  the  appendix  vermiformis 
may  also  form  an  opening  through  which  the  bowel  may  be  caught. 

Internal  strangulation  (hernia)  may  be  the  result  of  forcing  a  portion 
of  bowel  through  a  slit  in  the  omentum  or  mesentery,  or  into  peritoneal 
diverticula  and  openings,  such  as  the  duodeno-jejunal  fossa  {Freitzs 
retro-peritoneal  hernia)  or  the  foramen  of  Winslow. 

Diaphragmatic  hernise  are  not  of  extreme  rarity,  and  may  be  either 
of  congenital  or  traumatic  origin.  Most  cases  of  intestinal  strangulation 
occur  in  males  during  early  adult  life. 

(h)  Intussusception. — Invagination  is  the  descending  "  telescoping  of 
one  section  of  the  bowel  into  another,"  probably  caused  by  a  circum- 
scribed, irregular  peristalsis  of  the  intestine.  The  effect  of  the  latter 
state  in  producing  invagination  may  be  either  a  thrusting  forward  of 
the  receiving  portion  by  a  contraction  of  the  longitudinal  muscular  coat 
(Nothnagel),  or  a  thrusting  inward  and  downward  of  the  portion  imme- 
diately above  by  means  of  an  increased  or  spasmodic  peristaltic  action. 
Thus,  a  cylindric  or  sausage-shaped  tumor  results,  varying  from  a  half 
inch  to  over  a  foot  (1.3-30  cm.)  in  length.  The  layers  met  with  in 
intussusception  are  the  outer  or  receiving,  called  the  intussuscipiens, 
the  middle  or  returning  layer,  and  the  inner,  called  the  intussusceptum. 
The  seat  of  invagination  is  most  commonly  at  the  ileo-cecal  valve,  though 
it  is  often  found  in  either  the  ileum  or  colon  alone.  Sometimes  the  in- 
tussusception is  detected  in  the  rectum.  A  lateral  or  partial  invagina- 
tion may  also  occur,  due  to  the  attachment  of  a  tumor  within  the  bowel. 

The  intussuscepted  portion  of  intestine  is  usually  the  seat  of  perito- 
neal adhesions,  so  that  in  pronounced  cases  the  parts  are  so  firmly  agglu- 
tinated that  reduction  is  wellnigh  impossible.      The  engorgement  may 


872  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pass  into  an  intense  local  inflammation,  "vvith  final  necrosis  and  sloughing, 
and  even  the  discharge  per  rectum  of  the  invaginated  portion. 

Intussusception  occurs  most  frequently  in  children  prior  to  ten  years 
of  age,  and  males  suffer  more  than  females.  Invagination  is  an  occasional 
consequence  of  the  operation  of  circular  enterorrhapliy  (Robinson), 

(c)  J^()/yM//^s•. ^-Twists  of  the  intestine  are  met  with  most  commonly 
at  the  sigmoid  flexure  of  the  colon.  An  unusually  long  or  relaxed  mes- 
entery predisposes  to  the  condition,  so  that  the  axis  of  twisting  may 
either  consist  of  the  mesentery  itself  or  frequently  of  the  bowel.  Not 
rarely  the  pedicle  of  the  volvulus  contains  both  a  twist  and  a  sharp  bend 
in  the  bowel,  causing  complete  acute  strangulation.  The  latter  condition 
may  be  pronounced  in  such  cases,  or  at  least  be  hastened,  by  the  accumu- 
lation of  the  intestinal  gas  and  of  masses  of  feces, — by  bowel-adhesions 
to  an  adjacent  stump  of  omentum  (Nieberding).  The  passive  reactive 
pressure  of  the  coils  of  intestine  and  of  the  abdominal  walls  tends  also 
to  further  confine  the  enormously  dilated  and  twisted  loop  of  bowel  to 
its  abdominal  state.  Knots  may  be  formed  by  the  association  of  loops 
of  the  ileum  with  each  other  or  about  the  pedicle  of  a  twisted  cecum. 

Males  between  forty  and  sixty  years  are  especially  the  subjects  of 
volvulus.  Acute  intestinal  obstruction  invites  bacterial  invasion,  which 
is  the  probable  cause  of  the  general  symptoms. 

Chronic. — (a)  Fecal  Impaction. — Tnteatinal  Concretions. — Accumula- 
tion of  feces  (coprostasis)  is  a  common  cause  of  intestinal  obstruction, 
the  impaction  taking  place  usually  in  the  cecum  or  sigmoid  flexure. 

Though  not  infrequent  in  children,  fecal  obstruction  is  more  common 
in  adults  (particularly  in  females),  in  the  hysteric,  the  demented,  and 
the  hypochondriac.  Congenital  dilatation  of  the  colon  may  predispose 
to  coprostasis,  and  an  acquired  dilatation,  which  in  some  cases  becomes 
enormous,  is  often  the  result  of  paresis  of  a  portion  of  bowel  caused  by 
over-distention  for  a  long  period  of  time. 

Among  other  causes  of  obstruction  due  to  abnormal  contents  may 
be  mentioned  enteroliths.  These  are  intestinal  concretions  formed  of 
various  nuclei,  as  gall-stones,  hardened  feces,  phosphates  of  lime  and 
magnesia,  various  foreign  substances,  and  organic  derivatives.  Balls 
of  tangled  ascarides  may  mass  sufficiently  to  cause  obstruction. 

Foreign  bodies,  as  pins,  buttons,  coins,  fruit-stones,  may  also  cause 
obstruction  of  the  bowel.  It  is  stated  that  even  insoluble  mineral 
medicines,  as  bismuth  or  magnesia,  have  caused  obstruction. 

(b)  Tumars. — Tumors  cause  a  form  of  chronic  obstruction  that  may  at 
any  time  develop  suddenly  into  the  acute  type.  They  may  do  so  either 
as — (1)  new  groivths  in  the  wall  of  the  intestine  itself,  or  by  (2)  com- 
pression and  traction  from  ivithout.  Again,  the  intestinal  neoplasms 
may  be  malignant  or  beni(/n  in  nature.  Carcinoma  of  the  bowel  is  at 
once  the  most  frequent  and  important  of  these.  It  may  be  either  cir- 
cumscribed and  annular,  causing  a  gradual  narrowing  of  the  bowel- 
lumen,  or  a  diffused  infiltration  of  the  intestinal  wall,  commencing 
either  in  the  mucosa  or  in  its  glands  (cylindric  epithelioma).  Its  most 
common  seat  of  growth  is  the  large  bowel,  about  the  sigmoid  flexure. 

Sarcoma  usually  attacks  the  small  bowel,  starting  beneath  the 
mucosa,  and  is  of  the  recurrent  variety.  Regional  infection  of  the 
mesenteric  and  retroperitoneal  glands  {Lohstein  s  cancer)  is  also  a  usual 


INTESTINAL   OBSTRUCTION.  873 

consequence    of    sarcoma.       It    may    occur    in    children    or    in    young 
adults. 

Benign  tumors  may  be  polypoid,  adenomatous,  fibromatous  and  lipo- 
matous.  Intestinal  obstruction  due  to  compression  or  traction  may  be 
caused  by  tumors  (omental)  or  by  adhesions  of  the  pelvic  viscera. 

(c)  Cicatricial  strictures  cause  chronic  intestinal  obstruction,  as  after 
the  healing  of  various  ulcers,  the  cicatrices  of  which  slowly  contract. 
Cicatricial  stenosis  of  the  colon  is  commonly  due  to  the  cicatrization  of 
dysenteric  ulcers.  In  the  rectum  the  stenosis  is  usually  a  result  of  a 
syphilitic  lesion.  Tuberculous  and  rarely,  typhoid  ulceration  may  l>e 
followed  by  stricture  of  the  small  intestine. 

(d)  Congenital  stricture  is  rare,  and  is  more  purely  surgical  than  the 
preceding  cases.  It  is  often  an  occlusion  or  an  imperforate  condition  of 
the  anus  {atresia  ani),  and  is  only  mentionable  in  this  connection. 

(e)  Paresis  of  Peristalsis. — This  condition — called  also  adynamic  ob- 
struction— while  it  is  a  functional  aifection,  is  held  to  be  either  a  circum- 
scribed or  diffuse  paresis  of  the  intestinal  muscular  coat.  It  is  caused  by 
some  such  inflammatory  disturbance  as  enteritis  or  peritonitis,  or  even 
by  the  manipulations  employed  in  abdominal  sections.  Here  the  obstruc- 
tion is  due  to  an  accumulation  of  feces  and  gases  in  the  paretic  portion 
of  the  bowel,  causing  tympanites,  vomiting,  and  constipation.  Intestinal 
stasis  may  be  due  to  the  presence  of  kinks,  as  shown  by  radiography 
(Jordan). 

Special  Pathology. — The  pathologic  changes  that  accompany 
nearly  every  form  of  intestinal  obstruction  are  briefly  stated  as  follows : 
Accumulative  dilatation — with  hypertrophy  in  chronic  cases — of  the 
intestine  above  the  seat  of  disorder,  and  an  emptiness,  narrowing,  and 
even  atrophy  below  the  obstruction.  The  affected  walls  of  the  bow^el 
are  inflamed,  and  there  is  a  surrounding  acute  or  chronic  peritonitis. 
Catarrhal  and  sometimes  diphtheritic  inflammation  of  the  mucosa  may 
develop.  Gangrene,  ulceration,  and  perforation  of  the  bowel,  with 
resulting  generalized  peritonitis,  may  also   ensue. 

Symptoms. — Acute  Obstruction. — There  is  a  suddenly  developed  ab- 
dominal pain  that  may  follow  some  abrupt  or  severe  exertion.  Early 
vomiting  and  absolute  constipation  are  also  conspicuous  and  important 
symptoms.  If  the  obstruction  is  high  in  the  small  bowel,  distressing 
hiccough  and  eructations  may  precede  the  vomiting.  Except  for  the 
possible  discharge  of  the  intestinal  contents  below  the  seat  of  obstruc- 
tion, the  constipation  is  usually  complete  and  obstinate.  The  early 
symptoms,  however,  are  caused  by  strangulation  rather  than  by  obstruc- 
tion. Accompanying  the  latter  condition  there  is  tympanites,  which  is 
most  marked  in  obstruction  of  the  colon.  Intermittent  and  colicky  at 
first  (partial  obstruction — Treves),  the  pain  soon  becomes  agonizing  and 
constant.  Vomiting.,  also,  alternating  with  painful  retching,  is  more 
constant  and  severe  after  several  hours.  The  material  at  first  ejected  is 
gastric  and  mucous ;  it  then  becomes  bilious,  and  finally  is  character- 
istically stercoraceous. 

The  constitutional  symptoms  develop  early,  are  intensely  threatening 
to  life,  and  cause  rapid  and  profound  collapse.  The  pinched  and  pallid 
features,  cool  and  moist  skin,  Hippocratic  expression,  rapid  and  feeble 
pulse,  the  usually  subnormal  temperature,  shallow  and  accelerated  breath- 
ing, marked  thirst,  scanty  urine,  great  anxiety  and  prostration — all  indi- 


874  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cate  the  gnivity  of   the  eomlition.      McClures   experiments   show   the 
symptoms  to  be  due  to  absorption  of  bacterial  toxins. 

The  p/ii/siral  ej-atiunotioit  will  discover  a  swollen,  extremely  tender, 
and  tympanitic  belly.  Exatjirerated  peristalsis  of  the  intestine  above 
the  obstruction  may  be  visible  on  the  surface  of  the  abilomen.  Bor- 
borviimi,  ffurirliuix,  and  si)lashinj;  mav  be  heard  on  auscultation. 

Chronic  Obstruction. — The  symptoms  are  more  dependent  upon 
the  special  causes  operating  than  in  acute  obstruction.  The  fact  that 
early  in  the  case  only  partial  obliteration  of  the  intestinal  lumen  may 
be  rightly  inferred  in  many  of  the  chronic  forms  of  obstruction  has 
given  rise  to  the  discriminating  term  of  oitesfitial  cioistriction.  In  gen- 
eral, the  clinical  history  is  one  of  iinj-eashii/  and  intractable  constipa- 
tion, sometimes  alternating  with  diarrhea,  due  to  catarrhal  inflammation 
of  the  mucosa  above  the  obstruction.  Paroxysms  of  colicky  pain  and, 
later,  augmenting  tympanites,  vomiting,  and  prostration,  attend.  These 
symptoms  may  merge  suddenly  into  those  of  the  acute  form  of  obstruction. 
The  bowel-movements  in  chronic  obstruction  are  irregular,  infrequent, 
slight,  and  sometimes  accompanied  by  pain  and  tenesmus.  The  stools 
consist  often  of  small,  hard,  ribbon-like,  or  scybalous  masses,  and  may 
contain  blood  and  mucus.  When  the  stenosis  is  in  the  small  intestine 
the  constipation  is  less  apt  to  occur  on  account  of  the  fluidity  of  the 
contents.  Sometimes,  and  particularly  in  old  ]ieople,  the  rectum  be- 
comes distended  with  hardened  accumulations  of  feces  ;  there  is  in  such 
cases  a  constant  feeling  of  fulness  and  a  harassing  desire  to  defecate, 
but  the  attempts  thei'eat  are  ineflfectual  {ride  Ty{)hlitis,  p.  870). 

In  cicatricial  stenosis  there  are  a  prolonged  and  variable  history  of 
constipation,  occasional  vomiting,  localized  pain,  and  meteorism. 

Physical  Examination. — Inspection  sboAvs  the  abdomen  to  be  dis- 
tended from  meteorism,  the  movements,  and  contour  even,  of  the  coils 
of  intestine  in  active  peristalsis  above  the  seat  of  stricture  being  evi- 
dent. A  tumor  or  the  throbbing  aorta  (excited,  perhaps,  by  pressure 
of  the  distended  bowel  or  gi'owth)  may  be  palpated.  Tympany  and 
borborygmous  noises  may  also  be  noted. 

Diagnosis. — Locality  of  the  Obstruction. — Given  the  symptoms  of 
a  sudden,  severe,  and  exacerbating  ])ain  in  the  abdomen  ;  of  marked, 
and  later  feculent,  vomiting ;  of  absolute  constipation  and  of  tympanites 
and  profound,  early,  systemic  depression, — a  diagnosis  of  acute  intestinal 
obstruction  may  be  made.  The  determination  of  its  seat  is  often  very 
difiicult.  First'may  be  mentioned  the  differential  diagnosis  between  ob- 
struction occurring  in  the  small  and  in  the  large  intestine.  In  the  former 
vomiting  occurs  early,  is  scanty,  and  later  feculent,  while  in  the  latter 
there  is  less  vomiting  and  the  vomitus  is  seldom  feculent.  Again,  in 
obstruction  of  the  small  gut  the  distention  is  both  less  marked  and  higher 
situated,  while  in  that  of  the  large  gut  tympanites  is  often  (juite  marked, 
is  more  central,  is  associated  with  tenesmus,  and  sometimes  with  mucus 
and  blood.  If  the  cause  of  obstruction  be  a  tumor  or  stricture,  the 
locality  may  be  successfully  palpated  or  the  lower  limit  of  the  active  coils 
of  hvpertrophied  intestine  may  be  defined. 

Examination  per  rectum  with  the  finger  or  with  the  rectal  tube,  by 
means  of  liquid  distention  or  gaseous  inflation  of  the  colon,  may  enable  us 
to  determine  the  seat  of  obstruction  in  certain  cases.     The  detection  of  a 


INTESTINAL    OBSTIiUCTION.  Hl^ 

deeply-seated  incarcerated  hernia  (in  the  abdominal  fossae  and  pouches, 
diaphragm,  or  obturator  foramen)  is  often  made  only  posfrnortern. 

Nature  of  the  Obstruction. — This  is  even  more  difficult  of  discovery 
than  the  preceding.  The  following  causes  of  obstruction  with  their 
differentiation  may  be  referred  to  in  attempting  a  diagnosis  :  Strangu- 
lation often  affords  a  previous  history  of  peritonitis  or  abdominal  sec- 
tion or  of  recurrent  attacks  of  abdominal  pain,  occurring  mostly  in 
young  adults.     Early  fecaloid  vomiting  is  common. 

Intussusception  usually  gives  a  negative  previous  history.  The  sud- 
denness of  the  attack,  without  appreciable  cause,  occurring  in  a  child, 
and  associated  with  colicky  pain,  tenesmus,  and  the  presence  of  mucus 
and  bloody  stools,  and  of  an  elongated  cylindric  tumor  in  the  right 
iliac  or  umbilical  regions  often  render  this  condition  easy  of  diagnosis. 
It  is  to  be  noted  that  absolute  constipation  and  meteorism  are  here 
unusual.     The  intussusception  may  be  felt  in  the  rectum. 

In  volvulus  it  may  be  helpful  to  elicit  a  history  of  former  constipa- 
tion and  flatulence,  with  evidences  of  atony  of  the  bowel,  in  persons  of 
advanced  years,  along  with  marked  abdominal  tympany,  tenderness 
over  a  distended  coil,  Avhich  toay  perhaps  be  outlined  (Wahl),  a  rigid 
abdomen,  and  sometimes  dyspnea  from  great  gaseous  distention. 

The  history  in  cases  of  fecal  obstruction  is  nearly  always  one  of 
obstinate,  habitual  constipation,  and  occurs  especially  in  females  and 
neurotic  subjects.  The  onset  is  gradual ;  pain  is  less  acute;  and  tym- 
pany and  fecal  vomiting  are  less  prominent  and  late  in  appearance. 

Obstruction  due  to  large  enteroliths  or  foreign  bodies  may  be  only  sur- 
mised :   especially  is  this  true  when  symptoms  of  appendicitis  arise. 

Biliary  calculi  may  give  a  history  of  previous  attacks  of  hepatic  colic 
and  of  recurrent  jaundice. 

In  the  chronic  obstructive  form  of  stricture  of  the  bowel  due  to  cica- 
trices or  neoplasraata  the  history  of  dysentery,  tuberculosis,  sarcoma, 
or  carcinoma  should  be  considered  {vide  Carcinoma  Intestiiialis). 

In  obstruction  caused  by  intestinal  far  esis  there  is  generally  a  history 
of  a  previous  enteritis,  peritonitis,  or  celiotomy.  The  abdomen  is  smooth, 
though  tympanitic  throughout,  and  there  is  no  perceptible  peristalsis. 

Not  rarely  it  will  be  of  therapeutic  as  well  as  of  diagnostic  import- 
ance to  ascertain  whether  an  attack  of  acute  obstruction  is  primary,  or 
whether  it  is  the  terminal  exacerbation  of  a  chronic  condition,  such  as 
carcinoma  of  the  bowel.  Here  a  study  of  the  past  history  of  the  patient,  as 
well  of  the  present  signs  of  a  probable  nature,  will  afford  considerable  aid. 

Differential  Diagnosis. — Acute  intestinal  obstruction  must  be  discrim- 
inated from  acute  generalized  peritonitis. 

Acute  Generalized  Peritonitis.  Acute  Intestinal  Obstruction 

Etiology. 

There  is  a  history  of  causal  conditions  or       There  is  a  history  of  previous   chronis 

diseases  (ulcer,  appendicitis,  pelvic  in-  obstruction    or    hernia.     (The   young 

fection).  are  most  liable  to  intussusception.) 

An  early  and  considerable  rise  of  temper-       No  early  rise  (except  in  volvulus),  but 

ature  ;  later  variable  or  may  be  absent.  later  with  advent   of  peritonitis,  and 

subnormal  temperature  develops  later. 
Pain  continuous  and  diffuse  and  increased       Pain  in  short  paroxysms  and  localized. 

by  movements. 
Vomiting,  but  not  stercoraceous.  Vomiting  becomes  characteristically  ster- 

coraceous  early. 


876  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Acute  Generalized  Peuitonitis.  A<  ite  Isti-^tixal  OiisTUutTioN. 

Eiiiiloyy. 

Collapse  occurs  late.  Earlier  onset  of  ooUajise. 

In  septic  cases,  leukocytosis  with  imreasc  Tiure  may  be  im-reasi'  in  ninnher  of  ien- 
in  polynudear  cells.  kocyles. 

Distention  of  thealHh)nien  is  usually  i;enei-al  Less  marked,  unless  tjie  obstruction  he  situ- 
anil  marked.  ated  in  the  lower  seirnient. 

Visihle  peristaltic  waves  absent.  I'lesent  and  pronounced  when  tiie  seat  of 

obstruction  is  low,  and  course  of  wave 
may  be  revei-sed. 

Tenderness  decided  ami  general.  Tenderness  ioialized  and  usually  slight. 

Signs  of  effusion  appear.  Less   common,   due    to   .secondary   perittt- 

nitis. 

Auscultation  negative.  l.iMid  gurgling  and  splashing  sounds  audi- 

ble over  the  abdomen  (colon). 

It  must  also  be  diiferentiated  ffoni  acute  enteritis,  in  -which  (particu- 
larly when  due  to  toxic  minei-als)  there  is  more  apt  to  be  diarrhea  with 
considerable  mucus  and  blood,  an  elevated  temperature,  intense  gnstric 
pain,  associated  with  traces  of  the  poison  in  the  vomitus,  and  an  absence 
of  marked  tympanites  and  fecal  vomiting. 

The  various  forms  of  abdominal  rolic,  as  enteralgia,  hepatalgia,  and 
nejdiralgia  sh<iuld  not  be  mistaken  for  acute  intestinal  obstruction. 

Course,  Complications,  and  Prognosis. — A  case  of  acute  ob- 
struction usually  terminates  within  from  two  to  seven  days.  The  chronic 
form  may  last  weeks,  and  even  months,  with  progressive  emaciation  and 
anemia,  until  the  superaddition  of  more  or  less  acute  symptoms,  lasting 
from  ten  to  fourteen  days.  The  ■prognosia  is  unfavorable  in  the  acute 
cases  unless  recognized  early.  The  chronic  forms,  due  to  fecal  or  other 
impaction,  often  recover.  Life  may  be  prolonged  by  surgical  interfer- 
ence in  certain  cases  if  they  are  taken  in  their  inception. 

Complications  that  may  occur,  as  secondary  peritonitis,  gangrene, 
perforation,  septico-pyemia,  and  enteritis,  are  all  grave. 

Treatment. — The  treatment  of  acute  intestinal  obstruction  is  sur- 
gical. The  only  indication  for  therapeutic  interference  in  acute  obstruc- 
tion i.s  presented  by  the  incessant  vomiting.  For  this  symptom  no  other 
measures  are  comparable  to  gastric  lavage  and  starvation.  It  is  well  in 
most  eases  to  withliold  food  for  some  hours  to  prevent  retching,  and 
aggravation  of  the  condition.  The  lavage  is  strongly  advised  ))y  Kuss- 
maul,  who  claims  that  both  the  tension  above  the  seat  of  stricture  and 
the  inordinate  peristalsis  are  thus  greatly  diminished  and  exceptionally 
cured.  It  may  be  repeated  every  six  hours.  Hypodermic  injections  of 
morphin  for  the  pain  induce  deceptive  tranquillity.  When  the  cause  or 
character  of  the  obstruction  is  unknown,  cathartics  should  absolutely  not 
be  given.  If  it  has  been  determined  that  fecal  impaction  is  the  trouble, 
it  is  still  prudent  to  avoid  purgatives  until  the  main  mass  has  been 
moved,  as  in  many  cases  there  are  both  paresis  and  inflammation  at  the 
seat  of  impaction,  so  that  this  class  of  agents  would  in  most  cases  at 
least  be  useless,  if  not  harmful.  High  rectal  injections,  copious,  steady, 
and  regularly  repeated,  are  to  be  practised,  using  for  this  purpose  pre- 
ferablv  ''  a  warm  saline  solution  of  olive  oil  "  (particularly  if  scybala  be 
present)  administered  while  the  patient  is  in  an  inverted  position  by 
means  of  a  fountain  syringe,  so  that  the  flow  is  readily  controllable.  The 
abdomen  should  be  methodically  kneaded  and  the  patient  at  times  well 


CARCINOMA    OF  TIIK   INTESTINE.  H71 

shaken.  This  method  of  treatment,  hy  hydrostatic  pressure,  can  and 
must  be  carried  forwiu-d  without  undue  viok;nce,  and  if  it  be  unsuccess- 
ful, the  intestines  are  to  ])e  inflated  from  a  la)'ge  india-rubber  bag  with 
air  or  hydrogen  gas  (Senn),  of  which  two  to  three  galhms  may  be  cau- 
tiously introduced.  Tliorough  manipulation  of  the  abdomen  from  below- 
upward,  particularly  if  it  be  a  case  of  intussusception,  may  be  combined. 
In  the  latter  condition  inflation,  early  and  perseveringly  applied,  cures 
the  majority  of  instances.  If  not  promptly  relieved,  immediate  opera- 
tion is  to  be  encouraged  and  advised.  Although  the  statistics  of  Fitz 
show  the  mortality  in  cases  without  operation  to  be  lower  (69  per  cent.) 
than  with  operation  (83  per  cent.),  I  am  convinced  from  personal  obser- 
vation that  the  less  favorable  results  from  abdominal  section  would  not 
obtain  if  it  were  performed  in  due  time. 

In  chronic  obstruction  the  treatment  of  the  underlying  or  etiologic 
coHditions  and  various  complications  is  to  be  conducted  on  general  prin- 
ciples. Additionally,  the  patient's  dietary  is  to  be  arranged  with  care, 
and  the  bowels  moved  with  unfailing  regularity,  by  the  use  of  unirri- 
tating  laxatives  and  enemata.  If  total  obstruction  persist  despite  medical 
treatment,  surgical  treatment — enterectomy,  enterotomy,  or  other  opera- 
tion, as  the  circumstances  of  individual  cases  may  dictate — is  required. 

The  after-treatment  consists  in  keeping  the  bowels  active  and  regular 
bj  habit,  diet,  and  an  aperient  pill  if  needed.  Massage  and  electricity 
to  the  abdomen  are  found  useful  at  this  time. 

Stenosis  of  the  Duodenum. — Duodenal  stenosis  invariably  de- 
velops secondarily  upon  morbid  processes  either  in  the  duodenum  or 
adjacent  organs.  Extensive  studies  of  the  subject  have  been  made  by 
•Leichtenstern,  Perry  and  Shaw,  Wilms,  Boas,  Laffer,  and  others.  The 
causes  are  principally  intra-duodenal — ulcer  of  the  duodenum  (53.44  per 
cent.),  carcinoma  of  the  duodenum,  sphincteric  action  of  the  muscular 
layer  of  duodenum,  and  gall-stones.  Among  extra-duodenal  factors  are 
"  diseases  of  the  pancreas,  compression  by  the  root  of  the  mesentery, 
adhesions,  morbid  growths,  kinking,  and  gall-stones."^  Symptoms. — 
When  the  stenosis  is  suprapapillary  or  at  the  ampulla  of  Vater,  marked 
dilatation  of  the  stomach  and  of  the  duodenum  above  the  stenosis  usually 
occurs.  When  at  the  ampulla,  obstruction  may  show  acholic  stools  con- 
taining enormous  numbers  of  fatty  acid  crystals  and  jaundice.  Neither 
blood  nor  bile  are  found  in  the  vomitus,  as  a  rule.  Stenosis  below  the 
ampulla  of  Vater  is  characterized  by  absence  of  meteorism,  biliary,  but 
never  fecal,  vomiting,  the  tempoi'ary  disappearance  of  meteorism  in  the 
epigastrium,  after  vomiting,  and  early  anuria.  Stenosis  due  to  kinking 
causes  sudden  severe  pain,  frequent  vomiting,  and  decided  shock.  The 
prognosis  is  dependent  on  the  special  cause,  while  the  treatment  is  appro- 
priately surgical. 

CARCINOMA  OF  THE  INTESTINE. 

{Carcinoma  Intestinalis.) 

Carcinoma  of  the  intestine  is  the  commonest  cause  of  chronic  intes- 
tinal obstruction.     The  stenosis  is  usually  partial.     Primary  intestinal 
carcinoma  is  rare  in  comparison  with  that  of  gastric  carcinoma. 
'  American  Journal  of  the  Medical  Sciences,  Sept.,  1912,  by  tlie  writer. 


878  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Pathology. — When  carcinoma  attacks  tlie  intestine  it  is  usuall}'  in 
the  ibnu  of  a  cylindric-oellcd  epithelioma,  although  it  may  assume  the 
various  forms  as  found  in  carcinoma  of  the  stomach — namely,  scirrhous, 
medullarv,  and  colloid.  The  growth  may  be  annular  or  seniipolypoid,  or 
it  may  occur  as  a  diftuse  infiltration  of  the  bowel-walls.  Ulceration  of 
the  surface  of  the  carcinoma  may  take  place,  and  the  glandular  structures 
of  the  abdominal  cavity  may  reveal  metastatic  growths.  The  most  fre- 
quent seat  of  intestinal  carcinoma  is  the  rectum,  and  next  in  order  of  fre- 
quency are  the  sigmoid  flexure,  the  transverse  and  descending  colon,  the 
papilla  duodcnalis.  the  ascending  colon,  and  the  lower  and  middle  por- 
tions of  the  ileum.  The  bowel  is  dilated  above  the  constriction  and 
filled  with  fecal  matter.  The  muscular  coat  is  hypertropliied.  Below 
the  narrowing  the  intestine  may  be  atrophied.  Rectal  adenoma  may 
develop  into  carcinoma  (adenosarcoma). 

Ktiology. — Heredity  and  advanced  age  are  of  chief  importance  as  pre- 
disposiuii  causes.  Antecedent  intestinal  ulceration  may  afford  a  nidus  for 
carcinomatous  growths.  Carcinoma  may  invade  the  appendix.  J  larte,  from 
statistics  based  on  101  cases,  concludes  that  carcinoma  occurs  in  from  -|-  of 
1  per  cent,  to  1  per  cent,  of  all  cases  operated  on  for  chronic  appendicitis. 

Symptoms. — A  description  of  the  course  of  rectal  carcinoma  belongs 
to  surcrical  works.  The  symptoms  of  carcinoma  of  the  bowel  above  the 
rectum  are  often  vague,  and  vary  according  to  the  ])ortion  involved  by 
the  neoplasm.  With  or  Avithout  an  appreciable  tumor  in  the  abdomen 
the  history  is  usually  that  of  chronic  obstipation  of  the  intestines.  There 
are  irregular  attacks  of  sharp,  colicky  pains,  especially  a  few  hours  after 
eating,  distressing  defecation,  obstinate  constipation,  perhaps  alternating 
with  diarrhea,  sometimes  vomiting,  Avhich  may  be  feculent,  and  not  rarely 
slight  meteorism.  The  special  symptoms  of  carcinoma  of  the  papilla  of 
Vatcr  are  vomiting,  jaundice,  and  colic.  The  progressive  emaciation 
and  debility  are  marked.  In  advanced  cases  of  stenosis  the  feces  are 
passed  in  small,  compressed  lumps  resembling  sheep's  dung. 

Physical  Examination. — Inspection  of  the  abdomen  may  show  the 
presence  of  a  tumor  along  the  line  of  the  sigmoid  flexure  or  colon ; 
peristalsis  may  be  seen  above  the  site  of  the  carcinoma,  communicating 
its  movements  to  the  abdominal  walls.  Palpation  may  be  resorted  to 
in  order  to  confirm  the  above,  and  the  growth  is  then  frequently  found 
to  be  nodulated.  A  sign  which  is  practically  diagnostic  of  stenosis  is 
a  sudden  appearance  of  small  coils  of  bowel  which  vanish  very  quickly 
and  reappear  again  (Boas).  Percussion  may  give  either  dulness  or  a 
muffled  tympany  over  the  tumor  and  for  some  distance  above  (often 
sharp! v  defined),  on  account  of  accumulated  masses  of  feces. 

Diagnosis. — This  may  rest,  in  some  cases,  upon  heredity,  the  age, 
the  evidences  of  the  cancerous  cachexia,  sliarp.  radiating  abdominal 
pains,  bloody  stools,  and  the  detection  of  a  firm  and  nodular  tumor. 
Patchy  pigmentation  of  the  skin  and  small  angiomas  are  corroborative 
features.  An  ar-ray  examination  may  prove  an  aid  in  the  diagnosis.  The 
prospects  for  early  diagnosis  are  unfavorable  (J.  Boas^). 

Differential  Diagnosis. — (a)  Carcinoma  of  the  bowel  above  the  rectum 

needs  to  be  discriminated  from  other  abdominal  tumors.     For  example, 

sarcomata,  fibromata,  myomata,  adenomata,  and  cystomata  may  produce 

symptoms  of  obstruction  like  those  due  to  carcinomatous  growths.     The 

'  Forlschr.  der  Med.,  February,  1906. 


CARCINOMA    OF  TIIK  INTESTINE.  879 

cancerous  cachexia  may  bo  simulated  by  other  conditioriK.  The  advanced 
age  of  the  patient  and  tlio  rapid  and  downward  progress  of  the  disease 
will,  however,  point  toward  malignancy.  KnterolitkH,  foreign  hodici^ 
and  old  peritonitic  adhesions  may  need  to  be  excluded  also.  Fecal  masses 
may  exist  above  and  overshadow  the  presence  of  carcinoma. 

{b)  The  portion  of  the  bowel  involved  by  the  neoplastic  growth  is  also 
difficult  of  definite  diagnosis.  The  locality  of  the  tumor  as  detected  by 
palpation,  associated  with  special  symptoms,  is  of  value  in  arriving  at 
a  diagnosis  of  the  diseased  portion  of  the  bowel,  lleulin  ^  has  studied 
carefully  primary  cancer  of  the  duodenum,  and  asserts  that  the  com- 
parative frecjuency  of  duodenal  involvement  is  due  to  limited  motion  of 
the  organ,  being  thus  subject  to  injury.  When  it  occurs  above  the 
papilla  of  Vater  the  symptoms  greatly  resemble  those  of  dilatation  of  the 
stomach.  An  important  point  separating  carcinoma  above  from  that 
below  the  papilla  is  the  presence  or  absence  of  bile  in  the  vomit,  being 
absent  if  situated  above.  When  the  carcinoma  involves  the  papilla  of 
Vater  symptoms  of  biliary  obstruction  necessarily  follow.  A  hard, 
nodular  mass  may  sometimes  be  felt  in  the  lower  epigastric  region ; 
this  coupled  with  increasing  gastric  dilatation  and  marked  persistent 
jaundice  would  indicate  carcinoma  of  the  duodenum.  It  is  apparent, 
however,  that  carcinoma  of  the  pylorus.,  of  the  left  lobe  of  the  liver,  or 
of  the  omentum  or  mesenteric  glands,  or  a  thickened  cecum  might  all 
be  easily  confounded  with  carcinoma  of  the  bowel  at  various  adjacent 
parts  of  its  course.  The  injection  of  fluid  into  the  bowel  may  be  re- 
sorted to  in  locating  the  probable  situation  of  the  growth.  Thus,  if 
obstruction  from  carcinoma  exists  in  the  sigmoid  flexure,  liquid  will  be 
arrested  there  and  the  rectum  distended  ;  while,  if  the  stenosis  be  high 
up  in  the  large  or  small  intestine,  the  colon  will  be  found  comparatively 
emptied  of  feces  and  will  be  distended  with  the  injected  liquid.  Carcinoma 
of  the  appendix  usually  gives  rise  to  the  symptoms  of  appendicitis  with 
slight  fever.  These  cases  generally  occur  between  the  ages  of  twenty 
and  thirty  years  (Kernhadjian). 

Course  and  Complications.— ^Carcinoma  of  the  intestine  some- 
times runs  a  rapid  course,  and  may  last  but  a  few  months  ;  in  the  scir- 
rhous variety,  however,  the  disease  may  last  two  or  three  years. 

Intestinal  carcinoma  may  perforate  the  bowel  and  cause  fatal  puru- 
lent peritonitis.  Or,  owing  to  extreme  distention  by  fecal  accumulation 
between  a  cancerous  stricture  of  the  sigmoid  flexure,  for  instance,  and 
the  resistant  ileo-cecal  valve,  rupture  of  the  colon,  followed  by  perito- 
nitis, may  result.  Extension  of  the  growth  into  surrounding  tissues, 
with  ulceration,  may  lead  to  cellulitis,  phlebitis,  and  pyemia ;  and  ex- 
tension from  the  rectum  may  cause  purulent  vaginitis  and  cystitis. 

The  prognosis  is  almost  hopeless. 

Treatment. — This,  from  a  strictly  medical  standpoint,  is  simply 
palliative.  The  diet  should  be  highly  nourishing  and  easily  assimilable, 
but  when  the  symptoms  of  acute  obstruction  supervene  the  administra- 
tion of  food  by  the  mouth  is  contraindicated.  Opium  or  cannabis  indica 
for  the  pain,  and  stimulants  for  the  depression,  may  also  be  serviceable. 

Lavage  of  the  stomach  gives  decided  relief  for  recrurgitation  on  ac- 
count  of  the  damming  back  of  accumulated  food  detritus. 

^  Ga2.  hebdom.  de  Med.  et  de  Chir.,  February  13,  1898  ;  These  de  Paris,  1897 ;  Saunders' 
Tear-Book,  1899,  p.  194. 


880  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Carcinoma  of  the  bowel  may  be  treated  surgically  by  colotomy,  ex- 
cision, lateral  anastomosis  of  the  bowel,  enterostomy,  and,  if  the  growth 
be  situated  in  the  rectum,  by  extirpation  by  means  of  sacral  resection 
(Kraske's  opfration).  Opera bility  does  not  necessarily  depend  upon  the 
duration  of  the  disease. 


HABITUAL  CONSTIPATION. 

{Costiveness.) 

Definition. — Chronic  fecal  retention,  habitual  infrequency,  nregu- 
larity,  difficulty,  or  insufficiency  of  the  evacuations  of  the  bowels. 

Although  constipation  is  a  symptom,  and  although  habitual  consti- 
pation is  frequently  a  symptom  of  chronic  disease,  the  causal  elements 
of  the  latter  may  be  so  indefinite  and  obscure  that  the  former  takes  on 
all  the  individual  importance  of  a  functional  affection.  I  describe  habit- 
ual constipation,  therefore,  as  a  disease  sui  (/tmci'is  ("idiopathic"). 

Ktiology. — In  the  majority  of  cases  habitual  constipation  is  the 
direct  effect  of  a  lack  of  expulsive  or  peristaltic  power,  and  also  of  a 
deficiency  of  the  hepatic  and  intestinal  secretions.  Schmidt,  Strasburger, 
and  Lohrisch  claim  that  too  thorough  digestion  and  absorption  of  food- 
stuffs is  one  of  the  primary  factors  in  the  production  of  habitual  con- 
stipation. The  more  recent  investigations  of  Pletneu,^  however,  throw 
doubt  upon  the  latter  theory  ;  he  thinks  that  the  more  rational  explana- 
tion is  a  deficient  secretion  in  the  gastro-intestinal  tract.  Two  sets  of 
causes  operate  to  bring  about  these  conditions  of  abnormal  defecation  : 

General  Causes. — [a)  Temperament:  it  has  been  observed  often  that 
people  of  a  nervous  and  "bilious"  or  motive  temperament,  of  the  dark 
type,  are  much  troubled  with  constipation.  Anemic  brunets — per- 
sons having  pale  skin  and  dark  hair  combined — are  particularly  so 
affected,  although  alternating  periods  of  diarrhea  may  supervene,  owing 
to  the  hydremic  state  of  the  blood.  "Torpid  liver"  and  "sluggish 
bowels"  are  commonly  held  to  be  synonymous  with  these  physical  cha- 
racteristics. (6)  Habit :  a  sedentary  life  conduces  to  secretive  inactivity. 
Thus,  a  lazy  life,  in  which  the  calls  of  nature  are  irregularly  attended  to 
or  habitually  neglected,  leads  to  frequent  over-distent  ion  of  the  rectum 
and  paresis,  a  common  cause  of  chronic  constipation.  Again,  the  femi- 
nine false  modesty  (so  called)  that  prompts  a  postponement  and  suppres- 
sion of  the  desire  to  defecate  in  public  places  tends  to  obtund  the  sensi- 
bility of  the  rectum  to  fecal  masses.  The  accumulation  of  these  fecal 
masses  causes  paralytic  over-distention,  their  hardening  into  scybala,  and 
difficulty  of  exjjulsion.  (c)  Grencral  bodily  weakness,  and  diseases,  as 
neurasthenia,  hysteria,  anemic  brain-  and  spinal-cord  affections  (causing 
inhibitory  disturbances  of  the  intestinal  nerve-supply),  acute  fevers, 
hepatic  disorders,  especially  the  presence  of  jaundice,  and  the  habitual 
dependence  upon  and  use  of  purgatives,  {d)  Diet:  the  constant  use  of 
concentrated  articles  of  food,  as  meats,  in  which  little  residual  mat- 
ter is  left  to  stimulate  the  bowel  to  peristalsis.  On  the  other  hand,  a 
very  coarse  diet  may  leave  such  an  excess  of  residue  as  to  cause  fecal 
impaction.  {e)  A  change  of  drinking-water,  or  water  from  chalky 
regions.  Constipation  is  also  caused  by  the  use  of  an  insufficient  amount 
^Zeitsch.f.  ezpenm.  Path.  w.  Therap.,  Band  v.,  Heft  1,  p.  186,  1908. 


HABITUAL   CONSTIPATION.  881 

of  water  daring  the  intervals  between  meals.  (/)  Abundant  and  pro- 
Io7u/ed  diuresis  and  diaphoresis,  l>y  causing  loss  of  fluids,  also  may  induee 
chronic  constipation. 

Local  Causes. — (a)  Atony  of  the  abdominal  muscles  from  obesity  or, 
in  females,  as  a  result  of  improper  dress  and  many  pregnancies,  (b) 
Atony  of  the  large  bowel  (the  sigmoid  flexure  in  particular)  from  chronic 
colitis,  (c)  Pressure  by  tumors,  (d)  The  presence  of  intestinal  stenosis 
from  external  or  internal  constriction,  (e)  Congenital  stricture  or  giant 
growth  of  the  colon,  with  coprostasis  (as  in  Formad's  case).  (/)  Tonic 
contraction  of  the  muscular  coat,  as  in  basilar  meningitis  and  lead-pois- 
oning,    (g)  Enteroptosis.     (h)  Retention  of  the  gastric  contents. 

Symptoms. — In  cases  in  which  there  is  no  adequate  cause  for  habit- 
ual constipation  other  than  a  constitutional  or  inherent  peculiarity  there 
may  be  the  true  appearance  of  perfect  health.  Nothing  is  complained 
of  save  the  fact  that  an  evacuation  of  the  bowels  occurs  too  infrequently. 
The  term  "  constipation  "  is,  individually  speaking,  almost  wholly  a  rela- 
tive one — i.  e.,  one  person  may  enjoy  good  health  with  but  one  evacuation 
every  other  day,  another  with  two  passages  per  diem,  while  still  another 
must  have  one  stool  a  day,  cceteris  paribus,  to  feel  perfectly  well.  The 
last  is  usually  considered  an  average  normal  state  with  most  people. 

Symptoms  of  habitual  constipation  may  be  direct  or  reflex.  Direct 
or  local  troubles  are  seen  in  the  feeling  of  fulness,  weight,  and  pressure 
in  the  perineum  and  abdomen.  Flatulence,  colicky  pains,  and  alterna- 
ting diarrhea  occur  not  infrequently.  The  hurried  and  inattentive  per- 
formance of  defecation  gives  rise  to  the  so-called  "cumulative  constipa- 
tion," in  which  the  accumulated  feces  are  but  partially  evacuated  with 
the  movement,  and  the  rectum  consequently  is  not  emptied.  A  sense 
of  fulness  then  remains,  and  complete  relief  is  not  felt  in  these  cases. 

Reflex  and  general  symptoms  are  malaise,  languor,  hebetude,  irrita- 
bility of  temper,  headache,  facial  flushing,  palpitation,  cold  extremities, 
anorexia,  vertiginous  attacks,  paresthesia,  menstrual  distress  in  women, 
sleeplessness,  and  bad  dreams.  Pressure  on  the  sacral  and  visceral 
nerves  may  cause  neuralgias.  The  tongue  is  coated.  Palpation  of  the 
abdomen  often  shows  the  presence  of  doughy-like  fecal  tumors  at  the 
cecum  or  at  the  hepatic,  splenic,  and  sigmoid  flexures,  or  of  bologna- 
like masses  at  intervening  places.  In  marked  cases  attacks  of  nausea 
and  vomiting,  with  diarrhea.,  may  ensue ;  fever  may  also  be  present. 

Complications  and  Sequelae. — Hemorrhoids,  ulcerative  colitis, 
perforation,  and  enteritis  may  be  associated  with  chronic  constipation. 
Not  rarely  do  we  have  as  results  dilatation  of  the  colon  or  sacculation, 
with  the  presence,  in  old  people  mainly,  of  enteroliths  (calcified  scyb- 
ala)  ;  also  intestinal  obstruction  and  typhlitis,  or  cerebral  hemorrhage 
or  hernia  from  violent  straining  efi'orts. 

Diagnosis. — Bearing  in  mind  the  relativity  of  constipation  in  dif- 
ferent individuals,  the  diagnosis  is  read  at  sight.  The  detection  of  the 
causes  is  not  difficult,  though  sometimes  tedious.  An  etiologic  diagnosis 
may  require  modern  methods,  such  as  an  r-ray  examination,  the  examin- 
ation of  the  feces  according  to  Schmidt  and  the  procedure  known  as 
rectoromanoscopy.  "  In  spastic  constipation,  hypertonicity  is  found  in 
the  distal  portion  of  the  colon,  and  normal  tonicity  with  hypermotility  in 
the  proximal  portion"  (Singer  and  Holzknecht).  Hypochondriasis  or 
melancholia  should  be  carefully  placed  either  as  precedent  to  or  conse- 

56 


882  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

quent  upon  chronic  constipation,  the  nervous  condition  often  acting  to 
pro(hice  the  latter,  and  I'ice  versa. 

Tht'  prognosis  is  usimlly  favorable,  but  should  be  guarded. 

Treatment. — Hygienic. — Causative  factors  must,  of  course,  be  re- 
moved, modified,  or  lessened.  Systematic  regularity  as  to  time  and 
frequency  and  sufficiency  of  movements  of  the  bowels  should  be  en- 
joined upon  and  practised  by  the  patient.  Exercise  is  of  signal  value,  and 
particularly  horseback  riding  or  gymnastic  motions  that  bring  the  ab- 
dominal muscles  into  play.  Attention  to  the  calls  of  nature  should  be 
esteemed  a  duty,  and  projier  time  and  heed  must  always  be  given  to  the 
completeness  of  defecation.  The  dietetic  reijimcn,  if  properly  looked 
after,  often  avails  much  in  relieving  this  affection,  and  foods  calculated 
to  be  easily  digestible,  but  leaving  a  moderate  residue  after  digestion,  are 
to  be  recommended.  Such  are  bread  made  of  unbolted  flour,  plenty  of 
vegetables  and  fruits,  butter,  and  such  laxative  articles  as  figs  or  honey. 
Certain  substances  which  swell  from  imbibing  water,  but  are  not  digested 
or  absorbed,  such  as  agar-agar,  liquid  vaseline,  coarse,  raw,  wheat  bran, 
and  the  like,  may  be  advantageously  taken  with  the  food.  Prof.  L,  B. 
Mendel,  experimenting  with  agar-agar,  found  that  the  greatest  part  of  it 
was  excreted  in  the  feces  unchanged ;  this  substance  resists  intestinal 
enzymes  and  bacterial  decomposition,  and  is  recommended  for  chronic 
constipation.  Gompcrts^  has  had  experience  of  its  use,  and  advises  lo- 
gram  doses  twice  daily,  eaten  with  milk  or  cream,  the  same  as  a  modern 
breakfast  food.  After  regular  movements  of  the  bowels  have  begun,  the 
dose  of  agar  is  reduced.  Luke-  has  had  good  results  with  the  use  of 
sour  milk.  A  glass  of  cold  water  taken  regularly  at  bed-time  and  in  the 
morning  before  breakfast  is  efficacious  and  a  point  of  common  knowledge. 

Remedial. — The  methods  and  means  offered  for  the  cure  of  chronic 
constipation  number  legion.  From  the  little  aperient  pill  or  '•  peristaltic 
persuader  "  to  the  cannon-ball  rolled  externally  along  the  course  of  the 
large  bowel  is  made  up  such  a  list  of  drugs  and  measures  as  to  leave  un- 
tenable any  plea  of  lack  of  resource.  Drugs  occupy  a  subordinate  part 
in  the  treatment  of  hahitual  constipation.  Indeed,  their  use  should  be 
restricted  to  those  periods  when  the  bowels  become  unusually  obstinate. 
The  constant  use  of  laxative  and  purgative  drugs  tends  to  a  confirmation 
of  the  condition. 

I  have  found  of  value  in  lithemic  and  dyspeptic  subjects  the  laxative 
bitter  waters  (Hunyadi  Janos,  Kissingen,  Friedrichshall,  Carlsbad). 

Among  those  laxatives  and  cathartics  most  commonly  used  may  be 
mentioned  aloes,  rhubarb,  Rochelle  and  Epsom  salts,  compound  licorice 
powder,  castor  oil.  jalap,  senna,  mercury,  colocynth,  and  podophyllin. 
Important  adjuncts  in  combination  with  one  or  more  of  the  above  are 
the  extract  of  nux  vomica  (or  strychnin)  and  the  extracts  of  belladonna, 
hyoscyamus,  and  physostigma.  The  much-used  aloes,  strychnin,  and 
belladonna  pill  can  be  used  for  a  considerable  length  of  time  in  the  hope 
of  stimulating  a  normal  intestinal  and  sphincteric  activity,  and  thus  in- 
ducing even  a  cure  in  some  cases.      The  fornmla  is  as  follows : 

i;..  Aloin.,  gr.  iij-v  (0.194-0.324); 

Strychnime  sulphat.,  gr.  f^-     (0.0216-0.0324); 

Extr.  belladonna,  gr.  ij-ijss  (0.129-0162). 
M.  et  div.  in  pil.  No.  xx. 
Sig.   One  pill  at  bedtime. 
1  Amer.  Jour.  Med.  Sci..  October,  1909.  '•*  Practitioner,  1910,  Ixxxiv.,  fi53. 


DILATATION  OF  THE  COLON.  883 

Sulphur  in  confection,  alon^  with  the  official  pill  of  aloes  and  iron, 
has  been  recommended  for  tlie  habitual  constipation  of  anemia.  In 
senile  atony  of  the  bowel,  with  much  flatulence,  a  laxative  pill  having 
in  combination  apafetida  or  capsicum  is  often  beneficial. 

The  subjoined  foi'midse  are  nlso  serviceable: 

'Sf.  Ext.  cascar.  sagrad.,  3ss  (2.0) ; 

Ext.  nucis  vomicae,  gr.  iv  (0.269); 

Ext.  physostigmat.,  gr.  iij  (0.194); 

Ext.  beiladonnge,  gr.  ij  (0.129). 

M.  et  ft.  in  pil.  No.  xx. 
Sig.   One  at  night,  or  night  and  morning. 

(Aloes,  gr.  j  (0.0648),  or  podophyllin,  gr.  ii-iij  (0.129-0.194),  or  ext. 
colocynth.  comp.,  gr.  ii-iij  (0.129-0.144),  may  be  substituted  for  cascara 
in  the  foregoing  formula.)  Spastic  constipation  {e.  g.,  that  due  to  lead 
intoxication)  may  at  times  be  relieved  successfully  by  the  use  of  seda- 
tives, such  as  bromides,  valerian,  asafoetida,  and  opium. 

The  mechanical  means  of  relieving  habitual  constipation,  as  by 
enemata,  are  injurious  if  long  continued,  by  reason  of  their  irritating 
effect  on  the  rectal  and  colonic  mucous  membrane.  At  times  when  the 
stomach  is  weak  or  irritable,  a  loaded  bowel  may  be  relieved  by  an  ordi- 
nary  enema  of  soap  and  water  or  by  one  containing  |  to  1  ounce  (16.0- 
32.0)  of  castor  oil,  with  1  or  2  drams  (4.0-8.0)  of  oil  of  turpentine  if 
there  be  some  flatulence.  Glycerin  enemata,  containing  from  -|-  to  2 
ounces  (16.0-64.0)  of  the  agent,  may  be  used.  Fleiner  has  suggested 
oil-injections.  From  2  to  4  ounces  of  sweet  oil  warmed  to  body-heat 
by  standing  the  containing  bottle  in  a  vessel  of  hot  w^ater,  may  be 
injected  slowly  through  a  piston-syringe  on  retiring  and  retained  until 
next  morning.  Riesman,^  who  has  had  a  considerable  experience  of 
their  use,  speaks  strongly  in  favor  of  oil-injections.  Paraffin  injections 
of  the  consistency  of  a  salve  at  the  temperature  of  the  body  are  warmly 
recommended  by  Lipowski ;  they  tend  to  prevent  absortion  of  fluids  in 
the  rectum.  Suppositories  of  soap,  molasses  candy,  or  glycerin  are  in- 
cluded in  the  armamentarium.  Massage  also  claims  an  important  part 
in  the  relief  of  habitual  constipation.  It  acts  by  stimulating  the  peris- 
talsis and  the  abdominal  muscles,  and  should  be  employed  at  set  times  in 
the  day  preceding  a  desired  evacuation  of  the  bowels.  The  hand  of  the 
masseur,  or  that  of  the  trained  patient  even,  when  systematically  used  in 
this  way,  may  be  effectual  when  all  other  means  have  failed.  The  regular 
rolling  of  a  metal  ball  along  the  course  of  the  greater  gut  may  be  men- 
tioned for  its  novelty  as  well  as  for  its  undoubted  efficacy.  The  application 
of  the  fai^adic  current  to  the  abdominal  walls  or  galvanization  of  the  lumbo- 
abdominal  circuit  deserves  proper  trial  in  many  cases.  Hydrotherapeutic 
measures,  or  cold  sponging  and  baths,  are  nearly  always  useful  adjuncts. 


DILATATION  OF  THE  COLON. 

{Ectasia  of  the  Colon. ) 

This  is  usually  a  chronic  condition,  though  not  rarely  it  is  acute.     It 
may  also  be  general,  but  in  the  majority  of  cases  it  is  confined  to  the 
^  The  Therapeutic  Rerieic,  February,  1904. 


884  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

colon,  and  particularly  to  the  siirnioid  Hexuro.  The  postt/iortcDi  findings 
are  tliose  of  hyiicrtiophic-  dilatation  of  tlie  bowel,  and  rarely  ulcerative 
and  catarrhal  lesions  of  the  intestinal  mucosa  are  noted.  The  siirmoid 
flexure  is  prone  to  become  dihiied  in  sultjects  in  whom  it  is  congenitally 
elongated.  Atony  of  the  muscular  coat  is  a  leading  causative  element. 
The  most  distinctive  features  are  constipation,  which  generally  dates 
from  infancy,  and  great  abdominal  di><ti'>ttion.  Peristaltic  waves  may  be 
visible  upon  the  surface.  The  condition  may  exhibit  constijiation  alter- 
nating with  regular  daily  movements,  and  the  distention  changing  to  a 
normal  softness  of  the  abdominal  parietes.  I  have  recently  seen  a  case 
of  this  kind  in  a  male  aged  twenty-seven.  In  the  treatment  of  the  con- 
stipation, lavage  of  the  intestine  with  a  very  long  tube  is  superior  to 
laxatives  or  purgatives.  A  diet  calculated  to  prevent  or  relieve  constipa- 
tion is  indicated.  Vegetable  foods  leaving  a  gross  residue  should  be 
prohibited.  Massage,  galvanism,  and  hydrotherapy  are  all  capable  of 
beneficial  effects  in  suitable  cases.  Strychnin  is  a  valuable  remedy,  as  is 
also  betanaphtol  for  its  antifermentative  action,  and  in  cases  attended 
with  constriction  surgical  measures  should  be  considered. 


COLOPTOSIS. 

{Displacement  of  Colon.) 


Coloptosis. — Displacement  of  the  colon  in  various  directions  is 
occasionally  observed.  In  7  cases  reported  by  W.  W.  Babcock  ^  the 
stomach  was  not  found  to  be  displaced.  Certain  sections  of  the  colon 
show  accessory  loopings  and  tortuosities,  as  the  result  of  an  unusually 
long  mesentery.  The  transverse  colon  and  cecum  are  most  often  seen 
to  deviate  from  their  normal  course  and  may  depend  upon  anomalous 
formation ;  while  tympany  and  obstinate  constipation  may  favor  the 
condition.     The  symptoms  are  those  of  dilatation  of  the  colon  (p.  883). 

Diagnosis. — Irregular  abdominal  distention  with  tympany  over  such 
areas.  Inflation  of  the  colon  with  gas  or  water  may  enal)le  one  by 
careful  percussion  to  detect  with  some  certainty  this  condition.  At 
times  the  position  of  the  colon  is  shown  by  skiagraphs  taken  after  the 
colon  lias  been  well  filled  with  an  emulsion  in  which  bismuth  is  contained. 

Treatment  is  practically  that  of  dilatation  of  the  colon. 


INTESTINAL    AUTO -INTOXICATION. 

This  condition  was  alluded  to  in  the  discussion  of  lithemia  and  also  that 
of  chronic  gastritis,  but  it  demands  brief  special  description.  Although 
not  a  pathologic  entity,  it  is  readily  recognized  clinically  and  known  to 
be  due  to  the  absorption  into  the  circulation  of  toxic  bodies,  namely, 
albumoses  and  leucomaines.  which  are  formed  during  intestinal  digestion. 
If  these  substances  enter  the  circulating  blood  rapidly  and  in  sufficient 
quantity,  acute  intestinal  auto-intoxication  is  the  result ;  this  often  assumes 
the  nature  of  a  bilious  attack  or  migraine  in  the  course  of  the  chronic 
variety,  or  it  may  follow  obstinate  constipation. 

^International  Medical  Maf/azine,  March,  1901. 


INTESTINAL  AUTO-INTOXf(JATfON.  885 

The  chronic  form  is  the  most  common,  if  we  except  cliiMrcn,  in  whom 
the  reverse  is  true. 

The  etiology  is  vjiriod  and  (A'Um  obscure  in  the  case  in  question. 
The  ingestion  of  proteins  in  excessive  amounts  is  doubtless  the  most 
potent  causative  factor.  Fat  and  sugar  taken  in  amounts  above  the 
physiologic  capacity  of  the  organism  are  also  responsible  for  the  condition 
in  certain  cases,  and  the  same  may  be  true  of  certain  aljnormalities  of 
metabolism.  Moreover,  obstructive  conditions  of  the  intestinal  tube, 
constipation,  and  chronic  appendicitis  or  any  pathologic  changes  that  will 
iijterfere  with  the  function  of  motion,  may  act  as  causes. 

Fortunately  for  mankind,  certain  protective  functions  often  prevent 
the  development  of  auto-intoxication.  Thus  the  liver  destroys  the  toxic 
bodies  as  a  rule,  but  deficient  hepatic  function  leads  to  their  formation 
in  excessive  amounts.  Again,  the  digestive  tract,  skin,  and  especially 
the  kidneys  are  normally  active  in  the  elimination  of  these  poisonous 
substances.  It  is  the  putrefactive  products  not  oxidized  to  indican  that 
constitute  the  toxins. 

Diagnosis. — "  The  physician  should  never  make  the  diagnosis  of 
intestinal  auto-intoxication  until  he  has  made  a  careful  differential  diag- 
nosis eliminating  everything  else"  (Forchheimer).  The  group  of  symp- 
toms most  commonly  observed  is  as  follows  :  Headache  (often  of  the  type 
of  migraine),  vertigo,  a  high-tension  pulse,  constipation,  signs  of  hepatic 
congestion,  flatulence,  indicanuria,  at  times  albuminuria,  furred  tongue, 
and  the  presence  of  chronic  ulcerative  stomatitis  (Rigg's  disease).  Unless 
the  indican  and  conjugated  sulphates  in  the  urine  be  excessive  in  amount, 
they  cannot  be  regarded  as  indicative  of  intoxication.  In  a  considerable 
proportion  of  cases  vomiting  and  often  diarrhea  are  associated  with  fever 
and  skin  eruptions  (erythema,  urticaria),  or  arthritis  resembling  rheuma- 
tism, or  distressing  myalgic  pains  occur.  The  constipation  may  alternate 
with  diarrhea  or  mere  irregularity  of  bowel  action  exists.  "  A  careful 
physical  examination  of  the  colon,  more  particularly  by  light  percussion, 
will  indicate  the  presence  of  an  overfilled  condition  of  the  bowel,  most 
commonly  in  its  descending  portion.  Palpation  may  detect  a  doughy 
mass  or  masses  in  one  or  more  sections  of  the  colon,  and  after  removal  of 
these  fecal  accumulations  more  or  less  thickening  of  the  intestinal  walls, 
due  to  a  catarrhal  state  with  infiltration,  may  be  detectable."^  The 
nervous  manifestations  most  prominent  in  the  clinical  picture  are  a  feel- 
ing of  languor,  insomnia,  loss  of  physical  and  mental  energy,  vertigo, 
and  irritability,  with  occasional  headaches. 

Treatment. — In  the  acute  form  the  treatment  of  the  cause  suffices 
as  a  rule.  Purgation  by  means  of  mercurials  followed  by  a  saline  are 
indicated  first  of  all.  The  diet  must  be  fluid  and  much  restricted  in 
amount,  milk  and  gruels  being  especially  serviceable.  Water  is  to  be 
taken  freely,  if  retained.  In  the  chronic  form  digestible  solids,  com- 
posed principally  of  vegetables,  milk  (particularly  sour  milk),  bread,  and 
cereals  should  form  the  protein  in  the  diet.  These,  with  fruits,  bacon, 
and  butter,  in  right  proportions,  will  give  65  grams  of  protein  daily. 
While  it  is  the  proteins  in  abnormal  amount  that  excite  the  fermentative 
and  putrefactive  processes,  I  have  observed  instances  in  -which  the  carbo- 
hydrates (sugar,  starch)  seemed  to  act  as  the  cause,  hence  the  latter  must 
1  Journal  of  the  Indiana  State  Medical  Association,  by  the  writer,  July,  1908. 


886  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sometimes  be  excluded  from  the  dietary.  Laxative  articles  of  food  and 
such  as  leave  a  maximum  residue  in  the  intestines  are  efficacious  in  over- 
coming constipation.  The  use  of  two  or  three  glasses  of  cold  water  or 
mineral  water  on  retiring,  on  rising,  and  between  meals  favors  elimina- 
tion, both  through  the  bowels  and  kidneys. 

The  function  of  the  latter  is  of  the  highest  importance  as  a  channel 
of  elimination.  If  the  above  suggestions  do  not  aftbrd  thorough  relief 
daily  to  the  bowels,  warm  saline  laxatives  before  the  morning  meal  are  to 
be  advised.  Among  the  most  eitioient  are  sodium  phosphate  and  sodium 
sulphate,  or  the  aperient  waters,  as  Ilunyadi,  Apenta,  Carlsliad,  Veronica, 
an<l  the  like.  It  may  be  necessary  to  administer  a  mercurial  from  time 
to  time  to  maintain  biliary  secretion.  Gastric  lavage  and  colonic  irriga- 
tion should  be  resorted  to  in  the  acute  gastro-intestinal  attacks.  The 
mouth  condition  and  gastric  features  must  be  treated  as  recommended  in 
appropriate  sections  of  this  work.  Cutaneous  elimination  is  to  be  aided 
by  hot  baths  or  Turkish  or  Russian  baths  ;  they  must  be  carefully  adapted 
to  the  individual  cases.  Physical  exercise  deserves  proper  trial  in  most 
cases  and  massage  is  also  a  useful  adjunct  when  active  exercise  is  unsuit- 
able. 

For  the  flatulence  which  often  proves  annoying,  intestinal  antiseptics 
are  indicated.  Of  undoubted  value  for  this  purpose  are  ^9-napthol,  salol, 
benzosol,  and  menthol.  These  remedies  should  be  administered  as  sug- 
gested by  Forchheimer,  namely,  in  the  form  of  an  intestinal  pill  or  one 
dissolved  only  in  an  alkaline  medium,  and  Waldstein  recommends  a  coat- 
ing with  an  alcoholic  solution  of  shellac  containing  salol  to  accomplish 
this  object.  It  has  been  suggested  to  raise  the  content  of  Bacillus  coli  com- 
munis in  the  bowel  ''  by  instillation  either  of  the  autogenous  mixed  forms 
or  strains  from  other  individuals  "  (Bassler).  The  underlying  and  etiologic 
conditions  and  complications  must  receive  due  attention  in  every  case. 


NEUROSES   OF  THE  INTESTINE. 

As  in  the  case  of  the  stomach,  these  embrace  derangements  of  (n) 
secretion,  (b)  sensation,  and  (c)  motion. 

(a)  SECRETORY  DISTURBANCES. 

Unquestionably  the  intestinal  secretion  may,  through  a  purely  ner- 
vous influence,  be  augmented.  This  manifests  itself  most  frequently  in 
the  primary  morbid  secretion  of  mucus  {mucous  colic)  and  in  membranous 
enteritis.  Moreover,  the  fact  that  an  actual  catarrh  of  the  intestinal 
mucosa  may  supervene  as  a  secondary  event  is  undeniable. 

MUCOUS     COLIC. 
{Colitis   Colica,  Enttrllis  Monhranacea.) 
Definition.— A  peculiar  pathologic  condition,  chiefly  of  the  large 
intestine,  attended  by  a  morbid  secretion  of  mucus. 

Pathology. — In  the  truly  primary  form  there  are  no  morbid  lesions 
discoverable  in  the  mucosa.  From  mucous  colic  we  must  distinguish 
membranous  enteritis,  which  is  associated  with  an  inflammatory  process 


NEUROSES  OF  THE  INTESTINE.  887 

of  the  mucosa  and  accompanies  typhoid  fever,  dysentery,  and  many  other 
affections.  Tliis  is  a  catarrh  of  the  colon,  while  true  mucous  colic,  the 
disease  under  consideration,  is  a  functional  (secretory)  disturbance. 

[J^tiology. — Sex  has  a  decided  influence,  80  per  cent,  of  cases  are  ob- 
served in  neurotic  women.  It  is  rare  in  children.  Direct  niechauical  irrita- 
tion of  the  rectum  (horseback-riding,  bicycle-i'iding,  hardened  scybala, 
etc.).  Bacteria  are  believed  to  play  a  causative  role,  particularly  the 
Bacillus  coli  communis. 

Symptoms. — I  have  found  the  condition  associated  with  a  consti- 
pated habit — a  fact  that  may,  in  part,  explain  its  occurrence,  since  time 
is  thus  allowed  for  cast-formation.  The  important  feature  is  the  panaoye,, 
at  varying  intervals,  of  long,  ribbon-like  threads  of  mucus,  or  of  more  or 
less  perfect  casts  of  the  gut,  with  tenesmus  and  severe  colicky  pains. 
The  stools  consist  of  a  turbid  ground-substance,  which,  on  the  addition 
of  acetic  acid,  becomes  opaque  and  striped ;  cellular  detritus,  consisting 
parti}'  of  granules  and  partly  of  cellular  elements,  including  blood. 
Symptoms  of  neurasthenia  are  present  and  are  often  quite  pronounced. 

The  individual  paroxysms  vary  in  duration  from  one  to  ten  days  or 
more.  In  one  case  observed  by  me  the  attacks  lasted  about  two  days, 
recurring  regularly  at  the  end  of  every  three  months.  Ordinarily  the 
recurrence  is  after  a  shorter  interval. 

Diagnosis. — A  microscopic  examination  of  the  pieces  of  membrane 
insures  the  diagnosis.  It  is  to  be  recollected,  however,  that  membranes 
are  not  passed  with  every  attack,  and  that  there  is  a  complete  absence 
of  the  signs  of  organic  disease  between  the  attacks  of  colic. 

Course  and  Prognosis. — The  disease  pursues  a  very  chronic 
course  and  lasts  for  many  years.  The  bodily  nutrition  suffers  consider- 
ably if  the  attacks  are  frequent  and  severe,  but,  as  a  rule,  this  does  not 
occur  until  a  late  stage  in  the  affection.      The  risk  to  life  is  slight. 

(6)  SENSORY  DISTURBANCES. 

It  may  be  noted  here  that  the  sensory  nerves  of  the  intestines,  as 
well  as  the  inhibitory  and  vaso-motor  dilators,  are  traceable  to  the 
splanchnics.     Increased  sensibility  of  the  sensory  nerves  produces — 

ENTERALGIA. 

{Neuralgia  of  the  Intestine.) 

l^iology. — This  is  commonly  met  with  in  •  hysteric,  neurasthenic, 
and  anemic  subjects.  It  occurs  as  a  reflex  neurosis,  as  in  the  case  of 
cold,  gout,  and  irritative  lesions  of  the  pelvic  organs  (kidneys,  liver). 
Enteralgia  is  symptomatic  of  many  local  affections  and  conditions 
that  induce  direct  irritation  of  the  sensory  nerve-filaments  of  the  in- 
testine ;  among  these  are  inflammation  of  the  mucosa,  foreign  bodies, 
gall-stones,  abnormal  distention  with  gas,  and  enteroliths.  Under  these 
circumstances  the  condition  is  associated  with  increased  activity  of  the 
motor  nerves  or  heightened  contraction  of  the  muscularis,  forming  true 
intestinal  colic.  In  lead  colic  it  is  probable  that  the  lead  acts  di- 
rectly upon  the  nerves  or  their  ganglionic  cells.  I  have  repeatedly 
observed  the  action  of  certain  exciting  causes  {e.  g..  nervous  shocks). 

Symptoms. — Enteralgia  may  develop  very  suddenlg,  but  oftener  it 


888  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sets  in  less  abruptly,  and  is  then  attended  Avith  eructations  of  gas,  ex- 
pulsion of  flatus,  and  the  like.  In  the  fully-developed  attack  the  pain 
may  attain  to  great  violence,  causing  the  patient  to  '■''  bend  double  "  or 
even  faint,  and  its  character  is  variously  described  as  boring,  tearing, 
or  cutting.  The  pain  may  be  confined  to  a  circumscribed  spot  or  may 
be  diffuse.  The  attacks  arc  sometimes  brief,  or  they  may  be  character- 
ized by  a  sudden  subsidence.  At  other  times  they  last  for  days  or  per- 
haps weeks,  and  then  subside  gradually.     Mecurrences  are  common. 

Hypogastric  neuralgia  is  a  term  applied  to  neuralgia  aff'ecting  the 
sensory  nerves  lying  in  the  most  dependent  segments  of  the  intestine. 
Here  the  nerve-fibers  entering  into  the  hemorrhoidal  plexus  are  involved. 
It  is  caused  chiefly  by  tabes,  by  hemorrhoids,  and  by  the  neurotic  state 
so  common  to  females.  This  form  of  neuralgia  has  its  seat  in  the  hypo- 
gastric region,  and  is  accompanied  by  a  distressing  sensation  of  pressure 
in  the  rectum  and  bladder,  and  by  an  irresistible  desire  to  go  to  stool ; 
pains  also  radiate  to  the  sacrum,  thighs,  and  perineum. 

Diagnosis. — The  various  organic  diseases  and  conditions  mentioned 
under  Etiology,  in  the  course  of  which  colic  is  a  common  symptom,  must 
be  separated  from  the  true  neurotic  enteralgia.  The  former  are  distin- 
guished from  the  latter  by  a  group  of  symptoms  peculiar  to  themselves 
(fever,  aggravation  of  the  pain  upon  pressure,  vomiting,  constipation, 
or  diarrhea),  and  by  the  usual  definite  causes  furnished  by  the  history. 

Renal  and  hepatic  colic  bear  a  superficial  similarity  to  enteralgia. 
The  former  conditions,  however,  are  distinguished  first  by  the  seat  and 
direction  of  the  pain,  and  secondly  by  the  appearance  of  jaundice  in 
hepatic  colic  and  of  hematuria  in  renal  colic.  Rheumatism  of  the 
abdominal  muscles  is  easily  eliminated,  since  it  is  generally  combined 
•with  rheumatism  in  other  parts  of  the  body ;  the  pain  is  also  greatly 
increased  upon  throwing  the  muscles  into  contraction,  as  in  stooping  or 
rising ;  finally,  it  vanishes  in  response  to  the  action  of  the  salicylates. 

DIMINISHED    INTESTINAL   SENSIBILITY. 

This  implies  diminished  peristalsis  or  constipation.  A  greater  or 
less  degree  of  anesthesia  of  the  bowel  attends,  with  a  loss  of  desire  to 
go  to  stool  and  an  accumulation  of  feces  in  the  rectum.  This  is  a  usual 
concomitant  in  many  diseases  of  the  brain  and  cord,  with  which  paraly- 
sis is  associated.  Motor  innervation  may  remain  intact,  and  when  atony 
of  the  intestine  is  absent  spontaneous  movements  of  the  bowels  occur ; 
when  atony  is  present,  however,  to  a  marked  degree  (motor  paralysis), 
the  feces  must  be  artificially  removed. 

(c)  DISTURBANCES   OF   MOTILITY. 

When  the  contractility  of  the  muscularis  is  increased  from  purely 
nervous  causes  the  result  is — 

NERVOUS   DIARRHEA. 

This  condition  presents  no  morbid  lesions.  The  increased  contrac- 
tility results  from  an  exaggerated  irritability  of  the  motor  nerves  of  the 
bowels.    It  may  also  result  from  morbid  processes  in  the  central  nervous 


NEUROSES  OF  THE  JNTESTINE.  889 

system  and  in  other  organs  of  the  body;  in  short,  the  condition  may  be 
a  reflex  one. 

Examples  of  this  sort  are  caused  by  tabes,  by  gastric  disturbances, 
as  after  certain  foods  and  drinks,  by  dentition,  and  the  like.  Most 
cases,  however,  are  encountered  in  persons  having  an  abnormally  irrita- 
ble nervous  organization — i.  e.  the  neurasthenic  and  hysteric  classes. 
In  such  the  effect  of  mental  excitement,  of  fright,  and  similar  psychic 
influences  is  to  induce  diarrheal  evacuations. 

SytnptotSiS. — The  stools  vary  in  number  from  two  or  three  to 
twenty-four  or  more  daily.  In  rare  instances  they  are  soft — not  truly 
diarrheal — and  formed,  yet  they  may  be  quite  frequent.  Blood  and 
mucus,  pus,  and  other  morphologic  elements  are  absent  from  the  de- 
jections. It  is  characteristic  of  nervous  diarrhea  that  the  stools  follow 
one  another  in  rapid  succession,  usually  during  the  morning  hours,  and 
then  discontinue  for  the  greater  part  of  the  day.  The  bodily  nutrition 
is  often  well  preserved. 

In  the  diagftiosis  organic  affections  of  the  bowel  are  to  be  carefully 
eliminated. 

ENTEROSPASM. 
{Spasm  of  the  Intestine.) 

By  this  term  is  meant  a  concurrent  spasm  of  both  the  longitudinal 
and  circular  muscular  fibers,  usually  inducing  spasmodic  constipation, 
and  sometimes  total,  though  temporary,  occlusion  of  the  bowel. 

Its  causes  are  similar  to  those  of  nervous  diarrhea,  and  the  condition 
is  clinically  related  to  enteralgia.  Neither  pain  nor  constipation,  how- 
ever, is  a  constant  feature-  The  stools  may  assume  the  form  of  a  rib- 
bon or  of  large  rounded  masses  (sheep's  dung),  but  they  are  not  pathog- 
nomonic. They  may  also  be  covered  with  mucus.  Ewald  distinguishes 
between  an  idiopathic  and  a  secondary  or  symptomatic  spasm,  the  lat- 
ter being  a  concomitant  of  basilar  meningitis  and  of  chronic  lead- 
poisoning  (see  also  Constipation,  p.  880).  Another  variety  affects  the 
rectum  (proctospasm),  and  is  generally  secondary  to  some  other  rectal 
affection,  as  fissure  of  the  anus ;  it  may,  however,  occur  as  a  neurosis  in 
the  hysteric  and  nervous  class  of  subjects. 

The  diagnosis  of  true  functional  enterospasm  can  only  be  made  after 
all  organic  causes  that  may  produce  spasm  of  the  bowel  have  been 
excluded. 

CONSTIPATION. 

This  is  a  common  condition  as  a  neurosis.  It  is  due  to  an  abnormity 
of  function  of  the  intestinal  nerves  that  leads  to  a  weakened  peristaltic 
action,  and  is  met  in  hysteria,  neurasthenia,  and  the  various  forms 
of  psychoses.  Central  nervous  affections  often  manifest  atony  of  the 
intestine  as  a  symptom ;  hence  this  form  is  not  a  disease  sici  gen- 
eris. Cases  of  this  class  do  not  respond  to  any  variety  of  cathartics 
(Ewald). 

Paralysis  of  the  external  sphincters  is  a  common  concomitant  in  a 
great  variety  of  local  (catarrhal)  and  central  nervous  diseases.  Under 
these  circumstances  the  act  of  defecation  may  be  purely  reflex,  owing  to 


890  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

loss  of  control  of  the  voluntarv  muscles :  or  it  may  be  voJu)itari/,  ex- 
cept when  the  person  affected  is  not  upon  his  guard,  or  during  mental 
excitement,  micturition,  sneezing,  and  like  influences. 

Treatment  of  Intestinal  Neuroses. — A  suitable  change  of  en- 
vironment, including  an  appropriate  arrangement  of  the  dietary,  is  of 
primary  importance,  and  is  uniformly  applicable  in  this  class  of  sufferers. 
Further,  the  treatment  of  special  cases  has  peculiar  reference  to  the 
character  of  the  nervous  derangement.  After  making  an  accurate  diag- 
nosis a  search  for  the  factors  of  the  greatest  etiologic  importance  should 
be  made,  and  these  must  then  be  vigorously  assailed. 

In  the  secret  on/  neuroses  an  associated  mucous  colic  must  be  cor- 
rected, the  digestion  is  to  be  improved  if  faulty,  and  the  obstinate  con- 
stipation overcome.  For  the  latter  symptom  enemata  containing  ox- 
gall, either  alone  or  in  combination  with  salines,  are  especially  service- 
able. Kussmaul  and  Fleiner  have  obtained  the  best  results  from 
regular  large  oil-enemata  administered  once  or  twice  daily.  During  the 
painful  attacks  copious  enemata  of  normal  saline  solution  to  which  has 
been  added  oil  of  peppermint  (5  drops  to  the  pint  at  a  temperature  of 
100°  F.)  will  sometimes  bring  speedy  relief  from  the  pain  and  other 
distressing  colonic  symptoms,  and  will  assist  nature's  efforts  at  separating 
the  cast-formations.  Pain  must  be  at  times  relieved  by  morphin.  The 
results  of  treatment  of  mucous  colic,  however,  are  unsatisfactory.  Sur- 
gical measures  have  been  adopted  in  .selected  cases. 

In  the  sensory  disturbances  in  which  the  activity  of  the  sensory 
nerves  is  increased  (enteralgia  and  hypogastric  neuralgia)  the  treatment 
may  be  considered  under  two  headings :  first,  the  relief  of  the  neuralgic 
pains  ;  and  secondly,  the  correction  of  the  causes  or  conditions  on  which 
the  enteralgia  depends.  If  the  pain  be  severe,  opium  or  morphin  may 
be  required.  Especially  good  as  an  antispasmodic  is  codein,  which 
may  suffice  in  all  save  the  severer  cases.  The  object  should  be  to  give 
the  minimum  amount  of  the  opiate  that  will  meet  the  necessities  of  the 
case,  with  a  view  to  obviating  a  resultant  constipation.  In  hypogastric 
neuralgia  I  have  found  suppositories  containing  opium  to  be  little  short 
of  magical  in  their  effects. 

In  cases  in  which  there  is  constipation  due  to  diminished  sensibility, 
with  a  loss  of  motor  innervation  (atony  of  the  bowel),  the  feces  must  be 
artificially  removed  unless  the  underlying  condition  can  be  successfully 
overcome.  It  is  especially  important  that  the  environment — physical  and 
psychic — be  so  regulated  as  to  bring  about  an  improvement  in  the  gen- 
eral condition  of  the  patient.  It  may  become  necessary  to  employ  tonic 
preparations  of  strychnin,  iron,  or  arsenic. 

The  treatment  of  nervous  diarrhea  involves  the  same  principles,  so 
far  as  the  indication  presented  by  the  peculiar  nervous  organization  is 
concerned,  as  in  the  sensory  and  secretory  neuroses.  It  is  especially 
important  to  prevent  the  operation  of  the  direct  causes — fright,  mental 
excitement.  Astringents  and  intestinal  antiseptics  are  not  called  for, 
unless  the  bodily  nutrition  be  affected  thereby.  Enterospasm  is  to  be 
met  by  the  same  remedies  that  are  used  to  control  enteralgia. 


DISEASES   OF  THE  LIVER.  891 

IX.   DISEASES  OF  THE  LIVER. 
ANOMALIES  IN  SHAPE  AND   POSITION. 

Altered  Shape. — Malformations  of  the  liver  may  be  either  the  result 
of  disease  or  of  pressure  of  adjacent  structures.  The  former  "  may  be 
due  to  syphilis,  foetal  peritonitis,  or  possibly  to  tuberculosis  "  (Rolleston). 
Of  the  latter  class  the  most  important  cause  is  tight  lacing,  met  with 
almost  exclusively  in  women  and  producing  the  so-called  "corset-liver." 
The  lower  part  of  the  right  lobe  of  the  liver  is  usually  the  part  affected  ; 
the  hepatic  parenchyma  is  atrophied,  owing  to  continued  compression, 
and  shows  deep  grooves  that  correspond  to  the  position  of  the  lower  ribs. 
The  connective-tissue  capsule  and  the  peritoneal  coat  are  both  thickened 
at  this  point.  In  marked  cases  the  right  lower  lobe  may  become  con- 
verted into  a  dense  fibrous  band.  Among  other  acquired  causes  of 
anomalies  in  shape  may  be  mentioned  deformities  of  the  vertebrae  and 
ribs,  or  tumors  of  the  ribs  or  adjacent  structures  (pylorus)  pressing 
against  the  liver.  Moser  invites  attention  to  multiple  lobulation,  as 
many  as  16  lobules  having  been  found ;  this  is  due  to  pathologic  causes 
and  is  not  a  morphologic  phenomenon. 

Diagnosis. — Rarely,  clinical  symptoms  are  present.  "  A  constant 
sensation  of  pressure  and  pulling  is  felt  in  the  hepatic  region,  and 
sometimes,  as  a  result  of  venous  stasis,  there  is  a  temporary  but  decided 
swelling  of  the  isolated  portion,  and,  possibly,  violent  pain  and  indica- 
tions of  irritation  of  the  peritoneum,  such  as  vomiting  and  an  approach 
to  collapse.  Jaundice  is  rare  in  consequence  of  this  deformity  "  (Striim- 
pell).  The  danger  of  this  condition  lies  in  a  possible  mistaking  it  for  an 
abdominal  tumor  (Pepper),  amyloid  disease,  passive  congestion,  or  neiv 
growths  of  the  organ  (Striimpell). 

Primary  alterations  in  the  shape  of  the  organ  may  be  due  to  active 
or  passive  congestion,  hereditary  syphilis,  hypertrophic  or  atrophic  cir- 
rhosis, acute  yellow  atrophy,  carcinoma,  abscess,  or  hydatid  cyst.  The 
accompanying  symptoms  would,  of  course,  be  those  of  the  special  disease 
causing  the  deformity. 

Anomalies  of  position  are  not  infrequently  met  with,  the  organ 
being  displaced  upward,  downward,  or  laterally.  The  most  common 
cause  of  lateral  displacement  is  an  abnormal  lengthening  of  the  suspen- 
sory ligament.  The  organ  may  occupy  the  epigastric  region  or  be  dis- 
placed into  the  lower  part  of  the  abdominal  cavity,  but  a  change  in  the 
posture  of  the  patient  or  external  pressure  is  often  sufiicient  to  replace 
the  organ.  The  symptoms  (if  present  at  all)  consist  of  a  dragging  sensa- 
tion, often  amounting  to  pain  that  may  be  severe  and  referred  to  the 
right  shoulder.  On  physical  examination  palpation  may  reveal  a  fissure 
between  the  right  and  left  lobes,  together  with  a  movable  tumor  pre- 
senting the  size  and  normal  outlines  of  the  liver,  which  by  manipulation 
may  be  reposited.  Percussion  gives  tympany  over  the  normal  hepatic 
area,  which  changes  to  flatness  when  the  organ  is  pressed,  or  falls  into 
its  natural  position. 

Displacement  upward  may  result  from  gastric  or  intestinal  distention, 


892  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

marked  ascites,  or  an  abdoiiiinul  tumor ;  Avliile  dowmvard  displacement 
may  be  due  to  a  mediastinal  tumor,  emphysema,  or  a  pleural  effusion. 

Diagnosis. — Among  the  conditions  likely  to  be  confounded  with 
movable  liver  may  be  mentioned  careiuoyiui  of  the  omentum  or  of  the 
pi/Iorus,  de%'mo/d  ei/sts.  tionors  of  the  ovari/  and  uterus,  hydro-  or  pyo- 
nephrosis, tumors  of  the  kidney,  and  chrome  proliferative  perito7u'tis. 
By  a  careful  study  of  the  symptomatology,  and  in  the  absence  of  the 
normal  physical  signs  over  the  hepatic  area,  the  diagnosis  can  usually  be 
established,  although  marked  fatty  degeneration  or  atrophic  cirrhosis 
may  coexist  with  any  of  the  above  conditions  and  cause  marked  <liminu- 
tion  in  the  area  of  hepatic  dulness.  Steele's  careful  studies  of  100  cases 
of  floating  liver  show  that  colicky  pains,  often  accompanied  by  jaundice 
and  simulating  hepatic  colic,  occur  in  nearly  40  per  cent,  of  the  cases. 

The  treatment  of  movable  liver  is  merely  palliative,  and  consists  in 
the  application  of  a  suitable  bandage  for  preventing  the  displacement. 


JAUNDICE. 

(Icterus.) 

Definition. — A  condition  in  which  the  tissues  and  secretions  are 
stained  with  bile-pigments.     Jaundice  is  not  a  disease,  but  a  symptom. 

Hepatogenous  or  ohstruetive  jaundice  is  more  commonly  seen  in — 
(1)  Inflammatory  swelling  of  the  duodenum  or  of  the  lining  membrane 
of  the  duct,  which  is  by  far  the  most  common  factor  in  its  causation,  and 
demands  separate  consideration  {vide  infra.  Catarrhal  Jaundice) ;  (2) 
Foreign  bodies  within  the  ducts,  as  gall-stones  or  parasites  ;  (3)  Stric- 
ture or  obliteration  of  the  duct ;  (4)  Tumors  within  the  duct  or  ob- 
structing its  orifice ;  (5)  Pressure  on  the  duct  from  without,  as  by  a 
tumor  of  the  liver,  stomach,  pancreas,  or  omentum ;  also  by  fecal  ac- 
cumulations, displaced  organs  (e.  g.  floating  kidney),  a  pregnant  uterus,  en- 
larged glands  in  the  fissure  of  the  liver,  and,  more  rarely,  by  abdominal 
aneurysm  ;  (6)  Lowered  blood-pressure  in  the  vessels  of  the  liver  favor- 
ing resorption  of  bile,  as  in  simple  icterus  of  the  neAv-born  (Frerichs). 

CATARRHAL   JAUNDICE. 

(Hepatogenous  Jaundice;    Icterus   Catarrhalis :    Duodeno-cholangitis :  Inflammation 

of  the  Common  Bile-duct.) 

Definition. — A  condition  characterized  by  a  discoloration  of  the  tis- 
sues from  retention  and  absorption  of  bile  and  resulting  from  a  catarrhal 
inflammation  of  the  lining  membrane  of  the  ducts,  more  especially  the 
larger,  and  of  the  duodenum. 

Pathology. — On  examining  a  liver  and  gall-bladder  in  situ  the 
former  is  usually  found  enlarged,  lighter  in  color  than  normally,  and  of 
a  distinct  icteroid  tint.  On  making  a  longitudinal  section  drops  of  bile 
can  be  collected  on  the  edge  of  the  section-knife. 

The  gall-bladder  is  found  distended  with  bile,  and  on  firm  pressure  a 


CATARRHAL  JAUNDICE.  893 

tough  plug  of  mucus  is  usually  expelled  from  the  common  duct  into  the 
duodenum,  after  which  bile  flows  into  the  intestine  freely.  The  mucosa 
linino:  the  ductus  communis  is  swollen  and  inllamed,  and  the  catarrhal 

o  ... 

process  may  extend  to  the  cystic,  and  in  some  cases  to  the  hepatic,  duct. 
As  a  rule,  that  portion  of  the  common  duct  lying  in  the  intestinal  wall 
is  more  frequently  and  more  deeply  involved.  If  the  disease  becomes 
chronic,  a  formation  of  connective  tissue  occurs,  owing  to  the  irritation 
caused  by  the  retained  secretion,  and  atrophy  of  the  liver-cells,  with 
biliary  cirrhosis,  may  result.     Suppuration  is  rare. 

Toxic  (hematogenous)  jaundice,  so-called,  has  for  its  lesion  extensive 
catarrh  of  the  intra-hepatic  bile-ducts  from  their  origin.  Here  duodenal 
catarrh  is  not  necessary  for  the  production  of  jaundice.  It  was  formerly 
assumed  that  the  pigment  (hemoglobin)  was  liberated  in  the  blood ;  but 
Stadelmann  and  others  have  shown  that  the  bile  containing  the  poison, 
or  its  irritant  products  (toxins),  excite  inflammation  of  the  finer  ducts. 

Ktiolog"y. — Simple  catarrhal  jaundice  results  in  a  majority  of  cases 
from  extension  of  inflammation  in  gastro-duodenal  catarrh,  and  the 
principal  predisposing  causes  are  as  follows :  (a)  Exposure  to  cold  and 
wet ;  (6)  The  use  of  improper  foods,  including  faulty  cooking  and  im- 
proper mastication  ;  (c)  The  excessive  or  prolonged  use  of  irritants  (tea, 
coffee,  alcohol) ;  (d)  Prolonged  anxiety  and  mental  or  physical  overwork  ; 
(e)  Certain  acute  diseases,  as  pneumonia,  relapsing  fever,  typhoid  fever, 
and  malaria  (toxic  jaundice,  vide  supy^a) ;  (/)  Portal  obstruction,  occur- 
ring in  chronic  heart-  or  kidney-disease ;  (^)  More  rarely  it  has  occurred 
in  epidemic  form,  although  said  to  be  common  around  the  Mediterranean 
Sea.  Barker  and  Sladen  ^  found  that  food  (probably  meat)  was  the  most 
likely  source  of  the  infectious  agent  in  an  epidemic. 

Symptoms. — Preceding  the  development  of  the  distinctive  features 
by  several  days,  dyspeptic  symptoms  are  in  evidence  {vide  Gastro-hepatic 
Symptoms).  The  principal  symptoms  in  detail  are  :  (a)  Icterus^  or  tint- 
ing of  the  body  surface  may  be  the  first  symptom  noticed  in  this  condi- 
tion, appearing  usually  on  the  forehead  and  neck  and  rapidly  spreading 
over  the  entire  body.  The  conjunctivae  also  early  become  discolored,  and 
the  general  hue,  though  variable,  is  commonly  a  bright  lemon-yellow.  In 
chronic  cases  the  color  is  apt  to  change  to  a  bronzed  or  deep-green  tint. 

(6)  Secretions  and  Excretions. — The  urine  and  sweat  are  often  found 
to  contain  bile-pigment,  the  patient's  linen  frequently  being  discolored. 
In  extreme  cases  the  urine  may  be  dark-green  in  color,  while  in  those 
of  average  severity  it  is  of  a  lighter  or  deeper  greenish-yellow  hue. 
The  shaken  specimen  foams,  and  the  froth  has  a  yellow  color-tint. 
Often  the  presence  of  bile  is  detected  before  any  noticeable  coloring 
of  the  conjunctivae  occurs.  In  cases  of  intense  or  long-standing 
jaundice  albumin  and  tube-casts  may  be  present,  and  the  latter  may 
be  bile-stained.-  Hyaline  casts  are  often  found  in  cases  of  moderate 
intensity. 

^  Bidletin  Johns  Hopkins  Hospital,  October,  1909. 

'^  Tests  for  Bile. — Gmelin's  test,  or  the  play  of  colors,  consists  in  bringing  a  few  drops 
of  nrine  in  contact  with  the  same  quantity  of  commercial  nitric  acid  on  a  plain  white 
slab,  whereupon  various  shades  of  yellow,  green,  red,  and  violet  are  produced. 

Rosenbach's  test  is  made  by  filtering  the  suspected  urine  and  touching  the  filter-paper 
with  a  drop  of  nitric  acid.  If  bile  be  present,  a  green  circle  will  form  at  the  point  of 
contact.      (See  also  Choluria.) 


894  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  bowels  are  constipated,  and  the  stools  are  pale-drab  or  slate- 
colored  ;  they  are  usually  very  fetid.  Diarrhea,  however,  may  be  pres- 
ent, owing  to  the  production  of  irritating  substances  and  decomposition. 

The  tears,  saliva,  and  milk  are  rarely  stained  with  bile-pigment.  The 
expectoration  also  is  rarely  tinted,  unless  pneumonia  or  some  form  of 
pulmonary  infiltration  coexists. 

(c)  Circulation. — The  pulse,  although  not  appreciably  altered  in  vol- 
ume or  tension,  is  usually  slow  (often  30  or  even  20  beats  per  minute), 
thou^ih   this  is  not  an  unfavorable  symptom. 

(d)  The  temperature  is  usually  normal,  although  slight  elevations 
may  occur  (100°-101°  F.— 37.7°-38.3°  C). 

(e)  Q-astro-hepatic  Symptoms. — Dyspeptic  symptoms — viz.  anorexia, 
a  sense  of  fulness  after  eating  with  flatulence,  acid  eructations,  nausea 
and  vomiting,  accompanied  by  a  dull,  heavy  pain  over  the  hepatic  area, 
with  some  tenderness  on  pressure — are  present.  These  often  develop  in- 
sidiouslv  ;  rarelv  they  occur  suddenly  with  a  severe  rigor  or  chill,  vio- 
lent headache,  and  vomiting — c.  (/.,  at  the  onset  in  the  epidemic  form. 

(/)  Cutaneous  Phenomena. — Pruritus  or  itching  often  becomes  a 
troublesome  symptom,  being  more  common,  however,  in  the  chronic 
forms.  Lichen,  urticaria,  furuncles,  and  sweatings  (diffused  and  local- 
ized) may  develop,  the  latter  being  often  limited  to  the  skin  covering 
the  abdomen  and  the  palms  of  the  hands. 

A  peculiar  disease  of  the  skin  called  xanthelasma  or  hita  higoidea 
mav  also  occur.  It  consists  of  bright-yellow^  spots,  slightly  elevated, 
appearing  on  the  eyelids,  and  rarely  on  other  parts  of  the  body. 

In  the  severer  forms  ecchymoses  and  sometimes  profuse  hemorrhages 
may  occur  into  the  skin  and  mucous  membranes.  These  are  usually 
associated  Avith  symptoms  of  a  grave  type.  In  chronic  forms  the  coagu- 
lation time  of  the  blood  is  much  delayed. 

{g)  Nervous  Sj/mptoms. — Headache  and  vertigo  are  common  ;  irri- 
tability of  temper,  despondency,  and  wakefulness  or  mental  dulness 
almost  equally  so.  With  the  oncoming  of  darkness  vision  may  grow 
indistinct  {hemerahjna)  or  it  may  attain  unnatural  clearness  {nyc- 
talopia). Rarely,  objects  look  yellow  (.ranthopsia).  The  nervous  phe- 
nomena observed  in  catarrhal  jaundice  are  attributable  to  the  effects 
of  the  bile-acids.  In  certain  cases,  however,  associated  with  destruc- 
tion of  the  hepatic  substance,  as  in  acute  yellow  atrophy,  carcinoma, 
cirrhosis,  and  fatty  degeneration,  grave  cerebral  symptoms  (acute 
delirium,  convulsions,  and  coma)  may  develop  suddenly  and  prove 
fatal.  This  class  of  symptoms  has  been  named  acholia,  cholemia,  or 
cholesteremia  (the  latter  owing  to  the  mistaken  supposition  that  cho- 
lesterin  is  the  poisonous  product).  The  true. nature  of  the  toxic  agent 
in  the  blood  is  unknown.  In  some  fatal  terminations  of  this  character 
death  was  due  directly  to  a  renal  complication. 

The  physical  signs  in  a  case  of  simple  catarrhal  jaundice  show  on 
palpation  and  percussion  an  increase  in  the  hepatic  area,  the  lower  bor- 
der of  the  liver  projecting  in  some  instances  several  fingers'  breadths 
below  the  ribs.  Karely,  the  distended  gall-bladder  projects  below  the 
lower  lobe  of  the  liver,  as  when  there  is  complete  obstruction  near  or  at 
the  duodenum,  and  then  it  can  be  distinctly  palpated. 

Diagnosis. — The  etiology  (errors  in  hygiene  and  diet),  a  history 


CATARRHAL  JAUNDICE.  805 

of  previously  existing  gastro-intestinal  catarrh,  the  age  of  the  patient 
(young  adult  life),  and  the  appearance  of  the  jaundice  unaccompanied 
by  pain  or  general  emaciation,  together  with  an  absence  of  symptoms 
pointing  to  cirrhosis,  carcinoma,  or  acute  yellow  atrophy,  form  a  char- 
acteristic grouping  of  clinical   indications. 

Duration  and  Prognosis. — 'I'he  duration  of  catarrhal  jaundice 
varies  from  two  to  eight  weeks.  If  the  symptoms  continue  longer  than 
two  months,  grave  doubts  may  be  entertained  as  to  the  case  being  one  of 
simple  jaundice.  The  prognosis  is  guardedly  favorable.  A  rise  of  tem- 
perature usually  indicates  mischief  (Pepper),  while  hemorrhages  of  the 
skin  and  mucous  membranes  always  influence  the  issue  unfavorably. 

Treatment. — The  diet  and  hygiene  are  the  first  considerations  in  the 
treatment.  Rich,  highly  seasoned  foods,  rich  pastries,  fats,  and  sweets, 
are  to  be  interdicted ;  starchy  foods,  lean  meats,  bread,  soups  (contain- 
ing no  fat),  and  green  vegetables  may,  however,  be  used  in  moderation. 
Skimmed  milk,  butter-milk,  and  alkaline  drinks  (Vichy  and  Saratoga 
mineral  waters)  may  be  used  freely,  while  sour  wines,  lemonades,  and 
tamarind-water  are  allowable.  Systematic  bathing  (Turkish  or  Russian 
baths,  under  supervision)  and  regulated  hours  of  sleep  exert  a  bene- 
ficial eifect.  The  free  use  of  pure  water  often  does  good  by  increasing 
the  flow  of  bile  and  by  dislodging  plugs  of  mucus. 

Gerhardt  and  Kraus  have  recommended  the  faradic  current,  applied 
over  the  region  of  the  gall-bladder ;  manipulation  has  also  been  tried 
with  a  view  to  removing  the  obstruction,  but  without  success. 

The  first  therapeutic  indication  is  to  keep  the  bowels  freely  soluble 
by  the  use  of  saline  aperients,  as  Hunyadi  water  or  Carlsbad  salts  {\  to 
1  teaspoonful  in  hot  water  before  meals).  The  latter  remedies  tend  to 
lessen  the  catarrhal  inflammation  by  depleting  the  mucous  membranes. 
In  obstinate  constipation  calomel  or  rhubarb  may  be  employed. 

Conspfcuous  among  other  remedies  may  be  mentioned  the  alkalies, 
sodium  bicarbonate,  salicylate,  and  phosphate,  which  tend  to  increase  the 
flow  of  bile  and  render  it  less  thick  ;  hydrochloric  acid  (which,  accord- 
ing to  Ewald,  by  aiding  digestion  prevents  the  formation  and  consequent 
absorption  of  toxic  substances),  in  combination  with  the  bitter  tonics — 
gentian,  quassia,  and  nux  vomica ;  ammonium  chlorid,  which  sometimes 
proves  beneficial;  and  silver  nitrate  (gr.  |-J — 0.008-0.016,  thrice  daily). 

Injections  of  cold  water  (60°-70°  F.— 15.5°-21.1°  C),  daily,  in 
quantities  of  1  or  2  quarts  (1—2  liters),  are  highly  recommended  as 
promoting  the  secretion  of  bile  ;  while  lavage,  practised  daily  and  over  a 
protracted  period  of  time  (one  to  two  months),  has  proved  highly  bene- 
ficial, especially  when  gastro-duodenal  catarrh  has  existed. 

Itching. — This  troublesome  symptom  may  often  be  relieved  by  the 
external  application  of  a  solution  of  borax  or  sodium  bicarbonate  (.^ss— 
Oj— 16.0-512.0),  or  of  menthol  and  alcohol  (gr.  x-sj— 0.648-32.0). 
Internally,  large  doses  of  the  bromids  or  the  continued  use  of  pilocarpin, 
as  recommended  by  Witkowski,  are  worthy  of  a  trial. 

Flatulence. — To  this  end  it  is  important  to  regulate  the  diet,  avoid- 
ing starches  and  sugars.  Charcoal  tablets,  bismuth  subnitrate  or  salicy- 
latei,  and  betanaphtol  are  all  useful.  Irrigation  of  the  colon  with  some 
efficient  antiseptic  in  solution  is  often  a  factor  of  service. 

Headache  is  caused  by  the  circulation  in  the  blood  of  some  toxic 


896  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

principle.     Of  drugs,  caftein  citrate,  camphor  monobromate.  and   phe- 
nacetin,  either  singly  or  in  combination,  may  be  recommended. 

AVhen  the  obstruction  is  due  to  mechanical  causes  (biliary  calculi, 
tumors  pressing  on  the  duct)  the  treatment  is  surgical. 

OTHER   FORMS    OF   JAUNDICE. 

Hemohepatogenous  Jaundice  {Hemolytic^  Toxic). — The  labors 
of  J^tadelmann.  Hunter,  ^iaunyu,  and  others  have  definitely  shown  that 
all  jaundice  is  hepatogenous,  since  bile-pigments  are  formed  only  in  the 
liver.  To  the  cases.  hoAvever,  in  which  destruction  of  erythrocytes  due 
to  toxemia  furnishes  the  hemoglobin  from  which  the  bile-pigments  are 
formed  in  excess,  the  term  hemohepatogenous  jaundice  has  been  given. 
This  toxic  or  hemolytic  jaundice  occurs  in  many  infections,  both  acute 
and  chronic  (typhoid  fever,  yellow  fever,  septicopyemia,  malaria,  pneu- 
monia, so-called  infective  jaundice),  and  in  pernicious  anemia  and 
chlorosis.  In  the  same  category  belong  the  intoxications — e.  g.,  snake 
venom,  cold-tar  products,  chloroform,  poisoning  with  ptomains,  mushrooms, 
phosphorus,  and  the  like. 

Chronic  Family  Jaundice. — There  is  a  chronic  jaundice  probably  of 
hemolytic  origin,  which  appears  in  several  members  of  a  family,  fre- 
quently in  two,  three,  or  four  generations.^  It  dates  either  from  birth,  or 
is  first  noticed  during  adolescence,  and  persists  throughout  life.  "  Bilious 
attacks,"'  enlargement  of  the  spleen,  and  a  moderate  grade  of  anemia  are 
the  chief  features.  The  stools  are  not  colorless  and  contain  no  bile,  but 
urobilin.     The  prognosis  as  to  life  is  good,  but  treatment  is  without  avail. 

Experiments  conducted  by  Mlinzer,  Starling,  Hopkins,  and  others 
tend  to  show  that  the  liver-function  is  not  suppressed  by  many  of  the 
conditions  and  aftections  mentioned  above ;  but,  on  the  other  hand,  that 
increased  secretion  (poIychoUa)  and  increased  formation  of  bile-pigments 
(polychroynia)  may  prevail.  Again,  the  poisons  or  toxins  may  cause  swell- 
ing of  the  cells  and  compression  of  the  biliary  capillaries  ;  this  would  cause 
obstructive  jaundice.- 

ACUTE  INFECTIOUS    CHOLECYSTITIS. 

Definition. — An  acute  inflammation  (infective)  of  the  gall-bladder. 

Pathology. — Five  pathologic  varieties  —  catarrhal,  suppurative, 
phlegmonous,  gangrenous,  and  membranous — are  recognized.  The  gall- 
bladder progressively  enlarges  and  becomes  filled  with  mucopurulent  or 
purulent  or  (rarely)  hemorrhagic  material.  The  cystic  duct  is  often 
occluded.  In  the  supparative  form  ulcers  may  coexist  and  perforation, 
followed  by  localized  peritonitic  abscess  or  acute  diffuse  peritonitis,  may 
occur.  The  lesions  of  cholangitis,  either  catarrhal  or  suppurative,  and 
also  cholelithiasis,  may  be  associated.  Cholecystitis  may  exist  without 
gall-stones. 

Ktiology. — The  bacterial  excitants  include  the  streptococci,  staphy- 
lococci, the  pnemococcus,  the  colon  bacillus,  and  the  typhoid  bacillus. 

Among  predisposing  conditions  are  many  of  the  acute  infections,  as 
typhoid,  typhus,  malaria,  sepsis,  pneumonia,  puerperal  fever,  and  cholera. 

1  Vide  Gaz.  d.  Hop.,  May  14,  1910,  Chalier;  Amer.  Jour.  Med.  Set.,  June,  1910,  Tiles- 
ton  and  Griffin. 


ACUTE  INFECTIOUS  CHOLECYSTITIS.  897 

DaCosta  has  collected  58  cases  of  typhoid  cholecystitis,  ills  fi;.njres 
show  that  it  may  occur  at  almost  any  age,  and  of  4S  cases  in  which  the 
sex  was  stated,  20  were  males  and  22  females. 

Symptoms. — The  onset  is  abrupt,  with  pain  (often  paroxys)iial)  in 
right  side  of  the  abdomen  or  epigastrium.  Tlic  region  of  the  gall-bladder 
is  acutely  sensitive,  and  with  the  development  of  spreading  peritonitis 
the  tender  area  grows  correspondingly.  Rigidity  of  the  right  rectis 
may  be  observed.  In  many  cases  a  tumor  occupies  the  seat  of  the  gall- 
bladder. It  is  detected  on  palpation  as  a  firm,  pear-shaped  tumor  or  as 
a  "mere  resisting  mass  below  the  costal  margin."  The  latter  is  often 
due  to  peritonitic  abscess  following  perforation. 

Nausea  and  vomiting,  which  may  be  persistent,  are  usual  symptoms 
at  the  outset.  Jaundice  occurred  in  17  out  of  58  cases  (DaCosta). 
Among  the  general  symptoms  chills  are  conspicuously  absent.  Fever 
may  be  present,  but  by  no  means  always ;  the  pulse  becomes  rapid  and 
feeble,  the  abdomen  distended,  and  prostration  profound.  Bayard  Holmes 
noted  cardiac  disturbance  as  the  most  characteristic  symptom  in  46  cases. 
In  the  suppurative  form  a  blood  examination  generally  shows  leukocyto- 
sis. The  writer  ^  has  reported  three  cases  of  cholecystitis  complicating 
lobar  pneumonia.  Jaundice  occurred  in  two  of  the  cases.  This  serious 
affection  may  be  entirely  latent. 

Differential  Diagnosis. — Appendicitis  may  be  mistaken  for  chole- 
cystitis, particularly  if  the  appendix  be  situated  abnormally  high  up. 
The  discrimination  would  here  rest  upon  the  history  (following  typhoid 
or  other  infection),  the  presence  of  a  tumor  and  marked  sensitiveness  in 
the  region  of  the  gall-bladder,  corroborated  by  jaundice. 

Acute  intestinal  obstruction  may  be  closely  simulated  in  cases  in 
which  adhesions  between  the  gut  and  gall-bladder  are  present.  In  such 
cases  exploratory  celiotomy  is  to  be  advised  or  at  least  considered  with 
a  view  to  clearing  the  diagnosis.  Recurrent  cholecystitis,  a  not  uncom- 
mon complaint,  gives  the  history  of  recurring  attacks  of  pain  simu- 
lating cholelithiasis.  In  one  of  my  cases  Laplace  operated  and  found 
the  gall-bladder  somewhat  enlarged  and  the  seat  of  catarrhal  chole- 
cystitis. Osier  suggests  that  in  some  of  these  cases  gall-stones  may 
have  been  present  and  have  passed  before  the  operation  (see  also  p.  898). 

Prognosis. — This  is  dependent  upon  the  special  variety,  although 
it  is  among  the  most  fatal  of  diseases.  A  fatal  result  is  the  rule  in 
purulent  and  phlegmonous  cholecystitis.  In  the  catarrhal  form  recov- 
ery is  not  infrequent  (DaCosta).  Pneumococcal  cholecystitis  is  more  acute 
and  severe  than  that  due  to  colon  or  typhoidal  infection  (Richardson). 
Gangrenous  cholecystitis  is  rare  and  quite  fatal. 

Treatment. — This  embraces  absolute  rest,  rectal  alimentation,  the 
relief  of  pain  by  the  judicious  use  of  morphin,  and  of  other  symptoms 
as  they  arise.  Stimulants  are  necessary  as  a  rule.  If  the  diagnosis  of 
suppurative  or  phlegmonous  cholecystitis  can  be  established,  surgical 
intervention  is  imperatively  demanded  as  a  rule. 

Chronic  Cholecystitis. — By  this  term  is  meant  chronic  inflammation 
of  the  gall-bladder,  either  secondary  to  an  acute  cholecystitis  or  a  chronic 
low-grade  infection  from  the  beginning.  It  cannot  be  diiferentiated  clinic- 
ally from  cholelithiasis,  with  which  it  is  associated  in  the  majority  of  cases. 

1  American  Medicine,  vol.  ix.,  No.  11,  ^larch  18,  1905. 
57 


898  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CALCULOUS   CHOLECYSTITIS. 

( BUiari/  i 'alcnli ;   Gull utoius  ;   Cfudtiitli id^).-'. ) 

Definition. — Concretions  formed  in  the  tjall-bladder,  usually  due  to 
infection  ot'its  walls ;  they  set  up  characteristic  disturbances  {c/ioli'lithiasis). 

Htiology. — Catarrhal  inHauiraation  of  the  gall-bladder  excites  patho- 
logic production  of  cholesterin  by  perverting  metabolism  inside  the  mucus- 
secreting  cells  in  its  walls.  Schlirmayer  believes  that  cholelithiasis  is 
really  an  expression  of  a  metal>olic  disease  of  the  liver.  Infective  catarrh 
of  the  small  intrahepatic  ducts  leads  to  an  albuminous  exudation,  which 
precipitates  bilirubin-calcium  calculi  in  the  bile.  Scheel  found  gall- 
stones in  15  per  cent,  of  2753  cadavers.  In  67  per  cent,  of  those  show- 
ing gall-stones  the  bile  passages  were  apparently  not  pathologic.  The 
exi'itini/  cause  is  an  infective  inflammation  of  the  gall-bladder  and  bile- 
ducts  due  to  various  organisms — e.  //.,  the  colrm  bacillus  and  the  typhoid 
bacillus.  Among  predisposing  causes  are :  (a)  Female  sex,  especially  be- 
tween the  ages  of  forty  and  sixty.  Senac's  statistics,  out  of  a  total  of 
311  individuals,  give  227  women  (Dujardin-Beaumetz).  (b)  Stagnation 
of  bile,  due  to  an  excessive  diet  of  starches  and  of  fits,  a  sedentary  life, 
constipation,  tight  lacing,  pregnancy,  obesity,  chronic  obstruction  to  the 
outflow  of  bile  (tumors,  visceroptosis).  Kehr  claims  that  stones  can  de- 
velop in  sterile  bile,  when  the  flow  is  obstructed,  (c)  It  may  occur  during 
childhood,  {d)  Disorder  about  the  pancreas  may  be  the  cause  of  gall- 
stone formation  (Croftan).  {e)  Insanity,  particularly  chronic  melancholia. 
(/)  Incidence.  Brockbank  found  among  13,047  completed  postmortem 
records  7.4  per  cent,  were  gall-stones. 

Composition  and  Appearance. — Gall-bladder  calculi  are  formed 
principally  from  cholesterin  mixed  with  some  bilirubin-calcium  from  the 
earliest  stage.  Certain  salts  (lime,  potash,  soda,  traces  of  iron  and 
copper)  also  enter  into  the  composition.  Those  formed  in  the  hepatic 
ducts  are  composed  of 'bilirubin-calcium  alone.  In  size  they  vary  from 
the  smallest  particle  of  sand  to  that  of  a  goose-egg.  Fagge  reports 
a  calculus  weighing,  in  a  dry  state,  462  grains  (30.0).  The  color 
varies  from  white  or  light-yellow  to  that  of  a  dark-green  (pigment- 
lime  calculi),  and  may  present  any  variation  between  these  tw^o  ex- 
tremes. The  nucleus  often  consists  of  cholesterin,  the  outer  layer 
being  usually  the  harder,  and  made  up,  for  the  most  part,  of  lime- 
salts.  The  cholesterin  gall-stones  cut  like  Avax,  are  white,  and  the 
cut  section  presents  a  crystalline  appearance.  Other  forms  are  apt 
to  be  brittle.  The  surfaces  may  be  smooth,  striated,  or  hollowed 
out,  solitary  calculi  being  usually  round  or  ovoid,  while  multiple  stones 
often  present  smooth  facets,  due  to  the  massing  together  of  the  calculi 
(Dujardin-Beaumetz).  They  are  usually  olive-sliaped,  but  may  be  pyra- 
midal, cylindric,  lenticular,  pisiform,  cubic,  finger-shaped,  or  olivary. 
Their  seat  is  usually  the  gall-bladder,  but  they  may  be  found  anywhere 
along  the  biliary  passages. 

Symptoms. — The  passage  of  a  calculus  through  the  duct,  if  it  sets 
up  a  "  perialienitis  "  or  inflammation  of  the  structures  surrounding  it 
{cholecystitis),  will  give  rise  to  hepatic  colic,  whereas  a  permanent  block- 
ing of  the  duct  will  cause  symptoms  of  chronic  obstruction  (vide  infra). 

Hepatic  Colic. — When  a  gall-stone  becomes  impacted  in   a  bile-duct 


CALCULOUS  CHOLECYSTITIS.  899 

the  patient  experiences  agonizing  pain  (tearing,  cutting,  or  lancinating 
in  character)  in  tlie  right  hypochondriac  region,  radiating  to  the  riglit 
shouMer,  and  accompanied  often  by  profuse  sweating,  vomiting,  and  a 
feeble,  running  pulse.  The  most  common  seat  of  the  pain  is  two  to 
three  inches  to  the  right  of  the  median  line  and  about  an  equal  distance 
below  the  ensiform  cartilage.  Less  frequently  it  is  in  the  region  of  the 
gall-bladder.  This  happens  in  cases  in  which  the  gall-stone  is  impacted 
in  the  cystic  duct,  and  may  be  due  either  to  distention  of  the  gall-)d:idder, 
or,  more  commonly,  to  associated  cholecystitis.  Hepatic  colic,  however, 
may  occur  independently  of  the  passage  of  biliary  calculi,  as  from  non- 
calculous  cholecystitis  (Stockton,  Riedel).  If  pain  is  severe  without 
relation  to  meal  time,  you  should  suspect  cholelithiasis.  On  the  other 
hand,  large  calculi  have  been  found  in  the  dejecta  without  having  ex- 
cited hepatic  colic.  I  saw  an  instance  in  which  the  gall-stone  was  the 
size  of  an  English  walnut.  A  rigor  or  chill  often  precedes  the  attack,  which 
is  usually  accompanied  by  moderate  fever  (Charcot's  intermittent  fever), 
the  temperature  reaching  101°-102°  F.  (38.3°-:38.8°).  If  the  stone 
passes  through  the  common  duct  without  becoming  impacted,  jaundice 
and  pain  may  be  absent.  When,  however,  occlusion  of  the  common 
duct  occurs,  the  jaundice  becomes  intense.  This  symptom  may  be 
present,  though  less  marked,  before  the  gall-stones  reach  the  ductus  com- 
munis. Jaundice  occurs  in  about  50  per  cent,  of  the  cases  (Fitz),  and 
it  sets  in  within  forty-eight  hours  after  the  onset  of  the  attack. 
Physical  examination  reveals  on  inspection  a  slight  prominence  in 
the  hepatic  area,  and  on  palpation  the  edge  of  the  liver  can  often  be 
distinctly  felt  below  the  costal  margin — at  times  as  low  as  the  umbilical 
level ;  it  is  sensitive  on  pressure,  and  particularly  the  gall-bladder,  which 
can  be  often  palpated.  If  the  latter  viscus  contains  many  calculi,  and 
the  abdominal  wall  is  relaxed,  crepitation  may  be  noticeable  to  the  pal- 
pating fingers  (rarely).  Tenderness  in  Boas'  area  to  the  right  of  the 
spine  between  the  tenth  and  twelfth  rib  is  a  valuable  confirmatory  sign. 
The  swollen  organ,  after  the  cessation  of  the  colic,  quickly  subsides. 
Tenderness  over  Mayo  Robson's  point  at  the  junction  of  the  lower  third 
with  the  upper  two-thirds  of  a  line  drawn  from  the  tip  of  the  ninth  rib 
to  the  umbilicus  is  a  characteristic  feature.  Recurrences  of  the  attacks 
after  varying  intervals  of  time  are  common,  and  in  the  female,  especially 
at  the  menstrual  period.  Finally,  the  gall-stone  may  be  expelled  and 
the  colic  cease  to  return.  Multiple  stones,  however,  may  be  passed. 
Hyperchlorhydria  is  commonly  present. 

Rupture  of  the  duct,  folloAved  by  fatal  peritonitis,  has  been  known  to 
occur.  Localized  peritonitis  results  from  extension  of  inflammation 
through  the  walls  of  the  gall-bladder.  Biliary  colic  is  of  variable  dura- 
tion, lasting  from  a  few  hours  to  a  few  days  or  one  or  more  weeks  even. 
Examination  of  the  urine  after  the  paroxysm  reveals  bile,  uric  acid,  and 
urates.  The  pulse  often  becomes  slowed.  Exner  found  about  0.4  per 
cent,  of  sugar  in  the  urine  in  39  out  of  40  cases  of  gall-stones.  On  the 
other  hand,  Kausch  has  found  glycosuria  in  only  one  of  85  cases. 

The  prognosis  as  regards  life  is  good,  but  as  regards  recovery  only 
guardedly  favorable.  Cardiac  distress  with  palpitation  may  occur  during 
hepatic  colic  and  form  a  serious  complication.  Fatal  syncope  has  also 
been  known  to  occur,  and  gall-stone  ileus,  especially  near  to  the  ileo- 
cecal valve,  may  terminate  life.     If  evidences  of  an  infectious  inflam- 


900  DISJiASES  OF  THE  DRIESTIVE  SYSTEM. 

mation  arise,  the  outlook  is  tlien  more  serious.  The  se(iueL\;  ■will  be  dis- 
cusseil  hereafter  (vide  infra). 

Diagnosis. — The  diau'iiosis  of  gall-stones  is  sometimes  diflicult  on 
aceoiuit  of  tlie  obscure  clinical  symptoms  and  the  absence  of  physical 
signs.  When,  however,  the  calculus  becomes  impacted  in  the  duct, 
symptoms  of  biliary  colic — intense  pain  in  the  epigastrium  and  right 
hypochondriac  region,  radiating  to  the  back  and  right  shoulder — usually 
appear.  The  attack  is  of  brief  duration,  with  abrupt  cessation.  There 
are  also  fever,  vomiting,  and  in  one-half  the  instances  jaundice.  The 
urine  should  be  examined  early,  since  bile  may  be  present  many  hours 
before  icterus  occurs.     Biliary  calculi  are  not  often  found  in  the  dejecta. 

Differential  Diagnosis. — Gastralgia  occurs  in  neurotic  individuals,  and 
is  characteiized  by  severe  paroxysnuil  pains  in  the  epigastrium,  extend- 
ing to  the  back  and  l>ase  of  the  chest.  It  occurs  when  the  stomach  is 
empty  and  is  relieved  by  eating.  Firm  pressure  over  the  epigastrium 
often  alleviates  the  pain  temporarily,  and  the  absence  of  fever,  jaundice, 
stones  in  the  dejecta,  and  the  negative  urinalysis,  together  with  the  his- 
tory of  former  attacks,  would  tend  to  differentiate  it  from  hepatic  colic. 

Renal  Colic. — The  pain  in  this  condition  starts  in  the  flank  of  the 
affected  side  and  is  transmitted  down  the  ureter,  and  there  is  localized 
tenderness.  The  testicle  and  inner  side  of  the  thigh  ai-e  very  painful, 
the  former  being  often  retracted.  ISlicturition  is  frequent  and  sometimes 
painful,  and  the  urine  is  scanty  in  amount  and  often  mixed  with  blood. 

Intestinal  Colic. — In  this  variety  the  pain  is  of  a  boring  or  twisting 
character,  usually  centering  about  the  umbilicus.  It  is  relieved  by  firm 
pressure.  iVbdominal  distention  is  often  present,  and  relief  comes  Avith 
the  passing  of  flatus.  Usually  there  is  a  history  of  an  indiscretion  in 
diet.  When  due  to  lead-poisoning,  the  history,  the  blue  line  on  the  gums, 
and  the  presence  of  wrist-drop  would  tend  to  confirm  the  diagnosis. 

Reflex  colie,  due  to  uterine  or  ovarian  disease,  may  also  occur.  The 
recurrence  of  the  attacks,  together  with  causes  and  symptoms  pointing  to 
pelvic  disease,  would  establish  the  identity  of  the  condition. 

CHRONIC    OBSTRUCTION    OF    THE    DUCTS   BY   GALL-STONES. 

The  obstruction  may  exist  either  in  the  common  or  the  cystic  duct. 

1.  Obstruction  oif  the  Common  Duct. — Pathology. — The  result 
of  the  irritation  produced  by  the  presence  of  the  stone  is  a  catarrhal  pro- 
cess (cholangitis)  that  may  either  remain  chronic  or  terminate  in  suppu- 
ration {suppurative  cholangitis).  In  a  case  of  simple  obstruction  the  gall- 
bladder is  often  moderately  enlarged,  though  rarely  extending  below  the 
lower  border  of  the  liver.  The  common  duct  is  greatly  distended,  the 
stone  being  usually  located  near  its  termination.  Occasionally  two  or 
more  calculi  are  ju'esent,  completely  obliterating  the  canal.  The  hepatic 
duct  and  its  branches  are  greatly  dilated,  and  often  contain  thin,  colorless 
mucus,  the  lining  membrane  being  smooth  and  clear.  The  liver  in  these 
cases  is  firmer  in  consistency  than  normal,  showing  some  increase  in  the 
connective-tissue  element  (biliary  cirrhosis).  Following  moderate  enlarge- 
ment of  the  organ  progressive  atrophy  may  rarely  occur.  When  suppu- 
ration has  occurred  the  mucous  membrane  is  greatly  swollen  and  reddened, 
and  in  some  instances  shows  erosion  or  ulceration  (Ulcerative  Angio- 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  IJY  GALL-STONES   901 

cholitis).  The  process  often  ascends  the  hepatic  ducts  into  the  liver, 
with  infection  of  this  organ,  and  in  the  severer  cases  ahscess-formation. 
On  the  other  hand,  it  may  extend  to  the  gall-bladder,  giving  rise  to  em- 
pyema of  the  latter.  In  some  instances  the  gall-bladder  has  been  per- 
forated and  abscesses  have  formed  between  the  liver  and  stomach. 
Diverticula  are  sometimes  found  postmortem,  containing  biliary  calculi. 

While  cholelithiasis  is  a  common  cause  of  catarrlial,  suppurative,  and 
ulcerative  angiocholitis,  it  not  rarely  complicates  hydatid  disease,  carci- 
noma of  the  bile-ducts,  and  the  acute  infections,  particularly  typhoid 
fever  {vide  Acute  Infectious  Cholecystitis,  p.  806).  Rarely  foreign  bodies 
(fish-bones,  lumbricoids)  operate  as  excitants. 

Symptoms. — Chronic  obstruction  by  gall-stones,  with  coexisting  ^-a- 
tarrhal  inflammation  (catarrhal  angiocholitis),  is  characterized  by  a  dis- 
tinctive group  of  symptoms,  amon^  the  most  prominent  of  which  are — 

Jaundice. — This  may  be  constant  and  very  intense,  or  intermittent 
and  slight,  depending  upon  the  amount  of  obstruction  present.  There 
are  periodic  elevations  of  temperature  accompanied  by  a  deepening  of 
the  jaundice,  when  this  symptom  already  exists  (ball-valve  action  of  the 
stone).  Itching  is,  as  a  rule,  a  most  distressing  feature.  A  stone  low 
down  produces  obstruction  also  of  the  pancreatic  ducts,  in  which  case  the 
stools  will  contain  a  great  amount  of  fat  and  undigested  muscle-fibers. 

Pain,  occurring  in  paroxysms  and  referred  to  the  region  of  the  liver. 
This  is  accompanied  by  fever  that  may  reach  a  high  degree  (102°-103° 
F. — 38.8°-39.4°  C.),  also  by  chills  and  sweating,  resembling  the  parox- 
ysms of  malaria.  Painful  points  in  the  right  side  posteriorly  may  be 
annoying ;  these  are  either  constant  or  paroxysmal. 

The  chills  are  often  intense,  and  may  present  a  quotidian,  tertian,  or 
quartan  form.  The  temperature  of  the  intervals  is  normal.  The  pecu- 
liar exacerbations  of  temperature  were  first  described  by  Charcot,  and  to 
them  has  been  given  the  name  of  Charcot's  intermittent  fever.  Con- 
cerning their  nature  Murchison  writes:  "These  paroxysms  may  be 
more  or  less  periodic,  and  may  extend  over  several  months,  without 
necessarily  indicating  pyemic  hepatitis,  the  patient  ultimately  recover- 
ing." He  adds  that  they  are  probably  analogous  to  febrile  paroxysms 
produced  in  passing  a  catheter  along  the  urethra.  Charcot  believes  the 
etiologic  factor  to  be  a  septic  poison,  bacterial  in  origin  and  the  result 
of  chemical  changes  in  the  bile.  Various  microorganisms  have  been 
detected  in  the  bile  in  such  cases  (bacterium  coli  commune,  streptococcus 
pyogenes,  et  al). 

Gfastrie  Disturbances. — These  may  excite  alarm  during  the  par- 
oxysm. Intense  pain  is  complained  of  in  the  epigastrium,  accompanied 
often  by  nausea  and  vomiting,  which,  however,  usually  subsides  at  the 
close  of  the  paroxysm,  while  the  jaundice  at  this  time  deepens.  Lichty 
found  disturbance  of  the  gastric  secretion  in  75  per  cent,  of  the  case*,  of 
which  two-thirds  showed  hyperchlorhydria.  Gastric  motility  was  dis- 
turbed in  about  the  same  proportion  of  cases. 

The  symptoms  of  suppurative  cholangitis  are  intense.  The  par- 
oxysms of  fever  occur  more  frequently,  the  temperature  merging  into 
the  remittent  type.  Grave  constitutional  symptoms,  indicating  septico- 
pyemia, are  present,  and  the  case  rapidly  tends  to  a  fatal  issue.  The 
attacks  of  colicky  pain  occur  with  jaundice,  but  the  latter  symptom  is 


902  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

less  intense  than  in  the  catarrhal  form.  As  to  hepatic  enlargement,  the 
converse  is  true  ;  this  organ  takes  on  progressive  enlargement  and  "  may 
descend  as  low  as  the  umbilicus,  the  swelling  being  uniform  and 
smooth  and  tender  to  pressure"  (Robson).  It  should  be  borne  in  mind 
that  pain  may  be  absent  when  the  disease  is  not  dependent  on  gall- 
stones. Pneumonia  and  empyema  are  serious  and  not  uncommon  com- 
plications. In  ulct'ratiiu-  ani^iocholitis  severe  hemorrhage  may  occur, 
resulting  either  in  raelena  or  hematemesis.  Mayo  Robson  reports  a 
case  in  which  hematemesis  was  the  only  antemortem  symptom  and  had 
been  the  cause  of  death.  The  process  being  a  septic  one,  it  leads  to  the 
constitutional  disturbances  of  septicemia  or  septico-pyemia.  Pancrea- 
titis may  be  caused  by  stones  in  the  common  duct. 

2.  Obstruction  of  the  Cystic  Duct. — This  almost  invariably 
causes  distention  of  the  gall-bladder  (dropsy  of  the  gall-bladder).  If 
obstruction  of  tiie  cystic  duct  alone  occurs,  jaundice  may  be  entirely 
absent,  the  bile  in  the  distended  tissues  being  replaced  by  a  thin,  mucoid 
fluid.  This  is  more  apt  to  exist  as  the  obstruction  becomes  more  chronic. 
In  some  instances  the  distention  is  so  great  as  to  reach  below  the  um- 
bilicus, and  the  dilated  viscus  has  even  been  mistaken  for  an  ovarian 
tumor.  Osier  records  a  case  in  which  18  oz.  (550.0)  of  fluid  were  re- 
moved from  the  gall-bladder.  The  contents  are  neutral  or  alkaline  in 
reaction,  albumin  being  often  present  in  abundance.  Catarrhal  inflam- 
mation of  the  gall-bladder  may  be  associated,  causing  pain,  at  times  being 
so  severe  as  to  simulate  hepatic  colic,  and  sensitiveness  in  the  region  of 
the  organ,  although,  as  a  rule,  few  symptoms  are  presented.  The  ex- 
aminer can  feel  an  elastic,  gourd-shaped  tumor  closely  connected  with 
the  liver,  movable  in  respiration  in  the  vertical,  and  also,  under  the 
influence  of  the  palpating  fingers,  in  the  lateral  direction.  Occasionally 
Riedel's  tongue-like  projection  of  the  anterior  margin  of  the  right  lobe 
is  palpable.  Given  a  gall-bladder  well  filled  with  stones  and  a  relaxed 
abdominal  wall,  gall-stone  crepitus  may  be  detectable. 

The  writer  has  reported  some  cases  giving  a  more  or  less  characteristic 
clinical  history  of  cholelithiasis,  in  which  gall-stone  crepitus  on  palpation 
furnished  proof  of  stones  in  the  gall-bladder.  In  one  case  he  combined 
auscultation  with  palpation  and  detected  a  grating  sound.' 

If  the  obstruction  persist  for  a  length  of  time,  calcification  or 
atrophy  of  the  bladder  are  common  sequeUu.  Complete  obliteration 
of  the  cavity  of  the  gall-bladder  may  ensue. 

Among  rarer  sequelae  of  chronic  obstruction  may  be  mentioned — (a) 
Empyema  of  the  (J all-bladder. — When  this  takes  place  the  organ  be- 
comes greatly  distended,  and  has  been  known  to  contain  as  much  as  a 
pint  of  purulent  material.  The  symptoyns  of  suppurative  cholecystitis 
simulate  and  accompany  those  of  purulent  cholangitis ;  they  are  some- 
times preceded  by  those  of  catarrh  of  the  gall-bladder  and  ducts.  Per- 
foration may  occur,  giving  rise  to  circumscribed  periportal  abscesses  or 
to  generalized  jjeritonitis  (see  also  Acute  Infectious  Cholecystitis,  p.  894), 
More  Remote  Bffects  of  Gall-stones. — These  will  be  spoken 
of  under  three  headings : 

1.  Stricture  of  the  duct,  resulting  from  ulceration  and  cicatrization 
produced  by  the  passage  of  a  stone. 

2.  Intestinal  obstruction,  due  to  impaction  of  stones  or  volvulus. 

1  Inlet-national  Medical  Magazine,  Dec,  1899. 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  BY  CALL-STONES.   903 

3.  Biliary  fistulae  resulting  from  perforations. 

1.  Stricture  of  the  Duct. — Obliteration  of  the  common  duct  may  re- 
sult from  the  passage  of  a  gall-stone,  giving  rise  to  ulceration  and  cica- 
trization, or  the  stone  may  become  impacted  and  lead  to  adhesions  and 
permanent  closure  of  the  duct  below  it  (Murchison).  When  due  to  ulcera- 
tion the  seat  of  the  stricture  is  usually  low  down  in  the  common  duet.' 

Symptoms. — The  symptoms  are  those  of  chronic  obstructive  jaundice 
(Osier).  In  many  cases  there  will  be  an  antecedent  history  of  the  passage 
of  gall-stones.  In  all  cases  in  which  the  symptoms  of  gall-stones  are 
followed  by  permanent  jaundice  without  pain  it  may  be  suspected  either 
that  the  calculus  has  become  firmly  impacted  or  that  it  has  produced 
organic  stricture  or  closure  of  the  duct. 

2.  Intestinal  Obstruction  from  Impaction  of  Gall-stones. — The  ileum 
is  commonly  the  seat  of  obstruction  by  gall-stones,  that  may  give  rise  to 
intussusception  or  cause  ulceration  and  gangrene  of  the  bowel  with  per- 
foration and  fatal  peritonitis.  The  latter  event,  however,  occurs  more 
frequently  when  the  biliary  concretions  are  situated  in  the  cecum.  Rarely 
they  are  found  in  the  appendix,  and  may  produce  appendicitis.  Cases 
of  impaction  in  the  rectum  of  biliary  calculi  have  been  recorded.  I  have 
recently  seen  a  case  with  Dr.  R.  Bruce  Burns. 

Symptoms. — If  the  impaction  occurs  in  the  small  intestine,  the  abdo- 
men becomes  tympanitic  and  tender  on  pressure.  The  contents  of  the 
stomach  are  first  vomited,  followed  by  bile  and  stercoraceous  matter. 
Symptoms  of  peritonitis  develop  and  continue  until  either  the  impaction 
disappears  or  death  ensues.  Ileus,  the  result  of  biliary  concretions,  is 
common  in  females  of  advanced  age,  and  adhesions  about  the  gall-bladder 
region  may  obstruct  the  lumen  of  the  bowel.  The  history  of  previous 
acute  attacks  would  tend  to  confirm  the  diagnosis.  The  pain  is  intense. 
The  duration  of  the  last  attack  is  often  short. 

3.  Perforation  may  occur  with  the  establishment  o{  fistulous  com- 
munications between  the  gall-bladder  and  stomach,  intestinal  canal,  blad- 
der, vagina,  lungs,  abdominal  parietes,  or  portal  vein.  Fistulse  between 
the  gall-bladder  and  stomach  are  rare,  though  cases  are  recorded  by 
Oppolzer,  Frerichs,  Cruveilhier,  Murchison,  and  others.  Cruveilhier 
states  that  vomited  gall-stones  necessarily  reach  the  stomach  through 
fistulous  tracts,  as  the  passage  through  the  pylorus  would  be  impossible. 

Fistulae  into  the  duodenum  are  of  much  more  common  occurrence, 
ulceration  taking  place  usually  in  the  fundus  of  the  gall-bladder  and  in 
the  descending  or  third  portion  of  the  duodenum  :  39  cases  are  recorded 
of  fistulous  communication  with  the  colon  (Osier).  I  have  reported  a 
fortieth  case.^  In  6  of  9  cases  reported  by  Murchison  carcinoma  of  the 
gall-bladder  was  present.  Fistulse  into  the  urinary  passages  may  occur, 
2  authenticated  cases  being  reported.  The  distended  gall-bladder  may 
come  in  contact  with  the  urinary  viscus,  or  the  stone  may  perforate  into 
the  pelvis  of  the  kidney  and  pass  through  the  ureter  into  the  bladder. 

Fistulous  openings  through  the  abdominal  parietes  are  the  most  com- 
mon, the  place  of  exit  of  the  biliary  concretions  being  usually  in  the 
region  of  the  gall-bladder  or  at  the  umbilicus,  to  which  it  maybe  directed 

^  In  vol.  ix.  pp.  22  and  130,  Pat/wlogic  Transactians,  two  cases  are  recorded  in  which 
the  strictures  were  exactly  similar  to  those  of  the  urethra,  one  being  situated  in  the 
hepatic  duct  of  the  left  lobe  and  the  other  in  the  common  duct. 

^  Clinical  Lecture,  International  Clinics,  vol.  ii.,  third  series,  p.  27. 


904  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

by  the  suspensory  ligament  of  the  liver.  As  many  as  GOO  stones  have 
been  removed  from  the  gall-bladder  in  this  manner.  Advanced  life  and 
female  sex  are  said  to  be  ]tredis])08ing  causes.  Courvoisiers  statistics 
show  184  cases,  in  78  of  whicli  recovery  took  place. 

Fistul*  into  the  pleura,  bronchi,  and  vagina  have  been  recorded,  but 
are  extremely  rare.  Courvoisier  records  -4  cases  of  fistuhv  into  the 
lungs,  only  7  of  which  terminated  in  recovery.  Fauconneau,  Dufoesne, 
Frerichs,  Bristowe,  and  Murchison  mention  cases  of  fistuhx?  into  the  portal 
vein,  with  the  presence  of  biliary  conductions  in  the  latter. 

Diagnosis. — I  would  strongly  urge  an  exploratory  celiotomy  as  an 
accurate  means  of  diagnosis  in  obscure  cases. 

Treatment  of  iP'oregoing  Conditions. — The  indications  for 
treatment  in  cholelithiasis  are  [a)  to  remove  the  cause  ;  (b)  to  relieve 
the  paroxysms  of  hepatic  colic ;  and  (c)  to  adopt  palliative  or  radical 
measures  for  the  removal  of  the  stones. 

Preventive  Treatment. — This  has  reference  to  the  removal  or  miti- 
gation of  the  predisposition.  The  diet  should  be  as  simple  as  possible, 
consisting  largely  of  skimmed-milk,  lean  meat,  eggs,  fruit,  and  green 
vegetables.  Fatty  foods,  sugars,  starches,  and  pastries  are  to  be  strongly 
interdicted.  All  foods  should  be  thoroughly  masticated,  so  as  to  digest 
easily,  and  meals  should  be  taken  at  regular  intervals.  Systematic 
exercise  in  the  open  air  is  of  signal  value,  as  it  stimulates  the  How  of 
bile.  Punkliauer  strongly  recommends  horseback-riding  for  obstructions 
in  the  connnon  duct.  Among  the  drugs  mostly  used  in  the  treatment  of 
predisposing  conditions,  as  hepatic  torpor  and  the  like,  I  would  advise 
the  following :  Sodium  sulphate,  combined  with  the  extract  of  taraxacum 
(Harley) ;  ox-gall  (Dubney),  in  5-  to  10-gr.  (0.824-0.648)  doses,  three 
times  daily  (to  relieve  flatulency  and  stimulate  the  biliary  secretion),  or 
sodium  salicylate  (gr.  x  to  xv — 0.648  to  0.972,  three  times  daily).  In 
my  own  experience  a  dram  (4.0)  of  sodium  jdiospliate  dissolved  in  a  glass 
of  hot  water  in  the  morning  on  rising  has  yielded  excellent  results.  The 
same  dose  may  be  repeated  before  the  noon  and  evening  meals,  if  re- 
quired. The  bowels  should  be  kept  freely  soluble,  constipation  being 
carefully  avoided. 

To  prevent  recurrences  a  course  of  alkaline  treatment  at  some  of  the 
more  noted  mineral  springs  (Bedford,  Vichy,  Carlsbad)  is  often  attended 
with  good  results.  The  efficacy  of  the  Carlsbad  treatment  lies  in  reduc- 
ing inflammatory  processes,  and  not  in  the  expulsion  nor  solution  of  the 
gall-stones.  "As  the  result  of  Carlsbad  treatment.  Fink,  in  375  cases, 
had  good  results  in  291  =  72.8  per  cent.,  of  which  20  cases,  or  4.95  per 
cent.,  liad  relapse"  (Forcheimer). 

Treatment  of  the  Paroxysm  of  Biliary  Colic. — At  the  very  onset  of 
an  attack  of  hepatic  colic  the  prompt  exhibition  of  morphin  or  of  codein 
may  greatly  mitigate  an  attack.  The  former  may  be  given  hypodermi- 
cally  in  ^  to  -^gr-  (0.008-0.016)  doses  every  hour  until  relief  follows; 
the  latter  is  exhibited  by  the  mouth  in  doses  of  1  gr.  (0.0648)  every 
hour.  Inhalations  of  chloroform,  with  morphin  hypodermically,  the 
former  being  continued  until  the  latter  has  taken  effect,  is  the  typical 
treatment  of  an  attack.  Oilman  Thompson  recommends  chloroform 
(iTt  XX — 1.33)  by  mouth  for  the  relief  of  pain. 

Hot  baths  and  hot  applications  (with  counter-irritation)  over  the  liver 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  BY  GALLSTONES.   905 

are  valuable  aids  in  tlie  treatment  of  hepatic  colic,  bein^  given  nt  a  tem- 
perature of  98°  to  100°  F.  (8fJ.f;°  to  :57.7°  (J.j,  and  continued  for  twenty 
minutes,  if  endurable,  so  as  to  effect  relaxation.  If  cardiac  depression 
results  and  the  pulse  becomes  weak,  the  baths  should  be  discontinued. 
Hot  flaxseed-poultices,  cloths  wrung  out  of  hot  water,  hot  hop-bags,  or 
turpentine  stupes  may  be  applied  over  the  hepatic  region  until  the  attack 
subsides.     Ice-poultices  have  been  advised  by  Buchetan. 

If  shock  or  syncope  should  develop,  the  body-temperature  must  be 
maintained  by  hot  bottles  or  bricks  placed  in  contact  with  the  surface  of 
the  body,  together  with  strychnin  (gr.  -^ — 0.0021),  atropin  (gr.  ^517  — 
0.00042),   and  brandy  (1   dram — 4.0)   hypodermically. 

Nausea  and  vomiting  may  be  reduced  by  15-drop  doses  of  spirits  of 
chloroform  every  half  hour ;  also  by  brandy  or  champagne. 

In  mild  cases  sodium  salicylate  (gr.  viij-xv — 0.518-0.972  in  twenty- 
four  hours),  recommended  by  Prevost  and  Binet,  or  codein  (gr.  j),  Avith 
phenacetin  (gr.  x),  every  few  hours  gives  relief.  The  free  use  of  olive 
oil  or  glycerin  in  hepatic  colic  has  been  followed  by  a  beneficial  effect 
(Rosenberg,  Goodhart).  The  former  is  given  in  quantities  of  4  to  6  oz. 
(128.0—192.0)  by  the  mouth  every  three  or  four  hours,  nausea  being  pre- 
vented by  concealing  the  taste  with  lemon-juice  ;  the  latter,  recommended 
by  Ferrand,  is  given  in  doses  ranging  from  1  to  2  tablespoonfuls,  repeated 
in  the  same  length  of  time.  Purgation  and  remedies  presumed  to  act  as 
cholagogues,  given  during  an  acute  seizure,  are  harmful  in  their  effects. 
The  aim  should  be  to  reduce  the  inflammatory  TDrocess  in  the  gall-bladder. 
D.  D.  Stewart  well  says  :  "  The  treatment  of  recent  cases  of  stone  in  the 
common  duct  belongs  to  the  physician  but  a  short  time  only."  If  the 
gall-bladder  is  palpable  after  an  attack  of  hepatic  colic,  the  cystic  duct 
is  probably  obstructed  and  the  treatment  is  surgical. 

Treatment  for  Removal  of  Gall-stones. — Solvents  for  the  stones  have 
been  tried  at  various  times,  among  them  being  Durandes  method  (tur- 
pentine and  ether),  but,  so  far,  all  such  methods  of  treatment  have  been 
unsuccessful.  The  free  use  of  pure  water  by  the  mouth,  together  with 
copious  rectal  injections  of  cold  water  daily  is  to  be  advised.  It  mav  be 
rendered  alkaline  by  sodium  bicarbonate  or  borate  in  a  3  per  cent,  solution. 

Willoughby  reports  a  case  in  which  prompt  recovery  ensued  from  the 
use  of  toluylenediamine  after  three  years  of  unsuccessful  treatment ;  he 
began  with  1  grain  daily,  and  increased  to  2  grains. 

Of  the  various  surgical  measures  for  the  removal  of  gall-stones  the  fol- 
lowing are  the  chief:  (a)  Removal  of  the  stone  from  the  common  duct 
(choledochotomy) ;  (b)  Removal  of  the  stone  from  the  cystic  duct  (cho- 
lecystotomy) ;  (c)  Establishing  a  fistulous  opening  between  the  gall-blad- 
der and  the  bowel  (cholecystenterostomy) ;  (d)  Extirpation  of  the  gall- 
bladder (cholecystectomy),  the  latter  operation  giving  a  mortality  of  17 
per  cent.,  according  to  Murphy's  statistics.  And  operative  procedure 
is  indicated  in  infectious  (suppurative)  cholecystitis  as  well  as  in  infec- 
tious (suppurative)  cholangitis  ;  e.  g.,  evacuation  and  drainage.  W.  Mayo 
has  operated  in  510  cases  of  cholelithiasis  with  a  death-rate  of  only  3 
per  cent.  Of  326  cases  of  gall-stone  complicated  with  biliary  infection 
and  malignant  disease,  16,  or  5  per  cent.,  proved  fatal.  Kehr  has  never 
had  a  recurrence  in  900  operations  for  cholelithiasis ;  Toeplitz  has  had 
recurrence  in  14.2  per  cent. 


yOG  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CARCINOMA  OF  THE  BILE-DUCTS. 

Carcinoma  of  tlie  gull-blailder  ami  lule-ducts  may  occur  as  a  primary 
disease  and  exist  over  a  long  period  of  time  without  being  recognized. 

Pathology. — Tlie  gall-bladder,  as  the  result  of  obstruction  of  the 
duct,  is  often  greatly  distended,  measuring  as  much  as  7  inches  (17.7  cm.) 
in  length  (in  a  case  reported  by  Harley)  from  the  entrance  of  the 
duct  to  the  fundus,  and  being  filled  with  a  cloudy  licjuid,  somewhat 
resembling  barley-water,  that  contains  flakes  of  epithelium,  granular 
matter,  and  particles  of  inspissated  bile.  If  the  growth  be  near  the 
duodenal  orifice,  the  common  and  cystic  ducts  are  often  greatly  dis- 
tended, and  the  dilatation  may  extend  into  the  hepatic  ducts  and  their 
branches.  The  liver  may  be  enlai-ged,  and  in  more  than  one-half  of  the 
instances  presents  the  secondary  nodules  that  are  characteristic  of  the 
disease.  Microscopically,  carcinoma  of  the  gall-bladder  exhibits  marked 
variations  in  different  cases ;  ''  it  may  be  either  columnar  or  spheroidal 
celled  "  (Rolleston). 

Htiology. — The  causes  of  carcinoma  of  the  bile-ducts  are  the  same 
here  as  elsewhere,  and  among  these  the  mechanical  or  inflammatory  theory 
of  Virchow  must  be  accepted.  Tight-lacing  and  mechanical  irritation  by 
gall-stones  are  followed  in  many  instances  by  cancerous  degeneration  ; 
Osier  states  that  "  biliary  calculi  are  present  in  at  least  seven-eighths  of 
all  cases."  Among  other  factors,  heredity  and  age  (after  forty)  play  an 
important  part.  Although  carcinoma  of  the  liver  undoubtedly  occurs 
more  frequently  in  males,  Musser  found  that  out  of  100  cases  of  carci- 
noma of  the  ducts,  75  occurred  in  the  female  ;  and  Ames  found  the  ratio 
to  be  4  to  1  in  favor  of  females. 

Symptoms. — The  signs  and  symptoms,  according  to  Harley,  present 
nothing  characteristic  to  distincruish  them  from  other  causes  of  obstruction 
in  the  ducts.  On  palpation  in  the  early  stages  the  gall-bladder  is  found 
moderately  enlarged,  but  later  it  rapidly  undergoes  diminution  in  size. 
Jaundice  becomes  very  intense,  and  remains  permanent.  Throughout 
the  course  of  the  disease  all  the  symptoms  referable  to  chronic  obstruction 
of  the  duct  by  gall-stones  (paroxysmal  pain,  gastric  disturbance,  rise  of 
temperature,  Charcot's  fever)  may  develop. 

Examination  of  the  urine  and  feces  reveals  the  presence  of  bile-pigment 
in  the  former  and  its  absence  in  the  latter.  The  urine  often  shows  the 
presence  of  bile-stained  casts  {vide  Fig.  64). 

Ascites  not  rarely  occurs  during  the  later  stages,  with  the  involvement 
of  surrounding  organs  by  contiguity,  as  well  as  with  the  appearance  of 
secondary  nodules  in  the  liver  and  the  development  of  cachexia. 

Diagnosis. — Carcinoma  of  the  biliary  ducts  cannot  always  be  detected 
by  physical  examination.  Distinct  evidence  of  chronic  obstruction  of  the 
duct,  as  persistent  and  intense  jaundice  (which  occurs  in  three-fourths  of 
the  cases),  the  development  of  cachexia  and  the  absence  of  cancerous  in- 
volvement of  other  organs,  however,  will  tend  to  characterize  it.  Often 
a  hard  tumor-mass  is  present  in  the  region  of  the  gall-bladder,  project- 
ing in  the  direction  of  the  umbilicus.  It  should  be  recollected  that  the 
bile-ducts  are  oftener  the  seat  of  the  primary  aff'ection  than  the  liver. 
Cholelithiasis  may  simulate  carcinoma  in  all  its  symptoms,  except  those 
due  to  metastasis. 


STEXOSIS  OF  THE  BrLE-DCCTS.  907 

Prognosis. — Tlie  prosmosis  of  carcinoma  of  the  bile-ducts  is,  like 
tiiat  of  otiier  orsana,  absolutely  fatal,  though  the  course  of  the  diseaae  ia 
not  3o  rapid  aa  that  of  carcinoma  elsewhere  until  secondary  involvement 
of  the  liver  occurs. 

Treatment. — The  treatment  is  merely  palliative.  Operative  meas- 
urea  are  rarely  justifiable,  since  the  disease  is  rarely  recognized  before 
the  liver  becomes  involved.  As  seven-eighths  of  the  cases  follow  obstruc- 
tion of  the  duct  by  gall-stones,  the  preventive  treatment  of  the  latter 
should  be  carefully  observed  whenever  symptoms  of  disordere<i  liver-func- 
tion manifest  themselves. 

The  treatment  of  the  pain,  anemia,  and  emaciation  will  be  described 
m  the  discussion  of  Carcinoma  of  the  Liver. 


SEENOSIS  OP  THE  BILE-DUCTS. 

Sten'OSIS  may  result  from  any  of  the  following  causes :  (a)  Round- 
worms  in  the  duct  (rarely) ;  (b)  Foreign  bodies,  aa  seeds ;  (c)  Ulceration 
and  cicatrization  following  the  passage  of  gall-stones  (most  commonly) ; 
(d)  Pressure  from  without,  aa  from  tnmors  (carcinoma  chiefly)  of  the 
head  of  the  pancreas  and  pylorus  (rare) ;  (e)  Abdominal  tumors  ; 
(/')  Aneurysm  of  the  abdominal  aorta  or  of  the  celiac  axis  (rare) ;  (g) 
Secondary  enlargement  of  the  lymphatics  of  the  liver  (common);  (h) 
More  rarely  in  man  than  in  the  lower  animals  distoma  hepaticum  of 
IiTea*-flukes  and  echinococci ;  (i)  Adhesions  due  to  chronic  peritonitis. 

PSathxjlogy. — If  the  stenosis  is  of  recent  origin,  the  liver  is  enlarged 
and.  aKows  more  or  less  congestion,  with  some  increase  of  the  connective- 
tisBae  elements.  The  substance  is  firmer  than  normal,  the  color  varying 
firom  an  oKve-green  to  a  deep  bronze.  If,  however,  the  obstruction  be 
«rf  long  standing,  the  presence  of  the  dilated  intra-hepatic  ducts  and  the 
increase  of  connective  tissue  cause  secondary  atrophy  of  the  hepatic 
with,  a  diminution  in  the  size  of  the  organ. 

SSnnptoms. — The  symptoms  vary  greatly  according  to  the  cause  of 

rtenosis.  but  in  the  main  they  are  those  of  chronic  obstruction  of  the 
-viz.  paroxysmal  pain  in  the  region  of  the  Kver.  referred  to  the 
right  shoulder ;  jaundice  of  varying  intensity,  but  gradually  deepening 
affcer  each,  attack;  and  gastric  disturbance,  with  ague-like  paroxysms 
(fever  and  sweating),  the  latter  being  most  frequently  met  with  in  occlu- 
^iL  from  gall-atones. 

IMagnosis. — The  pattognomonic  symptoms  determining  the  nature 
of  the  stenoaia  are  very  often  wanting,  and  the  diagnosis  is  rendered  cor- 
respondingly difficult.  On  the  other  hand,  stenosis  or  complete  occlusion 
of  the  bile-passages  calls  for  diagnosis  principally  on  account  of  the 
special  cause  or  causes  of  the  given  case. 

When  the  condition  is  due  to  lumbricoid  worms  reflex  aymptoms 
usually  appear,  as  pruritus  of  the  nose  and  anus,  grinding  of  the  teeth 
(JorTTig  sleep,  and  convulsions. 

In  carcinoma  of  the  head  of  the  pancreas  or  the  pylorug  pressing  on 
the  ducts  the  growth  may  be  detected  by  palpation,  together  with  a  rec- 


908  DISEASES   OF  THE  DRiESTIVE  SYSTEM. 

ognition  of  other  more  or  less  characteristic  features  [vide  Carcinoma  of 
Pancreas),  and  the  rapid  course  of  the  disease. 

Ahdominal  aitenri/sni  may  give  rise  to  obstruction  of  the  duet  without 
being  evidenced  by  pliysical  signs.  Usually,  however,  when  the  saccula- 
tion presses  against  the  bile-duct,  the  throbbing  in  the  epigastrium,  the 
tumor  (which  can'  often  be  grasped),  and  the  expansile  pulsation  on  pal- 
pation will  tend  to  establish  the  cause  of  the  obstruction. 

When  due  to  catieeroKs  )wclules  in  the  liver  there  is  usually  a  history 
of  primary  carcinoma  of  the  stomach,  mammary  gland,  rectum,  or  of  one 
of  the  pelvic  viscera.  Osier  records  a  case  in  which  jaundice  (thought  to 
have  been  catarrhal  in  origin)  developed  seven  Aveeks  previously.  On 
careful  examination  "  a  small  nodule  was  detected  at  the  umbilicus,  which 
on  removal  proved  to  be  scirrhus." 

When  the  stenosis  is  due  to  ulceration  following  the  passage  of  gall- 
stones, the  history  of  biliary  colic,  and  of  paroxysmal  pain  with  jaundice 
and  intermittent  fever,  will  serve  to  establish  the  cause. 

If  the  fever  be  of  the  continued  type  and  the  liver  uniformly  enlarged, 
with  the  development  of  jaundice,  the  case  is  probably  one  of  hypertro- 
phic cirrhosis ;  whereas  if  the  enlargement  be  progressive  and  nodules 
can  be  detected  on  palpation  in  addition  to  the  appearance  of  cachexia 
and  jaundice,  carcinoma  is  undoubtedly  present. 

Physical  signs  aid  but  little  in  the  diagnosis,  as  obstruction  of  the 
common  duct  is  usually  unattended  by  any  great  enlargement  of  the 
gall-bladder. 

In  many  cases  only  by  remembering  the  various  causes  and  elim- 
inating them  carefully,  one  by  one,  can  a  diagnosis  be  rendered. 

Prognosis. — The  prognosis  varies  according  to  the  cause  of  the 
stenosis.  Generally  speaking,  the  outlook  is  rather  grave,  since  many 
of  the  causative  conditions  are  fatal.  If  the  obstruction  is  due  to  cica- 
tricial contraction,  the  prognosis  is  guardedly  favorable  as  to  life,  but 
hopeless  as  to  recovery.  If  the  obstruction  is  permanent,  the  case  ends 
fatally. 

Treatment. — The  treatment  of  occlusion  of  the  bile-ducts  varies 
according  as  it  is  due  to  cicatricial  contraction  following  ulceration  or  to 
foreign  bodies  (seeds  or  lumbricoid  worms),  or  to  gall-stones  or  tumors 
pressing  upon  or  involving  the  ducts  or  adjacent  organs  (pancreas, 
pylorus).  If  the  stenosis  follows  ulceration  in  the  duct,  and  is  sufficient 
to  cause  almost  complete  occlusion  with  biliary  retention,  the  operation 
of  cholecystenterostomy  may  become  necessary  in  order  to  prevent  dila- 
tation of  the  gall-bladder  with  resorption  of  bile. 

Foreign  bodies  in  the  duct  may  be  removed  by  free  purging,  aided  by 
the  liberal  use  of  alkaline  mineral  waters.  In  critical  cases  the  operation 
of  cholecystotomy  is  recommended. 

Gall-stones  form  the  most  frequent  cause  of  stenosis,  and  the  treat- 
ment, both  for  the  prevention  and  removal  of  calculi,  has  already  been 
described  in  the  discussion  of  Biliary  Calculi  {vide  p.  904). 


ICTERUS  NEONATORUM.  909 

ICTERUS  NEONATORUM. 

Definition. — By  the  term  icterus  neonatorum  is  meant  jaundice 
occurring  in  the  new-born.  It  is  seen  in  about  two-thirds  of  all  new- 
born infants,  is  unaccompanied  by  any  other  lesions,  and  pursues  a 
favorable  course.  Icterus  neonatorum  must  not  be  confounded  with 
jaundice  occurring  in  the  new-born  and  dependent  upon  various  patiio- 
logic  causes — e.g.,  congenital  stricture  or  absence  of  the  duct,  syphilitic 
disease  of  the  liver,  duodenal  catarrh,  and  septicemia,  as  a  result  of  in- 
fection through  the  umbilical  vein.  In  this  form  the  skin  and  conjunc- 
tivae are  more  or  less  icteroid,  the  urine  is  loaded  with  bile-pigment, 
while  the  feces  are  of  a  pipe-clay  variety.  Hence  it  differs  in  its  sympto- 
matology from  true  icterus  neonatorum. 

The  secretion  of  bile,  like  the  secretion  of  urine,  begins  long  before 
birth,  and  Zweifel  has  found  bile-pigment  and  bile-acids  in  the  contents 
of  the  intestines  of  a  three-months'  fetus.  Hence  children  may  be  born 
laboring  under  an  attack  of  well-marked  jaundice. 

Htiology. — The  following  are  the  main  causes  :  1.  The  ductus  venosus 
may  remain  patulous,  allowing  some  of  the  portal  blood,  containing  bile, 
to  flow  into  the  systemic  circulation  (Quincke).  2.  Diminished  pressure 
in  the  portal  vessels  from  ligation  of  the  umbilical  vein  causes  increased 
tension  in  the  hepatic  capillaries  and  absorption  of  bile.  3.  It  is  prob- 
able that  the  external  conditions  are  in  some  way  concerned  in  the  appear- 
ance of  the  disease  (Oser).  4.  The  destruction  of  numerous  red  cor- 
puscles may  be  followed  by  an  increased  amount  of  bile-pigment  in  the 
liver. 

Sj^mptoms. — The  skin  is  tinted  greenish-yellow,  resembling  some- 
what that  of  chlorosis.  The  mucous  membranes  are  pale  and  the  con- 
junctivae pearly-white,  except  in  the  severer  cases,  when  they  show  a 
slight  discoloration.  The  icterus  usually  appears  on  the  second  or  third 
day  of  life.  The  pulse  is  feeble  and  sometimes  rapid.  Auscultation  over 
the  base  of  the  heart  often  reveals  a  soft  systolic  murmur,  associated 
with  a  venous  hum  in  the  neck.  According  to  Murchison,  icterus  neo- 
natorum differs  from  the  pathologic  form  in  that — 1.  The  conjunctivae 
are  of  a  natural  color ;  2.  The  urine  is  free  from  bile-pigment ;  3.  The 
yellow  color  gradually  fades  from  the  skin  after  a  few  days ;  4.  The 
child  is  quite  w^ell  and  the  bowels  are  acting  properly. 

Prognosis. — The  jaundice  gradually  disappears  spontaneously  at 
the  end  of  three  or  four  days. 

Treatment. — As  a  rule,  nothing  beyond  hygienic  measures  are 
required.     The  diet  need  not  be  restricted. 


VASCULAR  (CIRCULATORY)   AFFECTIONS  OF  THE 

LIVER. 


ANEMIA. 


The  physical  symptoms  of  this  condition  are  absolutely  nil,  and  its 
existence  only  discoverable  ^postmortem.  Its  most  common  causes  are 
those  of  general  anemia,  fatty  and  amyloid  degeneration. 


910  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

HYPEREMIA. 

Definition. — An  excess  of  blood  in  the  liver.  This  may  be  of  two 
varieties  :   (a)  active  and  (6)  passive,  the  latter  being  the  more  common. 

ACUTE    HYPEREMIA. 
{^Active  Congestion.) 

Definition. — An  excess  of  arterial  blood  in  the  liver. 

Ktiology. — Among  the  common  causes  are  luxurious  living,  sedentary 
habits,  alcoholism,  traumatism,  acute  infectious  diseases  (typhus,  typhoid), 
and  pernicious  malaria.  The  condition  may  also  be  vicarious,  due  to  a 
sudden  cessation  of  menstruation  or  of  hemorrhage  in  other  parts  of  the 
body.  A  'physiologic  condition  is  the  temporary  hyperemia  that  occurs 
during  the  ingestion  of  a  full  meal. 

Symptoms. — There  are  no  symptoms  characteristic  of  this  condition ; 
those  present  in  the  different  cases  are  varied  and  referable  to  disturb- 
ances of  other  viscera,  as  in  coexisting  cardiac  hypertrophy  or  gastro- 
intestinal catarrh.  There  is  a  sense  of  fulness  and  distress  in  the  right 
hypochondrium,  most  marked  during  the  height  of  the  digestive  process, 
with  teyidernest  on  palpation  over  the  margin  of  the  organ. 

Prognosis  and  Course. — It  is  impossible  to  make  any  definite  state- 
ment as  to  the  course  and  prognosis  of  active  hyperemia,  these  depending 
wholly  upon  the  cause  of  the  affection.  When  due  to  errors  of  diet  ana 
hygiene  the  condition  is  easily  remedied ;  the  prognosis  of  hyperemia 
accompanying  hepatic  cirrhosis,  however,  is  decidedly  grave. 

PASSIVE    HYPEREMIA. 
{Passive  Congestion.) 

Definition. — An  increase  of  venous  blood  in  the  liver. 

Pathology. — The  organ  is  enlarged  and  changed  to  a  deep-red 
color,  while  its  substance  is  firmer  than  the  normal.  The  center  of  the 
lobule  (the  area  of  the  hepatic  vein)  becomes  deeply  pigmented,  the  pe- 
riphery (occupied  by  the  portal  vein)  being  lighter  in  color,  sometimes 
owing  to  fatty  infiltration.  Because  of  its  mottled  appearance  this  has 
received  the  name  of  the  "nutmeg  liver." 

In  long-standing  passive  congestion  there  is  an  increase  of  connective 
tissue,  due  to  a  proliferation  of  round-cells,  causing  atrophy  of  the 
parenchyma.  The  blood  in  the  central  capillaries  becomes  altered,  the 
capillaries  themselves  are  distended,  and  brown  pigment  is  deposited 
about  the  center  of  the  lobules.  The  organ  becomes  very  much  darker 
in  color,  and  to  this  condition  the  name  "cyanotic  induration"  or 
"cardiac  liver"  has  been  given.  Later,  contraction  of  the  connective 
tissue  occurs,  causing  a  diminution  in  the  size  of  the  organ,  and  forming 
the  so-called  "atrophic  nutmeg  liver." 

Ktiology. — The  causes  that  lead  to  passive  hyperemia  are  both  local 
and  general.     Among  local  causes  may  be  mentioned  the  following  : 

1.  Pressure  over  the  portal  area  from  without,  as  from  a  tumor  or  cyst. 

2.  Disease  of  the  walls  of  the  veins,  as  in  syphilitic  phlebitis. 

3.  Coagulation  of  the  blood  in  the  veins  (thrombosis). 
Among  the  general  causes  are — 


DISEASES  OF  THE  PORTAL    VEIN.  911 

1.  Chronic  valvular  disease  affecting  the  right  side.  Passive  hyper- 
emia also  occurs  in  mitral  disease. 

2.  Pulmonary  emphysema  and  cirrhosis  of  the  lung, 

3.  Intrathoracic  tumors,  which  by  their  mechanical  action  cause  an 
increased  pressure  in  the  efferent  branches  of  the  hepatic  veins. 

Symptoms. — Often  the  patient  experiences  a  sensation  oi  fulness 
and  weight  in  the  region  of  the  liver  that  amounts  in  some  instances  to 
actual  pain.  Jaundice  is  usually  present,  but  varies  in  intensity,  and  is 
due  to  obstruction  of  the  smaller  ducts  from  distention  of  the  hepatic 
venules.  Hematemesis  and  also  hemorrhoids  (bleeding)  may  occur,  and 
symptoms  of  gastro-intestinal  disturbance  are  usually  present.  In  marked 
cases  the  stools  are  clay  colored.,  showing  the  absence  of  bile  ;  the  urine 
is  loaded  with  bile-pigment;  and  jaundice  deepens  with  the  development 
of  ascites  or  anasarca  from  portal  obstruction.  On  palpation  the  organ 
is  tender  and  increased  in  size,  extending  in  some  instances  fully  a  hand's 
breadth  below  the  costal  margin.  In  pronounced  cases  the  whole  organ 
pulsates,  ovi^ing  to  the  regurgitation  of  blood  into  the  hepatic  veins  (see 
also  p.  659). 

Diagnosis. — The  diagnosis  of  passive  congestion,  per  se,  is  often 
very  difficult,  but  when  secondary  to  heart  and  lung  diseases  it  is  ren- 
dered more  plain. 

The  prognosis  and  treatment  depend  upon  the  causal  factors. 


DISEASES  OF  THE  PORTAL  VEIN. 

THROMBOSIS   AND   EMBOLISM. 

Pathology. — In  the  early  stages  the  clot  presents  a  grayish-red  or 
yellowish  appearance,  and  on  loosening  it  is  found  to  adhere  more  or  less 
closely  to  the  inner  coat  of  the  vein.  Later  it  becomes  a  mass  of  small 
white  fibrin  tightly  adherent  to  the  sides  of  the  blood-vessel,  which  itself 
undergoes  fibroid  change  (adhesive  pylephlebitis).  Organized  thrombi 
are  rarely  found,  except  in  the  smaller  branches  of  the  portal  area.  If 
the  thrombus  obstruct  the  vessel,  collateral  circulation  may  be  established 
for  years.  Septic  softening,  however,  is  a  very  common  result,  and 
pylephlebitis  even  more  so.  If  a  parietal  or  channelled  thrombus  be 
formed,  partial  or  complete  circulation  may  be  re-established  and  recovery 
take  place.      Hemorrhagic  infarction  may  occur,  but  it  is  rare. 

Ktiology. —  Thrombi  are  rare  occurrences  in  the  portal  vein.  Among 
the  causes  that  lead  to  their  formation,  however,  may  be  mentioned — 
(a)  Traumatism  ;  (h)  cirrhosis  ;  (c)  carcinoma  of  the  liver,  stomach,  and 
pancreas ;  (<:/)  pressure  from  without,  as  in  proliferative  peritonitis  in- 
volving the  gastro-hepatic  omentum,  abscesses,  enlarged  glands,  or  im- 
pacted calculi  pressing  on  the  veins ;  (e)  it  may  be  occasioned  by  ulcera- 
tive affections  of  the  bowels  and  appendicitis,  and  pylephlebitis  may 
precede  its  occurrence ;  (/)  slowing  of  the  circulation  due  to  splenic 
diseases,  such  as  marasmus. 

Symptoms. — Symptoms  may  be  almost  lacking  in  portal  obstruction, 
or  the  condition  may  simulate  cirrhosis  of  the  liver.  In  ordinary  cases 
the  symptoms  are  very  slight,  the  hepatic  circulation,  as  shown  by  Cohn- 


912  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

heim  and  Litton,  being  "  sufficient  for  the  nourishment  of  the  liver  and 
secretion  of  the  l)ile  "  (Henry). 

If  the  occlusion  be  complete,  edema  follov-ed  by  the  rapid  development 
of  ascites  may  occur.  In  such  cases  loss  of  strength  is  persistent  and 
progressive,  and  death  may  result  from  exhaustion.  Hemorrhages  due  to 
venous  stasis  may  occur  from  the  nose,  stomach,  and  intestines.  Jaundice 
and  diarrhea  occur  frequently,  the  former  being  the  result  of  obstruction 
to  the  biliary  passages  from  the  same  causes  that  produce  the  thrombosis 
or  of  the  diminished  pressure  in  the  portal  area.  On  palpation  the  liver 
is  found  slightly  enlarged  and  tender  on  pressure,  and  projecting  below 
the  lower  margin  of  the  ribs ;  the  spleen  is  also  enlarged.  Percussion 
also  reveals  enlargement  of  the  splenic  area.  If  ascites  is  present,  percus- 
sion will  reveal  dulness  in  the  flanks,  changing  with  the  position  of  the 
patient ;  and  on  gently  tapping  one  side  of  the  belly-wall,  with  the  hand 
on  the  opposite  side,  a  wave  of  fluctuation  will  be  felt. 

Diagnosis. — The  diagnosis  of  portal  thrombosis  is  often  extremely 
difficult.  "A  suggestive  symptom,  however,  is  sudden  onset  of  the  most 
intense  engorgement  of  the  branches  of  the  portal  system  "  (Osier). 

Sequelce. — If  the  emboli  are  septic  in  origin,  an  abscess,  with  all  its 
accompanying  symptoms,  will  be  the  result.  Hemorrhagic  infarction 
may  occur,  but  is  very  rare,  since  a  free  anastomosis  exists  between  the 
lobular  plexuses  and  the  hepatic  artery. 

"  Pylethrombosis  may  be  regarded  as  probable  if  no  other  possible 
cause  of  the  portal  obstruction  seems  likely,  and  if  we  are  able  to  discover 
a  cause  for  thrombosis,  like  a  former  attack  of  circumscribed  peritonitis  " 
(Striimpell). 

The  prognosis  is  always  unfavorable,  although  certain  cases  have 
been  demonstrated  by  autopsy  to  have  improved  temporarily. 

Course  and  Duration. — Nothing  definite  can  be  stated  in  regard 
to  the  course  and  duiation.  since  these  depend  entirely  upon  the  cause. 

Treatment. — The  symptoms  resulting  from  portal  congestion,  due 
to  thrombi  in  the  portal  vein,  are  those  described  under  Cirrhosis  of  the 
Liver,  and  the  treatment  is  identical  with  that  of  interstitial  hepatitis. 
Septic  emboli  rarely  give  rise  to  abscesses  ;  the  treatment  is  symptomatic. 
It  has  been  recommended  to  take  the  coagulation  period  of  the  blood, 
and  if  found  to  be  abnormally  brief,  citric  acid  should  be  employed. 

SUPPURATIVE   PYLEPHLEBITIS. 

Definition. — A  purulent  inflammation  of  the  ])ortal  vein  or  its 
branches. 

Pathology. — If  noted  in  the  early  stages,  the  coats  of  the  portal 
vein  are  distended  and  thickened,  and  the  connective  tissue  surrounding 
the  portal  area  is  infiltrated  and  the  seat  of  minute  ecchymoses.  The 
inflammation  usually  originates  in  the  smaller  veins  of  the  portal  system 
or  in  the  hepatic  branches  of  the  vein  itself;  the  main  trunk  is  attacked 
least  often.  Numerous  thrombi  are  found  obstructing  the  vein  and  its 
branches,  which  finally  undergo  suppuration.  From  these,  emboli  enter 
the  circulation  and  are  carried  to  all  parts  of  the  liver,  forming  meta- 
static abscesses.  In  advanced  cases  the  Avhole  organ  (especially  the  pe- 
ripheral parts)  becomes  infiltrated  with  pockets  of  pus,  that  communicate 


SUPPURATIVE  PYIjEPHLEBITIS.  913 

with  the  portal  vein  or  its  branches,  and  extend  in  some  instances  into 
the  mesenteric  or  gastric  veins.  A  single  large  abscess  may  bo  present, 
but  multiple  abscesses  are  the  rule.  The  contents  may  be  very  fetid  and 
bile-stained,  or,  as  in  many  instances,  they  may  be  composed  of  thick, 
creamy  laudable  pus.  From  this  focus  of  suppuration  metastatic  embolic 
abscesses  may  occur  in  the  lungs,  brain,  kidneys,  and  joints. 

The  macroscopic  appearance,  with  the  organ  in  situ,  is  sometimes 
practically  normal.  The  liver  may  present  a  uniform  enlargement,  the 
surface  being  of  normal  color  and  the  capsule  non-adherent.  More  com- 
monly, however,  the  cortex  presents  a  mottled  appearance,  and  numerous 
yellowish-white  spots  are  seen  beneath  the  capsule. 

Ktiology. — The  most  frequent  source  of  purulent  pylephlebitis  is 
appendicitis  with  abscess.      Rarely  the  disease  arises  idiopathically. 

Among  other  causes  are — (a)  A  secondary  (becoming  a  general)  pyemia. 
(b)  Ulceration  of  the  intestines,  occurring  in  dysentery  and,  more  rarely, 
in  typhoid  fever.  (<?)  Gastric  ulcer,  (d)  Pelvic  abscess ;  abscess  of  the 
spleen,  {e)  Specific  infection  through  the  umbilicus,  occurring  in  the 
newborn.     (/)  The  condition  is  more  frequent  in  males. 

Symptoms. — The  symptoms  vary  according  as  to  whether  the  case 
remains  one  of  suppurative  pylephlebitis  or  terminates  in  hepatic  abscess. 
If  the  condition  is  part  of  a  general  pyemia,  the  symptoms  referable  to 
the  liver  may  be  almost  negative.  The  liver  is  usually  enlarged  and 
tender  on  pressure ;  this  enlargement  is  most  marked  when  an  hepatic 
abscess  coexists.  Though  pain  is  present,  it  is  not  always  severe ;  it  is 
frequently  referred  to  the  epigastrium,  and  may  radiate  laterally  or  down- 
ward. Percussion  in  the  left  axillary  line  shows  splenic  enlargement, 
and  the  organ  can  in  some  instances  be  felt  below  the  costal  margin,  con- 
stituting the  '■'■acute  splenic  tumor''  of  septicopyemia. 

f\iQ fever  is  of  septic  type;  the  elevation  in  temperature  is  accompa- 
nied by  rigors  or  chills  and  followed  by  profuse  sweating.  Jaundice  of 
varying  intensity  is  present,  although  usually  it  is  not  pronounced,  the 
complexion  being  merely  doughy  or  muddy.  Diarrhea  is  not  an  infre- 
quent symptom  of  this  condition.  Nausea  and  vomiting  are  often  marked. 
As  the  case  advances  the  pulse  becomes  rapid  and  small,  and  delirium 
develops,  followed  by  stupor,  coma,  and  death. 

Duration  and  Prognosis. — The  duration  of  suppurative  pylephle- 
bitis is  usually  from  one  to  three  or  four  weeks  or  longer.  The  prognosis 
is  absolutely  fatal. 

Diagnosis. — The  diagnosis  of  suppurative  pylephlebitis  is  sometimes 
extremely  difficult,  unless  the  case  is  complicated  by  hepatic  abscess,  as 
enlargement  of  the  liver  is  not  constant  in  the  former  condition.  The 
etiology,  septic  temperature,  enlargement  of  the  spleen,  jaundice,  and 
pain  in  the  region  of  the  liver  would  all,  however,  point  to  this  affection. 

The  differential  diagnosis  of  hepatic  abscess  will  be  spoken  of  later. 
Typhoid  fever  and  the  typhoid  form  of  ulcerative  endocarditis  (without 
murmurs),  as  well  as  malaria,  must  be  excluded. 

Treatment. — Unfortunately,  the  treatment  of  suppurative  pylephle- 
bitis can  only  be  palliative.  Surgical  measures  are  rarely  curative,  unless 
the  abscess  is  single  and  localized  and  shows  signs  of  pointing.  The 
circulation  is  to  be  supported  by  free  stimulation.  The  leading  symptoms 
should  be  met  as  they  arise. 

ns 


914  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


STENOSIS. 

Obstruction  of  the  portal  vein  may  be  due,  as  before  mentioned,  to  (a) 
thrombosis ;  (b)  cicatricial  contraction  from  cirrhosis  or  syphilis  of  the 
liver ;  and  (c)  tumors  pressing  on  the  portal  area.  The  first  cause  is  the 
more  common,  chiefly  because  mechanical  obstruction,  by  causing  a  stasis 
of  the  blood-current,  induces  the  formation  of  a  thrombus. 

The  symptoms  of  portal  stenosis  may  be  nil :  if  the  stenosis  occurs 
slowly,  the  hepatic  artery  furnishes  sufl^icient  blood  to  carry  on  the  func- 
tions of  the  liver,  and  the  compensatory  circulation  is  established  by 
means  of  the  systemic  vessels.  If  due  to  thrombosis,  the  symptoms  of 
portal  engorgement  appear  suddenly  with  the  development  of  edema  and 
ascites.     The  liver  is  rarely  enlarged. 

Prognosis. — This  depends  wholly  upon  the  cause  of  the  affection. 
Thrombi  in  the  portal  vein  often  give  rise  to  a  suppurative  pylephlebitis, 
terminating  in  hepatic  abscess ;  tumors  are  rarely  accessible ;  whereas 
fibroid  conditions  of  the  liver  causing  cicatricial  contraction  are  incurable. 
As  a  rule,  the  prognosis  may  be  said  to  be  guardedly  unfavorable. 


AFFECTIONS   OF  THE  HEPATIC  BLOOD-VESSELS. 

OsLER  records  a  case  of  stenosis  of  the  hepatic  veins  that  was  asso' 
ciated  with  fibroid  obliteration  of  the  inferior  vena  cava,  with  a  greatly 
enlarged  and  cirrhotic  liver. 

Among  other  affections  of  the  hepatic  veins  are  (a)  Emboli,  orig- 
inating from  a  thi'ombus  in  the  right  auricle,  and  (b)  Dilatation,  from 
stasis  of  the  blood-current  flowing  to  the  right  heart,  due  to  enlarge- 
ment of  the  latter. 

Aff'ections  of  the  hepatic  arteries  are  exceedingly  rare,  but  may  occur 
in  one  of  the  following  forms :  (a)  Aneurysm. — Only  10  or  12  cases  of 
aneurysm  have  been  reported,  {b)  Hypertrophy  and  Dilatation. — These 
may  occur  in  connection  with  general  hepatic  cirrhosis,  the  cicatricial 
bands  obstructing  the  lumen  of  the  artery,  and  causing  thickening  in 
some  places,  and  ampullne,  or  sac-like  dilatations,  in  others,  {c)  Sclerosis. 
— This  may  form  a  part  of  a  general  arterio-sclerosis.  though  it  occurs 
oftener  in  connection  Avith  cirrhosis  or  syphilitic  hepatitis. 


ATROPHY   AND    HYPERTROPHY   OF  THE  LIVER. 

(a)  Atrophy. — vSimple  atrophy  of  tlie  liver  may  result  from  pressure 
(corset-liver),  syphilis,  advanced  cirrhosis,  senility,  and  from  the  toxic 
action  of  phosphorus,  arsenic,  or  chloroform — all  factors  that  induce 
rapid  fatty  degeneration  with   cell-destruction. 

{b)  Hypertrophy  is  of  two  kinds — (1)  true  and  (2)  false.  (1)  True 
hypertrophy  may  be  subdivided  into  simple  and  numerical  (hyperplasia), 
the  latter  referring  to  an  increase  in  the  number  of  the  parenchymatous 


HEPATIC  INFILTRATIONS  AND  DEGENERATIONS.  015 

•> 

cells,  and  not,  necessarily,  implying  an  increase  in  the  size  of"  the 
organ. 

The  two  causes  of  simple  hypertrophy  are  active  and  passive  conges- 
tion. The  principal  causes  of  numerical  hypertrophy  are  as  follows : 
Leukemia,  hypertrophic  cirrhosis,  atrophic  cirrhosis  (hyperplasia),  syph- 
ilis, diabetes,  and  malaria. 

(2)  Pseudo-  or  false  hypertrophy  occurs  in  amyloid  and  fatty  infiltra- 
tion, carcinoma,  and  abscess,  and  consists  in  an  increase  in  the  tissues 
least  concerned  in  the  function  of  the  organ. 


HEPATIC  INFILTRATIONS  AND  DEGENERATIONS. 

AMYLOID   INFILTRATION. 
{Waxy,  Lardaceov^,  Baconr/,  or  Albuminoid  Infiltration ;  Amyloid  Disease.) 

Definition. — A  deposit  in  the  hepatic  connective  tissues  of  a  pecu- 
liar substance,  which  was  formerly  held  to  resemble  starch,  but  has  re- 
cently been  shown  to  be  related  to  coagulated  albumin.  Recklinghausen, 
who  is  also  supported  by  other  investigators,  contends  that  at  first  there 
is  hyaline  change  only,  and  that  later  amyloid  transformation  occurs. 
Amyloid  material  contains  nitrogen,  hence  is  related  to  the  proteids. 

Pathology. — The  organ  is  increased  in  all  of  its  diameters  and  of 
firmer  consistence  than  the  normal.  The  edges  are  rounded  and  not  well 
defined,  and  the  surface  is  of  a  light  color,  presenting  in  some  instances 
a  mottled  appearance.  On  section  the  surface  presents  a  grayish-brown, 
glistening  appearance,  which  when  scraped  fails  to  exude  oil-droplets,  as 
in  the  fatty  liver. 

On  microscopic  examination  the  connective-tissue  trabeculae  and  the 
intima  and  media  of  the  capillary  walls  (the  starting-points)  are  chiefly 
affected,  the  lumen  of  the  latter  being  lessened  ;  this  decreases  the  blood- 
supply  to  the  liver,  and  often  directly  induces  fatty  degeneration.  The 
hepatic  cells  may  be  atrophied. 

etiology. — Amyloid  degeneration  is  most  probably  of  microbic 
origin.  Thus  animals  artificially  infected  with  bacteria  have  shown 
amyloid  change  in  the  liver,  spleen,  etc. 

Krawkow  and,  later,  Davidsohn  injected  staphylococcus  cultures, 
Gouget  injected  proteus  cultures,  and  Carriere,  the  tubercle  bacilli,  and 
all  obtained  amyloid  degeneration.  Tuberculous  foci  that  remain  closed 
ofiF  are  rarely  attended  with  amyloid  change,  while  ulcers  of  the  in- 
testines, the  trachea,  and  the  larynx  show  it  with  remarkable  fre- 
quency. 

Predisposing  Causes. — Amyloid  infiltration  may  occur  primarily  in  the 
liver,  but  it  is  often  a  part  of  a  general  infiltration,  affecting  especially 
the  spleen  (sago  spleen)  and  kidneys.  It  is  also  found  in  some  syphilitic 
scars  and  in  certain  tumors  and  old  thrombi. 

It  is  a  frequent  sequel  to  long-standing  and  exhausting  suppurating 
and  cachectic  affections,  as  necrosis  of  the  bones,  hip-joint  disease,  and 
pyelitis;   "  especially  is  this  the  case  when  they  occur  in  an  hereditary 


916 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tuberculous  or  syphilitic  constitution  "  (^llarley).  Amyloid  disease  may 
also  complicate  chronic  malaria,  leukemia,  and  pseudoleukemia.  In 
children  tuberculosis  and  rachitis  not  uncommonly  contribute  to  amyloid 
infiltration. 

Tests  and  Chiu-co-tfristics  of  Amyloid  Matei'ial. — lodin  gives  a  blue 
color  upon  the  iuldition  of  sulphuric  acid  ;  "this  reaction  is  often  not 
obtained  at  all  or  it  may  be  atypical  '  (Oser).  Lugol's  solution  (the 
aqueous  solution  of  iodin  and  potassium  iodid)  gives  a  brown  tint  to 
amyloid  liver-substance  and  stains  ordinary  hepatic  tissues  a  yellow 
color.  Gentian-violet  gives  a  reddish  or  pinkish  hue  to  amyloid  sub- 
stance, while  normal  tissue  is  stained  blue. 

The  following  is  taken  from  Harley's  Comparative  Table  of  Amyloid 
Tests  : 


Starch. 


Amvi-oid. 


Water. 


Ether. 
Heat. 
Sulphuric  acid 

Iodin. 


Dissolves    on 

ing. 
Insoluble. 
Dries  up. 
Chars. 


boil 


boil- 


Becomes  blue. 


Cholesterin. 
Unchanged. 

Dissolves. 

Melts. 

Becomes  green, 
blue,  etc. 

Remains  un- 
changed. 


Dissolves    on 
ing. 

Insoluble. 

Dries  up. 

Swells  up,  reddish- 
brown. 

Blue  color  with  Hj- 
SO4,  which  is  de- 
stroyed by  excess. 

Sulphate  of  indigo Amyloid      tissue 

soaked  in  it  be- 
comes a  brilliant 
blue,  while  with 
ordinary  liver-tis- 
sues the  blue 
fades  to  a  pale 
green. 

Symptoms. — When  amyloid  disease  occurs  in  children  the  subjects 
are  poorly  developed  and  puny,  the  complexion  is,  as  a  rule,  muddy  or 
sallow,  and  the  abdomen  usually  prominent.  Occasionally  the  skhi  is 
exceedingly  transparent.  At  any  age  gastro-intestinal  symptoms  occur, 
prominent  among  which  are  marked  constipation  and  a  capricious  appe- 
tite. Mental  phenomena,  as  impairment  of  memory  and  inability  to  con- 
centrate, are  not  unusual  in  this  disease.  Pain  about  the  hepatic  region 
is  a  rare  symptom.  The  spleen  is  usually  enlarged  from  coexistent 
amyloid  infiltration.  The  urine  often  contains  albumin  (globulin  is 
nearly  always  present),  renal  epithelium,  and  Avaxy  tube-casts ;  it  is  of 
somewhat  lowered  specific  gravity,  but  may  be  scanty  and  dark  colored. 
Diarrhea,  with  slimy  dejecta,  is  commonly  present.  The  physical  sit/ns 
show  an  increase  in  the  area  of  hepatic  dulncss  ;  the  edges  of  the  organ 
extend  below  the  costal  margin  and  have  a  rounded  outline.  Sometimes, 
however,  the  edge,  even  in  a  very  great  enlargement,  is  sharp.  Wilks 
speaks  of  an  amyloid  liver  weighing  14  lbs. — 6.35  kgms.  (Osier).  In 
rare  instances  the  liver  is  reduced  in  size. 

Diagnosis. — The  foregoing  symptoms  and  physical  signs,  in  con- 
junction with  an  ordinarily  clear  etiology  (syphilis,  tuberculosis,  or  other 
primary  process  in  some  other  part  of  the  body). and  amyloid  degenera- 
tion elsewhere,  are  sufficient  to  establish  the  diagnosis. 

Treatment. — As  amyloid  disease  is  almost  invariably  a  secondary 


FATTY  INFILTRATION   OF  THE  LIVER.  917 

condition,  the  treatment  must  be  directed  to  the  removal  of  the  primary- 
cause,  whether  syphilis,  tuberculosis,  or  rickets.  It  has  been  shown  re- 
cently that  amyloid  degeneration  may  disappear  if  the  primary  cause  can 
be  removed.  The  diet  should  consist  of  nitrogenous  or  animal  substances, 
with  a  minimum  amount  of  fat.  French  rolls  and  bran-  or  gluten-bread 
are  allowable,  together  with  lean  meat,  wholesome  cereals,  and  green 
vegetables.  Stimulants  are  to  be  strictly  avoided.  Moderate  exercise, 
with  the  judicious  use  of  Turkish  (^hot-air)  and  Russian  (hot-vapor)  baths, 
is  also  of  great  value. 

Many  drugs  are  mentioned  in  the  treatment  of  this  disease,  among 
the  more  important  being  the  ammonium  salts  (the  chlorid,  gr.  v  to  x — 
0.324  to  0.648 — three  or  four  times  a  day)  and  other  alkalies. 

When  syphilis  has  been  clearly  established  as  an  etiologic  factor  of 
the  disease,  the  tincture  of  iodin  in  10- to  15-minim  (0.666-0.999)  doses, 
well  diluted,  has  been  recommended  to  be  given  three  or  four  times  daily. 
Cod-liver  oil  as  a  nutritive,  if  tuberculosis  be  associated,  has  been  tried 
with  good  effect.  Of  tonics,  the  dilute  mineral  acids,  given  in  moderate 
doses,  have  probably  achieved  the  best  results. 

FATTY   LIVER. 

The  term  fatty  liver  embraces  (a)  fatty  infiltration,  or  a  deposit  of 
fat  in  the  otherwise  normal  hepatic  tissues ;  and  {b)  fatty  degeneration, 
in  Avhich  a  conversion  of  the  albuminates  of  the  cells  into  fat  occurs.  It 
should  be  recollected,  however,  that  the  latter  condition  is  invariably 
preceded  and  accompanied  by  the  former,  so  that  most  instances  of  fatty 
liver  partake  of  the  nature  of  both  processes. 

FATTY   INFILTRATION. 

Pathology. — The  infiltration  occurs  often  in  localized  areas,  and 
may  be  so  intense  that  the  organ  when  cut  presents  a  shiny,  oily  appear- 
ance. The  liver  is  often  evenly  enlarged,  and  may  weigh  twelve  to 
fifteen  pounds.  The  edges  are  rounded  and  the  substance  less  firm  than 
normally.  Portions  of  the  liver-substance  float  in  water.  The  color  is 
light  yellow  or  grayish.  Microscopically,  the  protoplasm  of  the  cell  is 
seen  to  be  pushed  to  one  side  by  the  fat  droplets,  which  tend  to  coalesce. 
Fatty  infiltration  may  end  in  fatty  degeneration. 

Etiology. — («)  Fatty  infiltration  may  form  part  of  a  general  obesity 
or  it  may  follow  gastro-intestinal  disorders  even  in  childhood,  {h)  It 
often  occurs  in  wasting  diseases,  as  carcinoma,  syphilis,  chronic  malaria, 
and  tuberculosis. 

Symptoms. — The  subjective  symptoms  of  fatty  infiltration  may  be 
entirely  wanting,  since  the  function  of  the  liver  is  not  impaired  to  any 
extent.  When  they  are  present  progressive  anemia  and  debility  are 
noted,  and  are  accompanied  by  nervous  irritability  and  insomnia.  In 
marked  cases  the  cardiac  rhythm  is  disturbed,  causing  a  feeble  and 
irregular  impulse. 

The  physical  signs  are  Avell  defined,  and  the  area  of  hepatic  dulness  is 
uniformly  increased,  extending  in  some  instances  as  low  as  the  umbilicus. 
The  enlargement,  however,  is  not  so  great  as  in  amyloid  disease. 

Differential  Diagnosis. — Fatty  infiltration  of  the  liver  is  not  apt 
to  be  mistaken  for  any  other  affection  of  this  organ.      The  occurrence  of 


918  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

general  obesity,  together  with  an  entire  absence  of  symptoms  of  obstruc- 
tion to  the  portal  vessels  or  bile-ducts  or  of  other  evidences  of  fatti/  df- 
ili-neration  (particularly  feeble  heart-sounds),  will  help  to  distinguish  it 
from  this  latter  condition.  The  etiologic  factors  above  mentioned  will 
also  ;iid  in  the  differentiation. 

Prognosis. — This  is  decidedly  favorable,  as  the  function  of  the  liver 
in  many  instances  is  not  impaired  in  the  slightest  degree. 

Treatment. — As  the  disease  is  of  gradual  development  and  long 
duration,  a  modification  of  the  diet  constitutes  the  first  essential  of  the 
treatment.  That  prescribed  under  the  Treatment  of  Amyloid  Liver  is 
admirably  suited  to  this  affection.  Saccharine  and  farinaceous  articles 
of  food  (potatoes,  oatmeal,  and  sweetmeats)  must  be  eschewed.  Wlieat- 
bread  must  be  partaken  of  sparingly,  and  in  its  place  gluten-  and 
bran-bread  or  crusts  of  French  rolls  should  be  used.  Fish,  lean  meats, 
fresh  vegetables,  and  fruits  are  also  allowable.  Alcoholic  beverages 
must  be  interdicted.  When  fatty  liver  develops  in  tuberculous  subjects, 
the  ingestion  of  fats  and  carbohydrates  should  be  restricted. 

Graduated  daily  exercise  to  stimulate  metabolism  and  Turkish  or 
Russian  baths,  judiciously  used,  are  important  factors  in  the  treatment. 
Medicinally,  the  salts  of  the  alkalies  are  highly  recommended  :  sodium 
sulphate  (in  dram — 4.0 — doses,  taken  on  an  empty  stomach)  and  ammo- 
nium carbonate  (gr.  xv  to  xxx — 1.0  to  2.0 — in  twenty-four  hours). 


FATTY  DEGENERATION   OF    THE  LIVER. 

Pathology. — (.)n  examining  a  liver  that  is  the  seat  of  marked  fatty 
degeneration  the  organ  is  found  smaller  than  normally,  and  the  sub- 
stance is  light  yellow  in  color,  soft,  pliable,  and  easily  torn.  On  section 
the  relation  betAveen  the  interlobular  connective  tissue  and  the  acini  is 
lost,  the  latter  being  replaced  by  fat-cells  and  oil-droplets.  Scattered 
areas  of  pigmentation  may  be  observed  throughout  the  organ. 

Microscopically,  the  cells  lose  their  shape  and  become  globular  ;  the 
nuclei  tend  to  coalesce,  and  finally  disappear,  together  with  the  cell-wall, 
giving  rise  to  compound  globule-cells,  which  do  not  tend  to  coalesce  and 
are  stained  black  by  osmic  acid.  Crystals,  granular  debris,  Lener's 
spheres,  cholesterin,  tyrosin,  and  phosphatic  crystals  are  also  found  in 
this  form  of  granular  change.  Histologic  differences  are  recognized  at 
the  present  day  between  this  disease  and  acute  yellow  atrophy. 

Ktiology. — The  following  are  among  the  recognized  causes  of  the 
affection  :  (a)  The  excessive  use  of  beer  or  alcoholic  liquors,  (h)  It  may 
be  a  sequence  of  amyloid  disease,  {e)  Diminution  of  the  oxygen-supply 
to  the  tissues,  occurring  in  phosphorus-,  chloroform-,  or  arsenic-poisoning, 
and  in  certain  wasting  diseases  (carcinoma,  phthisis,  and  chronic  dysen- 
tery), {d)  It  may  occur  as  a  complication  in  the  grave  anemias,  espe- 
cially pernicious  anemia,  in  acute  infectious  diseases,  and  the  intoxica- 
tions, as  well  as  in  pregnancy. 

Symptoms. — I  feel  convinced  that  partial  or  mild  cases  of  fatty  de- 
generation of  the  liver  present  no  morbid  symptoms  of  diagnostic  import. 
Pain,  jaundice,  and  ascites  may  occur  separately  or  conjointly,  but  form 
the  exception  rather  than  the  rule.     The  severe  forms  are  characterized 


PERIHEPA  TITIS.  9 1 9 

by  the  symptoms  seen  in  phosphorus-poisoning  and  acute  yellow  atrophy, 
to  the  discussion  of  which  the  reader  is  referred. 

Complications. — The  disease  may  be  complicated  with  fatty  change 
in  the  kidneys.  Under  these  circumstances  the  urine  is  diminished  in 
amount,  of  low  specific  gravity,  and  contains  an  abundance  of  albumin, 
fatty  or  oily  casts,  and  crystals  of  cholesterin,  leucin,  and  tyrosin.  In 
marked  cases  there  is  a  verj  feeble  and  irregular  cardiac  impulse,  accom- 
panied by  attacks  of  vertigo  and  syncope,  the  latter  symptoms  indicating 
beginning  degeneration  of  the  cardiac  muscle.  Edema  of  the  lower  ex- 
tremities and  anasarca  may  occur  as  complications  of  this  condition. 

The  physical  signs  elicited  by  palpation  and  percussion  show  increas- 
ing diminution  in  the  size  of  the  liver  as  the  disease  advances. 

Diagnosis. — The  chief  diagnostic  points  of  fatty  degeneration  may 
be  summated  thus :  (a)  A  history  of  alcoholism,  of  poisoning  by  drugs 
^arsenic,  phosphorus,  or  chloroform),  or  of  an  acute  infectious  disease 
(acute  yellow  atrophy) ;  (b)  Grave  general  symptoms,  as  albuminuria, 
edema,  ascites,  cardiac  failure,  terminating  often  in  acholia  or  cholemia  ; 
(e)  Progressive  diminution  in  the  size  of  the  organ.  When  these  occur 
conjointly  the  diagnosis  is  established  beyond  a  doubt. 

Prognosis. — The  prognosis  is  entirely  dependent  upon  the  cura- 
bility of  the  cause.  If  due  to  an  excessive  use  of  stimulants,  the  process, 
if  recognized  early,  may  be  arrested ;  if  associated  with  an  acute  infec- 
tious disease,  the  outlook  is  unpromising. 

Treatment. — The  indications  for  treatment  may  be  divided  into  the 
dietetic,  hygienic,  and  medicinal.  The  same  precautions  regarding  diet 
should  be  observed  as  in  fatty  infiltration.  An  open-air  existence,  short 
of  injurious  exposure,  aided  by  hot  salt-water,  Turkish,  or  Russian  baths, 
under  restriction,  is  sure  to  improve  the  general  condition  of  the  patient. 

The  medicinal  treatment  varies  according  to  the  cause  of  the  disease. 
If  due  to  grave  anemia,  iron  (tinct.  ferri  chlorid.  or  syrup,  ferri.  iodid.) 
may  be  given  in  ascending  doses.  Poisoning  by  drugs  that  produce  fatty 
degeneration  of  the  liver  is  to  be  combated  by  their  respective  antidotes. 
Gastro-intestinal  disturbances,  if  coexistent,  demand  appropriate  treat- 
ment. For  the  latter  Frerichs  recommends  highly  the  salts  of  the  alka- 
lies (sodium  sulphate  in  dram — 4.0 — doses  taken  on  an  empty  stomach 
and  ammonium  carbonate).  Ascites  and  cardiac  asthenia,  when  occurring 
as  complications,  must  be  met  by  suitable  measures. 


PERIHEPATITIS. 

ACUTE    PERIHEPATITIS. 
{Pyo-pneumothorax  SubpJireniciis.) 

Definition. — An  inflammation,  either  suppurative  or  fibrinous,  of 
the  peritoneal  covering  of  the  liver  and  the  corresponding  portion  of 
the  diaphragm. 

Pathology. — The  morbid  changes  may  consist  in  a  purely  plastic 
inflammation,  the  serous  layers  being  thickened,  opaque,  and  covered 
■with  a  fibrinous  exudate  leading  to  adhesion.     In  the  majority  of  cases, 


920  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

however,  the  intlamiuatory  product  is  chicUy  purulent,  and  is  ribhoned 
by  fibrous  bands  so  as  to  form  circumscribed  areas,  filled  with  pus,  lying 
between  the  liver  and  the  diaphragm  ;  this  constitutes  the  subphrenic 
abscess.  The  latter  is  found  more  commonly  to  the  right  than  to  the 
left  of  the  suspensory  ligament.  It  may  contain  much  pus  (1  quart — 1 
liter — or  even  more),  which  in  most  cases  is  mixed  with  air  or  gas  de- 
rived from  the  gastro-iutestinal  canal.  Karely,  bilirubiu-crystals  are 
found,  betraying  the  presence  of  bile.  If  the  latter  be  present  in  large 
amount,  the  pus  assumes  an  ocher-yellow  hue. 

Htiology. — The  fibrinous  variety  may  result  from  the  direct  exten- 
sion of  one  or  other  of  the  acute  forms  of  inflammation  of  the  liver  (ab- 
scess, hydatid  cyst),  from  a  pleurisy  spreading  along  the  lymphatics  in 
the  diaphragm,  or  from  traumatism — particularly  a  blow.  The  suppura- 
tive form  [pyo-pneumotJiorax  subphrenicus,  Leyden)  may  be  caused  in 
the  same  manner  as  the  former,  but  far  oftener — in  more  than  one-half 
of  the  instances — it  follows  perforation  of  a  gastric  ulcer,  and  far  less 
commonly  perforation  of  a  duodenal  or  colonic  ulcer.  Appendicitis  and 
penetrating  wounds  are  not  infrequent  causes.  Perihepatitis  is  a  grave 
complicating  event  in  carcinoma  (of  the  stomach,  esophagus,  and  intes- 
tines), in  lobar  pneumonia,  and  purulent  pleuritis. 

Symptoms. — Those  of  the  acute  fibrinous  variety  are  either  alto- 
gether missing  or  too  vague  to  admit  of  correct  interpretation.  The 
coappearance,  however,  of  severe  pain,  increased  on  deep  breathing,  and 
tenderness  over  a  circumscribed  area  either  in  the  right  hypochondrium 
or  the  epigastrium,  after  the  action  of  some  known  cause  or  the  occur- 
rence of  one  of  the  causative  affections,  is  suggestive  of  this  form  of  the 
complaint.  A  friction-sound  may  at  times  be  heard  below  the  seventh 
rib  in  the  mammillary  or  over  the  epigastrium,  as  in  two  of  my  cases. 
It  is  of  short  duration,  and  is  limited  usually  to  the  end  of  inspiration. 
Plastic  pleurisy  may,  however,  be  an  associated  condition. 

In  suppurative  perihepatitis  the  symptoms  are  sometimes  screened  by 
those  of  the  special  causative  complaint ;  but  in  my  experience,  in  cases 
due  to  perforation,  the  onset  is  rapid  and  severe  and  is  marked  by  acute 
pain  referred  to  a  circumscribed  spot  in  the  hepatic  region,  great  tender- 
ness., rapid,  embarrassed,  and  pjainful  respiration  (owing  to  implication 
of  the  diaphragm),  by  vomiting  (often  bilious,  though  at  times  hemor- 
rhagic) or  nausea.,  and  by  faint  jaundice  in  some  cases.  Shortly  the 
general  features  of  circumscribed  peritoneal  abscess  also  appear — rigors, 
irregular  fever,  sweats,  and  progressive  prostration  and  emaciation. 

Physical  Signs. — Inspection  discloses  bulging  of  the  right  hypo- 
chondrium and  often  of  the  epigastrium.  The  same  regions  are  immo- 
bile, but  this  is  best  appreciated  by  j)alpation.  Palpable  friction  may  at 
times  be  obtained.  The  anterior  edge  of  the  liver  is  felt  even  as  low  as 
the  umbilical  level.  Percussion  reveals  a  variable  increase  of  hepatic 
dulness  upward,  sometimes  touching  the  fourth  rib.  The  upper  level  of 
the  fluid  is  movable  on  change  of  posture,  and  this  is  particularly  striking 
if  gas  be  contained  in  the  abscess  ;  the  presence  of  the  latter  also  causes 
a  zone  of  tym])anitic  resonance  above  the  dull  area,  wdiile  overlying  the 
latter  there  is  the  semitymj)anitic  area  of  the  retracted  lung.  Ausculta- 
tion reveals  o,  friction-sound  and  an  absence  of  breath-sounds  and  of  the 


CIIRONTC  PERinKPATITIS.  921 

vocal  resonance  over  the  dull  and  tyrnpiuiit  ic  areas,  wliile  the  respi)-;itory 
sounds  over  the  dis[)laced  lung  are  broncho-vesicuhir. 

Differential  Diagnosis. — Acute  perihepatitis  often  remains  unrec- 
ognized during  life.  It  may  be  confounded  with  empyema  of  the  right  side, 
but  the  two  conditions  have  different  modes  of  development.  Perihepatitis 
is  preceded  and  accompanied  by  abdominal  symptoms ;  empyema  mani- 
fests thoracic  symptoms — e.  y.  cough  and  pleuritic  pain.  At  a  later 
stage  the  exaggerated  respiratory  murmur  above  the  dull  area,  the 
slighter  cardiac  displacement  toward  the  left,  and  the  greater  hepatic 
displacement  downward  in  suppurative  perihepatitis  aid  in  the  differen- 
tiation. The  introduction  of  the  trocar  in  the  seventh  or  eighth  inter- 
costal space  in  the  mid-axillary  line  may  also  be  helpful,  especially  if 
the  exudate  be  found  to  contain  bile-pigment.  PfuJiVs  sign — the  more 
ready  escape  of  the  fluid  during  inspiration  on  aspiration  of  abscesses 
below  the  diaphragm — may  not  be  without  value.  The  points  narrated 
above  may  likewise  serve  to  separate  pyo-pneumothorax  from  suppurative 
perihepatitis  (see  also  Pneumothorax,  p.  607).  To  differentiate  from 
acute  plastic  pleurisy,  Cantlie's  sign,  or  grasping  the  liver  between  the 
hands  and  moving  it  backward  and  forward,  thus  causing  pain  running 
up  into  the  supraclavicular  fossa,  may  be  employed. 

Course  and  Prognosis. — In  the  milder  or  fibrinous  variety  the 
outlook  is  favorable  and  the  course  is  brief.  On  the  other  hand,  the 
suppurative  type  due  to  perforation,  if  not  early  brought  under  proper 
surgical  treatment,  often  terminates  unfavorably  by  gradual  asthenia. 
Rarely  the  pus  is  resorbed,  or  it  may  find  an  outlet  through  the  lungs, 
abdominal  walls,  or  other  avenue,  followed  by  slow  recovery. 

The  treatment  is  the  same  as  for  localized  peritonitis.  The  first 
evidence  of  the  presence  of  pus  is  the  signal  for  surgical  interference — 
evacuation  and  drainage,  and  Wakar^  favors  the  transpleural  method. 

CHRONIC   PERIHEPATITIS. 
{Zuckergussleber.) 

This  affection  is  a  chronic  inflammation  of  the  perihepatic  fibrous 
membrane,  which  becomes  opaque  and  thickened.  Contraction  of  this 
capsule  ensues,  with  compression  of  the  liver  and  atrophy  to  one-half 
the  size  of  the  normal  organ  (as  in  a  case  reported  by  Rumpf^),  and  par- 
tial or  total  occlusion  of  the  vessel  and  bile-ducts.  These  changes  are 
most  marked  in  cases  that  follow  acute  suppurative  perihepatitis.  Genuine 
instances  show  no  hyperplasia  of  the  interstitial  connective  tissue  ;  hence 
the  condition  is  closely  related  pathologically  to  "  Glissonian  cirrhosis." 

The  main  causes  of  chronic  perihepatitis  are  great  and  protracted 
local  pressure,  as  from  a  corset,  and  certain  occupations.  It  may  repre- 
sent a  portion  of  a  more  general  chronic  inflammation  of  the  serosa.  I 
believe  that  syphilis  is  the  leading  single  cause,  and  could  discover  no 
other  factor  pi-esent  in  two  cases  that  yielded  to  antisyphilitic  treatment. 
A  circumscribed  form  (benign)  may  occur  from  local  pressure. 

The  diagnosis  is  generally  problematic.  Of  especial  clinical  worth 
are  the  etiology,  pain  in  the  right  hypochondriac  region — particularly 
in  cases  due  to  syphilis — absence  of  the  signs  of  stasis  of  the  gastro>- 
intestinal  tract,  and  the  very  protracted  course. 

^  Deutsche  Zeltschrijt  fur  Chir.,  Leipsic,  January,  1912 
"^  Deutsch.  Arch.  f.  klin.  3Ied.,  March  13,  1895. 


922  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  treatment  is  purely  palliative,  apart  from  the  effort  to  remove 
the  special  cause,  whether  this  be  syphilis,  occupation,  or  other  influ- 
ential factor. 


ABSCESS   OF  THE  LIVER. 

(Hepatic  Abscess;  Suppurative  Hepatitis.) 

Definition. — A  circumscribed  collection  of  pus  iu  the  hepatic 
parenchyniii. 

Pathology. — If  examined  m  situ,  a  liver  that  is  the  seat  of  ab- 
scess-formation is  usually  found  to  be  symmetrically  enlarged,  and  on 
careful  palpation  one  or  more  areas  of  fluctuation  (either  deep  or  super- 
ticial,  according  to  the  location  of  the  abscess)  may  be  detected.  If 
single,  its  position  is  usually  in  the  right  lobe  near  the  convexity  of  the 
organ  (70  per  cent,  of  cases).  The  tissue  surrounding  the  abscess-wall 
is  usually  deeply  injected,  the  "vvall  itself  in  acute  cases  being  poorly 
defined,  but  grayish  in  color,  irregular  and  shreddy,  and  composed  of 
necrotic  liver-cells,  pus-corpuscles,  and  often  amebjB.  In  chronic  cases 
it  becomes  greatly  thickened  and  often  cartilaginous  in  appearance. 

The  amount  of  fluid  contained  in  a  liver-abscess  may  exceed  2  or  3 
quarts  (2-3  liters),  and  its  color  varies  from  grayish-white  to  a  creamy, 
reddish-brown.  The  collection  in  some  instances  resembles  healthy  pus. 
I  have  spoken  of  the  methods  of  infection  and  of  some  of  the  different 
varieties  of  hepatic  abscess  in  the  discussion  of  Dysentery  (see  p.  72). 

Various  odors  are  described,  depending  largely  on  the  extent  of  bac- 
terial invasion  and  the  degree  of  necrosis.  Here  it  may  be  said  that  in 
amebic  dysentery,  hepatic  abscess  is  often  single  (involving  more  often 
the  right  lobe),  whereas,  in  general  pyemia,  multiple  abscesses  are  the 
rule.  Multiple  tropical  abscess,  however,  is  not  uncommon  and  is 
indistinguishable  from  those  that  are  met  in  temperate  climates  as  the 
result  of  infection  via  the  portal  vein. 

In  these  instances  the  surface  of  the  organ  presents  many  small 
yellow  areas  beneath  the  capsule,  varying  from  5  to  15  mm.  (-j— f  inches) 
in  diameter.  Usually,  in  such  cases  too,  the  appearances  of  a  suppura- 
tive pylephlebitis  present  themselves.  If  thrombi  have  formed  in  the 
portal  tributaries,  localized  necrotic  areas  are  the  result,  but  more  often 
the  invasion  affects  the  whole  portal  sj^stem,  the  liver  being  riddled  with 
abscesses.  If  the  abscess  is  secondar}''  to  obstruction  by  gall-stones  or 
inspissated  bile,  the  ducts  and  the  gall-bladder  are  greatly  distended,  their 
walls  and  immediate  vicinity  infiltrated  with  round  cells,  leading  to  sup- 
purative pericholangitis  and  invasion  of  the  hepatic  parenchyma. 

Microscopically,  the  hepatic  cells  are  altered  in  shape  and  devoid  of 
nuclei ;  they  undergo  rapid  degeneration.  A  round-celled  infiltration 
occurs  about  the  blood-vessels,  their  walls  being  filled  with  small  emboli 
containing  innumerable  staphylococci  and  streptococci.  As  the  sup- 
purative process  continues  liquefaction-necrosis  occurs,  resulting  in 
complete  destruction  of  the  hepatic  parenchyma. 

Ktiology. — Idiopathic  abscess  of  the  liver  is  rare  even  in  tropical 
climates.     The  affection,  when  apparently  excited  by  mechanical  causes, 


ABSCESS  OF  THE  LIVER.  923 

as  traumatism  or  obstruction  by  gall-stones,  is  invariably  a  micro-organ- 
ismal  affection,  and  the  principal  germs  are  streptococci,  staphylococci, 
and  the  ameba  coli. 

Gastric  ulcers,  typhoid  fever,  or  appendicitis  may  be  followed 
by  a  purulent  portal  pylephlebitis,  resulting  in  abscess-formation. 
On  analyzing  500  cases  of  suppurative  hepatitis  Kelsch  found 
that  in  85  cases  in  100  the  disease  was  associated  with  dysentery. 
Manson  records  a  total  of  3680  autopsies  made  on  dysenteric  patients 
in  tropical  countries,  and  of  these  21  per  cent,  showed  abscess  of 
the  liver.  Among  Europeans  in  tropical  climates  the  general  aver- 
age is  12  per  cent.  In  general  pyemic  processes  or  in  bone-sup- 
purations of  long  standing  infection  of  the  liver  occurs.  Suppurating 
wounds  of  the  head  may  be  followed  by  abscess  of  the  liver.  Among 
other  causes  may  be  mentioned  foreign  bodies  travelling  up  the  ducts,  as 
parasites,  round-worms,  liver-flukes ;  also,  more  rarely,  suppuroperforation 
by  mechanical  irritants  (needles,  pins,  fish-bones,  and  the  like),  and  sup- 
puration occurring  in  the  course  of  an  hydatid  cyst.  Leick  has  tabulated 
19  cases  of  hepatic  abscess  caused  by  the  ascaris  lumbricoides.  Among 
other  factors  are :  Age  (adult  life),  male  sex,  alcoholism,  and  malaria. 

The  manner  of  infection  is  variable;  it  may  be  {a)  through  the  portal 
vein  (most  commonly) ;  (h)  through  the  bile-ducts  ;  and  {c)  the  metastasis 
may  take  place  through  the  blood  (hepatic  artery),  (t?)  Exceptionally 
infection  may  occur  via  the  lymph-channels. 

Symptoms  of  Solitary  Abscess. — In  a  typical  case  of  hepatic 
abscess  the  most  prominent  symptoms  are — hectic  temjyerature,  pain,  ten- 
derness, and  enlargement  of  the  organ,  and  often  slight  jaundice,  although 
it  must  not  be  forgotten  that  any  or  all  of  these  may  be  absent  during 
its  development.  The  multiple  abscesses  occurring  in  pyemic  conditions, 
which  are  frequently  diagnosed  when  in  view  upon  the  postmortem  table, 
form  an  instance  of  this.  The  present  description,  however,  has  refer- 
ence chiefly  to  the  large,  solitary  abscess. 

To  facilitate  the  subject  I  shall  consider  the  more  important  symp- 
toms seriatim :  Pain  is  circumscribed  to  the  hepatic  region,  and  radi- 
ates to  the  right  shoulder  in  conjunction  with  the  other  symptoms  and 
physical  signs ;  it  is  very  characteristic,  although  not  pathognomonic  of 
hepatic  abscess.  In  the  earlier  stages  this  symptom  is  not  pronounced 
unless  the  abscess  or  abscesses  lie  superficially.  It  is  usually  of  a  dull, 
boring  character,  diff"ering  in  severity  with  the  patient's  position ;  it  is 
usually  aggravated  by  pressure  over  the  costal  margin  and  by  lying  on 
the  left  side,  this  tending  to  drag  the  liver  by  its  own  weight  from  its 
normal  position.  Luschka  explains  the  radiation  of  pain  to  the  right 
shoulder  by  stating  that  filaments  of  the  phrenic  nerves  that  distribute 
themselves  in  the  suspensory  ligament  and  Glisson's  capsule  are  irri- 
tated. The  phrenic  arises  from  the  third,  fourth,  and  fifth  cervical 
nerves,  and,  as  the  fourth  supplies  sensation  to  the  right  shoulder,  the 
impression  is  thus  transmitted  through  the  central  nervous  system. 

In  acute  cases  accompanied  by  rapid  destruction  of  the  hepatic  tis- 
sues the  temperature  usually  rises  rapidly,  reaching  103°  or  104°  F. 
(39.4°— 40°  C.)  in  the  course  of  from  twenty-four  to  thirty-six  hours.  Its 
course,  however,  is  irregular  and  intermittent,  and  it  may  be  hectic  in 
character ;  just  as  often  it  resembles  a  tertian  or  quartan  intermittent  or 


924  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

a  remittent  malarial  fever.  Jiii/ors  or  decided  chills  fVei(uently  accom- 
pany the  rise  of  temperature,  and  diirinjjj  the  decline  profuse  sweatings 
may  take  place.  In  chronic  abscess  of  the  liver  pyrexia  may  be  entirely 
absent.  Less  commonly  the  temperature  may  remain  continuously  bigh, 
with  slight  morning  remissions.  The  pulse  is  usually  rapid  in  proportian 
to  tlie  temperature. 

The  physical  signs  in  a  case  of  hepatic  abscess  are  always  present  to 
a  greater  or  less  degree,  and  are  often  pathognomonic. 

Inspection  msLj  re\eii\  nothing  during  the  entire  course  of  the  dis- 
ease, although  if  there  be  intense  congestion  involving  the  anterior  sur- 
face of  the  right  lobe,  bulging  of  the  ribs  on  that  side  will  occur,  with  a 
marked  prominence  in  the  hypochondriac  region  extending  three  or  more 
finger-breadths  below  the  costal  margin. 

Palpation  confirms  inspection  and  reveals  tenderness  on  pressure 
below  the  costal  margin  in  the  mammary  line.  The  liver,  if  projecting 
below  the  edge  of  the  ribs,  is  usually  enlarged  uniformly,  unless  the 
abscess  involves  the  surface  of  the  margin.  As  the  upper  right  lobe  is 
more  often  involved,  the  increase  in  diameter  is  upward,  thus  render- 
ing palpation  negative.  In  rare  instances  the  abscess  gives  rise  to 
fluctuation  on  palpation,  and  a  friction  fremitus  if  the  peritoneum  be 
inflamed. 

Percussion. — The  area  of  hepatic  dulness  may  be  increased  unifonnly, 
but  it  is  usually  most  marked  upward  and  to  the  right  (fifth  rib),  and 
posteriorly  to  the  level  of  the  angle  of  the  scapula.  This  high  position 
of  the  upper  boundary  of  dulness  which  starts  about  the  nipple-line 
serves  to  differ'^ntiate  abscess  from  other  aff'ections  of  the  liver,  in  which 
the  enlargement  extends  in  a  downward  direction. 

Other  Symptoms. — The  skin  is  pale  and  shows  slight  icterus,  the 
conjunctivce  being  often  bile-stained;  intense  Jaundice,  however,  is  rare. 
Progressive  loss  of  flesh  and  strength,  with  g astro-intestinal  disturbance 
(fulness  in  the  epigastrium,  flatulence,  water-brash,  nausea,  and  occasional 
vomiting),  are  common  symptoms  at  the  onset.  The  bowels  are  variable, 
and  constipation  usually  alternates  with  diarrhea,  the  stools  in  some 
cases  containing  the  ameba  coli.  Ascites  may  develop  from  pressure 
on  the  inferior  vena  cavoe,  but  such  cases  are  rare.  The  spleen  may 
undergo  active  hyperplasia  in  acute  abscess-formation.  Pulmonary 
symptoms  (severe  cough,  characteristic  reddish-brown  sputum,  resembling 
anchovy  sauce,  broncho-vesicular  breathing,  rales)  are  commonly  present; 
they  are  due  to  compression  of  the  base  of  the  lung  by  the  abscess  press- 
ing upon  the  diaphragm.  In  fatal  cases  certain  nervous  symptoms  (mut- 
tering delirium,  cephalalgia,  subsultus  tendinum,  stupor,  coma)  make 
their  ap]iearanro.      A  marked  leuhocytosis  is  generally  present. 

Complications  and  Sequelae. — The  abscess  may  perforate  into 
the  pleural  cavity  (pyothorax),  bronchi,  lungs,  intestinal  tract,  stomach, 
pericardium,  peritoneal  cavity,  or  externally  through  the  abdominal 
wall,  giving  rise  to  various  symptoms.  If  rupture  occurs  into  the 
intestinal  tract,  sudden  diarrhea,  with  the  discharge  of  large  quantities 
of  pus,  takes  place.  If  the  rupture  is  into  the  lung,  the  physical  signs 
will  reveal  the  sudden  development  of  Aveak,  tubular  breathing  over  the 
base,  with  increased  tactile  fremitus  and  percussion-dulness,  together 
with  the  occurrence  of  profuse  and  typical  expectoration.    Reese,  Lafleur, 


ABSCESS  OF   THE  LI  VEIL  925 

and  Boston  found  the  ameba  coli  in  the  bronchiid  (lischarge.  Rupture 
into  the  abdominal  cavity  gives  rise  to  the  development  of  a  fatal  perito- 
nitis.     Cerebral  abscess  may  occur. 

Diagnosis. — The  clinical  symptoms  of  hepatic  abscess  are  of  diag- 
nostic importance  only  when  taken  in  the  aggregate,  since  the  pain, 
fever,  enlargement,  and  even  hectic  symptoms  occur  singly  in  other 
conditions  unaccompanied  by  suppuration.  The  principal  points  in  the 
establishment  of  the  diagnosis  of  the  affection  may  be  summed  up  as 
follows:  Residence  in  tropical  countries,  the  previous  existence  of 
typhoid  or  dysenteric  ulceration  (or  other  gastro-intestinal  inflamma- 
tion), the  characteristic  expectoration,  enlargement  of  the  liver,  with 
pain  and  tenderness  on  pressure,  and  in  some  instances  fluctuation  on 
palpation.  Pain  in  the  liver,  often  radiating  to  the  shoulder,  if  tlie 
patient  be  shaken,  is  a  certain  sign  (Malbot).  Skiagraphy  shows  the 
right  leaflet  of  the  diaphragm  to  be  displaced  upward  and  unaffected  by 
respiration.  Lastly,  exploratory  aspiration  with  a  medium-sized  needle 
is  to  be  resorted  to  in  dubious  cases  ;  it  may  reveal  pus-corpuscles,  hepatic 
cells,  staphylococci  and  streptococci,  the  ameba,  and  bile-pigment,  which 
when  found  are  pathognomonic  ;  if  the  abscess  be  secondary  to  an  echino- 
coccus  cyst,  the  presence  of  booklets  will  be  detected.  The  patient 
should  be  anesthetized,  since  the  puncture  may  have  to  be  repeated. 

Differential  Diagnosis. — Hepatic  abscess  may  be  misdiagnosed  for 
empyema^  suppurative  pylephlebitis^  malarial  fever,  and  hepatic  calculi. 

Empyema. — In  empyema  there  may  be  the  history  of  a  perforating 
wound  of  the  chest,  the  rupture  of  a  bronchiectatic  or  tuberculous  cavity. 
or  the  pre-existence  of  a  sero-fibrinous  pleurisy  ;  whereas  hepatic  abscess 
may  be  preceded  by  an  attack  of  amebic  dysentery,  intestinal  ulceration 
from  other  forms  of  infection,  impacted  gall-stones,  traumatism,  or  a 
pyemic  process.  In  both  there  may  be  the  occurrence  of  a  hectic  tem- 
perature, with  chills  and  sweating ;  but  in  empyema  cough  and  dyspnea 
are  prominent,  and,  if  the  pleural  cavity  communicates  with  a  bronchus, 
profuse  mucopurulent  expectoration  containing  pus-cells,  staphylococci, 
streptococci,  and  tubercle  bacilli  may  be  observed.  Rarely  an  abscess 
of  the  liver  penetrates  the  diaphragm  and  is  expectorated.  The  recog- 
nition of  hepatic  abscess  under  th'ese  circumstances  is  to  be  based  mainly 
upon  clear  previous  evidence  of  the  affection,  and  copious,  blood-tinted, 
purulent  expectoration.  The  detection  of  the  ameba  coli  in  the  sputum 
alone  would  set  the  diagnosis  at  rest.  The  contents  of  hepatic  abscess 
obtained  by  aspiration  consist  of  the  micro-organisms  of  suppuration, 
broken-down  liver-cells,  bile-pigment,  and  in  some  cases  the  ameba  coli. 
Inspection  in  empyema  reveals  bulging  of  the  intercostal  spaces  on  the 
side  implicated,  and  there  is  movable  percussion-flatness  over  the  base  of 
the  chest,  rising  posteriorly.  On  the  other  hand,  in  abscess  of  the  liver, 
the  lung  is  slightly  displaced  upward,  being  often  bound  to  the  diaphragm 
by  adhesions ;  and  the  upper  boundary  of  dulness  is  lowxr,  particularly 
in  front,  and  is  immovable. 

Suppurative  Pylephlebitis. — In  hepatic  abscess  there  are  present 
certain  physical  signs  (swelling,  fluctuation),  and  a  history  of  amebic 
dysentery,  rather  than  of  appendicitis,  as  in  suppurative  pylephle- 
bitis. 


926  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Hepatic  Absckss.  Malakia. 

History  of  traumatism,  dysentery,  intes-  History  of  previous  attacks.     Residence 

tinal  ulceration,  or  residence  in  tropi-  in   warm,   damp   climates    among   the 

cftl  countries.  lowlands. 

Hectic  character  of  the  temperature —  Regularly  recurrent  rise  of  the  tempera- 
high  every  evening  and  low  every  ture  (intermittent  or  remittent,  quotid- 
morning  ;  irregular  chills,  followed  by  ian,  tertian,  quartan,  or  septinarian), 
fevers  and  sweatings.  followed  by  profuse   sweating ;   chilis 

more  often  in  morning. 

An  irregular,  fluctuating  tumor  or  multi-  The  spleen  is  enlarged  :  also  there  is  a 
pie  nodules  in  the  liver  ;  no  splenic  en-  yellow-brown    coloration  of  the   skin, 
largement :  rapid  emaciation,  with  or  more   or  less   marked  ;    and,  in    long- 
without  jaundice,  but  no  cachexia.  standing  cases,  the  occurrence  of  ca- 
chexia. 

Blood   shows  simple  anemia  and  leuko-  The  presence  of  the  hematozoa  of  Laveran 

cytosis,  and  in  marked  cases  disinte-  and  free  pigment  in  the  blo(xl  ;  usually  a 

gration  of  red  blood-cells.  leukopenia. 

Abscess-contents  show  the  staphylococci.  Absent, 
streptococci,  amebie,   or   bacillus   coli 
communis,  and  pus. 

Quinine  is  resisted.  Quinine  acts  as  a  specific. 

Impacted  Calculi. — In  this  condition  attacks  of  hepatic  colic  are  often 
first  noticed,  folloAved  by  jaundice,  and.  if  impaction  be  not  absolute,  by 
the  occurrence  of  stones  in  the  feces.  In  abscess  the  pain  is  not  parox- 
ysmal, but  dull  and  boring  in  character,  increasing  in  severity  as  the 
disease  progresses.  In  chronic  impaction  jaundice,  dull  pain  over  the 
hepatic  area,  distention  of  the  gall-bladder  (which  in  some  instances  may 
be  palpated),  and  clay-colored  feces,  constitute  the  principal  symp- 
toms. There  occurs  also  an  intermittent  fever  as  in  hepatic  abscess,  but 
it  is  occasional — i.  e.  the  febrile  paroxysms  recur  at  longer  intervals. 
Again,  the  course  of  intermittent  hepatic  fever  associated  with  biliary 
calculi  is  much  more  chronic  than  the  fever-stage  of  suppurative  hepa- 
titis. On  the  other  hand,  in  abscess  of  the  liver  jaundice  is  compara- 
tively rare,  and,  unless  the  abscess  rupture  into  the  gastro-intestinal 
tract,  the  stools  show  nothing  abnormal.  In  some  instances  biliary  ab- 
scesses may  follow  impacted  calculi,  and  it  is  always  a  secondary  affection. 

Among  other  liver-conditions  that  are  liable  to  be  mistaken  for 
hepatic  abscess  may  be  mentioned  carcinoma,  hypertrophic  cirrhosis, 
hijdatid  cyst,  and  pancreatic  cyst,  the  differential  diagnosis  of  which  will 
be  spoken  of  under  these  diseases. 

Prognosis. — The  prognosis  of  hepatic  abscess  is  unfavorable,  the 
disease  generally  progressing  to  a  rapidly  fatal  termination.  Prompt 
evacuation  of  the  abscess  when  its  location  can  be  detected,  however, 
may  be  successfully  performed.  The  mortality  ranges  from  50  to  60 
per  cent.  In  rare  cases  the  walls  of  the  abscess  become  calcified  and 
the  disease  remains  latent.  The  single  large  abscess  that  most  often 
follows  dysentery  offers  the  best  opportunity  for  surgical  measures. 

Treatment. — Barring  operation,  the  treatment  of  abscess  of  the 
liver  is  purely  symptomatic.  The  temperature  often  responds  to  repeated 
spongings  with  cool  water  (65°  F. — 18.3°  C).  For  tlie  pain,  mustard- 
poultices,  the  turpentine  stupe,  or  hot  fomentations  over  the  he})atic  area, 
in  conjunction  with  full  internal  doses  of  opium,  prove  beneficial.  Full 
and  free  stimulation  and  the  free  exhibition  of  quinin  as  soon  as  the 
condition  is  detected  proves  supportive  and  controls,  in  a  measure,  the 


ACUTE  YELLOW  ATROPHY.  927 

pyemic  process.  L.  Rogers  holds  that  90  per  cent,  of  amebic  abscesses 
of  tlie  liver  can  be  prevented  by  large  doses  of  ipecac  (gr.  xxx-lx — 
2.0-4,0,  daily,  in  freshly  made  pills).  If  the  abscess  be  single  and 
localized,  prompt  evacuation  should  be  resorted  to.  Patients  who  have 
been  thus  cured  should  not  return  to  a  climate  in  which  tropical  dysentery 
occurs,  since,  as  in  a  case  reported  by  Marshall,  recurrence  may  take 
place. 

ACUTE  YELLOW  ATROPHY. 

[Malignant  Jaundice;  Icterus  Gravis.) 

Definition. — An  acute  and  probably  infectious  disease  (rare),  char- 
acterized by  a  rapid  destruction  of  the  parenchyma  of  the  liver  and  by  a 
diminution  in  the  size  of  the  organ  ;  also  by  jaundice,  hemorrhage,  and 
grave  cerebral  phenomena. 

Pathology. — Macroscopically,  in  a  case  of  acute  yellow  atrophy  the 
liver  is  seen  to  be  much  reduced  in  size,  weighing  but  15  or  20  ounces 
(480.0-640.0),  instead  of  its  normal  weight  (50  oz,— 1.6  kgms.).  The 
capsule  is  shrivelled  and  the  organ  is  of  a  pulpy  consistence,  and  changed 
in  appearance  from  a  mahogany-brown  to  a  grayish-yellow  hue.  Some- 
times the  liver  is  primarily  enlarged.  The  cut  section  often  presents 
areas  of  red  and  yellow  discoloration,  the  so-called  "  red  atrophy  "  and 
"  yellow  atrophy,"  the  former  being  a  later  stage  of  the  latter.  The  red 
appearance  is  due  to  an  excess  of  blood  in  the  capillaries,  with  free  pig- 
ment that  has  been  liberated  by  destruction  of  the  red  blood-cells. 
Microscopic  examination  reveals  destruction  or  necrosis  of  the  hepatic 
cells.  The  nuclei  have  disappeared,  and  the  cell-wall  contains  a  number 
of  fat-globules  of  various  sizes  containing  free  pigment.  In  advanced 
cases,  accompanied  by  total  disintegration  of  the  cells,  fat-droplets,  gran- 
ular debris,  cholesterin-plates,  leucin-spheres,  tyrosin-needles  (first  dis- 
covered by  Frerichs,  both  in  the  cells  and  in  the  blood-vessels),  and 
crystals  of  bilirubin  may  be  found.  Findlay  ^  found  the  fibrous  tissue 
to  be  increased  and  in  the  periphery  of  the  lobules  attempts  at  regenera- 
tion (proliferation  of  the  hepatic  cells).      The  common  duct  is  patulous. 

In  well-marked  cases  both  the  heart  and  kidneys  show  evidences  of 
fatty  degeneration.  The  spleen  is  greatly  enlarged  from  active  conges- 
tion, giving  rise  to  the  so-called  "  acute  splenic  tumor."  The  splenic 
substance  is  soft  and  easily  torn.  The  shin  and  mucous  membranes 
may  be  the  seat  of  numerous  ecchymoses,  and  dropsy  of  the  serous  cav- 
ities is  frequently  noted.  The  blood  is  dark  and  fluid  (disintegrated). 
Microscopically,  it  is  seen  to  contain  crystals  of  leucin  and  tyrosin. 

Etiology. — The  causes  of  acute  yellow  atrophy  are  both  primary 
and  secondary.  Primary  or  idiopathic  acute  yellow  atrophy  is  rare  and 
its  etiology  as  yet  unsettled.  Among  the  secondary  predisposing  causes 
are  age  (being  most  common  from  fifteen  to  thirty -five  years),  female  sex, 
mental  worry,  nervous  shock,  parturition,  syphilis,  chloroform  anesthesia 
(?),  and  certain  acute  fevers  (puerperal  fever,  typhoid,  septicemia,  ma- 
laria). Acute  phosphorus-poisoning  sometimes  presents  changes  resem- 
bling those  of  acute  yellow  atrophy.  The  disease  rarely  accompanies 
cirrhosis  of  the  liver  and  may  follow  a  debauch.     Rarely,  an  endemic 

^  British  Medical  JownuU,  June  2,  1900. 


928  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

form  is  assumed,  but  the  exciting  cause  is  thus  far  unknown.  The  disease 
is  probably  microorojanis^mal  or  toxic  in  nature,  and  althouirh  various  £rerms 
nave  been  discovered,  their  chiim  to  specificity  has  not  been  established. 

Symptoms. — The  clinical  history  of  acute  yellow  atrophy  varies 
considerably  in  the  early  stages  of  the  disease,  the  graver  symptoms  of 
the  later  stage  alone  being  pathognomonic.  The  attack  is  usually 
ushered  in  by  Iieadache,  maldisc,  anorexia,  jiaasca,  and  vomiting,  mod- 
erate/Vrcr,  and  after  a  few  daxs  Jaundice  appears.  Pliysical  examina- 
tion at  this  time  shows  the  area  of  hepatic  dulness  to  be  normal  or  only 
slightly  increased.  After  a  period  varying  from  a  few  days  to  two  or 
three  weeks  (during  which  the  typical  features  of  catarrhal  jaundice 
have  been  present),  grave  nervous  and  cerebral  symptoms  present  them- 
selves, as  restlessness  and  violent  headache,  followed  by  delirium,  which 
often  becomes  maniacal.  Coni'ulsio?is  then  appear,  and  are  succeeded 
by  stupor  and  coma,  the  latter  occurring  usually  within  forty-eight 
hours  from  the  onset  of  the  period  of  cerebral  excitement.  Often  coarse 
tre7}U)rs  are  noticed  in  the  voluntary  muscles,  and  with  the  onset  of  the 
second  stage  the  jaundice  usually  deepens. 

The  temperature  often  remains  normal  until  just  before  death,  when 
it  may  rise  one  or  two  degrees.  The  pulse  is  much  diminished  both  in 
volume  and  tension,  and  is  rapid  in  proportion  to  the  temperature.  The 
tongue  at  the  onset  is  covered  Avith  a  light  coating,  most  marked  on  the 
dorsum  and  tip.  Later,  it  changes  to  a  thick  yellow  color  and  becomes 
dry  and  fissured,  with  the  development  of  a  typhoid  state.  Vomiting 
appears  usually  during  the  premonitory  stage  and  often  becomes  in- 
tense;  the  vomit  consists  at  first  simply  of  the  gastric  contents,  which 
later  in  the  disease  becomes  mixed  with  blood  (hematemesis).  Hemor- 
rhages also  occur  into  the  skin  (ecchymoses)  and  from  the  mucous  mem- 
branes, giving  rise  to  epistaxis,  hematuria,  melena,  hemoptysis,  and  men- 
orrhagia.      Oo7istipation  with  clay-colored  stools  is  common. 

The  urine  in  acute  yellow  atrophy  is  often  scanty  in  amount,  high  col- 
ored, and  shows  an  increase  in  specific  gravity  (1028-1032).  The  urea 
is  greatly  diminished,  but  bile-pigments  and  albumin,  tube-casts,  leucin 
and  tifrosin  are  found  both  on  chemical  and  microscopic  examination. 
The  latter  can  be  easily  demonstrated  by  allowing  a  drop  of  the  urine  to 
evaporate  on  a  cover-glass  and  examining  under  the  microscope.  Tyrosin- 
crystals  are  deposited  in  the  form  of  sheaves  and  rosettes,  leucin  as 
globular  masses.  These  bodies  are  not  constantly  present.  Thus, 
out  of  34  cases  collected  by  Thierfelder.  in  which  the  urine  was  ex- 
amined in  this  relation.  "  in  7  the  result  was  negative ;  in  17  both  were 
found;  in  3  tyrosin  only;  in  7  leucin  only."  Among  other  products 
found  in  the  urine  worthy  of  mention  are  creatinin,  lactic  and  sarco- 
lactic  acids,  and  other  bodies  belonging  to  the  fatty  acid  series. 

Acute  yellow  atrophy  of  the  liver  is  a  striking  example  of  acid-intoxi- 
cation due  to  rapid  and  Avidespread  destruction  of  proteids  as  the  source 
of  the  fatty  acids — sarcolactic,  lactic,  diacetic,  and  /9-oxybutyric.  The 
rare  nervous  phenomena  of  the  disease  are,  in  part  at  least,  due  to 
the  diminished  alkalinity  of  the  blood  arising  from  the  abnormal  metab- 
olism. 

The  physical  signs  reveal  tenderness  over  the  hepatic  region,  often 
amounting  to  actual  pain.     During  the  second  stage,  in  extreme  cases,  the 


THE  LIVER  IN  PHOSPHORUS-POISONING.  029 

edges  of  the  organ  cannot  be  palpated  under  the  costal  margin.  Per- 
cussion, moreover,  shows  a  great  diminution  in  the  size  of  the  liver,  the 
area  of  dulness  in  a  case  recorded  by  liarley  extending  over  but  1  inch 
(2.5  cm.)  in  the  mammary  line  and  1|  inches  (3.1  cm.),  measured  per- 
pendicularly, in  the  mid-axillary  line. 

The  left  lobe  is  often  the  first  to  show  physical  signs  of  atrophy,  per- 
cussion giving  tympany  instead  of  flatness  in  the  upper  epigastric  region. 
As  the  atrophy  continues  the  tympany  exends  below  the  seventh  rib  from 
above  and  advances  upward  from  the  costal  margin,  leaving  but  a  small 
circumscribed  area  of  hepatic  dulness.  The  atrophy  is  usually  progres- 
sive until  death  occurs,  although  favorable  cases  have  been  recorded  in 
which  the  liver  increased  in  size  perceptibly  during  recovery  (Harley, 
p.  260). 

DiagfUOSiS. — The  symptoms  occurring  during  the  second  stage  of 
the  disease  are  usually  so  characteristic  as  to  leave  little  doubt  concern- 
ing the  diagnosis.  The  occurrence  of  gradually  increasing  jaundice 
with  vomiting,  grave  delirium,  hemorrhages,  the  presence  of  an  immense 
amount  of  bile,  with  leucin  and  tyrosin,  in  the  urine,  and  greatly  dimin- 
ished size  of  the  liver,  all  combine  to  form  a  typical  symptom-complex. 
Unfortunately,  leucin  and  tyrosin  are  also  found  in  the  urine  in  acute 
phosphorus-poisoning  and  rarely  in  severe  acute  infections. 

Differential  Diagnosis. — In  hypertrophic  cirrhosis  the  onset  is  more 
gradual.  There  is  generally  a  negative  previous  history  ;  and  an  examina- 
tion of  the  urine  fails  to  reveal  leucin  and  tyrosin  ;  fever  is  rarely 
present  in  cirrhosis,  and  the  physical  signs  often  show  a  considerable 
increase  in  the  area  of  hepatic  dulness. 

The  differential  diagnosis  between  this  disease  and  phosphorus- 
poisoning  is  given  under  the  latter  condition  {vide  infra,  p.  931). 

The  prognosis  is  almost  invariably  fatal,  since  every  case  of  true 
yellow  atrophy  is  associated  with  a  destruction  of  liver-cells  that  is 
accompanied  by  acute  toxemia. 

Treatment. — As  yet  no  specific  treatment  has  been  discovered,  all 
remedies  used  being  directed  to  the  relief  of  symptomatic  indications. 
The  gastro-intestinal  system  should  be  relieved  at  the  onset  by  divided 
doses  of  calomel.  For  the  vomiting  cracked  ice,  with  1-minim  (0.066) 
doses  of  the  wine  of  ipecac  repeated  every  half  hour  or  divided  doses 
of  opium,  may  be  given.  Marked  nervous  phenomena  with  delirium 
I  have  seen  controlled  by  cool  baths  and  the  ice-cap,  together  with  cam- 
phor, chloral,  or  other  antispasmodics  used  internally.  Free  stimulation 
should  be  begun  early  and  persisted  in  throughout  the  course  of  the 
disease. 


THE  LIVER  IN  PHOSPHORUS-POISONING. 

Following  the  ingestion  of  a  dose  of  phosphorus  varying  from  gr.  -|- 
to  gr.  1  (0.008-0.0648)  symptoms  of  poisoning  manifest  themselves 
(Taylor,  Wormley)  as  follows  : 

After  a  period  of  time  varying  from  three  to  twelve  hours  a  sense  of 
wretchedness,  nausea,  abdominal  pain  (not  intense),  and  often  vomiting, 
50 


930  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

occur.  The  vomitiis  consists  of  the  gastric  contents,  with  bile,  and  dur- 
ing the  first  few  hours  it  may  contain  phosphorus,  which  gives  it  a 
luminous  appearance  in  the  dark. 

After  the  second  or  third  day  the  vomiting  usually  ceases  with  the 
appearance  of  ./aM/uf/ct',  which  may  become  intense  as  the  process  con- 
tinues. Later  in  the  course  of  the  case  emesis  rt'commences,  the 
vomita  consisting  of  altered  blood,  giving  rise  to  the  so-called  "  black 
vomit."  At  this  stage  nervous  st/mptoma  usually  manifest  themselves 
(headache,  insomnia,  vertigo,  and  delirium,  with  convulsions  and  coma 
in  fiital  cases),  death  closing  the  scene  usually  in  from  thirty-six  to  forty- 
eight  hours. 

The  bowels  are  constipated,  although  attacks  of  diarrhea  may  super- 
vene, and  the  evacuations  are  in  some  instances  phosphorescent. 

Fever  is  irregular  and  usually  is  not  marked,  the  tem]ierature  swing- 
ing from  99°  to  101°  F.  (37.2°-38.3°  C).  In  fatal  cases  the  temper- 
ature may  become  subnormal  just  before  death. 

The  urine  is  scanty,  of  high  specific  gravity,  and  contains  bile,  bile- 
acids,  albumin,  sarcolactic  acid,  and  in  rare  cases  leucin  and  tyrosin 
(Wood).  Renal  epithelium  and  free  fat-globules  have  also  been  found. 
When  occurring  in  pregnant  women,  abortion  or  miscarriage  invariably 
follows. 

Physical  examination  reveals  a  liver  uniformly  enlarged  and  tender 
on  pressure.  In  protracted  cases  atrophy  of  the  organ  may  rarely 
occur. 

Ktiology. — The  most  common  causes  are — {a)  Occupation,  workers 
in  match-factories  being  the  most  frequent  suff'erers ;  {li)  The  accidental 
swallowing  of  phosphorus  (e.  g.  rat-poison,  friction-match  heads). 

Pathology. — On  opening  the  abdominal  cavity  in  a  case  of  phos- 
phorus-poisoning the  liver  is  seen  to  extend  below  the  costal  margin,  its 
surface  being  lighter  in  color  than  normal  and  mottled  in  appearance, 
and  its  substance  softer  in   consistence  and  friable. 

The  cut  section  presents  marked  evidences  o^'  fatty  degeneration,  the 
acini  being  lighter  in  color  than  the  interlobular  tissue.  Portions  of 
the  hepatic  parenchyma  are  deeply  bile-stained,  and  on  scraping  the 
cut  surface  bile-  and  fat-globules  Avill  be  found  on  the  edge  of  the  knife. 
The  gall-bladder  may  be  either  full  or  empty.  Microscopically,  disin- 
tegrated liver-cells,  fat-globules,  granular  ddbris,  biliary  coloring-matter, 
leucin-spheres,  cholesterin-plates,  and  tyrosin-needles  are  noted. 

The  gastric  mucosa  is  found  thickened,  opaque,  and  yellow-white  in 
appearance,  due,  as  pointed  out  by  Virchow,  to  a  universal  gastro-adeni- 
tis,  and  not  to  the  local  action  of  the  poison.  Ulcerative  or  erosive 
gastritis  is  very  rare  in   phosphorus-poisoning. 

The  kidneys  may  show  beginning  atrophy,  the  epithelium  in  the 
cortices  undergoing  granular  and  fatty  degeneration,  with  final  destruc- 
tion of  the  cells. 

The  blood  is  dark,  fluid,  and  not  easily  coagulable.  Concato  found 
that  during  life  the  white  corpuscles  are  increased  in  number,  and  that 
the  red  are  changed  in  shape  and  smaller  than  normal  (Wood).  Pete- 
chiae  and  ecchymoses  frequently  appear  in  all  parts  of  the  body. 

Diagnosis. — The  diagnosis  of  acute  phosphorus-poisoning  is  always 
extremely  difficult  and  often  impossible.     The  disease  with   which  it  is 


CIRRHOSIS  OF  THE  LIVER.  93  j 

most  apt  to  become  confounded  is  acute  yellow  atrophy  of  the  liver. 
The  difi'erential   points  may   be  summated   as  follows: 

Acute  PHOsPHORus-POisoNiNfj.  Acute  Yki.low  Atrochv. 

There  is  a  history  of  accidental  ingestion  There  may  Vje  an  endemic  hJatory. 

of  poison    (friotion-match    heads,   rat- 
poison)  or  occupation. 

The   onset   is    sudden  ;    violent   nausea,  A  slow  onset — malaise,  slight  fever,  with 

vomiting,  and  pain  over  the  region  of  nausea  and  vomiting  ;  jaundice  is  a  be- 

the   liver.     Jaundice   appears   on   the  ginning  symptom. 

second  or  third  day. 

Nervous   symptoms   appear   late  in   the  Nervous   symptoms   may    appear   early, 

disease — always  preceded  by  jaundice.  even  before  the  occurrence  of  jaundice. 

The  vomit  and  stools  are  phosphorescent.  Black  vomit   occurs   early   and   persists 

Black  vomit  precedes  death.  throughout. 

Temporary  arrest  of  symptoms  between  Progressive  march  of  symptoms  with  no 

the  occurrence  of  jaundice  and   black  remission. 

vomit. 

Sarcolactic  acid  is  present  in  the  urine,  Leucin  and  tyrosin  are  common  in  the 

and  rarely  leucin  and  tyrosin.  urine. 

Prognosis  and  Duration. — The  prognosis  in  phosphorus-poison- 
ing is  bad,  as  small  a  dose  as  gr.  ^  (0.008)  of  white  phosphorus  having 
caused  death  (Wormley).  The  duration  is  usually  from  one  to  six  days, 
although  the  symptoms  have  been  known  to  persist  for  twelve  days  be- 
fore death.    In  violent  cases  the  end  may  come  within  twenty-four  hours. 

Treatment. — The  initial  plan  of  treatment  is  by  causing  emesis  to 
free  the  system  of  the  poison  that  still  remains  undigested.  For  this 
purpose  copper  sulphate  (gr.  x — 0.648)  in  divided  doses  (gr.  ij  or  iij — 
0.129  or  0.194 — every  five  minutes)  should  be  given  until  free  vomiting 
occurs.  As  copper  sulphate  is  a  chemical  antidote,  forming  with  phos- 
phorus black  copper  phosphid,  it  should  be  continued  in  less  frequently 
repeated  doses  (gr.  ij — 0.129 — every  half  hour)  and  guarded  by  morphin 
to  prevent  vomiting.  If  emetics  by  the  mouth  fail  to  afford  relief,  apo- 
morphin  muriate  (gr.  \ — 0.0129),  hypodermically,  may  be  resorted  to. 
The  free  evacuation  of  the  stomach  should  be  followed  by  the  adminis- 
tration of  the  French  oil  of  turpentine.  Wood  recommends  that  1  part 
be  given  to  every  100th  part  of  the  poison  ingested.  Ordinary  turpen- 
tine is  useless,  but  combined  with  mucilage  of  acacia,  2  fluidrams  (8.0) 
of  French  oil  of  turpentine  may  be  given  every  fifteen  minutes  until  1 
ounce  (32.0)  has  been  taken. 

Alkalies  (magnesia)  have  been  given,  but  are  practically  valueless. 
Free  purgation  should  be  effected  if  possible  by  Rochelle  salts  or  mag- 
nesium citrate.  Demulcent  oils  are  never  allowable,  as  they  dissolve 
the  phosphorus  and  hold  it  in  solution.  After  absorption  of  the  poison 
and  degeneration  of  the  tissues  have  taken  place  all  known  remedies 
are  futile. 

CIRRHOSIS  OP  THE  LIVER. 

(Sclerosis  of  the  Liver ;  Nutmeg  Liver ;   Gin-drinker's  Liver  ;  Interstitial  Hepatitis^ 

Definition. — A  chronic  disease  of  the  liver,  characterized,  patho- 
logically, by  an  excess  of  connective  tissue.  It  presents  various  biliary, 
gastro-intestinal,  circulatory,  and  cerebral  symptoms. 

Pathology. — There  are  three  pathologic  varieties  :  (a)  atrophic  cir- 


93l!  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rhosis,   or   "  gin-driuker's  liver";  (/>)   hypertrophic  cirrhosis;   and  (c) 
biliary  cirrhosis. 

(a)  Atropliie  Cirrhosis  (Laefnwr's,  or  alcoholic  cirrhosis)  is  the  most 
common  form,  at  least  in  the  earliest  stages,  as  Foxwell's  studies  teach  ; 
the  alcoholic  (indurative)  liver  is  more  commonly  enlarged  than  decreased 
in  size.  Morse' examined  the  records  of  37  cases  of  cirrhosis,  and  found 
that  among  these  tiiere  were  13  instances  of  enlarged  liver,  11  of  nor- 
mal size,  and  12  smaller  than  normal.  In  typical  examples  the  capsule 
is  thickened,  the  organ  greatly  reduced  in  size,  hard,  granular,  and 
much  altered  in  shape.  On  section  (which  resists  the  cutting-knife) 
the  surface  presents  grayish-white  bands  of  connective  tissue  surround- 
ing yellowish  areas  (acini)  that  project  above  the  surface  from  com- 
pression (hob-nails);  hence  the  term   ''hob-nailed  liver." 

Microscopically,  the  process  is  seen  to  commence  as  an  increase  in 
the  connective-tissue  element  surrounding  the  terminal  branches  of  the 
portal  vein.  Compression  of  the  liver-cells  and  of  the  portal  veins, 
with  conseijuent  obstruction  of  the  circulation,  constantly  increases 
with  the  progress  of  the  proliferation  of  the  connective  tissue  and  its 
secondary  contraction.  Atrophic  changes  in  the  hepatic  cells,  however, 
are  often  comparatively  slight.  The  biliary  canaliculi  may  be  increased 
in  number.  AVeigert  and  his  disciples  contend  that  atrophy  or  degenera- 
tion of  the  acini  is  often  the  primary  change,  and  the  connective-tissue 
production  the  secondary — filling  the  gap,  so  to  speak. 

In  alcoholic  cirrhosis  the  liver  is  sometimes  large,  smooth,  or  slightly 
granular,  soft  rather  than  hard,  as  ordinarily  the  case,  and  presents  a 
light  yellow  color  {fatty  cirrhosis).  Histologically,  this  is  a  form  of 
true  cirrhosis,  as  shown  by  the  presence  of  an  increase  in  the  connective 
tissue,  with  which,  however,  fatty  infiltration  of  the  acini  is  associated. 

(b)  Hypertrophic  Cirrhosis  (Hanot). — On  examining  the  liver  in  situ 
during  hypertrophic  cirrhosis  the  various  diameters  of  the  organ  are  in- 
creased (the  left  sometimes  more  than  the  right),  the  lower  border  pro- 
jecting several  fingers'  breadths  below  the  ribs.  The  margin  of  the  liver 
is  well  defined,  the  substance  firmer  than  normal,  and  it  cuts  with  difii- 
culty.  The  organ  is  lighter  in  color  than  in  health,  and  presents  a 
yellow  or  mottled-green  appearance.  On  treating  a  section  with  com- 
pound iodin  solution  (Lugols)  the  color  changes  to  that  of  a  deep  mahog- 
any-red.    The  acini  are  darker  in  hue  than  the  interstitial  tissue. 

Microscopically.,  the  peripheral  zones  of  the  acini  are  seen  to  be 
the  seat  of  a  round-cell  infiltration,  with  the  formation  of  embryonal 
tissue;  later,  the  interlobular  connective  tissue  undergoes  hyperpla- 
sia, causing  obstruction  of  the  biliary  ducts  with  retention  of  l)ile, 
but  the  parenchyma  is  unchanged.  New-formed  bile-ducts  are  pro- 
liferated. 

(c)  Biliary  Cirrhosis. — French  writers  have  described  "  biliary  cirrho- 
sis "  as  opposed  to  a  "portal  cirrhosis"  (atrophic).  It  results  from 
obstruction  of  the  bile-ducts ;  this  causes  retention  of  bile  with  swell- 
ing of  the  organ  as  a  consequence.  The  action  of  the  chemical  irritants 
that  are  the  result  of  stasis  of  bile  starts  a  cirrhotic  process  around  the 
small  bile-ducts  (reactive  inflammation).  The  microscopic  appearances 
of  the  organ  simulate  those  of  hypertrophic  cirrhosis ;   but  the  hepatic 

^  Boston  Med.  and  Surg.  Jour.,  March  10,  1898. 


CIRRHOSIS  OF  THE  LIVER.  933 

cells  are  more  deeply  bile-stained.  Microscopically.,  the  firHt  discover- 
able changes  are  spots  of  insular  necrosis  in  the  peripheral  zones  of  the 
acini  (Stengel).  These  are  shortly  replaced  by  proliferation  of  the 
interlobular  connective  tissues.  The  formation  of  new-ducts  and  liver- 
cells  is  common. 

There  is  also  a  so-called  Glissonian  cirrhosis  (perihepatitisj  in  which 
the  capsule  of  the  organ  is  surrounded  by  a  dense  white  fibrinous  mem- 
brane, which  contracts,  reducing  the  size  of  the  liver  and  altering  its 
shape.  This  I  have  described  elsewhere  (yt'cZe  Chronic  Hepatitis,  p.  921). 
Syphilitic  cirrhosis  of  the  organ  receives  special  consideration  (p.  396). 

Ktiology. — (a)  Atrophic  Cirrhosis. — 1.  Alcoholism. — Freyhan,  ()sler, 
and  I  myself  have  found  this  causal  factor  operative  in  nearly  all  cases. 
Clinical  history  tends  to  prove  that  the  stronger  the  alcoholic  beverage 
[e.  g.  raw  spirits)  and  the  larger  the  amount  consumed  the  sooner  cir- 
rhosis develops,  although  the  quantity  necessary  to  produce  the  disease 
varies  greatly  in  different  individuals.  Doubtless  by  the  side  of  alcohol- 
ism all  other  causes  combined  are  comparatively  insignificant. 

2.  Spicy  foods  are,  according  to  some,  classed  as  predisposing  agents. 
Tiraboschi  records  a  case  that  had  long  been  induced  by  the  use  of  spicy 
foods  and  by  over-eating.  In  many  cases  ptomains,  the  products  of  mal- 
assimilation  through  faulty  digestion,  are  supposed  to  be  the  exciting  cause. 

3.  Male  Sex  and  Middle  Life. — The  cases  produced  by  alcohol  occur 
chiefly  in  males.  According  to  my  experience,  females  who  misuse 
potable  alcohols,  particularly  the  more  concentrated  liquors,  are  less 
susceptible  to  the  poison  than  males.  Two-thirds  of  the  fatal  cases 
occur  between  the  ages  of  35  and  50  (Hawkins),  although  cases  have 
been  known  to  occur  at  both  extremes  of  life.  Toxins  of  bacterial  origin 
may  cause  liver  cirrhosis.  Micro-organisms  have  also  been  found  in 
cirrhotic  livers,  especially  the  colon  bacillus,  but  no  specific  causative 
action  can  be  ascribed  to  it. 

4.  It  may  follow  the  acute  infectious  diseases,  notably  scarlet  fever. 

5.  Certain  chronic  diseases  (syphilis — congenital  lues  in  particular — 
rickets,  diabetes,  gout,  malaria,  carcinoma,  tuberculosis)  that  favor  the 
formation  of  connective  tissue  are  apt  to  be  complicated  by  cirrhosis, 
usually  partial. 

6.  Passive  congestion,  secondary  to  chronic  cardiac  lesions  or  to 
obstructive  lung-disease,  not  infrequently  gives  rise  to  hepatic  cirrhosis. 

7.  Fatty  cirrhosis  results  from  the  abuse  of  malt  liquors  in  some 
cases,  and  is  often  associated  with  more  or  less  obesity. 

[h)  Hypertrophic  Cirrhosis  (Hanot). — In  most  cases  there  is  an  absence 
of  recognizable  causes.  Sex  is  a  strongly  predisposing  cause,  males 
being  the  most  frequent  victims,  in  the  proportion  of  6  to  1.  It  is  not 
uncommon  in  young  adults.  In  catarrhal  jaundice  the  morbid  processes 
may  rarely  extend  to  the  liver  and  there  persist,  giving  rise  to  hyper- 
trophic cirrhosis.  Cases  are  met  with  in  children,  in  whom  it  may 
follow  the  acute  infectious  diseases.  Alcohol  plays  an  unimportant  role 
in  the  causation  of  Hanot's  cirrhosis.  The  disease  is  most  common 
among  the  inhabitants  of  warm  climates,  and  is  also  hereditary. 

((')  Biliary  Cirrhosis. — This  form  is  produced  by  chronic  obstruction 
of  the  bile-ducts  (see  also  Obstruction  of  the  Common  Duct,  p.  900). 

Symptoms. — Atrophic  Cirrhosis. — The  symptoms  of  this  variety  of 
cirrhosis    may   present    nothing   characteristic   as   long  as   the  sclerotic 


934  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

process  does  not  interfere  with  the  portal  circulation.  In  some  cases 
the  collateral  (compensatory)  circulation  is  maintained  throughout  the 
long  course  and  symptoms  fail  to  arise.  Among  the  prodromal  symptovxi, 
a  gradual  loss  of  flesh,  anorexia,  constipation,  a  coated  tongue,  slight 
jaundice,  dyspepsia,  and  occasionally  hematemesis  are  to  be  mentioned. 

As  the  obstruction  of  the  portal  circulation  bocouies  marked  the 
mucosa  of  the  gastro-intestinal  tract  is  congested,  and  gives  rise  to  aug- 
menting nausea  and  vo)>nthiq  (most  marked  in  the  morning),  and  hem- 
orrhar/i's  from  the  stomach  (hematemesis,  visible  and  occult)  and  intes- 
tines (nielena),  -which  may  be  frequent  and  jirofuse,  but  are  rarely  fatal. 
Severe  hemorrhages  may  also  occur  from  enlarged  varicose  esophageal 
veins.  The  tom/ue  is  coated.  Uneasiness  and  even  pain  may  be  ex- 
perienced in  the  hepatic  area.  Owing  to  the  establisiiment  of  a  compen- 
satory circulation  the  superficial  epigastric  and  internal  mammary  veins 
enlarge  and  form  about  the  umbilicus  ("  caput  Medusa  "). 

Hemorrhoids  are  common  and  are  due  to  passive  congestion  of  the 
hemorrhoidal  veins.  As  the  disease  progresses  the  genei-til  emaciation 
becomes  more  marked.  The  face  assumes  a  pinched  expression,  the  tip 
of  the  nose  has  a  purple  tinge  from  distended  veins ;  the  eyes  are  sunken, 
the  cheeks  hollow,  and  the  skin  presents  a  sallow  tint  (hepatic  fades). 
The  failure  of  the  compensatory  circulation  gives  rise  to  ascites,  or  hydro- 
peritoneum.  The  spleen  becomes  enlarged.  At  any  stage,  although 
generally  in  advanced  cases,  toxemic  sympioms  may  develop,  due  to  some 
poisonous  product  in  the  blood  of  unknown  nature  :  these  are  violent 
headache,  followed  by  wild,  noisy  delirium,  convulsions,  stupor,  and  coma. 
They  may  occur  without  jaundice,  and  have  been  mistaken  for  uremia. 
With  or  without  hemorrhages  secondary  anemia,  more  or  less  profound,  is 
observed.      Rogers  states  that  leukocytosis  is  common. 

Fever  may  be  absent  throughout  the  course  of  the  disease,  but  is  often 
present,  and  may  reach  100°-102°  F.  (37.7°-38.8°  C). 

Examination  of  the  urine  shows  it  to  be  of  increased  specific  gravity, 
loaded  with  urates,  and  containing  bile.  In  a  small  proportion  of  cases 
it  is  slightly  albuminous,  and  contains  casts,  though  out  of  28  urinalyses 
in  cases  of  cirrhosis  Henry  discovered  the  presence  of  albumin  in  but 
one.  The  amount  of  urea  is  constantly  diminished,  owing  to  the  dis- 
turbance of  the  urea-forming  function  of  the  liver.  An  excess  of 
indoxyl  sulphate  in  the  urine  is  a  freijuent  occurrence.  Roque  and 
Cordier  found  the  ascitic  fluid  to  be  tuberculous  in  nature  in  22  cases  of 
Laennecs  cirrhosis. 

The  physical  examination  in  a  typical  case  of  atrophic  cirrhosis 
reveals  a  distention  of  the  abdomen ;  there  may  be  also  an  extreme 
enlargement  of  the  superficial  veins  over  the  surface  of  the  body.  An 
icteroid  tint  of  the  skin  is  present  in  about  25  per  cent,  of  the  cases. 

Palpation  of  the  liver  and  spleen  may  be  greatly  interfered  with  by 
the  large  amount  of  peritoneal  fluid  present.  On  withdrawal  of  the 
latter,  however,  the  spleen  is  found  greatly  enlarged.  Palpation  com- 
monly detects  hardened  arteries,  and  W.  W.  Ford,'  in  an  analysis  of  500 
autopsies,  finds  that  practically  all  the  cases  of  beginning  cirrhosis  of 
the  liver  are  associated  with  renal  disease  and  cardiac  affections. 

The  liver  may  show  slight  enlargement  in  the  beginning  of  the  dis- 
ease;  but  it  soon  atrophies,  and  in  emaciated  subjects  with  lax  alKlominal 
1  University  of  Penna.  Med.  Bvll,  Philadelphia,  P'ebruary,  1904. 


CIRRHOSIS  OF  THE  LIVER.  935 

walls  its  finely  granular  or  nodular  edge  can  be  felt  above  the  margin 
of  the  ribs.  Percussion  shows  its  vertical  diameter,  which  normally 
extends  from  the  sixth  interspace  to  the  costal  margin,  and  averages 
about  4  inches  (10  cm.),  diminished,  especially  towani  the  median  line. 
Posterior  dulness  begins  lower  than  normally.  It  must  be  recollected 
that  the  liver  is  often  enlarged  in  otherwise  typical  cases.  An  alcoholic 
hypertrophic  cirrhosis  without  ascites  (Gilbert,  1899),  in  which  there  is 
a  marked  collateral  circulation  in  the  abdominal  wall,  occurs,  and  all  its 
symptoms  are  those  of  a  bivenous  hypertrophic  cirrhosis. 

Fatty  cirrhosis,  in  which  the  organ  is  sometimes  enlarged,  may  be 
latent  and  remain  unrecognized  or  be  discovered  on  the  post-mortem 
table.  In  five  of  my  six  cases  the  symptoms  resembled  those  of  the 
ordinary  form.  Among  complications  of  this  variety  may  be  mentioned 
tuberculosis,  pleurisy  with  effusion,  and  chronic  nephritis. 

{h)  Hypertrophic  Cirrhosis. — In  this  variety  of  the  disease  there  is 
usually  an  absence  of  any  alcoholic  history,  and  it  is  apt  to  be  met  in 
young  adults  and  even  children  {vide  Etiology).  Moderate  enlargement 
of  the  liver  may  be  present  before  any  digestive  disorders  are  observed. 
The  latter  may  be  absent,  except  the  presence  of  slight  jaundice  and  an 
occasional  disturbance  of  digestion,  until  late  in  the  course  of  the  dis- 
ease. Intense  jaundice,  fever,  and  hepatic  enlargement  may  then  appear, 
with  the  rapid  development  of  a  grave  general  condition.  The  urine  con- 
tains bile-pigment,  but  the  stools  are  not  typical  (pale  drab  or  slate  col- 
ored). Paroxysms  of  'pain,  resembling  mild  hepatic  colic,  may  occur  at 
irregular  intervals.  Hemorrhages  into  the  skin  from  the  mucous  surfaces 
(due  to  passive  congestion)  are  also  common.  In  long-standing  cases 
albumin  and  tube-casts  may  be  present  in  the  ui'ine.  Leucin  and  tyrosin 
have  also  been  found,  but  are  not  constant.  These  symptoms  are  prob- 
ably due  to  recent  inflammatory  infiltration  arising  in  the  course  of  an 
old  cirrhosis.  Splenic  enlargement  occurs,  but  ascites  is  exceedingly 
rare.  The  cases  run  an  extremely  chronic  course,  and  in  a  patient  of 
mine,  a  lad  of  fourteen  years,  the  grave  symptoms  mentioned  above  sud- 
denly developed  and  terminated  life  after  four  years  of  slight,  though, 
decisive,  attacks  of  jaundice,  with  moderate  hepatic  enlargement.  The 
stools  were  bilious  looking,  and  hemorrhao;es  from  the  mucous  surfaces 
frequently  occurred.     There  was  a  leucocytosis. 

Physical  examination  shows  a  uniform  and  progressive  enlargement 
of  the  organ  ;  the  lower  border  is  felt  distinctly  outlined  below  the  costal 
margin,  its  edges  being  rounded  and  at  times  granular. 

Percussion  shows  an  increased  area  of  hepatic  and  splenic  dulness. 

Late  in  the  disease,  in  addition  to  the  grave  symptoms  described 
above — icterus  gravis,  high  fever,  hemorrhages,  and  the  like — serious 
nervous  symptoms,  as  delirium,  convulsions,  stupor,  and  coma,  may 
supervene.  The  temperature  now  usually  ranges  from  102°  to  104°  F. 
— 38.8°-40°  C.  {febrile  jaundice) — although  fever  may  sometimes  be 
absent  throughout  the  course  of  the  disease.  Death  results  either  from 
an  intercurrent  disease  or  progressive  asthenia. 

Hemochromatosis  (Opie). — Recklinghausen  first  called  attention  to 
hemochromatosis  in  connection  with  cirrhosis.  Its  association  with 
diabetes  mellitus  and  bronzing  of  the  skin  I  have  previously  referred  to 
(p.  415).  There  are  cases,  an  illustration  of  which  was  reported  by 
Opie,  in  which  bronzing  of  the  skin,  cirrhosis  of  the  liver,  and  chronic 


936  DISEASES  OF  THE  DFGESTIVE  SYSTEM. 

interstitial  pancreatitis  occur  -without  diabetes.  Opie's  conclusions  may 
be  cited :  (1)  "  There  exists  a  distinct  morbid  entity,  hemochromatosis, 
characterized  by  the  widespread  deposition  of  an  iron-containing  pig- 
ment in  certain  cells  and  an  associated  formation  of  iron-free  pigments 
in  a  variety  of  localities  in  which  pigment  is  found  in  moderate  amount 
under  physiologic  conditions.  (2)  With  the  pigment  accumulation 
there  are  degeneration  and  death  of  the  containing  cells,  and  consequent 
interstitial  inflammation  of  the  liver  and  pancreas,  which  become  tlie 
seat  of  inflammatory  changes  accompanied  by  hypertrophy.  (3)  When 
chronic  interstitial  pancreatitis  has  reached  a  certain  grade  of  intensity, 
diabetes  ensues,  and  is  the  terminal  event  in  the  disease." 

((•)  Biliary  Cirrhosis. — Si/tuptoms  and  Diagnosis. — The  clinical  in- 
terest of  this  form  centers  principally  around  the  synijitoms  of  the 
causative  condition — chronic  obstruction  of  the  bile-ducts — which  have 
been  given  in  detail  elsewhere  {vide  p.  900).  With  the  latter  may  be 
associated  the  features  of  either  catarrhal  or  suppurative  cholangitis. 
Jaundice  is  usually  more  intense  than  in  the  hypertrophic  form,  particu- 
larly during  the  earlier  stages.  Intennittent  hepatic  fercr  is  commonly 
observed.     The  physical  signs  are  similar  to  those  of  Hanots  cirrhosis. 

The  diagnosis  of  biliary  cirrhosis  rests  on  the  presence  of  the  char- 
acteristic features  of  prolonged  obstruction  of  the  bile-ducts,  from  im- 
paction bv  gall-stones,  a  tumor  or  stricture  of  the  duct,  and  the  like, 
with  slow'  and  gradual,  smooth,  or  slightly  granular,  hepatic  enlarge- 
ment. It  is  to  be  recollected  that  when  obstruction  of  the  gall-ducts 
becomes  complete,  or  *' acute  fermentative  changes"  are  set  up  in  the 
retained  bile,  the  cases  may  terminate  acutely  {e.  g.,  in  acute  atrophy). 

General  Diagnosis.— (a)  Of  Atrophic  Cirrhosis. — An  assured  diag- 
nosis mav  be  based  on  the  following  points  :  1.  A  clear  history  of  the 
most  common  causes  (inebriety,  male  sex  and  middle  life,  rickets,  dia- 
betes, gout,  malaria).  2.  The  combined  presence  of  ascites,  with  Hippo- 
cratic  facies,  and  diminution  in  the  size  of  the  liver,  as  shown  by  the 
physical  signs.  3.  Absence  of  the  characteristic  features  of  acute  disease, 
and  the  negative  character  of  results  from  an  examination  of  the  heart, 
hint's,  and  kidneys.  It  is  to  be  recollected  that  the  volume  of  the  liver  is  not 
invariablv  decreased,  and  even  may  be  increased.  Hohlweg '  and  Brun- 
suggest  the  method  of  testing  the  tolerance  of  the  liver  for  levulose.  the 
normal  liver  not  permitting  this  su-bstance  to  pass  unmodified  in  the  urine. 

With  the  atrophic  form  of  cirrhosis,  chronic  peritonitis  with  ejfusion 
is  most  liable  to  be  confounded.  In  the  latter  disease  there  are  charac- 
teristic abdominal  tenderness,  fever,  and  usually  associated  tuberculous 
lesions  of  other  organs  (lungs,  kidneys,  intestines) :  but  the  hepatic 
facies  and  clearly  indicative  history  of  atrophic  cirrhosis  are  absent.  A 
large  peritoneal  effusion  is  in  favor  of  cirrhosis 

(b)  Of  Hypertrophic  Cirrhosis. — The  principal  diagnostic  points  are 
an  absence  of  the  usual  alcoholic  history,  slight  icterus,  extending  over 
a  variable  and  oftentimes  long  period,  paroxysms  of  pain,  mucous  and 
cutaneous  hemorrhages,  moderate  enlargement  of  the  liver  and  spleen 
(without  ascites),  and  the  development  of  grave  symptoms  at  any  stage — 
intense  jaundice,  fever,  sometimes  marked  nervous  phenomena. 

Differential  diagnosis  of  hypertrophic  cirrhosis  may  be  confounded  with 
carcinoma  of  the  liver,  hydatid  cyst,  hematic  abscess,  -dnd  fatty  cirrJiosis. 

"^  DeiUches  Archk\  /.  klin.  Med.,  B.  xcvii.,  H.  5  &  6.        '  Rijornw.  Med.,  April  18, 1910. 


CIEBIIOSIS   OF  THE  LIVER. 


9;i7 


Hypertrophic  Cirrhosis. 

Absence  of  rccoffnizable  causes. 

Occurs  in  younjr  adults  and  in  childliood. 

Usually  a  primary  affection. 

Jaundice  is  8lif!;ht  unless  f>;rave  symp- 
toms develop  ;  there  is  no  cachexia. 

Paroxysms  of  pain.  The  case  runs  a 
slow  course,  usually  lastinj:f  many 
years. 

Enlargement  is  uniform. 


(See  I 


Carcinoma  or  tiif  LtvKR. 

Hereditary  history. 

Usually  occurs  after  forty  years  of  a;^e. 

Often  occurs  as  a  secondary  ^'■rfjwth. 

Anemia  is  present,  and  also  the  develop- 
ment of  a  typical  cachexia. 

Pain  more  constant  vpith  rapid  emacia- 
tion. The  case  terminates  usually 
within  one  year. 

The   liver   is    irrej^ularly   enlarj^ed,   and 
contains  umbilicated  nodules, 
ig.  61. 


Fig.  61.— Showing  approximate  enlargement  of  the  liver  corresponding  to  the  diflFerent  dis- 
eases described  in  the  text  (after  Eindfleisch) :  I,  position  of  the  diaphragm  to  the  maximum 
enlargement  (carcinoma) ;  II.  II,  normal  situation  of  the  diaphragm ;  II,  III,  relative  dulness ; 
IV,  border  of  the  liver  in  cirrhosis ;  T',  border  in  health ;  VI,  lower  border  of  the  fatty  liver ; 
VII,  of  the  amyloid  liver;  VIII,  of  carcinoma,  leukemia,  and  adenoma. 


Hypertrophic  Cirrhosis. 

History  negative  as  to  alcohol.  More 
common  in  warm  climates. 

Occurs  idiopathically. 

Fever,  jaundice,  and  ascites  may  be  pres- 
ent singly  or  together. 

Anemia  and  emaciation  slowly  progres- 
sive.    There  is  a  leucocytosis. 

Regular  enlargement  of  the  liver.  No 
fluctuation  nor  thrill. 

Aspiration  is  negative. 


MULTILOCULAR  HYDATID    CvST. 

History  of  ingestion  of  the  embryo  of 
taenia  echinococcus  with  the  food. 

Simultaneous  occurrence  in  colonies  or  in 

others  in  the  vicinity. 
No  fever,  pain,  jaundice,  or  ascites. 

Emaciation  not  marked  ;  no  leukocytosis. 

On  palpation  an  irregular,  fluctuating 
tumor  is  felt  over  the  hepatic  area. 
giving  an  "hydatid  thrill." 

Aspiration  gives  a  clear,  serous  fluid,  rich 
in  chlorids,  and  containing  booklets. 


938  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Htpkrtrophic  Cirrhosis.  Abscess  of  the  Liver. 

Etiology  usually   nojiative.     May  rarely  History    of    dysentery,    traumatism,    or 

follow  acute  infectious  diseases.  pyemia. 

There   are   teudernesa  on  deep  pressure  Severe  and  constant  pain  ;  marked  ten- 

and   paroxysmal  pain.  derness. 

Hectic  symptoms  absent  althoucli  a  eon-  Hectic   symptoms    appear    early   (fever, 

tinued  fever  may. develop  usually  late.  chills,  and  sweating). 

Slow  course,  lasting  months  or  years.  Acute  course,  lasting  a  few  weeks. 

Slow  enlargement,   regular,   or    slightly  Rapid    development     of    a     fluctuating 

nodulated.     No  fluctuation.  tumor  in  the  hepatic  area. 

Aspiration  gives  negative  results.  The  aspirating-needle  reveals  pus. 

So-called  fatti/  cirrhosis  may  be  distinguished  from  hypertrophic  cir- 
rhosis, if  one  makes  due  allowance  for  its  etiology,  alcoholism,  and  the 
absence  of  jaundice. 

(c)  Biliary  cirrhosis  causes  enlargement  of  the  liver,  but  to  a  much 
more  moderate  extent  than  hypertrophic  cirrhosis.  In  the  former  the 
symptoms  of  chronic  obstruction  of  the  bile-ducts — jaundice  and  loss  of 
color  on  the  part  of  the  stools  (unlike  the  hypertrophic  form) — are  in 
evidence.  The  duration  of  biliary  cirrhosis  is,  on  the  whole,  shorter  than 
that  of  hypertrophic,  and  the  organ  is  more  likely  to  undergo  terminal 
diminution  in  size  (atrophy). 

Prognosis. — The  prognosis  of  the  atrophic  form  of  cirrhosis  is 
decidedly  unfavorable,  the  function  of  the  liver-cells  having  been 
impaired,  although  the  principal  source  of  danger  is  probably  the 
ascites ;  and  death  usually  takes  place  within  a  few  months  or  a  year 
after  symptoms  of  portal  obstruction  appear.  In  rare  cases  the  symp- 
toms abate,  owing  to  the  establishment  of  a  compensatory  circulation, 
and  may  remain  in  abeyance  for  months  or  years. 

The  prospect  of  life  is  much  enhanced  by  an  early  recognition  and 
removal  of  the  overshadowing  cause — alcoholism.  I  have  seen  a  few 
cures  made  in  this  manner.  Even  after  the  occurrence  of  jaundice, 
hemateraesis,  and  toxic  symptoms,  under  appropriate  treatment  patients 
have  been  known  to  enjoy  comparative  health  for  years. 

Treatment. — The  prophylaetie  treatment,  wliich  is  of  first  impor- 
tance, consists  in  improving  the  general  health  of  the  patient  and  in 
removing,  if  possible,  the  cause  of  the  affection.  Rest,  graduated  exer- 
cise, systematic  bathing,  and  regular  hours  for  eating  and  sleeping  should 
be  inaugurated  and  strictly  adhered  to.  Alcohol,  strong  coff'ee,  spices, 
and  gastro-intestinal  irritants  of  every  nature  must  be  interdicted.  H.  C. 
Wood  states  that  tavern-keepers  and  bartenders  who  are  unable  or  will 
not  cease  using  alcohol  may  greatly  prolong  life  by  substituting  hard  cider 
for  all  other  drinks.  The  diet  should  be  simple  and  easily  digestible.  An 
exclusive  milk-diet  has  been  highly  recommended  (Semmola). 

The  medicinal  treatment  is  largely  symptomatic,  no  remedy  having 
been  discovered  to  prevent  the  formation  of,  or  remove,  the  new-formed 
connective  tissue.  The  chief  object  is  to  deplete  the  portal  system  and 
prevent,  if  possible,  the  occurrence  of  ascites.  The  bowels  should  be 
kept  freely  open  by  the  use  of  saline  purgatives  (concentrated  solution 
of  Epsom  salts),  elaterium,  or  compound  jalap  powder.  The  skin  is  to 
be  kept  active  by  means  of  Turkish  or  Russian  baths  (under  supervision), 
and  in  extreme  cases  by  the  steam  bath  or  hot  pack,  employed  just  short 


CARCINOMA   OF  THE  LIVER.  f)Pji) 

of  the  point  of  exhaustion.  The  kidneys  should  also  bo  kept  active  by 
the  hydragogue  diuretics,  as  potassium  acetate,  squills,  calomel,  digitalis 
in  the  form  of  the  infusion,  or  Niemeyer's  pill.  Klempercr  and  f)tliers 
have  also  recently  recommended  urea  as  an  efficient  diuretic,  and  from  20 
to  30  grains  (1.29—1.94)  may  be  given  in  solution. 

If  the  case  be  syphilitic  in  origin,  potassium  iodid  should  be  exhibited. 

Ascites  calls  for  free  diuresis,  diaphoresis,  and  catharsis ;  and  if  not 
relieved  in  the  course  of  a  few  days,  tapping  should  be  resorted  to. 

The  operation  of  paracentesis  abdominis  is  free  from  danger.  The 
bladder  having  been  emptied,  a  spot  over  the  linea  alba  about  3  inches 
(7,5  cm.)  above  the  symphysis  pubis  is  anesthetized  preferably  by  means 
of  the  hypodermic  use  of  cocaine  (2  per  cent,  solution)  and  a  trocar  is 
quickly  thrust  through  the  abdominal  wall  for  a  distance  of  about  1  inch 
(2.5  cm.).  The  distance  is  determined  by  the  fore-finger,  which  is  placed 
at  the  desired  distance  from  the  point  of  the  cannula  before  its  insertion. 
The  patient  must  be  in  a  sitting  or  semi-reclining  position,  so  as  to  allow 
the  ascitic  fluid  to  collect  by  gravity  in  the  lower  part  of  the  abdominal 
cavity.  A  tube  having  been  attached  to  the  cannula  to  convey  the  liquid 
to  a  receptacle,  the  trocar  is  withdrawn,  the  fluid  allowed  to  run  out, 
the  cannula  removed,  and  the  wound  closed  by  antiseptic  gauze  or  a 
pledget  of  cotton.  A  collodion  dressing  is  then  applied  to  the  site  of 
puncture,  and  the  abdominal  binder,  which  has  been  previously  applied,  is 
tightened. 

JEpiplopexy  (Roberts's  operation),  or  suturing  the  great  omentum  to 
the  anterior  abdominal  wall  for  the  purpose  of  establishing  a  collateral 
venous  circulation,  for  the  relief  of  the  ascites  in  cirrhosis  is  useful  in 
advanced  cases.  The  Talma-Drummond  operation  should  be  undertaken 
earlier,  but  its  precise  value  has  not  as  yet  been  determined. 

Complications,  as  cardiac  hypertrophy,  tuberculous  peritonitis,  or 
chronic  meningitis,  demand  appropriate  treatment. 


CARCINOMA  OF  THE  LIVER. 

Definition. — A  malignant  growth  of  the  liver,  occurring  usually 
after  the  age  of  forty,  and  characterized  by  pain,  progressive  emaciation, 
cachexia,  and  the  appearance  of  a  nodular  mass  in  the  hepatic  paren- 
chyma.    It  may  be  primary  or  secondary,  though  the  former  is  rare. 

Pathology. — Histologically,  the  cells  are  not  distinctive,  being  iden- 
tical with  those  of  carcinoma  elsewhere ;  they  are  epithelial  in  charac- 
ter, having  a  small  vesicular  nucleus  and  much  protoplasm.  They  are 
altered  greatly  by  pressure,  and  vary  in  shape,  being  hexagonal,  poly- 
hedral, or  amorphous.  Large  giant-cells  and  spots  of  pigment  known 
as  "  brownish  granules "  are  not  uncommonly  found  in  the  cancerous 
mass.  The  so-called  colloid  cancers  are  nearly  always  mucoid,  and  the 
cells  have  undergone  a  mucoid  change ;  the  stroma  of  connective  tis- 
sue surrounding  the  cancer-nests  in  some  instances  undergoes  hyaline 
or  myxomatous  degeneration.     In  other  instances  the  interstitial  tra- 


940  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

beculre  completely  surround  the  epithelial  nests,  which  are  separatee'  by 
%  basement-membrane ;   this  variety  is  termed  ndi'Tio-rarriuoma. 

When  examined  microscopically,  nwduUan/  cancer,  either  in  a  large 
mass  (primary)  or  in  secondary  nodules  scattered  throughout  the  organ, 
is  the  most  common  variety  found  in  the  liver.  On  examining  a  liver  that 
is  the  seat  of  carcinoma,  one  of  two  conditions  usually  presents  itself: 
First,  the  organ  may  be  apparently  normal  with  the  exception  of  one 
lobe  (usually  the  right),  which  contains  a  dense  whitish  growth  of  firm 
consistence,  being  distinct  and  sharply  defined  from  the  surrounding 
liver-tissue.  On  section  the  tumor  is  often  of  uniform  density,  bluish- 
white  in  appearance,  and  exudes  a  milk-white  fluid  known  as  ''  cancer- 
juice,"  which,  when  examined  microscopically,  is  found  to  contain  large, 
nucleated,  and  irregularly-shaped  cells  containing  free  granular  matter. 
The  center  of  the  tumor  may  have  undergone  liquefaction-necrosis,  with 
the  formation  of  a  cyst,  or  it  may  be  the  seat  of  an  abscess.  Various 
smaller  nodules  may  be  scattered  throughout  the  organ  by  metastasis 
from  the  primary  growth.  The  second  and  most  common  condition  is 
secondary  carcinoma  of  the  liver,  the  primary  lesion  being  situated  in  the 
mammary  glands,  pylorus,  or  the  cervix  uteri.  The  organ  is  greatly  en- 
larged, as  a  rule.  Numerous  nodules  are  scattered  throughout,  and  can 
usually  be  seen  projecting  beneath  the  capsule,  those  superficially  situ- 
ated having  received  the  name  of  "  Farre's  tubercles."  In  the  center 
of  these  nodules  characteristic  pits  or  umbilications  are  often  present, 
caused  sometimes  by  contraction  of  the  interstitial  trabeculje  and  some- 
times by  a  central  softening.  On  section  they  are  usually  grayish-white 
in  color  and  of  firm  consistence,  although  cysts,  hemorrhages,  pus-cav- 
ities, or  areas  of  hyaline  and  fatty  degeneration  are  often  found.  The 
cells  are  identical  with  those  of  the  primary  growth,  and  are  composed 
for  the  most  part  of  cylindric  epithelium. 

In  rare  instances  carcinoma  occurs  simultaneously  with  cirrhosis  in  the 
same  liver,  the  organ  presenting  an  uneven,  nodular  appearance,  and 
beinjr  slightlv  increased  in  size  and  of  firmer  consistence  than  normal. 
When  examined  in  situ  the  external  appearance  does  not  differ  materi- 
ally from  that  of  cirrhotic  liver,  but  on  section  the  whole  organ  is  found 
to  be  infiltrated  with  various-sized  cancer-nodules  surrounded  by  bands 
of  cicatricial  tissue.  In  some  cases  the  excess  of  connective  tissue  and 
the  amount  of  contraction  are  extreme,  and  the  size  and  weight  are 
reduced  below  the  normal.  Eggels^  has  collected  163  cases  of  primary 
hepatic  carcinoma,  and  calls  attention  to  the  frecjuent  association  of 
atrophic  cirrhosis  and  carcinoma;  he  regards  the  cirrhosis  as  the  primary 
process. 

Ktiology. — Among  the  more  important  predisposing  factors  are — 

(rt)  Age. — The  disease  is  most  common  after  thirty-five  or  forty  years 
of  acre,  although  cases  are  not  rare  between  twenty  and  thirtv-five  years. 
Descroizilles  reports  the  case  of  a  child  eleven  years  old  who  died  with  a 
tumor  in  the  right  hypochondriac  and  iliac  region,  the  autopsy  revealing  a 
liver  studded  with  numerous  nodules,  as  was  demonstrated  microscopically, 

{h)  Sex. — Men  are  more  often  the  victims  of  carcinoma  of  the  liver  (pri- 
mary form)  than  women.  The  secondary  variety,  however,  is  slightly  more 
frequent  in  women,  following  carcinoma  of  the  uterus  or  mammary  gland. 

^  Ziegler's  Beitrdge,  1901,  xxx.,  p.  506. 


CARCINOMA    OF  THE  LIVKR.  941 

(e)  Heredity. — Licbtenstein  found  an  hereditary  predisposition  in  192 
out  of  1137  cases  (17  per  cent.). 

(d)  Traumatism  may  contribute. 

(e)  Mechanical  Ohfstruction. — J^rimary  carcinoma  of  tlio  gall-bladder 
and  bile-ducts  commonly  follows  chronic  obstruction  by  gall-stones. 

Symptoms. — There  may  either  be  almost  no  symptoms  of  carci- 
noma involving  the  liver,  or  its  manifestations  may  be  intense  and  varied 
according  to  the  extent  and  location  of  the  growth  or  growths.  Associ- 
ated gastric  symptoms,  often  due  to  a  primary  growth  at  or  near  the 
pylorus,  which  increase  as  the  disease  advances,  usually  attend.  A  more 
or  less  marked  cachexia  may  be  the  first  noticeable  feature.  The  chief 
symptoms  may  be  considered  in  detail,  as  follows : 

(a)  Jaundice. — Discoloration  of  the  skin  is  often  by  no  means  intense, 
and  may  be  entirely  absent.  Harley  states  that  true  icterus  was  present 
in  only  6  out  of  100  cases  seen  by  him,  though  few  observers  agree  with 
his  view  as  to  the  rarity  of  this  symptom.  The  reason  given  for  its  lack 
of  intensity  is  that  in  most  cases  the  growth  is  situated  in  the  right  lobe 
and  does  not  compress  the  bile-ducts. 

(b)  Paiii  is  usually  present  to  a  marked  degree.  It  is  dull  and  boring 
in  character,  and  localized  generally  in  the  right  hypochondriac  region. 
In  some  instances  (as  in  the  case  of  impacted  biliary  calculi)  it  may 
radiate  to  the  right  shoulder  and  the  scapular  region.  It  usually  increases 
as  the  hepatic  enlargement  progresses,  although  cases  of  enormous-sized 
cancerous  tumors  of  the  liver  have  been  known  to  occur  without  pain. 
The  character  and  location  of  the  pain  are  of  diagnostic  importance,  and 
will  be  spoken  of  under  the  differential  diagnosis. 

(e)  Ascites. — When  the  cancerous  growth  compresses  the  portal 
vessels,  and  also  in  cases  of  cirrhosis  with  carcinoma,  obstruction  to  the 
portal  circulation  occurs,  and  results  in  the  development  of  ascites. 
This  may  cause  distention  of  the  abdominal  cavity  to  such  an  extent  as 
to  occlude  the  physical  signs  of  hepatic  enlargement.  The  cancerous 
growth  may  also  invade  the  peritoneum  and  cause  an  effusion.  This 
symptom,  however,  is  not  frequent,  at  least  two-thirds  of  all  cases  ter- 
minating without  the  appearance  of  ascites. 

(d)  Fever  is  usually  absent  until  the  later  stages  of  the  disease.  It 
may  then  appear  and  rise  to  hyperpyrexia  (105°  F. — 40.5°  C),  but  it 
is  usually  moderate  in  degree,  irregular,  and  intermittent  in  type. 

(e)  Cachexia. — In  every  case  of  carcinoma,  at  some  stage  of  the  dis- 
ease, cachexia  develops ;  when  pronounced,  it  is  almost  pathognomonic. 
The  destructive  effect  of  the  neoplasm,  or  the  toxic  substances  produced 
by  it,  may  play  a  r61e  in  the  causation  of  the  cachexia.  At  all  events 
there  is  a  distinct  increase  in  the  excretion  of  nitrogen. 

(/)  Cerebral  Symptoyns. — These  may  be  absent  throughout.  In 
the  advanced  stages,  however,  such  striking  symptoms  as  violent  head- 
ache, mental  hebetube,  or  delirium  (less  frequently),  which  may  be 
maniacal  in  character,  appear.  These  symptoms  resemble  those  of 
cholemia  {vide  Hepatic  Cirrhosis,  p.  931).  The  patient  may  die  in 
sudden  coma. 

i  g)  The  development  of  metastases  {e.  g.^  in  the  peritoneum). 

Qi)  The  Blood. — There  is  a  decrease  in  the  erythrocytes   and  the 


942  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

hemo£;lobin.  J'cr  contra,  the  leukocytes  are  both  relatively  and  abso- 
lutely increased. 

Physical  Signs. — Inspection  often  reveals  enlargement  of  the  super- 
ficial veins  over  the  abdomen,  and  a  prominence  in  the  upper  epigastric 
and  hepatic  regions,  varying  Avith  the  degree  of  enlargement,  may  also 
be  seen.  In  the. nodular  t'ovm  and  late  in  the  disease,  when  emaciation 
has  become  extreme,  elevations  that  are  movable  with  respiration  can 
be  noticed  beneath  the  skin. 

On  palpat  1071  the  organ  can  be  distinctly  felt  projecting  below  the 
costal  margin  and  extending  in  some  instances  to  a  point  below  the 
level  of  the  umbilicus.  During  respiration  (forced)  the  liver  can  l)e  felt 
to  move  downAvard  and  upward,  the  organ  being  under  the  influence  of 
the  diaphragmatic  excursions.  In  emaciated  subjects  the  cancer-nodules 
are  readily  appreciable,  and  in  some  instances  the  central  pits  or  depres- 
sions are  ])alpable,  forming  a  characteristic  sign.  Cancerous  infiltration 
of  the  anterior  margin  is  most  easily  felt,  and  in  enormous  enlargements 
of  the  organ  I  have  detected  them  on  the  posterior  surface  as  well. 
Rarely  the  liver  is  found  to  be  uniformly  large.  Palpation  may  also 
show  splenic  enlargement,  due  to  passive  congestion. 

I^ercussion. — In  primary  carcinoma  (usually  found  in  the  right  lobe) 
the  percussion-dulness  is  increased  irregularly  downward  and  generally 
to  the  right.  On  the  other  hand,  in  secondary  growths  (usually  mass- 
ive) the  nodules  are  oftener  distributed  equally  throughout  the  liver. 
In  such  cases  the  area  of  dulness  may  extend  across  the  epigastrium  to  the 
left  hypochondriac  region,  the  heart  and  other  viscera  being  now  dis- 
placed. Posteriorly,  dulness  may  extend  upward  on  a  level  with  the 
fourth  rib,  and  anteriorly  downward  to  the  iliac  fossa.  The  organ  may 
now  weigh  from  15  to  20  lbs.  (6.5-9  kgms.),  while  in  the  average  case 
the  carcinomatous  liver  weighs  from  3  to  6  lbs.  (1.3-2.6  kgms.). 

Diagnosis.— In  forming  a  diagnosis  tlie  family  tendency,  the  history 
of  primary  carcinoma  elsewhere  in  the  body  (stomach,  colon,  esophagus, 
pancreas,  gall-bladder,  uterus,  mamma — Rolleston),  the  age,  the  localiza- 
tion of  the  pain  in  the  right  hypochondrium,  the  blood  findings,  the 
metastases,  the  cachexia,  and  the  progressive  enlargement  of  the  liver, 
presenting  umbilicated  nodules,  are  the  reliable  points.  The  appearance 
of  jaundice  or  ascites,  or  both,  is  confirmatory. 

Differential  Diagnosis. — Among  affections  of  other  organs  that  are 
likely  to  be  mistaken  for  carcinoma  of  the  liver  may  be  mentioned — 
(1)  carcinoma  of  the  pi/lorus  ;  and  (2)  carcinoma  of  the  colo7i  and  omen- 
tum. The  chief  diseases  of  the  liver  itself  apt  to  be  diagnosed  as  car- 
cinoma are — {a)  abscess,  (6)  syphilis,  (c)  benign  groivtJis  {adenomata^ 
angiomatd),  {d)  hydatid  cysts,  and  {e)  hypertroj)hic  cirrhosis. 

(1)  Carcinoma  of  the  Pylorus. — In  carcinoma  of  the  pylorus  the  phys- 
ical examination  frequently  shows  a  hard  nodular  tumor  that  is  most 
plainly  outlined  in  the  epigastric  region.  In  a  typical  case,  on  deep  inspi- 
ration, the  tumor  is  pressed  downward  by  the  liver,  but  is  not  pulled  up- 
ward by  forced  expiration,  as  in  hepatic  carcinoma.  In  many  instances, 
however,  adhesions  bind  the  stomach  firmly  to  the  liver,  which  may  be 
the  seat  of  secondary  involvement.  The  presence  of  jaundice,  as  well  as 
the  negative  results  from  an  examination  of  the  gastric  contents,  would 
tend  to  eliminate  pyloric  carcinoma. 


CARCINOMA    OF  THE  IJVER.  043 

(2)  Carcinoma  of  the  Colon  and  Omentum. — Secondary  carcinoma  of 
the  intestine  affects  most  frequently  the  sigmoid  flexure.  The  symptoms 
of  intestinal  obstruction  arise,  constipation  being  followed  by  attacks  of 
serous  diarrhea  due  to  irritation,  and  later  by  the  presence  of  blood  in 
the  stools.  In  carcinoma  of  the  liver,  on  the  other  hand,  the  bile-ducts 
may  be  obstructed,  causing  clay-colored  stools,  but  otherwise  the  dejecta 
are  normal ;  the  seat  of  the  nodular  enlargement  and  pain  is  located  in 
the  right  hypochondrium.  Jaundice  and  ascites  are  absent  in  carcinoma 
of  the  colon.  The  tumor,  if  palpable,  in  the  latter  condition  is  more 
movable  and  is  less  under  the  influence  of  the  diaphragm.  It  does  not 
give  an  absolutely  flat  percussion-note,  as  does  hepatic  carcinoma.  (Jar- 
cinoma  of  the  omentum  is  usually  secondary.  The  absence  of  small  mov- 
able tumors  in  the  umbilical,  lumbar,  or  hypogastric  regions,  ranging  in 
size  from  that  of  a  pea  to  a  walnut,  aids  in  the  elimination  of  carcinoma 
of  the  omentum.  As  the  latter  aff'ection  advances  the  abdomen  be- 
comes distended  and  painful  to  the  touch,  the  bowels  are  obstinately 
constipated,  and  the  physical  signs  reveal  the  presence  of  an  eff"usion 
which,  when  aspirated,  is  generally  serous,  but  sometimes  bloody.  Mi- 
croscopic examination  may  possibly  reveal  the  presence  of  cancer-cells, 
though  their  recognition  is  difiicult.  The  liver,  unless  primarily  in- 
volved, is  not  enlarged,  and  cachexia  does  not  usually  appear  until  late. 

From  he2)atic  abscess  the  points  of  difi'erentiation  are — 

Carcinoma  of  the  Liver.  Hepatic  Abscess. 

Is  often  hereditary.    There  is  a  history  of  There  is  a  history  of  traumatism  or  of  in- 

a  primary  growth  or  chronic  irritation.  testinal  ulceration,  as  in  dysentery. 

Occurs  usually  after  the  age  of  forty.  Occurs  at  any  age. 

Jaundice  is  rare.  Jaundice  is  sometimes  present. 

Fever  is  absent  or  slight.  Hectic  temperature,  chills,  and  sweating. 

Cachexia  is  present  and  almost  pathog-  Anemia  may  be  present,  but  never  ca- 

nomonic.  chexia. 

Pain  is  dull  and  boring  in  character,  and  Pain  is  sharp,  lancinating,  and  paroxys- 

more  constant.  mal. 

A  nodular,  umbilicated  tumor  or  tumors  A  fluctuating  tumor  may  sometimes  be 

may  be  detected.  detected  below  the  costal  margin. 

The  enlargement  is  downward.  The  enlargement  usually  upward. 

The  duration  is  a  few  months  to  one  year.  The  duration  is  usually  a  few  weeks. 

Microscopic  examination  reveals  disinte-  The   microscope   reveals  pus,  liver-cells, 

grated  liver-cells,  cancer-nests,  and  in  staphylococci     and     streptococci,    the 

some  cases  the  micro-organisms  of  sup-  bacillus  coli  communis  or  the  amceba 

puration.  coli. 

Benign  Growths  (Adenomata,  Angiomata). — Occasionally  growths 
are  detected  in  the  liver,  and  may  occur  at  any  age ;  when  these  are 
present  at  or  about  the  age  of  forty,  they  may  be  mistaken  for  carci- 
noma. The  absence,  however,  of  a  primary  growth  in  some  one  of  the 
other  viscera,  together  with  the  duration  of  the  growth  and  the  absence 
of  cancerous  cachexia,  would  tend  to  difierentiate  them  from  cancerous 
involvement.  An  examination  of  the  blood  may  be  of  service,  leuko- 
cytosis being  more  common  in  carcinoma. 

The  prognosis  is  invariably  fatal,  the  disease  terminating  rapidly 
in  from  a  few  months  to  a  year.  The  most  rapid  course  is  run  by  sec- 
ondary carcinoma  of  the  organ.  In  exceptional  cases  growths  favorably 
situated  have  been  removed  without  recurrence. 

Treatment. — The  treatment  is,  with  rare  exceptions,  purely  sympto- 


944  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

matic.  An  easily  digested,  nutritious  diet  should  be  given,  together  Avith 
active  stimulation  to  support  the  system.  The  pain  may  be  relieved  by 
the  free  use  of  morphin,  given  by  the  mouth,  rectum,  or  hypodermically. 
For  the  nausea  and  vomiting  that  are  apt  to  supervene  the  carbonated 
waters,  cracked  ice  vith  champagne,  or  repeated  doses  of  creasote  (beech- 
wood),  dilute  hydroeyanii-  acid,  or  wine  of  ipecac  (2  minims — 0.133 — 
every  hour  until  relieved)  may  be  given.  If  violent  delirium  should 
occur  during  the  later  stages  of  the  disease,  cold  compresses  to  the  fore- 
head or  vertex,  and  bromids  and  chloral  hydrate  given  in  rectal  enemata, 
may  prove  efficient. 


OTHER  NEW   GROWTHS  IN  THE  LIVER. 

(a)  Angioma,  Adenoma,  and  Cyst. 

Occasionally,  benign  growths  occur  in  the  liver,  and  often  with  an 
absence  of  symptoms  unless  their  increase  in  size  gives  rise  to  mechan- 
ical obstruction.  One  of  the  most  common  of  these  is  angioma,  which 
is  often  found  in  the  livei's  of  old  people.  Angiomata  consist  of  tortu- 
ous and  dilated  capillaries  in  the  hepatic  connective  tissue ;  they  rarely 
attain  to  a  size  larger  than  a  crab-apple,  and  usually  cause  no  symp- 
toms. Although  most  common  in  adults,  they  have  been  known  to 
occur  in  children. 

Adenomata  and  cystomata  may  also  occur  in  the  liver.  They  are  both 
benign  growths.  The  former  is  of  the  tubular  variety,  consisting  of 
connective-tissue  nests  lined  with  cylindric  epithelial  cells.  Von  Berg- 
man removed  a  portion  of  a  tuberous  adenoma  of  the  liver  with  perfect 
recovery  and  non-recurrence  of  the  growth.  Cysts  are  quite  rare.  Lipp- 
mann,^  who  searched  the  literature,  found  reported  3  retention  cysts,  9 
cystic  adenomas,  1  lymph  cyst,  and  3  cases  that  could  not  be  classified. 

(6)  Sarcoma. 

Of  the  many  varieties  of  sarcomata,  those  occurring  most  commonly 
in  the  liver  are  the  small  and  large  round-celled  and  the  melanotic  vari- 
ety, the  latter  often  being  secondai-y  to  sarcoma  of  the  choroid  coat  of 
the  eye.  These  grow  rapidly,  causing  a  Avidespread  destruction  of  the 
liver-structure,  with  a  change  in  the  size  and  shape  of  the  organ  that  is 
often  demonstrable  by  palpation.  E.  R.  Axtell  reports  a  case  in  which 
at  i\\Q  postmortem  the  upper  two-thirds  of  the  liver  revealed  an  entire 
absence  of  hepatic  structure,  and  consisted  of  three  tumor-masses.  On 
section  the  tumor  is  seen  to  be  of  firmer  consistence  than  the  surrounding 
liver-tissue,  and  presents  a  dark,  grayish-white,  striated  appearance.  If 
the  growth  be  of  the  pigmented  variety,  patches  of  a  deep  black  or  of 
different  shades  of  pigment  may  be  scattered  throughout  the  mass.  Met^ 
astasis  is  rapid  and  widespread  (lungs,  kidneys,  heart,  skin),  as  is  shown 
by  the  fact  that  other  organs  are  invariably  found  involved  at  the  time 
of  the  growth  and  development  of  the  .sarcoma  in  the  liver.  Melano- 
'  sarcoma  may,  in  rare  instances,  appear  as  a  primary  growtli,  and  attain 
to  a  considerable  size,  as  shown  by  a  case  reported  by  Bramwell  and 
Leith. 

^  Deutsche  Zeitscltrifl  Jiir  Chirurgie,  February,  1900. 


DISEASES  OF  THE  S  PL  KEN.  945 

The  symptoniH  are  those  of  mechanical  obstruction,  and  consist  of 
gastro-intestinal  disturbances  due  to  passive  con<festion,  edema,  and 
ascites.  Anemia  and  emaciation  may  become  marked  late  in  the  disease, 
but  cachexia  does  not  develop.  The  passage  of  an  intensely  dark-col- 
ored urine  (melanuria)  has  been  noted  in  some  cases.  Secondary  nod- 
ules may  appear  on  the  skin-surface. 

The  diagnosis  can  often  be  made  from  the  primary  growtli  (melano- 
sarcoma  of  the  choroid  or  sarcomata  of  the  lymphatic  glands)  and 
from  the  rapid  development  of  the  tumor.  From  carcinoma  of  the  liver 
melanosarcoma  may  be  distinguished  by  the  presence  of  ocular  symp- 
toms, particularly  blindness  of  one  eye,  by  the  rapid  widespread  meta- 
stasis, the  melanuria,  perhaps,  and  by  the  absence  of  a  true  cancerous 
cachexia. 

The  prognosis  is  absolutely  fatal,  and  the  treatment  merely  palliative. 


X.  DISEASES  OF  THE   SPLEEN. 

Diseases  of  the  spleen  are  mostly  secondary  to  other  diseases,  the 
consideration  of  which  embraces  an  appropriate  description  of  the  as- 
sociated splenic  disorders.  The  intimate  relation  between  the  spleen 
and  blood  accounts  for  the  frequency  with  which  this  organ  is  involved 
in  many  of  the  blood-diseases. 

DISLOCATION  OF  THE  SPLEEN. 

{Floating  Spleen.) 

Htiology. — This  may  be  either  congenital  or  due  to  the  increased 
weight  of  an  enlarged  spleen,  to  tight-lacing,  to  relaxation  of  the  liga- 
ments, or  to  traumatism,  and  is  often  met  in  splanchnoptosis.  Carcino- 
matous enlargement  of  the  left  lobe  of  the  liver  caused  it  in  my  case. 

Symptoms. — The  symptoms  are  vague,  and  are  the  result  of  press- 
ure. Distinct  symptoms  of  gastro-enteritis  and  neurasthenia  may  result 
from  a  wandering  spleen.  By  physical  examination  we  discover  with  the 
touch  the  spleen  as  a  mobile  tumor  pendant  from  the  left  hypochondrium ; 
the  tumor  is  superficial,  blunt-edged,  and  notched  on  its  anterior  border, 
and  may  be  replaced  by  the  hand  in  its  normal  position.  On  percussion 
over  the  splenic  area  the  normal  dulness  is  found  to  be  absent. 

Diagnosis. — It  is  important  to  distinguish  between  floating  spleen 
and  simple  enlargement ;  also  between  the  former  and  movable  hidney. 

The  prognosis  is  guarded  as  to  cure,  though  favorable  as  to  life. 
Twisting  of  the  pedicle  has  been  followed  by  strangulation,  with  the 
development  of  intense  pain  and  other  alarming  symptoms  (necrosis). 
Intestinal  obstruction,  due  to  pressure,  may  appear. 

The  treatment  must  be  mechanically  supportive,  consisting  of  pads 
and  bands.     Splenectomy  has  given  excellent  results. 

60 


946  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 


SPLENIC   HYPEREMIA. 

Acute  or  active  hyperemia  may  be  found  as  the  result  of  the  acute 
infectious  diseases,  giving  rise  to  the  acute  sph-nic  tiimo;  or  as  the  result 
of  amenorrhea,  or  of  injuries  and  inflammation  [circumscribed  hyper- 
emia). The  organ  is  uniformly  enlarged  (except  in  the  last-named  cases), 
and  is  darker  in  color  and  softer  in  consistence  ;  the  capsule  also  is 
tense.      This  condition  merges  insensibly  into  acute  splenitis. 

Chronic  or  passive  hyperemia  is  due  to  some  mechanical  obstruction 
of  the  portal  circulation  caused  by  tumors,,  cardiac,  hepatic,  and  pulmo- 
nary disease,  and  pylephlebitis.  The  spleen  is  enlarged,  firm,  dark-red 
in  color,  and  the  capsule  is  somewhat  thickened. 

The  symptoms  are  vague,  and  may  consist  of  simply  a  sense  of  weight, 
fulness,  and  pressure,  and  some  tenderness  in  the  left  hypochondrium. 
In  cases  of  extravasation  of  blood  and  rupture  of  the  spleen  the  symp- 
toms of  intestinal  perforation,  hemorrhage,  and  collapse  may  supervene. 

On  physical  cvamination  the  edge  of  the  spleen  may  be  palpated  be- 
low the  margin  of  the  ribs.  The  percussion-dulness  is  increased  in 
area,  especially  dounward  and  forward,  and  may  encroach  upon  the 
slightly  curved  umbilico-axillary  '"resonant  line.'" 

The  detection  of  acute  or  chronic  splenic  hyperemia  (enlai'gement)  is 
often  of  invaluable  aid  in  the  diagnosis  of  the  causative  disease. 

The  prognosis  and  treatment  are  embraced  in  those  of  the  disease 
causing  the  congestion.     The  a-rays  have  been  used. 


SPLENITIS. 


Definition. — This  term  comprises  acute  and  chronic  (hypertrophic) 
proliferative  splenitis  and  suppurative  inflammation. 

Pathology. — Xext  to  the  kidneys,  the  spleen  is  the  favorite  seat 
of  metastatic  inflammation  and  embolic  infarction.  Splenitis,  due  to  a 
benign  embolus  originating  in  the  left  side  of  the  heart  or  from  the 
aorta  above  the  splenic  arteries,  is  usually  circumscribed  to  a  zone  of 
sero-hemorrhagic  infiltration  about  the  resultant  infarct.  The  latter  is 
hemorrhagic  at  first,  and  later  becomes  particolored  or  mixed,  and  is  of 
a  yellow  color,  owing  to  partial  fatty  degeneration  ;  still  later  it  may 
become  whitish  and  remain  as  a  wedge-shaped  (the  base  being  periph- 
eral), cheesy  (necrotic  softening),  or  even  calcareous  mass  or  as  a  fibrous 
cicatrix.  Infection  of  the  infarcts  by  pus-micrococci  leads  to  the  devel- 
opment of  small  abscesses,  and  the  trabeculfe  surrounding  the  latter 
may  give  way  until  finally  one  large  pus-sac  may  be  formed.  Embolism 
may  follow  primary  splenic  arterial  or  venous  thrombosis. 

Perisplenitis  generally  follows,  and  sometimes  with  adhesions  attached 
to  adjacent  hollow  organs,  as  the  stomach  and  colon,  through  which 
the  perforating  abscess  may  discharge  its  purulent  contents.  An  unfor- 
tunate termination  is  the  bursting  of  the  abscess  into  the-  peritoneal 
cavity ;  a  more  fortunate  ending  results  in  an  external  opening.  In 
acute  splenic  tumor  there  is  an  active  congestion,  with  round-cell  infil- 
tration and  some  proliferation  of  the  splenic  cells.  The  spleen  is  mod- 
erately enlarged,  dark,  soft,  pulpy,  and  friable. 


SPLENITIS.  947 

In  cases  of  intense  vascular  engorgement,  as  in  the  acute  splenic 
tumor  of  severe  typhoid  fever,  intermittent  fever,  and  epilepsy  (during 
the  paroxysm),  hemorrhagic  extravasation  may  occur,  and  there  may 
finally  be  even  a  rupture  of  the  capsule  and  a  passage  of  the  blood  into 
the  peritoneal  cavity.  In  chronic  splenic  tumor  there  is  a  persistent 
hyperplasia  of  the  splenic  cells,  and  frequently  also  of  the  trabecular 
cells,  minus  the  acute  engorgement.  Cirrhosis  of  the  spleen  (chronic 
interstitial  splenitis)  diifers  characteristically  from  that  of  other  organs 
(as  the  liver  and  kidneys)  in  that  there  is  enlargement  instead  of  con- 
traction. Added  to  the  increase  in  the  size  of  the  spleen,  there  are  in 
both  forms  of  chronic  splenitis  thickening  of  the  capsule,  patches  often 
of  old  perisplenitis,  and  a  slaty  color  of  the  tissues,  with  more  or  less 
pigmentation. 

etiology. — The  disease  probably  never  starts  primarily  in  the 
spleen  itself.  Acute  proliferative  or  hyperplastic  splenitis  {acute  spdenic 
tumor)  is  seen  as  the  result  of  the  acute  infectious  diseases  (typhoid, 
typhus,  relapsing,  malarial  fevers.)  Chronic  proliferative  splenitis 
{chronic  splenic  tumor)  is  due  to  chronic  malarial  infection  or  repeated 
acute  attacks,  to  splenic  anemia,  chronic  passive  congestion  of  the  spleen, 
and  leukocythemia.  The  leukemic  spleen  represents  a  somewhat  differ- 
ent form  of  chronic  proliferative  splenitis  from  the  ordinary  forms. 
Acute  suppurative  splenitis  (abscess),  either  diffuse  or  circumscribed,  is 
usually  secondary  to  infectious  (pyogenic)  emboli,  as  in  ulcerative  endo- 
carditis and  pyemia.  Again,  as  the  result  of  simple  valvulitis  of  aortic 
thrombosis,  embolic  infarction  of  the  spleen  may  be  found,  which  may 
soften  and  break  down  in  abscess-formation  from  subsequent  infection. 
Abscess  of  the  spleen  may  also  follow  traumatism,  perforation  of  a  gas- 
tric ulcer,  and  the  extension  of  adjacent  inflammation. 

Symptoms. — These  are  indefinite  or  absent  in  most  cases.  Usually 
there  is  no  pain  or  tenderness  unless  perisplenitis  exists.  Considerable 
enlargement  of  the  spleen  may  be  attended  with  a  sense  of  tveight,  ten- 
sion, or  distress  in  the  left  hypochondrium,  and  perhaps  by  slight  dys- 
pnea. Anj  suppurative  fever  present  will  most  probably  be  disassociated 
from  the  idea  of  abscess  of  the  spleen,  provided  the  local  signs  of  pus 
be  absent.  Sudden  pain  appearing  in  the  gastric  region,  followed  by  the 
vomiting  of  pus  and  blood,  in  the  course  of  an  infectious  disease,  with 
splenic  enlargement,  may  be  due  to  the  rupture  of  an  abscess  of  the 
spleen.     Ascites  may  also  be  present. 

The  physical  examination  may  reveal  some  bulging  on  inspection, 
and  a  fluctuating  tumor  may  be  palpated.  The  enlargement  may  be 
sufficient  to  enable  one  to  feel  the  notch  in  the  spleen,  and  also  the  ante- 
rior and  lower  borders,  reaching  even  to  the  umbilicus.  The  percussion- 
dulness  is  correspondingly  increased. 

Diagnosis. — This  may  be  made  from  a  consideration  of  the  physi- 
cal signs  in  conjunction  with  a  study  of  the  primary  disease.  In  cases 
in  which  pus  is  suspected  an  exploratory  puncture  may  clear  the  diag- 
nosis. The  splenic  inflammation  is  rather  an  aid  to  diagnosis  than  a 
condition  essentially  needful  of  recognition  in  itself. 

Differential  Diagnosis. — Acute  suppurative  splenitis  might  be  mis- 
taken for  gastric  or  p>ancreatic  disease  ;  but  the  previous  history  in  the 
former,  as  contrasted  with  that  of  the  latter  affection,  conjoined  with  the 


948  DISEASES  OF  THE  DIGESTIVE  SYSTE3I. 

local  syraptoius  that  are  more  orlessciiaracteristieof  tlie  ori>an  involved, 
will  oenorally  lurnish  an  accurate  means  of  dift'erentiation. 

The  huge  enlargements  of  chronic  s})lenitis  may  be  confounded  with 
hepatic,  vena!,  omental,  or  ovarian  groirthx.  Here  a  careful,  discriminat- 
ing observation  of  the  constitutional  state  and  of  the  physical  signs  is 
requisite  for  a  diagnosis.  Splenic  enlargement  must  not  be  assumed 
when  a  lare/e  pleural  eff'ufion  on  the  left  side  is  causing  the  depressed 
lower  border  of  the  organ  to  be  felt.  Finally,  fecal  aernmulation  in 
the  splenic  Jlex lire  of  the  colon  may  be  mistaken  for  moderate  enlarge- 
ment of  the  spleen.  The  former  gives  an  irregular,  doughy  tumor, 
tympanites,  vomiting,  and  a  history  of  constipation  alternating  some- 
times with  diarrliea;  there  is  no  increase  in  the  si)lenic  area  of  dulness. 

Prognosis. — This  Avill  depend  upon  the  primary  systemic  condition. 
Abscess  is  a  grave  complication,  the  danger  consisting  of  rupture  and 
fital  peritonitis.  Even  in  acute  splenic  tumor  of  a  violent  type  there 
may  be  a  hemorrhagic  extravasation  so  severe  as  to  burst  the  capsule. 
Chronic  splenitides  are  not  in  themselves  grave  disorders. 

Treatment. — This  is  to  be  directed  mainly  at  the  causative  condition. 
Quinin  and  arsenic  are  often  useful  in  the  malarial  form,  and  the  chaly- 
beates,  iodids,  and  ergot  have  been  recommended  for  the  various  chronic 
splenic  enlargements.  Strapping  the  affected  side  affords  comfort.  Ab- 
scess must  be  treated  by  splenotomy  and  drainage.  Splenectomy  may 
1)6  usetid  in  certain  cases  of  simple  hypertrophy,  but  records  show  only 
about  20  per  cent,  of  recoveries  from  the  operation.  The  state  of  the 
patient  must  be  well  considered.      Splenectomy  is  never  justifiable. 


AMYLOID  DEGENERATION  OF  THE  SPLEEN. 

(Sago  Spleen.) 

This  occurs  as  a  part  of  the  cachectic  condition  attending  amyloid 
degeneration  of  other  organs  (liver,  kidneys).  The  condition  develops 
in  the  coui'se  of  cases  of  prolonged  and  wasting  discharges  (phthisis, 
empyema,  suppurative  ostitis,  syphilis,  chronic  peritonitis,  chronic  entero- 
colitis). The  spleen  is,  as  a  rule,  greatly  enlarged,  putty-like,  and 
rotund.  The  capsule  is  tense  and  glistening.  There  are  two  forms  of 
waxy  degeneration — namely,  the  so-called  ^"sae/o"  spleen  and  the  diffuse 
iraxy  or  lardaceous  spleen.  In  the  former  the  Malpighian  bodies  are 
chiefly  affected  and  appear  on  section  like  sago-granules 4  in  the  latter 
the  Avhole  splenic  pulp,  and  even  the  trabecule,  are  degenerated,  and  on 
section  the  spleen  appears  pale,  smooth,  and  homogeneous  (boiled-ham 
appearance).  This  may  be  but  a  late  stage  of  the  "  sago  "  spleen.  The 
spleen  gives  a  characteristic  reaction  with  iodin. 

The  symptoms  are  those  of  general  cachexia,  and  the  diagnosis  rests 
upon  the  detection  of  an  enlargement  of  the  organ  associated  with  evi- 
dences of  amyloid  disease  in  other  organs. 

The  prognosis  is  unfavorable,  and  the  treatment  does  not  differ  from 
that  indicated  for  the  underlying  and  causative  disease. 


DISEASES  OF  THE  PANCREAS  949 

MORBID   GROWTHS  OF  THE  SPLEEN. 

The  principal  new-growths  are  the  granuloinata,  as  tubercles  and 
syphilitic  gummata ;  also  secondary  carcinoma,  melanotic  sarcoma,  and 
hydatid  and  other  cysts.  Lymphadcnoma  {e.  //.,  in  leukemia),  angioma, 
and  fibroma  may  be  included  among  tumors  of  the  spleen. 

These  affections  of  the  spleen  are  all  of  rare  occurrence,  and  arc  not 
readily,  if  at  all,  discoverable  during  life.  They  are  of  no  clinical  or 
therapeutic  interest  apart  from  the  general  or  primary  disease.  It  may 
be  stated  that  carcinoma  of  the  spleen  is  always  secondary  ;  it  may  be 
diagnosticated  by  a  physical  examination,  showing  the  organ  to  be  en- 
larged, with  the  unmistakable  signs  of  the  primary  carcinoma,  as  of  the 
stomach.  Secondary  sarcoma  is  more  common,  and  is  recognized  by  an 
irregular  enlargement  and  the  presence  of  a  primary  tumor. 

Syphilitic  gummata  of  the  spleen  are  often  associated  with  amyloid 
degeneration  and  enlargement. 


RUPTURE  OF  THE  SPLEEN. 

This  may  occur  as  the  result  of  an  intense  hyperemic  engorgement, 
both  in  splenitis  from  the  rupture  of  an  abscess  and  from  traumatism. 
In  the  acute  splenic  tumor  of  typhoid  fever,  in  malaria,  and  during  an 
epileptic  paroxysm,  rupture  of  the  capsule  has  been  known  to  occur  on 
account  of  the  extravasation  of  blood.  The  symptoms  are  usually  mis- 
taken for  those  of  intestinal  perforation  with  internal  hemorrhage.  The 
treatment  is  surgical,  though  palliative  pending  the  surgeon's  arrival. 


XI.  DISEASES   OF  THE   PANCREAS. 
ACUTE  PANCREATITIS. 

Three  varieties  of  acute  pancreatitis — hemorrhagic,  gangrenous,  sup- 
purative— will  be  described  below,  following  the  usual  classification,  but 
it  is  to  be  recollected  that,  in  the  majority  of  instances,  these  are  indis- 
tinguishable clinically,  and  represent  but  different  stages  of  a  single 
disease. 

HEMORRHAGIC   PANCREATITIS. 

Pathology. — The  pancreas  is  enlarged,  usually  firm,  and  somewhat 
chocolate-colored.  Irregular  areas  show  the  circumscribed  as  Avell  as 
the  diffused  form  of  hemorrhagic  infiltration  of  the  interstitial  fat-tissue, 
with  thrombosis  of  the  pancreatic  veins  in  some  cases  (Day).  There 
is  also  an  infiltration  with  round-cells  of  the  interlobular  tissues.  Some 
cases  are  examples  of  degeneration  (non-inflammatory).  The  gastro-intes- 
tinal  mucosa  may  be  hyperemic,  ecchymotic,  or  in  a  slightly  catarrhal  state. 
Evidences  of  a  localized  peritonitis  {peripancreatitis)  are  not  frequent. 
Hemorrhage  with  inflammation  is  to  be  distinguished  from  true  hemor- 
rhagic pancreatitis.  Opie  and  Meakins  consider  hemorrhagic  pancreatitis 
to  be  primarily  a  necrosis,  the  inflammatory  changes  being  secondary. 


950  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Disse7ninated  fat-7it'orosis  is  quite  commonly  associated  uitli  hemor- 
rhagic pancreatitis.  Small  areas  of  a  peculiar  (tallow-like)  substance, 
ranging  from  the  size  of  a  miliary  tubercle  to  that  of  a  pea  or  even  larger, . 
are  found  scattered  in  the  f\itty  interlobular  pancreatic  tissue  in  the 
omentum,  mosentery.  and  sometimes  in  the  abdominal  fat.  H.  U.  Williams 
and  Kiitz  and  Winkler,  from  experimental  researches,  conclude  that  prob- 
ably the  fat-splitting  ferment  is  capable  of  causing  changes  similar  to  fat- 
necrosis.  H.  Coenen  believes  that  the  necrosis  is  the  result  of  autolysis 
from  activation  of  the  pancreatic  secretion  by  bacterial  action,  the  bacte- 
ria penetrating  into  the  pancreas  in  infected  bile  or  intestinal  juice. 

In  infectious  fevers  the  pancreas  may  show  diffuse,  parenchymatous, 
and  granular  degenerative  changes.  Chiari  has  pointed  out  that  post- 
morteni  digestion  is  frequent  in  the  pancreas. 

Htiology. — Most  of  the  cases  reported  have  occurred  in  men,  and  in 
persons  ^-ah  fifty  yeais  of  age.  An  especial  predisjwsitmi  to  the  disease, 
seems  to  be  the  result  of  cases  of  severe  and  obstinate  dyspepsia  (gastro- 
duodenal),  alcoholism,  obesity,  glycosuria,  and  traumatism.  Hemorrhage 
into  the  pancreas  may  cause  the  disease.  Opie  emphasizes  the  etiologic 
importance  of  gall-stone  and  gall-duct  disease,  and  suggests  that  pan- 
creatitis may  be  the  result  of  the  entrance  of  bile  into  the  pancreatic 
duct.  It  is  seen  occasionally  post-mortem  e.  g.,  in  acute  tuberculosis  and 
the  specific  fevers  (metastatic  infection).  The  direct  cause  is  probably 
an  infection  through  the  ducts  of  the  gland,  although  when  due  to  im- 
paction of  a  calculus  bacterial  infection  may  be  absent.  Flexner '  in- 
jected acids,  alkalies,  and  bacterial  cultures  into  the  duct  of  ^^  irsung 
and  the  interstitial  tissue,  and  produced  acute  pancreatitis. 

Symptoms. — The  onset  is  sudden  and  violent.  It  is  character- 
ized bv  excruciating,  deep-seated  pain,  usually  in  the  epigastrium  or 
between  the  xiphoid  and  umbilicus.  There  are  also  nausea  and  severe 
retching  and  vomiting,  constipation,  and  sj^eedy  collapse,  ending  fatally 
within  a  few  days  (second  to  the  fourth — Fitz).  The  vomitus  may  con- 
sist at  last  of  slimy  mucus  or  dark  blood.  Fever  is  generally  slight  at 
first,  though  it  may  touch  103°  or  104°  F.  later.  Dyspnea  and  a  rapid, 
feeble  pulse,  with  jactitation  and  marked  anxiousness  or  an  afebrile  de- 
lirium, may  perhaps  be  present.  In  some  cases  there  may  be  diairhea, 
with  thin  and  watery  stools  containing  free  fat.  Instances  may  be  re- 
peated in  which,  owing  to  the  coincident  presence  of  gall-stones,  there 
may  he  jaundice  and  colicky  pains  over  the  right  hypochondrium.  The 
jaundice,  however,  may  sometimes  be  due  to  swelling  of  the  head  of  the 
pancreas,  which  presses  upon  the  bile-duct.  Tympanites  occurs  in  a 
majoritv  of  the  cases.  Hiccough  and  albuminuria  have  also  been  noted. 
The  pain  and  collapse  may  be  due  either  to  a  circumscribed  peritonitis 
or  to  pressure  upon  the  solar  plexus.  Cyanosis  of  the  face  and  abdom- 
inal walls  is  common  (Halsted).  Localized  tenderness  and  moderate 
rigidity  above  and  to  the  right  of  the  umbilicus  are  sometimes  present. 

Diagnosis. — This  is  at  all  times  difficult,  since  many  or  all  of  the 
symptoms  enumerated  may  be  present  in  other  affections.  A  careful 
inquiry  into  the  previous  history  is  important.  The  sud<len  develop- 
ment of  an  intense,  deep-seated  pain  in  the  epigastrium,  followed  by 
vomiting,  collapse,  abdominal  distention.  Avith  circumscribed  resistance 
in  the  epigastrium,  and  the  presence  of  constipation  and  slight  fever, 
^  "  Experimental  Pancreatitis,"  Festschrift  in  honor  of  William  Henry  Welch. 


SUPPURATIVE  PANCREATITIS.  951 

should  point  strongly  to  hemorrhagic  pancreatitis.  The  detection  of"  free 
fat  in  the  dejections,  and  the  discovery  of  scattered  points  of  tenderness, 
are  significant.  Cammidge's  reaction  is  corroborative  evidence  where  a 
pancreatic  disorder  is  suspected.  Other  affections  may  give  a  positive 
response  (pneumonia,  appendicitis  with  diffuse  peritonitis).  Camrnidge  ' 
advises  that  the  urine  examination  be  controlled  by  an  examination  of 
the  feces. 

Differential  Diagnosis. — The  temperature  is  apt  to  be  higher  and  the 
pain  and  tenderness  less  localized  and  more  constant  in  peritonitis.  Fecal 
vomiting  would  indicate  obstruction  of  the  bowel.  Here  also  we  may 
determine  the  patency  of  the  bowel  by  injection  or  inflation.  Intestinal 
obstruction  is  of  comparatively  rare  occurrence  in  the  epigastrium,  where 
the  pain  and  distention  of  acute  pancreatitis  are  localized  ;  there  are 
likely  to  be  present  more  marked  and  general  tympany,  including  the 
flanks,  and  a  circumscribed  distention  of  the  intestinal  coils. 

In  perforating  gastric  or  duodenal  ulcer  there  is  a  history  of  pain 
after  eating,  hemorrhages  from  the  digestive  tract,  and  of  anemia. 

Corrosive  poisons  may  be  excluded  by  the  history  of  the  case  and  by 
an  examination  of  the  mouth  and  vomitus.  Hepatic  colic  must  be 
excluded ;  the  pain  is  intermittent,  and  referred  more  to  the  right  side 
than  in  pancreatitis.     There  is  in  pancreatitis  also  an  early  collapse. 

Acute  g astro-duodenitis  is  characterized  by  fever,  by  a  history  of  in- 
judicious eating,  followed  by  mild  inflammatory  symptoms  within  a  few 
hours,  and  by  an  absence  of  the  sudden  prostration  and  collapse  so  com- 
mon to  hemorrhagic  inflammation  of  the  pancreas. 

ProgfnosiS. — Acute  hemorrhagic  pancreatitis  in  most  cases  ends  in 
death.  In  view  of  the  ease  with  which  the  disease  may  be  overlooked  it 
is  quite  possible  that  certain  cases  of  milder  type  may  recover ;  in  these 
the  recovery  has  been  said  to  follow  a  different  affection.  Osier  reports  a 
case  diagnosticated  as  one  of  intestinal  obstruction  in  which  abdominal 
section  was  performed  and  recovery  followed.  Thayer  and  Korte  have 
also  reported  cases  of  cure  in  which  a  celiotomy  decided  the  diagnosis. 

Treatment. — The  treatment  as  for  shock  by  the  use  of  external 
heat  and  of  warm  saline  injections,  hypodermics  of  morphin,  atropin, 
strychnin,  and  of  diffusible  stimulants  may  probably  be  of  some  avail. 
Early  operation  with  a  view  to  establishing  free  drainage  is  the  impor- 
tant factor  in  the  treatment  (Ochsner). 

SUPPURATIVE    PANCREATITIS. 

Pathology. — The  suppuration  may  be  diffuse,  with  numerous  small 
abscesses ;  more  commonly  a  single  abscess  exists  in  the  head  or  body  of 
the  pancreas,  which  may  be  enlarged  and  its  structure  extensively  de- 
stroyed. The  abscess  may  communicate  with  peri  pancreatic  areas  of 
suppuration,  or  it  may  evacuate  either  into  various  organs  (duodenum, 
peritoneal  cavity)  or  externally.  Pylephlebitis  and  hepatic  abscess  or 
pyemia    may  follow.     A  disseminated    fat-necrosis  is  sometimes  found. 

]^tiologfy. — Most  of  the  cases  occur  in  adult  males  prior  to  fifty 
years  of  age.  Intemperance,  trauma,  and  dietetic  errors  are  among  the 
predisposing  causes.  Infection  takes  place  through  the  ducts,  or  from 
extension  of  neighboring  septic  foci.  Cholangitis,  due  to  gall-stones, 
may  extend  to  the  pancreatic  duct,  producing  suppurative  pancreatitis. 

Symptoins. — These  may  be  acute,  subacute,  or  chronic.  Acute 
1  Brit.  Med.  Jour.,  May  19,  1906. 


952  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cases  occur  less  frequently  than  the  latter.  Acute  suppurative  pancreatitis 
usually  begins  sudde7ili/,  with  severe  epigastric  pain,  vomiting^  hiccough, 
rhillif,  and  an  irrcguhn'  pi/einic  temperature,  progressive  ti/mpanites  (at 
times  limited  to  the  left  half  of  the  abdomen),  and  perhaps  acute  splenic 
enlargement.  Constipation  may  be  followed  later  by  diarrhea  (some- 
times fatty),  and  slight  jaundice  or  glycosuria  may  appear.  Brugsch 
and  Koenig  '  report  a  case  in  which  the  feces  showed  a  decided  diminu- 
tion in  the  absorption  of  fats.  Prostration  is  generally  great,  and  death 
may  set  in  within  one  week  from  the  onset. 

Not  seldom,  however,  the  course  is  prolonged  to  three  or  four  weeks, 
the  sym])tonis  ])ersisting  with  progressive  emaciation  and  final  exhaustion. 
Rujiture  of  the  circumscribed  peritoneal  abscess,  evidenced  by  copious 
dejections  in  which  the  sloughing  pancreas  has  been  found,  and  rapid 
diminution  in  the  size  of  the  abdomen,  may  take  place. 

Again,  the  onset  may  be  less  severe,  and  yet  the  case  progresses  steadily 
downward  with  little  pain,  slight  suppurative  fever,  anorexia,  anemia, 
and  gradually  increasing  debility,  lasting  for  months  or  even  a  year,  and 
ending  in  anasarca  and  death.      A  tender  swelling  is  often  p^dpable. 

Diagnosis. — A  limitation  of  the  pain  and  a  tender  mass  to  the  epi- 
gastrium, irregular  fever,  and  the  evidences  of  sepsis  (leukocytosis,  sup- 
purative type  of  fever)  are  probably  all  that  can  be  relied  upon  in  arriv- 
ing at  a  diagnosis.     In  fact,  the  diagnosis  is  hardly  made  antemortem. 

For  the  differentiation  from  circnnisrri/x'd  peritonitis,  perforative  gas- 
trie  ulcer,  and  obstruction  of  the  bowel,  vide  p.  951. 

The  progfnosis  is  unfavorable  and  the  treatment  surgical. 

GANGRENOUS   PANCREATITIS. 

Pathology. — The  pancreas  may  be  found  in  various  stages  of  necro- 
sis, depending  upon  the  duration  of  the  disease.  It  may  be  a  dark-brown, 
soft,  friable,  shreddy,  and  })utrid  mass,  witli  areas  of  hemorrhagic  infil- 
tration and  yellow  softening,  and  surrounded  by  a  dirty-greenish,  thin, 
purulent,  and  ichorous  fluid.  In  cases  lasting  for  from  three  to  seven 
weeks  the  gland  may  be  found  completely  sec^uestrated,  lying  in  the 
omental  cavity  as  a  small,  thin,  brownish-black,  shreddy,  and  foul-smell- 
ing detritus,  soaked  in  a  purulent  fluid.  The  peri-  and  para-pancreatic  tis- 
sues are  usually  involved  with  acute  peritonitis.  Splenic  thrombo-phlebitis 
is  commonly  associated,  and  disseminated  fat-necrosis  is  frequently  seen. 

etiology. — Males  and  females  are  equally  liable,  and  persons  past 
thirty  years  of  age  are  most  commonly  affected.  Hemorrhagic  pancrea- 
titis is  the  most  frequent  antecedent  of  the  gangrenous  form.  The  dis- 
ease may  result  also  from  perforative  ulceration  of  the  gastro-intestinal 
or  biliary  tract,  or  from  the  extension  of  a  catarrhal  inflammation  of 
those  tracts  into  the  pancreatic  duct  (Fitz).      Traumatism  is  a  cause. 

Symptoms. — These  are  essentially  the  same  as  those  of  hemorrhagic 
pancreatitis.  The  course  may  last  longer,  hoAvever,  so  that  death  may 
not  occur  until  the  second  or  fourth  week,  preceded  by  symptoms  of 
collapse.  The  necrotized  pancreas  may  be  discharged  per  rectum,  fol- 
lowed at  times  by  recovery.  An  epigastric  tumor  usually  appears. 
*  Berlin,  klin.  Work.,  December  25,  1905. 


CHRONIC  PANCREATITIS.  953 

CHRONIC  PANCREATITIS. 

Pathology. — The  pancreas  is  indurated  from  an  increased  develop- 
ment of  interstitial  fibrous  tissue.  The  glandular  substance  may  be 
nearly  obliterated,  and,  owing  to  pressure  upon  the  duct  of  VVirsung,  pan- 
creatic cysts  may  be  formed.  Interstitial  hemorrhages  and  peripancreatic 
adhesions  may  be  present.  In  chronic  suppurative  pancreatitis  tlujre  may 
either  be  small  circumscribed  abscesses  or  one  large  pyogenic  cyst. 

Ktiology. — Chronic  pancreatitis  may  be  due  to  several  attacks  of 
the  acute  disease  or  to  chronic  inflammation  of  the  pancreatic  duct,  often 
secondary  to  gastro-duodenal  catarrh.  Since  the  distribution  of  inflam- 
mation often  corresponds  to  that  of  the  lymphatics  the  infection  may  be 
lymphatic-  rather  than  duct-borne.  Persistent  inflammation  of  contiguous 
structures  may  excite  it.  The  majority  of  cases,  however,  arise  from  dis- 
ease of  the  hiliary  passages,  especially  cholelithiasis.  Chronic  alcoholism, 
syphilis,  tuberculosis,  and  trauma  probably  lead  to  this  disease.  The 
condition  may  be  limited  to  a  part  of  the  organ. 

Symptoms  and  Diagnosis. — The  symptoms  are  hardly  indicative 
of  the  disease.  The  symptoms  cf  chronic  gastric  catarrh,  frecjuently 
attended  by  diarrhea  and  large  stools,  may  compose  the  early  clinical 
picture.  Later  there  may  be  paroxysms  of  deep  epigastric  pain,  slight 
fever,  marked  anemia,  with  great  anxiety  and  faintness,  occurring  at 
irregular  intervals.  Some  ascites  and  jadndiee,  due  to  pressure,  may  be 
observed.  The  detection  oi  free  fat  in  the  dejections  (steatorrhea)  and 
undigested  muscle-fibers  (azotorrhea)  in  the  absence  of  diarrhea,  are  of 
great  semiotic  importance  in  the  interlobular  form.  It  has  been  sug- 
gested that  the  effect  of  the  administration  of  the  pancreatic  ferments 
may  be  taken  as  a  valuable  diagnostic  aid.  On  the  other  hand,  the  occur- 
rence of  glycosuria  without  pancreatic  disturbance  of  digestion  in  the  intes- 
tines (e.  ^.,  in  interacinar  pancreatitis)  and  lipuria  would  be  of  distinct  diag- 
nostic value.  The  presence  of  glycosuria  probably  indicates  an  extreme  de- 
gree of  destruction  of  this  gland  (Fitz).  Walko  regards  the  muscle-nucleus 
test  as  being  of  diagnostic  value.  Stadtmliller  advises  Sahli's  glutoid 
capsule  test.  Klieneberger^  advocates  the  casein  test  for  trypsin.^  The 
Mayos  found  81  per  cent,  of  their  cases  accompanied  by  gall-stones.  A 
cachectic  appearance  may  be  associated.  Circumscribed  resistance  on 
palpation  in  the  pancreatic  area  has  been  noted.  Evidences  of  hepatic 
cirrhosis  or  of  chronic  renal  and  arterial  disease  may  be  present. 

Differential  Diagnosis. — 

CHRONIC   PANCREATITIS.  PANCREATIC   CARCINOMA. 

History  of  acute  onset  in  some  cases.  More  gradual  onset  of  symptoms. 

Absence  of,  or  gradual  and  incomplete,  Evidence   of  complete   obstruction   of 

obstruction  to  flow  of  bile.  rapid  development. 

Distention  of  gall-bladder,  gradual  and  Gall-bladder  distention  more  rapid  and 

of  moderate  degree.  and  often  marked. 

Azotorrhea  less  common.  More  common. 

Enlarged  cervical  glands  absent.  Present  in  certain  proportion  of  cases. 

Emaciation  and  weakness  less  marked  Rapid,  becoming  pronounced,  and  char- 

and  of  slow  development.  acteristic  of  the  disease. 

The  prognosis  is  grave.     The  greater  portion  of  the  gland  may 

*  Medizinische  Klinik,  Berlin,  .January  16,  1910. 

2  For  the  methods  of  obtaining  the  pancreatic  secretion  from  the  duodenum,  see  special 
works  on  diagnosis. 


954  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

becomo  fiinctionless,  however,  as  the  result  of  progressive  fibrous  change, 
"svithout  iiiuch  impairment  of  the  health. 

Treatment. — The  major  treatment  is  dietetic.  Fat  and  starches,  since 
thev  demand  the  pancreatic  ferment  for  their  conversion,  are  to  be  inter- 
dicted, or,  if  permitted,  are  to  be.  so  far  as  may  be,  artificially  digested  by 
the  administration  of  ta})lets  of  panoreatin  and  soda  (gr.  v-x — 0.324-0.648) 
fifteen  or  twenty  minutes  after  meals.  Malt  diastase,  combined  with  alka- 
lies, should  also*  be  tried.  Minced  pancreas  promotes  the  digestion  of  fat 
(Abelmann).  Fey  reports  recovery  in  syphilis  of  the  pancreas  under  treat- 
ment with  mercurv  and  potassium  iodid.  The  surgical  treatment  consists  in 
the  relief  of  tension  by  opening  and  draining  the  gall-bladder  (Deaver). 


PANCREATIC  HEMORRHAGE. 

[Pancreatic  Apoplexy.) 

It  is  only  in  recent  years  that  this  fatal  affection  has  been  isolated  and 
defined,  and  mainly  througli  tlie  observations  of  Fitz,  Zenker,  and  Draper. 

Pathology. — The  pancreas  may  or  may  not  be  enlarged ;  it  may  also 
be  soft  and  friable.  The  hemorrhage  is  apt  to  occur  into  circumscribed 
areas  of  the  gland — e.  (/.,  its  head,  the  interstitial  and  subperitoneal  tis- 
sues. E.xtensive  hemorrhage  may  be  found  in  the  omentum,  transverse 
mesocolon,  in  the  retroperitoneal  fat-tissue,  and  adjacent  mucous  surfaces. 
Secondary  reactive  inflammations  and  necrosis  are  commonly  noted. 

Htioiogy. — Slight  hemorrhages  into  the  pancreas  may  be  found 
secondary  to  excessive  chronic  passive  congestion,  to  hemophilic  or  pur- 
puric cases,  and  acute  infective  diseases.  These  have,  however,  no  clin- 
ical import.  The  etiology  of  marked  hemorrhage  into  the  pancreas  is 
not  known.  Most  cases  have  occurred  in  males  (in  25  of  34  instances 
collected  by  the  writer),  and  in  adult  6r  advanced  middle  life  (the  age  in 
13  of  30  cases  having  been  over  forty-five  years).  In  the  majority  of 
cases  the  previous  health  was  apparently  good.  Traumatism  may  be  a 
direct  cause.  Again,  some  local  vascular  lesion  (e.  g.  necrosis),  superin- 
duced by  alcoholic  habits  or  a  rich  diet  in  an  atheromatous  person ;  or 
some  corrosive  action  of  the  pancreatic  secretion  may  operate  as  causes. 
It  has  been  ascribed  to  the  action  of  the  glycerin  set  free  during  the  fat- 
splitting  process  in  the  production  of  fat-necrosis.  There  was  a  history 
of  chronic  alcoholism  in  12  of  18  cases  (66.6  per  cent.).  Severe  sgmp- 
tomatic  pancreatic  hemorrhage  is  dependent  on  a  variety  of  primary  affec- 
tions of  the  gland — e.  g.,  acute  pancreatitis  and  carcinoma.^ 

Symptoms. — The  patient  may  have  been  in  apparently  robust  health 
when  the  attack  comes  on  with  sudden  and  startling  gravity.  The  most 
prominent  early  symptom  is  inteyise  epigasttrie  pain,  together  with  a  sense 
of  constriction.  Nausea  and  vomiting  may  be  associated,  and  the  latter 
is  usually  obstinate  and  gives  only  temporary  relief.  Ti/mpanites  may 
also  occur.  There  are  early  and  constant  general  evidences  of  internal 
bleeding — an  anxious  countenance,  restlessness,  depression,  yawning, 
pallor,  cold  sweat,  a  lowered  surface-temperature,  and  a  small,  rapid,  and 
weak  pulse.  Prostration  and  syncope  follow,  and  death  ends  the  case  in 
from  half  an  hour  to  twenty-four  hours.  Death  is  caused  by  reflex  par- 
alysis of  the  heart,  due  either  to  some  coincident  vascular  affection,  or  to 
pressure,  perhaps  upon  the  solar  plexus  and  semilunar  ganglion  (Zenker). 

^  "Pancreatic  Hemorrhage,"  Jour.  Amer.  Med.  Assoc,  Dec.  2,  1899,  by  the  writer. 


CARCINOMA    OF  THE  PANCREAS.  955 

My  table  includes  24  cases,  exclusive  of  16  reported  by  Fitz,  in  uhich 
the  condition  led  to  speedy  death  from  shock  or  from  compression  of  the 
solar  plexus.  Owing  to  its  "  idio[)athic  "  character  in  many  cases,  and 
quick  destruction  of  life,  pancreatic  hemorrhage  assumes  intense  medico- 
legal importance.     A  few  cases  reach  death  more  gradually. 

Diagnosis. — Given  the  suddenly  developed  signs  of  a  concealed  in- 
ternal hemorrhage,  with  pain  referred  distinctly  to  the  epigastrium,  and 
vomiting  and  rapid  collapse,  a  probable  diagnosis  may  be  made. 

Treatment. — This  consists  in  relieving  the  pain  and  in  overcoming 
the  collapse  by  free  stimulation.     An  exploratory  operation  is  advisable. 


CARCINOMA    OF    THE  PANCREAS. 

Path.olog'y. — Primary  carcinoma  is  the  more  frequent  variety.  It 
is  of  the  scirrhous  form  in  most  cases,  and  usually  involves  the  head  of 
the  gland,  which  may  attain  to  the  size  of  a  child's  head.  Not  rarely  the 
adjacent  organs  are  found  affected,  either  by  direct  or  metastatic  exten- 
sion of  the  disease,  or  by  the  pressure  of  the  growth ;  the  liver,  perito- 
neum, stomach,  portal  vessels,  bile-ducts,  and  aorta  may  thus  be  involved. 
The  pancreatic  duct  may  be  occluded,  so  as  to  form  retention-cysts.  In 
1000  autopsies  at  the  Johns  Hopkins  Hospital  there  were  5  cases  of 
secondary  carcinoma  of  the  pancreas.  Simple  extension  of  carcinoma 
of  the  stomach  or  of  the  duodenum  may  involve  the  pancreas. 

^tiologfy. — Men,  from  forty  to  sixty  years  -"■■f  age  are  most  liable  to 
carcinoma  of  the  pancreas,  though  it  has  been  met  with  in  the  neiv-born. 
Miralli^  has  collected  113  cases  of  primary  carcinoma  of  this  viscus  (Fitz). 

Sjntnptottis. — These  are  scarcely  ever  sufficient  to  indicate  the  dis- 
ease with  certainty.  There  are  usually  a  stubborn  dyspepsia,  a  pro- 
gressive loss  of  flesh  and  strength,  anemia,  and  a  dull,  or  sometimes 
neuralgic  J  epigastric  pain.  Nocturnal  paroxysms  of  pain  are  common,  and 
are  often  accompanied  by  signs  of  collapse.  In  some  cases  vomiting  and 
diarrhea  are  present.  The  stools  may  be  light  in  color  and  greasy,  and 
may  contain  blood.  There  may  also  be  found  an  abundance  of  undigested 
muscular  fibers  in  the  stools  in  the  absence  of  diarrhea  ;  this  is  an  incon- 
testable proof  of  faulty  pancreatic  digestion.  Steatorrhoea  is  not  com- 
monly present.  Among  the  pressure-effects  due  to  carcinoma  of  the 
head  of  the  pancreas  there  may  be  jaundice  (pressure  upon  the  com- 
mon duct),  which  persists  and  "  is  associated  with  an  enlargement  of 
the  liver  and  gall-bladder."  Ascites  may  appear  from  pressure  on 
the  portal  vein.  Chylous  ascites,  from  pressure  upon  the  thoracic 
duct,  has  been  observed.  The  inferior  vena  cava  may  be  com- 
pressed, causing  dropsy  of  the  lower  half  of  the  body ;  also  the  duode- 
num, followed  by  gastrectasis  or  by  signs  of  intestinal  obstruction. 
Carcinoma  of  the  tail  of  the  pancreas  may  be  a  cause  of  hydronephrosis 
of  the  left  kidney,  from  pressure  upon  the  ureter  (Fitz).  Marasjnus 
and  the  cachexia  develop  rapidly  in  pancreatic  carcinoma,  and  emaciation 
may  become  so  extreme  as  to  permit  of  a  satisfactory  palpation  of  the 
tumor,  which  occupies  a  position  near  the  median  line  above  the  umbili- 
cus. The  growth,  however,  is  palpable  in  about  one-third  of  the  cases 
only.  Grlycosuria  may  be  associated.  The  quantity  of  indican  in  the 
urine  is  diminished. 


956  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

Camiuidge'  dosi-ribcs  carefully  two  tests  for  glyeerose  in  the  urine, 
and  considers  these  as  reactions  A  and  B.  Both  of  these  reactions  are 
modifications  of  the  phenyl-hydrazin  test  for  glucose  in  the  urine,  which 
necessitates  that  the  urine  be  freed  of  any  glucose  before  applying  the 
test.  Cannuidge  claims  that  diseases  of  the  pancreas  are  recognized 
through  these  reactions.  Reaction  A  may  occur  with  the  urine  in  case 
active  tissue  changes  are  taking  place;  c.  </.,  in  cancer,  pneumonia,  etc. 
Treating  the  urine  with  perchlorid  of  mercury  prevents  reaction  A  in 
inflammatory  pancreatic  maladies,  but  has  no  ettect  upon  the  crystals 
that  form  in  case  of  pancreatic  cancer.  Should  no  crystals  form  by 
either  A  or  fi  method  the  ])ancreas  is  healthy  ;  crystals  formed  by  A 
and  not  by  li  method  suggest  active  inflammation  of  the  pancreas  ;  crvs- 
tals  formed  by  A,  due  to  acute  inflammation,  dissolve  in  one-half  minute 
in  33  per  cent,  of  sulphuric  acid ;  but  in  case  of  chronic  inflammation  it 
requires  two  minutes  to  dissolve  these  crystals:  Avhile  in  pancreatic 
cancer  the  crystals  obtained  by  A  and  B  methods  require  fully  three  to 
five  minutes  for  dissolution.  Sliould  the  organ  be  damaged,  as  a  result 
of  previous  disease,  these  crystals  dissolve  in  from  one  to  two  minutes. 
Crystals  forming  in  urines  from  persons  who  sufter  from  some  malady 
foreign  to  the  pancreas  were  found  to  dissolve  in  about  one  minute. 

Diagnosis. — Carcinoma  of  the  pancreas  is  probably  present  in  a 
given  case  in  which  there  are  rapid  and  progressive  emaciation,  deep- 
seated  epigastric  pain,  muscular  fibers  in  the  stools  witliout  diarrhea,  per- 
sistent jaundice,  enlargement  of  the  gall-bladder,  and  the  detection  of  a 
deeply-situated,  fixed,  and  firm  tumor  in  the  region  of  the  gland. 

Aortic  abdominal  aneurysm  may  be  mistaken  for  carcinoma  of  the 
pancreas  because  of  the  transmitted  aortic  pulsation.  ]>ut  in  aneurysm 
the  impulse  is  expansile  instead  of  two  and  fro,  while  the  cancerous 
cachexia  is  absent.  Chronic  pmicreatitis  is  distinguished  by  the  history 
of  gall-stone  attacks,  greater  tenderness,  and  the  less  marked  cachexia. 

It  is  sometimes  difficult  to  differentiate  a  malignant  tumor  of  the  pan- 
creas from  carcinoma  of  the  pylorus^  of  the  .stomach,  or  of  the  transverse 
colon  or  omentum;  the  following  points  will  help  in  the  differentiation 
of  the  former  two  : 

Carcinoma  of  the  Pancreas.  Carcinoma  of  tue  Pvlorus. 

The  tumor  is  deep-seated  and  fixed  ;  later  The  tumor  is  more  freely  movable,  and 

it  becomes  sliijhtly  movable.     It  is  not  is  usually  associated  with  dilatation  of 

associated  with  trastric  dilatation.  the  stomach. 

Symptoms  of  chronic  dyspepsia  appear.  There  are  more  marked  gastric  symptoms. 

The  vomitus  is  bilious:   rarely  contains  There  is  "  coflee-ground  "  vomitus;  it  is 

blood.  seldom  bilious. 

HCl  is  present,  while  there  is  an  absence  HCl  is  absent  from  the  gastric  contents ; 

of  lactic  acid.  lactic  acid  is  present. 

The   stools   contain    undigested    muscle-  Usually  the  bowels  are  constipated,  with 

fibers  and  sometimes  fiit.     There  is  an  occasional   diarrhea.      The   stools    are 

absence  of  pancreatic  secretions.     The  black  after  a  hemorrhage.     The  urine 

urine  may  contain  sugar.  does  not  contain  sugar. 

There   is   usually  jaundice;    sometimes  Usually  there  is  no  jaundice  or  ascites, 
ascites  is  present. 

Inflation  of  the  stomach  shows  the  absence  Inflation  shows  the  presence  of  a  pyloric 

of  a  pyloric  growth.  tumor. 

The  course  is  more  acute.     Death  may  The  course  is  more  chronic,  and  second- 
occur  within  a  few  weeks  or  months.  ary  growths  often  appear  in  the  liver. 
»  The  Lanci'l,  March  19,  1004,  p.  782. 


PANCREATIC  CYST.  ()r)7 

Neoplastic  growths  of  the  transverse  colon  are  also  more  often  super- 
ficial, and  are  movable  and  definable  witli  the  palpating  fingers.  There 
are  symptoms  of  intestinal  obstruction  here,  and  infiation  of  the  colon 
will  show  the  relation  of  the  tumor  to  the  gut.  In  carcinoma  of  the 
colon  the  urine  generally  contains  an  increased  amount  of  indican. 

A  discussion  of  the  prognosis  and  treatment  is  unnecessary.  Rob- 
son  records  14  cases  in  which  the  portion  of  the  gland  affected  was  re- 
moved with  10  deaths. 

Other  Tumors  of  the  Pancreas. — Exceptionally,  sarcoma, 
adenoma,  and  lymphoma  occur.  Sarcoma  is  rarely  primary.  Secondary 
nodules  are  more  common.  According  to  Korte,  of  10  cases  of  tumor  of 
the  pancreas  operated  upon  of  late  years,  6  recovered. 


PANCREATIC  CYST. 

Pathology. — ^Pancreatic  cysts  may  be  single  or  multiple,  and  large 
or  small.  When  large  they  develop  chiefly  to  the  left  of  the  median 
line.  Single  cysts  may  grow  to  an  enormous  size,  containing  as  much 
as  several  gallons  of  fluid.  The  contents  may  at  first  consist  simply  of 
retained  pancreatic  juice,  and  usually  the  liquid  is  dark  gray  or  dark 
brown,  alkaline,  and  hemorrhagic  or  albuminous.  A  hematoma  may  be 
converted  into  a  serous  cyst.  The  specific  gravity  is  from  1010  to  1024. 
Atrophy  of  the  pancreas  may  ensue.  Examined  microscopically,  the 
contents  reveal  leukocytes,  red  blood-corpuscles,  oil-drops,  fatty  degen- 
eration of  the  epithelium,  and  crystals  of  fatty  acids  and  cholesterin. 

Htiology. — Cysts  of  the  pancreas  may  be  due  to  occlusion  of  the 
pancreatic  duct  or  its  branches  by  compression  from  within  or  without 
the  gland.  They  may  also  be  due  to  tumors,  to  impaction  of  biliary  or 
pancreatic  calculi,  to  cirrhosis  or  angular  displacements  of  the  gland,  or 
to  the  obstructive  swelling  from  extension  of  catarrh  of  the  bowel 
(Krecke).  Of  121  cases  collected  by  Korte,  33  were  traced  to  trauma- 
tism. Lloyd  suggests  that  the  cysts  that  follow  local  injury  are  instances 
of  encysted  peritonitis  involving  the  lesser  omentum  or  that  portion  cov- 
ering the  pancreas  {pseudocysts).  Cysts  of  the  pancreas  usually  occur 
in  adults — in  QQ  of  116  cases  in  the  third  and  fourth  decades  of  life 
(Korte).      Railton,  however,  met  a  case  at  six  months  of  age. 

Symptoms. — Pain  may  be  absent,  or  it  may  occur  as  colicky 
paroxysms,  referred  either  to  the  epigastrium,  the  left  hypochondrium, 
or  even  the  left  shoulder.  Jaundice  and  ascites  are  present  in  large 
tumors.  Vomiting.,  constipation,  or  fatty  diarrhea  (rarely),  with  undi- 
gested proteids  in  the  dejecta,  or  clay-colored,  pasty,  and  off"ensive 
stools,  may  be  present.  Albumin  and  sugar  may  be  found  in  the  urine. 
Emaciation  is  not  infrequent.  Intestinal  hemorrhage  may  occur  and 
recur.  A  late  and  constant  symptom  is  a  feeling  of  pressure  in  the 
epigastrium.  Rarely  there  is  increased  salivary  secretion  (pancreatic 
salivation).  Occasionally  all  subjective  symptoms  are  absent,  and  these 
cysts  may  temporarily  disappear. 

On  physical  examination  a  smooth,  elastic,  lobulated  tumor  is  discor- 


958  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ered  in  the  region  of  the  pancreas  if  the  gro^vth  is  moderate  in  size. 
Sometimes  a  very  large  cyst  develops  in  a  remarkably  short  space  of 
time — I.  e.  in  a  few  weeks.  When  very  large  in  size  fluctuation  is  easily 
elicited.  It  may  be  slightly  movable  in  the  grasp  and  during  inspiration. 
It  usually  presents  between  the  stomach  and  transverse  colon  an  area  of 
dulness,  and  unless  the  tumor  be  of  large  size  it  is  surrounded  by  tym- 
panitic resonance  of  deeper  timbre  above  than  below.  Auscultation  may 
reveal  a  murmur  caused  by  compression  of  the  aorta.  When  the  cyst 
attains  enormous  dimensions  the  usual  mechanical  pressure-effects  are 
produced.  Kiirte  points  out  that  cysts  without  any  inflammatory  or 
traumatic  etiology  may  exist  for  many  years  or  even  decades. 

Diagnosis. — The  diagnosis  rests  on  the  typical  physical  signs — the 
discovery  .ui  j)alpation  of  a  smooth,  elastic,  lobulated,  or  rounded  tumor 
that  is  slightly  movable,  and  on  percussion  of  a  dull  area  that  is  not  con- 
tinuous above  with  the  spleen-  and  liver-dulness.  Resort  has  been  had 
to  filling  the  stomach  Avith  air  and  the  colon  with  water  (after  purging), 
and  tlius  proving  by  palpation  the  deep-seated  situation  (behind  the 
stomach  and  omentum)  of  the  tumor.  If  pancreatic  fluid  be  obtained 
from  the  supposed  cysts,  it  will  digest  albumins  and  emulsify  fats.  This 
test  is  not  wholly  reliable,  however.  A  pancreatic  cyst  may  be  mistaken 
for  an  ovarian  cyst,  for  hydatid  cyst  of  the  left  lobe  of  the  liver,  of  the 
mesentery,  renal  tumors  (cysts),  dropsy  of  the  gall-bladder,  and  retro- 
peritoneal  sarcoma  [Lohsteins  cancer).  The  diff'erentiation  must  be 
made  by  a  careful  study  of  all  the  points  in  the  case- 

The  progfnosis  is  good  under  proper  treatment — incision  and  drain- 
age.    Of  31  reported  cases  thus  treated,  only  2  proved  fatal. 


PANCREATIC  CALCULI. 

Pathology. — These  are  grayish-white,  rounded  concretions,  consist- 
ing principally  of  calcium  carbonate.  The  calculi  may  be  as  fine  as 
dust  or  as  large  as  an  almond.  Among  their  pathologic  eff'ects  are  fis- 
tulous communications  Avith  the  colon,  peritoneal  cavity,  and  stomach ; 
also  cystic  dilatations  of  the  duct  and  abscess-formation.  Atrophy  of  the 
organ  and  carcinoma  due  to  irritation  of  the  stones  may  be  associated. 

Htiology. — Pancreatic  calculi  presuppose  a  catarrhal  condition  of 
the  pancreatic  duct,  Avith  retention  or  anomalies  of  the  pancreatic  secre- 
tion, or  some  form  of  obstruction  of  the  duct.  The  condition  is  rare, 
and,  unlike  gall-stones,  more  common  in  males. 

The  symptoms  are  developed  when,  during  the  passage  of  the  stones 
along  the  duct  to  the  duodenum,  the  latter  excite  inflammation.  In  con- 
sequence, paroxysms  of  pain  occur  (pancreatic  colic)  that  are  usually 
attributed  to  gall-stones,  and  we  are  often  unable  to  differentiate  the  tAvo 
conditions.  The  radiation  of  pain  along  the  lower  left  costal  border  to 
the  back  rather  than  to  the  right  side,  and  possibly  the  detection  of  free 
fat  in  the  stools  or  (jlycosuria.  may  aid  markedly  in  the  diagnosis. 

The  finding  of  characteristic  calculi  in  the  stools  is  entirely  confirm- 
atory. MiniiJch  has  reported  a  case  in  Avliich  the  calculi  Avere  found  in 
the  stools.      Jaundice  rarely  appears  in  pancreatic  lithiasis. 

The  prognosis  is  mainly  dependent  upon  the  associated  lesions  and 
upon  certain  sequelre — pancreatic  cysts  and  chronic  pancreatitis. 


ACUTE  PERITONITIS.  959 

The  indications  for  treatment  do  not  differ  materially  from  those  of 
hepatic  colic.     Surgical  intervention  should  be  considered. 


XII.  DISEASES   OF  THE   PERITONEUM. 

ACUTE  PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneum.  The  con- 
dition may  be  primary  or  secondary.  Clinically,  two  varieties — f^eneral 
and  circumscribed — are  recognized,  while,  pathologically,  the  disease  is 
classified  according  to  the  nature  of  the  exudate. 

Anatomic  and  Physiologic  Peculiarities. — The  surface  area  of  the 
peritoneum  is  quite  extensive,  being  almost  equal  to  that  of  the  skin. 
Fluids  of  all  sorts  are  rapidly  absorbed  by  the  peritoneum,  and  thus,  if 
they  be  poisonous,  constitutional  infection  is  speedily  propagated. 

Pathology  — Upon  opening  the  abdomen  in  acute  generalized  peri- 
tonitis vascular  injection  both  of  the  serous  covering  of  the  intestine 
and  of  the  parietal  layer  is  observed.  Even  in  the  most  recent  cases 
the  coils  of  intestine  may  be  feebly  glued  together  by  lymph,  w-hile  in 
those  of  longer  duration  the  adhesions  are  quite  firm.  As  in  the  analo- 
gous inflammation  of  the  pleurae  or  pericardium,  we  distinguish  the  fol- 
loAving  forms  pathologically :  (a)  A  plastic  or  fibrinous.,  in  which  there 
may  be  also  a  small  amount  of  serum  present,  {b)  Sero -fibrinous  (inflam- 
matory ascites),  chiefly  characterized  by  considerable  sero-fibrinous  fluid; 
additionally,  the  coagulated  fibrin  forms  a  covering  for  the  parietal  and 
visceral  layers  of  the  peritoneum,  (c)  Purulent  (most  frequent).  The 
amount  of  inflammatory  exudate  varies  greatly,  and  is  frequently  enor- 
mous, exceeding  30  liters  (quarts).  Putrefactive  decomposition  of  the 
pus  may  occur,  especially  in  cases  due  to  gangrene  of  the  gut  or  to 
puerperal  peritonitis  (violent  forms),  giving  rise  to  a  thin  fluid  that  is 
grayish-green  in  color,  is  sometimes  distinctly  sanious,  and  ill-smelling. 
Off"ensive  gases  are  present  with  relative  frequency.  These  may  come 
from  the  intestinal  canal,  following  the  track  of  perforations ;  or  they 
may  be  due  to  decomposition  of  the  purulent  exudate,  {cl)  Hemorrliagic . 
This  form  is  common  in  cases  that  are  of  a  carcinomatous  or  tubercnlous 
nature,  and  in  subjects  whose  vitality  has  been  lowered  by  various  pri- 
mary affections.     It  may  also  be  of  traumatic  origin. 

Changes  in  the  Intestines. — The  effect  of  acute  peritonitis  is  to 
thicken  the  coats  by  inflammatory  edema ;  soon  the  musculature  is 
paralyzed.  An  associated  catarrh  of  the  mucosa  of  the  intestine  is 
sometimes  observed. 

The  different  pathologic  varieties  above  described  may  be  limited  to 
definite  portions  of  the  peritoneal  sac,  when  they  are  termed  "•  encapsu- 
lated "  or  localized  acute  peritonitis  (vide  supra).  In  localized  purulent 
peritonitis  further  extension  of  the  process  is  arrested  by  the  rapid  for- 
mation of  circumscribed  adhesions  due  to  the  exudation  of  lymph  ;  there 
are  also  undoubted  instances  of  circumscribed,  aplastic  peritoneal  ab- 
scesses. The  milder  forms  of  limited  plastic  and  sero-fibrinous  perito- 
nitis pursue  a  slower  course  than  the  purulent  variety,  and  commonly 
lead  to  the  development  of  firm  adhesions  (adhesive  peritonitis).  Since 
the  histologic  changes  in  acute  peritonitis  do  not  differ  from  those  ob- 


DGO  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

served  in  other  inflammations  of  serous  membranes,  the  reader  is  referred 
to  tlio  section  on  ]*leurisy  (p.  580)  for  their  oonsidcration. 

Ktiology. —  riie  irritants  causin<T  acute  peritonitis  may  b(. — ((/)  Or- 
ganized inflammatory  agents  [hacteriologic  irritants).  These  may  be  spe- 
cific or  non-specitic.  Aniono;  the  non-specific  agents  are  the  pyogenic  bac- 
teria. Grawitz  has  shown  that  the  hitter  can  only  cause  peritonitis  under 
certain  conditions:  they  excite  the  disease  when  injected  into  the  perito- 
neal cavity  or  wiien  poured  out  from  the  diseased  or  injured  membrane 
more  rapidly  than  the  peritoneal  tissue  can  dispose  of  them  ;  also  when  the 
epithelial  layer  has  from  any  cause  been  removed.  Absorption  may  be 
interfered  with,  while  the  pyogenic  micrococci  continue  to  enter  from  the 
bowel  or  other  viscera  in  great  numbers,  rnfoitunately,  the  clinical 
practitioner  often  meets  with  cases  of  peritonitis  in  which  tiiese  pyogenic 
organisms  are  the  only  positive  agents.  These  essential  conditions  obtain 
■when  the  membrane  is  wounded  by  the  perforation  of  gastric  and  intesti- 
nal ulcers,  and  also  in  perforation  of  the  gall-bladder,  in  rupture  of  the 
liver,  kidneys,  and  spleen,  when  the  latter  are  the  seat  of  abscesses,  and, 
with  uncommon  fre(juency,  in  appendicitides,  in  purulent  intiammation  of 
the  ovaries  and  of  the  Fallopian  tubes.  ''  There  are  instances  in  which 
peritonitis  has  followed  rupture  of  an  apparently  normal  Graafian  follicle  " 
(Osier).  These  perforative  forms  of  peritonitis  are  at  the  same  time  the 
most  serious  and  the  most  important.  "  Death  may  result  from  the  in- 
jection into  the  peritoneal  sac  of  putrid  li(iuid  if  the  dose  be  large 
enough  ;  but  it  is  practically  the  same  whether  the  fluid  is  injected  into 
the  blood-stream  at  once  or  allowed  to  find  its  way  into  the  peritoneal 
cavity,  and  the  result  follows  nearly  as  quickly  in  the  one  case  as  in 
the  other"  (Moullin).  The  rapid  absorption  of  li(juid  substances  gives 
full  opportunity  for  the  phagocytic  action  of  the  white  blood-corpuscles. 

Among  specific  organic  irritants  the  fuhcrcle  bacillus  deserves  especial 
mention,  though,  as  before  intimated,  a  discussion  of  its  characteristics 
is  not  in  place  here.  The  streptococcus  pyogenes  is  probably  responsible 
for  the  most  violent  forms  of  peritonitis  {e.  g.  those  occurring  in  puerperal 
sepsis  and  post-operative  varieties).  The  staphjlococcus  pyogenes  aureus 
(or  albus)  has  also  been  found  in  such  instances. 

The  bacterium  coli  commune  (always  present  in  the  intestinal  tract)  is 
frequently  the  leading  factor  in  peritonitis  of  intestinal  origin,  and 
usually  in  association.  The  streptococcus  is  often  present  also  in  these 
cases.  In  12  cases  of  primary  peritonitis,  11  were  instances  of  mono- 
infection ;  and  in  operations  upon  the  peritoneum  (not  involving  the  in- 
testine), 25  of  33  cases  were  mono-infections,  the  staphylococcus  aureus 
being  present  alone  in  12  and  the  streptococcus  in  5  (Flexner).  Occa- 
sionally other  organisms,  as  the  pneumococcus,  the  bacillus  of  Fried- 
lander.,  or  the  bacillus  pyocynneus.,  typhosus,  and  proteus.,  the  gonococeus., 
the  aerogenes  capsulatus,  and  the  antlira.r  bacillus,  have  been  found. 
Multi-infection  is  quite  common.  The  hacteriologic  classification  of  peri- 
tonitis "would  be  desirable  from  the  standpoint  of  treatment  (vide  infra), 
but  it  cannot  be  applied  clinically. 

(b)  Chemical  Irritants. — These  are  rather  numerous  and  varied,  though 
all  produce  their  eff'ects  in  one  of  two  ways.  First,  the  irritant  acts 
upon  the  membrane,  exciting  an  exudation  of  lymph.  Here  constitu- 
tional intoxication  is  secondary.  Secondly,  the  chemical  irritant  may  be 
quickly  absorbed,  and  produce  systemic  intoxication  immediately  (rare). 


ACUTE  PEBTTONITIS.  961 

((?)  Mechanical  irritants,  as,  for  example,  a  hernia,  which  may  produce 
a  localized  peritonitis. 

{d)  Peritonitis  may  be  due  to  a  direct  extension  of  infective  processes 
from  the  intestinal  tract  or  other  adjacent  organs  {;econdary  jjeritonitiH). 
The  bacteria  often  penetrate  the  intestinal  wall  and  gain  the  peritoneum 
by  way  of  the  lymph-channels.  The  disease  is  often  secondary  to 
pleurisy,  the  irritants  passing  through  the  diaphragm  along  the  course 
of  the  lymphatics.  Peritonitis  may  be  secondary  to  chronic  Bright's  dis- 
ease, gout,  and  arterio-sclerosis ;  in  such  cases  the  special  irritants  prob- 
ably reach  the  membraine  through  the  general  circulation. 

(e)  The  disease  is  very  rarely  primary  (idiojjatldc).  It  has  Ijccn 
attributed  to  exposure  to  cold  or  wet  {rheumatic  peritonitis).  ^Pheso  so- 
called  idiopathic  cases  are  probably  instances  of  cryptogenetic  infection. 

Clinical  History. — The  symptoms  are  both  of  a  local  and  a  general 
nature.  In  sthenic  cases  of  perforative  peritonitis  they  occur  simul- 
taneously with  great  severity  and  suddenness.  On  the  other  hand,  in 
asthenic  cases,  such  as  occur  frequently  in  those  already  afflicted  with 
some  serious  disease  that  is  apt  to  result  in  perforation  (for  example, 
typhoid  fever),  both  the  local  and  constitutional  symptoms  are  more  or 
less  overshadowed  by  the  disturbances  due  to  the  primary  affection.  Again, 
circumscribed  abscesses  of  the  peritoneum  often  lead  to  diffuse  suppura- 
tive peritonitis,  and  the  change  may  take  place  so  insidiously  as  to  defy 
detection.  These  anomalies  from  the  typical  onset  and  course  of  the 
disease  are  by  no  means  exceptional,  and  should  ever  be  distinctly  borne 
in  mind  by  the  physician. 

Local  Symptoms. — Among  these,  pain  is  the  chief.  The  seat  of 
greatest  intensity  of  the  initial  pain  corresponds,  in  most  instances,  with 
its  point  of  origin.  Hence  the  character  of  the  causal  disease  is  often 
betraj^ed  by  the  location  of  the  chief  pain.  For  instance,  if  this  ap- 
pears in  the  region  of  the  stomach  and  is  referred  to  the  back  or 
shoulders,  we  would  think  of  gastric  ulcer ;  if  in  the  ileo-cecal  region,  of 
appendicular  disease  ;  and  so  on.  It  follows  that  quite  commonly  the 
severest  pain  is  in  the  lower  half  of  the  abdomen.  It  is  almost  constant, 
increases  in  severity,  and  finally  becomes  general  and  excruciating ;  it 
is  also  much  increased  by  deep  respirations,  by  pressure,  and  by  bodily 
movements.  It  remits,  but  does  not  intermit,  though  it  may  be  slight 
in  asthenic  (secondary)  cases.  Here  the  patient  is  excessively  weak, 
while  his  sensibilities  are  greatly  blunted  by  the  primary  infection. 
Gastro-intestinal  symptoms  are  prominent,  more  particularly  vomiting, 
which  occurs  early  and  is  apt  to  recur  with  comparative  frequency.  It 
may  follow  the  taking  of  food,  though,  in  my  experience,  it  has  more 
commonly  taken  place  spontaneously ;  the  vomitus  then  consists  of  a 
watery  liquid  greenish  in  color  and  containing  mucus.  In  rare  instances 
it  is  a  dark-bi-own  liquid.  Vomiting  may  sometimes  be  absent,  however, 
owing  to  the  presence  of  marked  asthenia  or  coma.  Eructations  and, 
later,  hiccup,  ai-e  common,  and  constipation  is  usually  present  and  may 
become  exceedingly  obstinate.  On  the  other  hand,  there  may  either  be 
diarrhea  throughout  the  disease,  or  this  symptom  may  precede  the  con- 
stipation. It  is  to  be  ascribed  to  an  increased  peristalsis  due  to  intestinal 
catarrh.  Constipation  is  due  chiefly  to  paralysis  of  the  musculature  of 
the  intestine.  The  apex  of  the  heart  is  elevated ;  the  tongue  at  first  is 
furred  and  moist,  and  later  it  is  dry,  brown,  and  often  fissured. 

61 


962  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Constitutional  Symptoms. — At  the  onset  the  patient  in  sthenic  cases 
is  seized  witli  a  rigor  that  may  he  repeated.  The  shock  sustained  hy 
the  nervous  system  in  acute  peritonitis  is  most  intense ;  the  temperature 
rises  immediately,  thougli  it  does  not,  as  a  rule,  attain  to  a  high  level, 
and  it  fre(|ueiitly  presents  a  curve  more  or  less  characteristic  of  suppu- 
ration. The  rectal  temperature  is  often  relatively  liigh  :  the  respira- 
tions are  shallow  (costal)  and  much  accelerated,  ranging  from  thirty  to 
forty  per  minute.  We  have,  as  factors  to  account  for  this  increased 
frequency,  (a)  a  crowding  upward  of  tlie  diaphragm,  (h)  the  greatly 
enfeebled  heart,  and  (c)  the  pain  occasioned  by  throwing  the  diaphragm 
into  action.  The  heart  becomes  weak,  the  pulse-rate  at  first,  however, 
ranging  from  100  to  130,  with  a  rise  in  the  blood-pressure.  The  pulse 
toward  the  close  becomes  exceedingly  frequent  (130  to  150  beats  per 
minute)  and  is  almost  imperceptible.  Other  evidences  of  more  or  less 
marked  circiihitori/  collapse  soon  manifest  themselves.  The  patient  wears 
an  anxious  facial  expression,  the  eyes  are  sunken,  the  features  pinched  and 
cool,  the  lips  cyanotic,  and  the  extremities  are  likewise  cold  and  somewhat 
livid.  The  patient  invariably  assumes  the  supi7ie  position,  Avith  the  lower 
extremities  drawn  up,  so  as  to  lessen  the  tension  of  the  abdominal  muscles, 
and  thus  to  secure  the  greatest  possible  comfort.  The  urine  is  scanty  in 
amount,  high-colored,  and  contains  indican.  There  may  be  a  retention 
of  urine ;  though  oftener,  perhaps,  micturition  is  more  frequent  than  in 
health.  Leukocytosis  occurs,  if  we  accept  the  fulminating  cases  in  which 
leukopenia  maybe  found.  Marked  nervous  sy7nptoms  do  not  appear; 
indeed,  the  mind  usually  remains  quite  clear  to  the  close.  Moderate 
delirium,  however,  which  sometimes  gives  way  to  mild  stupor,  is  met 
with  occasionally.  In  the  asthenic  form  of  acute  peritonitis  the  consti- 
tutional features  differ  from  those  described  above.  The  temperature  is 
usually  subnormal  (except  in  the  rectum),  the  pulse  is  exceedingly  feeble 
and  running,  and  the  signs  of  collapse  are  well  marked  from  the  onset. 

Physical  Signs. — Inspection  reveals  the  gradually  increasing  abdom- 
inal distention,  that  frequently  becomes  excessive  if  the  intestinal  walls 
are  more  or  less  completely  paralyzed.  Often  the  amount  of  effusion 
soon  becomes  large,  when  the  abdomen  appears  widened.  The  degree 
of  distention  bears  a  definite  relation  to  the  severity  of  the  inflammatory 
process,  and  is  in  inverse  ratio  to  the  development  of  the  abdominal 
muscles.  Thus,  when  the  latter  are  poorly  developed  or  greatly  relaxed 
the  expansion  is  enormous.  On  the  other  hand,  when  they  are  strong 
the  muscles  are  apt  to  be  quite  tense,  permitting  of  a  relatively  slight 
enlargement ;  the  abdomen  may  even  show  a  small  concavity,  in  which 
case  the  walls  are  of  a  board-like  hardness.  The  cardiac  apex-beat  is 
displaced  upward  and  outward,  occupying  the  fourth  interspace. 

Palpation  elicits  extreme  tenderness,  more  particularly  in  the  vicinity 
of  the  umbilicus.  Rigidity  of  the  abdominal  wall  is  the  most  import- 
ant symptom  in  perforative  peritonitis  (J.  C.  Wilson).  In  not  a  few 
instances  of  acute  peritonitis  have  I  been  able  to  detect  a  distinct  fric- 
tion-rub. Percussion  gives  at  first  an  exaggerated  tympanitic  note. 
There  is  often  an  absence  of  liver-dulness  in  the  mammary  line,  and 
rarely  also  it  is  absent  in  the  mid-axillary  line.  In  pneumo-peritoneum, 
resulting  from  perforation  of  the  gut  or  stomach,  we  often  meet  with  an 
absence  of   liver-dulness,  especially  when  a  large  purulent  effusion  co- 


LOCALIZED    OR  PARTIAL  PERITONITIS.  9^3 

exists.  Again,  a  great  diminution  in,  or  even  the  total  efTacernont  of, 
the  dull  area  may  be  caused  by  coils  of  intestine  forcing  their  way  up 
between  the  anterior  surface  of  the  organ  and  the  abdominal  wall.  When 
air  is  present  within  the  abdominal  cavity  and  the  patient  lies  upon  his 
right  side,  splenic  dulness  disappears  from  displacement  by  the  air.  The 
lower  level  of  cardiac  dulness  is  as  high  as  the  fifth  rib. 

By  means  of  percussion,  sooner  or  later,  fluid  effusions  are  usually 
detectable  in  sthenic  cases.  On  the  other  hand,  there  may  be  in  mark- 
edly asthenic  cases  an  amount  of  liquid  exudation  present  that  is  often 
too  small  to  admit  of  detection.  When  the  effusion  is  considerable 
in  quantity,  there  is  percussion-dulness  over  the  most  dependent  parts ; 
when  tympanitic  distention  is  excessive,  however,  even  a  copious  effu- 
sion may  be  so  effectually  hidden  as  to  elude  discovery  in  this  way. 
I  have  elsewhere  reported  one  such  instance.'  When  the  decubitus  can 
be  altered,  the  line  of  dulness  will  be  found  to  be  movable,  but  the  degree 
of  mobility  varies  exceedingly,  depending  upon  the  extent  of  the  peri- 
toneal adhesions  present.  The  effused  material  is  partly  contained  in 
pouches,  giving  rise  to  areas  of  circumscribed  dulness. 

Course  and  Prognosis. — Asthenic  forms,  with  rapid  pulse,  leuko- 
penia, and  persistent  low  temperature,  are  perhaps  invariably  fatal. 
Though  the  local  signs  are  not  marked,  the  characteristic  evidences  of 
collapse  or  of  septicemia  appear.  The  duration  in  sthenic  cases  rarely 
exceeds  one  or  two  days  ;  in  asthenic  cases  it  is  longer,  lasting  from  four 
or  five  to  six  or  eight  days.  Death  sometimes  occurs  quite  suddenly, 
owing  to  cardiac  exhaustion  or  primary  shock.  The  clinical  peculiarities 
and  the  course  are  greatly  influenced  by  the  etiology — e.  g.,  cases  due  to 
Streptococcus  pyogenes,  Bacillus  pyocyaneus,  and  Bacillus  eoli  are  ex- 
tremely fatal,  while  those  due  to  the  gonococcus  and  pneumococcus  are 
more  benign.  Acute  generalized  peritonitis  arising  from  perforative 
appendicitis,  puerperal  sepsis,  or  from  external  injuries  is  usually  of  a 
violent  form  and  ends  fatally,  unless  subjected  to  early  operation.  Per- 
foration of  a  gastric  or  duodenal  ulcer  gives  a  better  prognosis,  since  the 
number  of  colon  bacilli  steadily  diminishes  from  the  ileocecal  valve  to 
the  stomach  (Gushing  and  Livingood).  When  the  disease  is  traceable  to 
rheumatism  or  exposure,  recovery  may  take  place.  A  case  of  the  sort 
occurred  in  my  own  practice  in  which  acute  serofibrinous  peritonitis  with 
considerable  effusion  was  associated. 

Peritonitis  in  Children. — Syphilitic  peritonitis  may  be  congenital, 
and  peritonitis  caused  by  an  inflamed  cord  may  be  met  in  the  newborn. 
In  children  the  common  causes  are  trauma  and  appendicitis. 

The  symptoms  differ  from  those  presented  in  the  adult.  However  severe 
the  pain,  the  child  merely  utters  a  short  cry  or  whine.  Constipation  and  vom- 
iting are  less  conspicuous  features.  Meteorism  is  pronounced  and  fever  high. 
Convulsions  not  rarely  occur.  The  condition  is  extremely  grave  in  young 
children. 

LOCALIZED    OR  PARTIAL   PERITONITIS. 
(Circumscribed  Peritonitis;    Visceral  Peritonitis.) 

This  is  a  localized  form  of  inflammation  of  the  peritoneum  that  is 
coextensive  only  with  the  serous  covering  of  single  organs,  and  involves 
a  limited  portion  of  the  membrane.     Hence,  to  the  various  forms  of  cir- 
^  International  Medical  Clinics,  vol.  iii.,  second  series,  p.  82. 


964  DISKASES  OF  TUK  DIGESTIVE  SYSTEM. 

cumscribcd  periionitis  such  terms  as  perihepatitis,  perisplenitis,  peri- 
nephritis are  applied.  The  comlition  is  found  in  its  most  important 
form  in  appendicitis,  but  the  jtoints  that  are  characteristic  of  localiza- 
tion in  this  disease  have  been  mentioned  elsewhere  {vide  Appendicitis,  p. 
8(33).      Localized  peritonitis  may  also  be  caused  by  carcinoma. 

Pjlo-pneniiiotJiorax  xubplirenims  is  the  term  applied  to  a  circum- 
scribed peritoneal  abscess  containing  air,  situated  between  the  liver  and- 
diajihrafrm.  The  condition  is  described  under  the  heading  Acute  Peri- 
hepatitis (p.  919). 

Local  pelvic  peritonitis  (perimetritis)  is  the  most  fre(iuent  variety, 
and  is  secondary,  as  a  rule,  to  inihimmation  about  the  uterus.  Fallopian 
tubes,  and  ovaries.  The  leading  causes  are  tuberculosis,  puerperal  septi- 
cemia, and  gonorrhea.  F.  Billings  points  out  that  when  abdominal 
rigidity  is  absent  in  this  form  rectal  examination  will  disclose  rigidity 
of  tlie  pelvic  muscles. 

Symptoms. — The  local  clinical  features  do  not  differ  from  those 
described  under  the  diftuse  form,  but  their  area  of  distribution  is 
more  or  less  strictly  limited  to  definite  regions.  By  e\'\Q\im^^i\\Q physical 
signs  Avith  care  fluid  collections  are  sometimes  demonstrable.  The 
constitutional  symptoms  are  likewise  similar  in  character,  though  less 
marked  than  those  belonging  to  the  diffuse  variety.  There  may  be 
rigors,  and  pyemic  symptoms  appear,  together  with  the  temperature- 
curve  peculiar  to  this  condition.  The  danger  of  involvement  of  the 
general  peritoneal  cavity  as  the  result  either  of  rupture  or  of  an  exten- 
sion of  septic  inflammation  is  a  constant  menace.  When  the  peritonitis 
remains  localized  these  cases  may  pursue  a  subacute  or  even  a  chronic 
course,  though  grave  constitutional  disturbance  finally  develops. 

Diagnosis. — In  attempting  to  diagnosticate  acute  generalized  peri- 
tonitis it  is  of  the  utmost  importance  to  keep  in  remembrance  the  sthenic 
and  asthenic  forms  of  the  afl'ection.  The  character  and  gravity  of  the 
symptoms  are  such  as  to  render  the  diagnosis  of  the  sthenic  form  entirely 
easy.  Especially  valuable  local  features  are  the  constant  pain,  the 
marked  tympany,  the  excessive  tenderness  under  pressure,  and  the 
vomiting  at  intervals  of  a  greenish  fluid  material.  Of  equal  importance 
are  general  disturbances  previously  depicted,  particularly  the  coo/,  sharp- 
ened features  and  the  ever-increasing  loeaJoiess  and  rapidity  of  the  pulse. 
These  clinical  manifestations  clearly  foreshadow  cardiac  exhaustion  or 
fatal  collapse.  When  the  cases  are  not  seen  until  the  advanced  stage 
has  arrived,  however,  the  diagnosis  presents  many  difficulties.  Nothing 
is  now  more  important  than  the  consideration  of  the  previous  history, 
with  a  view  to  determining  the  point  of  origin  and  tlie  probable  cause  of 
the  disease  (usually  some  such  primary  disease  as  ajjpendicitis  or  gastric 
ulcer),  as  well  as  the  accompanying  symjttoms  and  ])hysical  signs. 

The  smaller  number  of  cases  belonging  to  the  adynamic  type  are  from 
the  start  extremely  difficult  of  diagnosis.  Here  a  history  that  is  clearly 
indicative,  the  presen.e  of  moderate  tenderness,  and  augmented  tension 
of  the  abdomen,  with  profound  collapse,  would  point  to  this  condition. 

General  Differential  Diagnosis. — Hysteric  peritonitis  (so-called)  simu- 
lates the  genuine  form  so  closely  as  to  make  the  distinction  an  insur- 
mountable difficulty,  unless  there  be  accompanying  hysteric  manifesta- 
tions. Previous  similar  attacks  point  to  hysteria.  In  my  experience 
the  tenderness  has  been  out  of  proportion  to  the  gravity  of  the  constitu- 


LOCALIZED   OR  PAR'HAL  PERITONfTIH.  9^JO 

tional  disturbance.  The  patient  often  complains  bitterly  before  the 
abdomen  has  been  touched;  on  tlu;  other  hand,  wlien  liis  attention  has 
been  otherwise  engaged,  firm  and  prolonged  pressure  can  be  made. 

Acute  generalized  peritonitis  occasionally  supervenes  on  typhoid  fever. 
In  such  cases  it  is  caused  either  by  perforation  of  the  intestine  or  by  a 
direct  extension  of  inflammation  from  a  deep  typhoid  ulcer.  If  con- 
sciousness be  retained,  sudden  severe  pain,  tenderness  followed  by  ex- 
cessive tympany,  a  peculiar  indescribable /ar/e.s,  and  signs  of  collapse  will 
establish  the  diagnosis.  Peritonitis,  however,  develops  more  often  in 
those  grave  cases  of  typhoid  that  are  attended  with  coma,  marked  meteor- 
ism,  and  profound  adynamia,  and  under  such  conditions  it  often  remains 
unrecognized  {vide  Typhoid  Fever,  p.  35). 

In  acute  enteric  catarrh  the  meteorism  and  sensitiveness  under  press- 
ure are  usually  less  pronounced ;  the  disease  also  lacks  the  marked  con- 
stitutional symptoms  of  acute  peritonitis.  The  pain  is  colicky,  is  cha- 
racterized by  exacerbations,  and  even  intermits  in  entero-colitis,  while 
it  is  constant  in  peritonitis.  The  pain  in  acute  enteric  catarrh  is  often 
followed  by  diarrheal  stools. 

Intestinal  colic  is  distinguished  by  the  flatulence,  the  borborygmi,  and 
the  wandering  pain  in  the  absence  of  all  other  phenomena. 

Rheumatism  of  the  ahdomirial  muscles  excites  pain,  which,  however, 
is  superficially  located  (the  disease  affecting  the  muscular  layer),  and  is 
frequently  associated  with  rheumatism  in  other  parts  of  the  body.  There 
may  also  be  a  clear  history  of  previous  rheumatic  attacks. 

Pleuro-pneumonic'  diseases  may  simulate  peritonitis,  since  the  early 
symptoms,  especially  the  pain,  may  be  referred  to  the  abdomen.  The 
temperature  is  apt  to  be  higher  and  the  respirations  more  rapid  in  intra- 
thoracic affections — points  that  should  lead  to  a  thoracic  examination. 

Tubal  pregnancy  (after  rupture)  has  also  been  confounded  with  acute 
peritonitis,  but  its  differential  diagnosis  is  fully  discussed  and  must  be 
looked  for  in  special  works  on  gynecology  and  obstetrics. 

Rupture  of  an  abdominal  aneurysm  and  embolism  of  the  superior 
mesenteric  artery  are  also  conditions  that  give  rise  to  peritonitic  symp- 
toms— meteorism,  recurrent  vomiting,  and  violent  collapse. 

Acute  generalized  peritonitis  in  its  symptomatology  bears  a  close 
resemblance  to  acute  intestinal  obstruction,  and  the  discriminating  points 
have  already  been  tabulated  (vide  p.  875). 

Prognosis. — This  is  less  grave  than  in  the  diffused  form,  and  re- 
covery may  often  be  expected.  Timely  surgical  intervention,  particu- 
larly if  a  tendency  to  spreading  be  shown,  is  often  helpful  or  may  even 
lead  to  prompt  recovery. 

Sequelae. — If  recovery  should  take  place,  the  inevitable  result  is  the 
formation  of  adhesions  and  fibrous  bands,  the  contraction  of  which  may 
cause  constriction  of  the  bowels,  bile-ducts,  and  other  structures. 

Treatment. — Hygienic  and  Dietetic. — The  patient  should  be  placed 
in  the  position  that  will  give  him  most  comfort,  and  should  be  kept  ab- 
solutely undisturbed.  The  sick-room  should  be  of  good  size  and  well 
ventilated;  the  temperature  should  be  kept  at  from  %b°  to  70°  F. 
(18.3°-21.1°  C).  The  diet  demands  careful  attention.  Pancreatized 
milk  in  accurate  dosage  (oiv-vj — 128.0-192.0 — every  two  hours)  should 
be  administered,  and  if  the  stomach  will  not  bear  the  introduction  of 
nourishment,  recourse    should   be    had  to    rectal    alimentation.      Other 


966  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

liquid  food-stuffs,  as  meat-juices  and  egg-white  (diluted),  may  also  be 
allowed.  In  asthenic  cases  alimentation  must  be  generous,  although 
solid  articles  of  food  are  to  be  avoided. 

Medicinal. — Surgical  measures  are  recommended  by  most  writers  in 
the  treatment  of  generalized  peritonitis,  although  it  is  now  generally 
conceded  that  in  cases  due  to  mild  infection  by  the  gonococcus,  the 
colon  bacillus,  and  the  pneumococcus,  nothing  is  to  be  gained  by  opera- 
tion. This  is  especially  true  of  a  gonococcus  peritonitis  as  shown  by 
Hunner  and  Harris.'  Whenever,  however,  there  is  reasonable  doubt  re- 
jrardint^  tlie  diagnosis,  operation  should  not  be  delayed.  Formerly  the 
opium  method  of  treatment,  first  instituted  by  the  late  Alon/o  Clarke, 
was  followed  by  the  bulk  of  the  profession.  His  plan  was  to  administer 
^  gr.  (0.0324)  of  morphin  or  its  equivalent  (gr.  ij — 0.129)  of  opium,  and 
repeat  the  dose  every  second  hour  until  the  respirations  were  lowered  to 
ten  or  twelve  per  minute.  The  pupils  Avere  then  observed  to  be  con- 
tracted, the  pulse  from  76  to  80,  the  pain  relieved,  and  peristalsis  ar- 
rested. This  latter  effect  was  obtained,  even  though  in  the  case  of  some 
patients  larger  doses  of  opium  than  here  indicated  were  necessary ;  in 
others  smaller  doses  sufficed.  The  bowels  were  absolutely  let  alone.  It 
is  explained  that  in  favorable  cases  the  bowels  moved  spontaneously  at 
the  end  of  one  week,  and  that  the  patient  then  entered  upon  convales- 
cence. This  method  of  treatment  is  at  present  adhered  to  only  by  the 
ultra-conservative  element  of  the  profession.  Stockton^  advocates  the 
opium  treatment  in  the  milder  eases  before  the  peritoneal  inflammation 
has  become  generalized.  The  moderate  use  of  opiates,  hoAvever,  results 
only  in  covering  up  symptoms,  not  in  curing  the  patient.  Stockton 
believes  that  the  proper  treatment  of  oncoming  septic  peritonitis  is 
immediate  operation. 

The  saline  method  is  deservedly  popular  at  the  present  day.  Saline 
purgatives  are  exhibited  in  divided  doses  in  concentrated  solution  (oj-ij — 
4.0-8.0 — every  two  or  three  hours)  until  the  irritating  intestinal  contents, 
should  any  be  present,  are  removed,  and  additionally  several  copious 
serous  discharges  occur  daily.  Purgatives  do  good  when  given  in  this 
manner  principally  by  causing  a  rapid  exosmosis  of  serum  from  the  blood- 
vessels of  the  intestines,  by  removing  the  collateral  edema,  and  by  indi- 
rectly relieving  the  congestion  of  the  peritoneum,  thus  promoting  a 
rapid  absorption  through  the  latter  membrane.  By  increasing  the  peri- 
staltic movement  they  also  diminish  the  danger  of  peritoneal  adhesions. 
The  remedies  to  be  selected  will  depend  upon  two  primary  considera- 
tions:  first,  the  etiology  of  the  individual  case  (whether  a  communica- 
tion has  or  has  not  been  established  between  the  peritoneal  cavity  and 
the  bowel),  or  an  intra-peritoneal  abscess  or  abscess-cavity  in  one  of  the 
abdominal  viscera  ;  and  secondly/,  the  type  of  the  case,  whether  sthenic 
or  asthenic.  If  perforation  is  known  to  have  taken  place  or  the  occur- 
rence of  this  accident  is  strongly  suspected,  a  prompt  laparotomy,  fol- 
lowed by  the  free  use  of  salines,  is  the  proper  treatment.  After  the 
primce  vice  have  been  looked  after  by  the  surgeon,  salines,  for  the  reasons 
before  stated,  are  to  be  used  with  a  free  hand.  For  a  like  reason  they 
are  most  serviceable  in  peritonitis  due  to  extension  of  the  inflammation, 
and  also  in  the  puerperal  form.  If  the  patient  be  robust,  with  a  full, 
tense  pulse,  we  may  begin  the  treatment  by  the  use  of  mercury,  the 
^  BvUeiin  Johns  Hopkins  Hospital,  1902.         ^  Jour.  Avier.  Med.  Assoc,  April  11,  1908. 


CHRONIC  PERITONITIS.  'KJ? 

best  preparation  being  calomel,  exhibited  in  fractional  doses  (gr.  ss — 
0.0824)  every  hour  until  its  purgative  action  is  obtained  ;  this  is  to  be 
followed  by  the  salines.  Tlic  object  of  the  calomel  treatment  is  to  de- 
fibrinate  the  exudations  as  well  as  the  blood  of  the  patient.  Indications 
demanding  the  opium  treatment  do  not  often  present  themselves.  In  cases 
in  which  the  vital  forces  are  profoundly  depressed,  as  shown  by  the 
symptoms  of  collapse  and  there  is  not  even  a  reasonable  suspicion  of 
perforation,  opium  should  be  tried.  When,  however,  the  evidences  of  per- 
foration into  the  general  peritoneal  cavity  are  complete  and  competent 
surgical  skill  is  not  at  hand,  large  doses  of  morphin  are  imperative,  with  a 
view  to  relieving  pain,  keeping  the  patient  at  absolute  rest,  and  sustain- 
ing the  heart  against  the  exhausting  effect  of  shock.  The  bowels  should 
now  be  relieved  by  simple  large  enemata.  The  value  of  serum-therapy 
in  this  disease  is  as  yet  uncertain  (FoAvler).  For  the  systemic  collapse, 
and  for  combating  thirst  and  vomiting  I  can  warmly  recommend  saline  in- 
fusion, preferably  according  to  Murphy's  drop  method  of  rectal  irrigation. 

Local  Treatment. — At  the  onset,  if  the  patient  be  strong,  from  twenty 
to  thirty  leeches  are  to  be  applied  to  the  abdomen.  The  ice-bag  or  ice- 
poultices  are  often  of  distinct  service  in  the  earlier  stages.  Later,  in 
localized  peritonitis,  blisters  may  be  useful,  although  objectionable  in 
the  event  of  surgical  intervention  becoming  necessary.  In  cases  in  which 
meteoric  distention  is  not  great  I  have  also  made  repeated  trial  of  an 
ointment  containing  ung.  ichthyol  (sj — 32,0)  ;  ung.  belladonnae  (sss — 
16.0)  ;   ung.  hydrarg.  (iij — 64.0)  ;  this  is  applied  thrice  daily. 

In  order  to  relieve  the  tympany  turpentine  stupes  are  serviceable. 
I  have  also  had  favorable  results  from  the  insertion  of  the  long  rectal 
tube  (soft  esophageal)  well  up  in  the  colon.  Large  high  enemata  should 
be  used ;  and  turpentine  combined  as  follows  may  prove  efficacious : 

;^.    Turpentine,  3ij(8.0); 

Ox-gall,  3ij(8.0); 

Milk  of  asafetida,  giv  (128.0) ; 

Warm  water,  §vj  (192.0). 

Puncturing  the  abdomen  with  a  hypodermic  needle  in  order  to  re- 
lieve tympany,  as  recommended  by  Loomis,  may  also  be  resorted  to, 
though  I  have  had  no  personal  experience  of  its  use. 

Pain. — No  matter  what  general  plan  of  treatment  is  pursued,  the  pain 
must  be  relieved  by  opium  in  some  form.  Thirst  is  to  be  relieved  by  chipped 
ice,  over  which  a  little  brandy  may  be  sprinkled.  Thevomiting  is  best  treated 
by  carbonated  water  exhibited  in  small  quantities,  or  by  iced  champagne 
similarly  administered.     One-drop  doses  of  creosote  are  also  of  value. 


CHRONIC  PERITONITIS. 

Definition. — Chronic  inflammation  of  the  peritoneum. 

Pathologfy  and  Btiology. — The  anatomic  characters  presented 
by  different  cases  are  greatly  varied,  though  for  convenience  of  study 
they  may  be  considered  under  two  divisions  (as  in  the  acute  form) :  1. 
Local ;  2.  G-eneral.  The  latter  may  be  (a)  Adhesive,  when  the  peritoneal 
layers  are  inseparable  and  indistinguishable,  with  an  obvious  thicken- 
ing, and  the  intestinal  coils  are  everywhere  seen  to  be  grown  together. 


968  DISEASES  OF  THE  DICESTU'E  SYSTEM. 

The  cause  is  usually  a  previous  acute  attack,  and,  doubtless,  the  con- 
dition is  commonly  produced  by  the  acute  progressive  form  (Mikulicz), 
which  is  localized  at  the  start.  Rheumatism  is  also  an  occasional 
factor,  and  adhesive  peritonitis,  confined,  as  a  rule,  to  small  circum- 
scribed areas,  may  be  engendered  by  the  trocar  used  lor  taj)ping  in 
ascites. 

[b)  Proliferative  Peritonitis. — •"  The  essential  anatomic  feature  is  great 
thickening  of  the  peritoneal  layers,  usually  without  much  adhesion  " 
(Osier).  It  has  been  found  to  be  associated  with  cirrhosis  of  the  stom- 
ach, liver,  and  other  abdominal  organs.  The  amount  of  liquid  effusion, 
varying  in  composition  from  serum  to  pus,  is  usually  moderate,  and  it 
may,  owing  to  adhesions,  be  loculated.  The  omentum  is  sometimes 
rolled  up  in  the  form  of  a  massive  cord,  its  long  axis  taking  the  trans- 
verse direction.  In  an  autopsied  case  of  chronic  peritonitis  apparently 
secondary  to  hepatic  cirrhosis  I  observed  in  the  thickened  membrane 
numerous  small  hard  nodules  that  were  at  the  time  regarded  as  being 
tuberculous  in  nature.  It  is  to  be  pointed  out,  however,  that  a  number 
of  cases  of  pseudo-tuberculosis  have  been  recently  reported.  In  several 
of  these  an  operative  incision  was  followed  by  recovery,  and  this  was  put 
down  as  a  cure  of  tuberculous  peritonitis  till  the  microscope  showed  the 
nodules  to  be  fibrous.  Among  etiologic  factors  chronic  alcoholism  stands 
first.  In  one  case  that  I  saw,  acute  followed  by  chronic  rheumatism 
seemed  to  be  the  only  assignable  cause.  The  condition  is  sometimes 
secondary  to  chronic  nephritis,  to  syphilis,  or  a  general  fibroid  process. 
(e)  Cancerous  Peritonitis. — Quite  often  in  connection  with  cancerous 
growths  in  the  peritoneum  a  well-marked  peritonitis  is  evident.  There 
may  be  a  liquid  exudation,  which  is  apt  to  be  bloody  and  chylous. 

{d)  Chronic  Tuberculous  Peritonitis. — This  is  the  most  important  vari- 
et}^  and  it  may  be  part  of  a  multiple  serositis.  The  inflammatory  lesions 
are  quite  pronounced,  as  a  rule,  and  lead  to  marked  thickening  of  the 
layers — changes  that  are  to  the  naked  eye  identical  in  appearance  with 
those  noted  under  the  preceding  forms,  but  which  on  histologic  ex- 
amination show  the  presence  of  tubercles  and  caseous  degeneration. 
The  amount  of  liquid  effusion  varies  within  wide  limits,  and  is  usually 
blood-stained.  The  frequent  association  of  hepatic  cirrhosis  with  tuber- 
culous peritonitis  should  be  remarked.  From  tuberculous  peritonitis, 
tuberculosis  of  the  peritoneum  is  also  to  be  distinguished  clinically  ;  the 
latter  may  be  acute  or  chronic,  and  the  lesions  consist  in  the  deposit  of 
various  sized  tubercles  without  much  collateral  inflammation.  Acute 
and  chronic  tuberculosis  of  the  peritoneum  have  received  due  consider- 
ation in  their  appropriate  place  (p.  281). 

(e)  "  Chronic  Hemorrhagic  Peritonitis." — This  term  should  be  limited 
in  its  application  to  that  form  first  described  by  Virchow,  in  which  the 
peritoneum  is  at  intervals  partly  covered  by  a  membrane  of  new  con- 
nective tissue  that  alternates,  as  it  were,  with  layers  of  hemorrhagic 
extravasation.  A  similar  condition  results  from  the  frequent  use  of 
the  trocar  for  ascites. 

Chronic  Localized  Peritonitis. — This  is  of  frequent  occurrence,  and  is 
confined  most  commonly  to  the  serous  covering  of  the  spleen,  liver,  and 
certain  portions  of  the  bowel,  particularly  of  the  appendix.  The  condi- 
tion results  in  the  formation  of  firm  adhesions,  with  matting  of  the  in- 
testinal  coils  and  fibrous  bands.     It  is  usually  the   sequel  of  localized 


CHRONW  PERITONITIS.  960 

acute  peritonitis  occurring  in  connection  with  inflammatory  diseases  of 
the  different  abdominal  orgnns. 

Sjntnptoms  of  the  General  Forms.— Whetlicr  chronic  peritonitis 
follows  the  acute  form  or  not,  it  always  develops  insidiously.  Most  cases 
remain  quite  obscure,  and  not  a  few  are  totally  devoid  of  clinical  mani- 
festations. The  patient  may  complain  of  disorders  of  the  alimentary 
tract,  and  especially  of  constipation.  On  the  other  hand,  diarrhea  is 
observed  in  tuberculous  peritonitis  from  associated  intestinal  ulceration. 
Rarely  pressure,  from  the  traction  force  of  the  adhesions,  on  the  common 
duct  or  portal  vein  gives  rise  to  obstructive, /awTzc^zce,  or  ascites,  as  the  case 
may  be.  I  saw  an  instance  recently  in  Avhich  compression  of  the  veins 
leading  to  the  lower  extremities  caused  unilateral  edema.  Suhjective 
abdominal  sensations,  as  uneasiness,  oppression,  heat,  and  pain  (often 
colicky  in  character),  are  experienced.  Sometimes  pain  is  entirely 
absent. 

Creneral  symptoms  appear,  though  they  are  quite  vague  as  a  rule. 
An  irregular  fever,  hectic  in  type,  is  occasionally  observed.  Later,  in- 
creasing general  weakness,  emaciation,  and  general  nervous  disturbance 
become  rather  prominent  clinical  features.  Some  of  these  phenomena, 
however,  may  be  due  to  associated  aifections.  When  the  peritonitis  is 
tuberculous  we  frequently  see  clinical  evidence  of  the  primary  process  in 
other  parts  of  the  economy  {vide  Tuberculous  Peritonitis,  p.  281). 

Physical  Signs. — Inspection  usually  shows  the  belly  to  be  slightly, 
though  unequally,  enlarged.  As  in  acute  peritonitis,  so  here  we  may  find 
the  belly  flat,  or  even  concave,  with  great  tension  of  its  walls.  Fluctua- 
tion is  sometimes  obtainable  over  limited  areas  only,  since  the  fluid  is 
not  free,  but  encapsulated.  The  rolled-up  and  shrunken  omentum  may 
he  palpable  as  a  sausage-shaped  transverse  coil,  and  thick  bands  of  ad- 
hesion may  also  not  rarely  be  felt,  in  different  places,  as  hard,  uneven 
masses  simulating  neoplasmata.  The  percussion-dulness  varies  consider- 
ably with  the  amount  of  efiusion,  its  arrangement,  the  degree  of  peri- 
toneal thickening,  as  well  as  with  the  character  and  locality  of  the  fibrous 
bands.  It  follows  that  in  some  cases  irregular  areas  of  tympanitic  per- 
cussion-resonance and  of  dulness  are  to  be  found  side  by  side.  Obviously, 
too,  changing  the  patient's  posture  would  not  give  movable  dulness, 
owing  to  sacculation  of  the  fluid.  A  marked  sense  of  resistance  is  ex- 
perienced on  percussion  over  the  dull  area.  Friction-fremitus  can  some- 
times be  elicited,  and  less  irec^Vieniij  friction-sounds  also  during  forced 
breathing. 

Symptoms  of  Chronic  l/ocal  Peritonitis. — This  condition  is 
often  entirely  latent.  When  not  so,  the  most  characteristic  indication 
is  constant  pain,  distinctly  colicky  in  nature  and  often  quite  intense. 
The  physical  sigris  are  negative,  as  a  rule.  Very  rarely  a  resistant,  ill- 
defined  mass,  corresponding  with  the  seat  of  greatest  pain,  can  be  felt. 
A  fibrous  band  may  be  so  arranged  as  to  form  a  snare  through  which  a 
knuckle  of  bowel  may  pass,  with  resulting  strangulation.  Fitz's  analysis 
of  295  cases  of  strangulation  showed  63  to  be  caused  in  this  way. 

Differential  Diagnosis. — That  form  of  chronic  peritonitis  (serous 
or  granular)  most  frequently  seen  in  females  at  the  commencement  of 
puberty  is  hard  to  discriminate  from  tuberculous  peritonitis,  since  the 
latter  may  be  more  or  less  latent.     Tuberculous  peritonitis  is  generally 


970  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

attended  with  fever,  more  paiu  and  tenderness,  and  there  is  a  more  rapid 
accumuhvtion  of  the  exudate.  Again,  the  general  features,  dehility  and 
loss  of  tlesh,  progress  more  rapidly  than  in  granular  peritonitis.  The 
detection  of  conclusive  evidence  of  the  disease  in  persons  clo.sely  related,  or 
on  plivsieal  examination  of  associated  pulmonary  tuberculosis  or  pleuritis, 
■would'  render  the  diagnosis  of  tuberculous  peritonitis  almost  certain.  In 
obscure  cases  the  guinea-pig  should  be  inoculated  with  the  exudate  (see 
Pleurisy,  ]).  5<S0). 

Course  and  Prognosis. — The  milder  varieties  of  simple  chronic 
peritonitis  may,  though  rarely,  reach  a  favorable  issue.  In  cases  belong- 
ing to  this  category  tiie  disease  takes  a  chronic  course,  and  leads  gradu- 
allv  to  a  condition  of  extreme  debility,  even  if  it  does  not,  as  is  usually 
the  ease,  materially  shorten  life.  Tuberculous  peritonitis  has,  until  re- 
cently, been  regarded  as  being  almost  uniformly  fatal  at  the  end  of  several 
months.  Cures  that  must  be  attributed  to  the  surgeon's  work,  however, 
are  at  present  by  no  means  uncommon.  Rarely,  spontaneous  cures  also 
occur,  particularly  in  peritoneal  tuberculosis  without  fever  or  with  only 
slight  fever.     '•  This  form  runs  in  itself  a  favorable  course  "  (C.  Fenger). 

Treatment. — The  patient  should  be  enabled  to  enjoy  the  benefits  of 
good  sanitary  surroundings.  Close  attention  is  to  be  paid  to  the  diet, 
the  coarser  vegetables  and  sweets  being  prohibited,  since  they  increase 
the  pain  by  exciting  the  production  of  gas.  A  change  of  air  has  im- 
proved the  condition  in  several  instances  occurring  in  ray  own  practice. 
The  usual  constipation  may  be  relieved  by  simple  enemata  or  by  the 
use  internally  of  the  fluid  extract  of  cascara  sagrada.  Tonics  and  alter- 
atives, the  latter  with  a  view  to  promoting  the  absorption  of  the  exudate, 
may  also  be  employed,  and  I  would  recommend  especially  for  this  pur- 
pose the  double  iodids,  as  in  the  formula  given  in  the  discussion  of 
Pleurisy  (vide  p.  595).  In  the  early  stages  some  degree  of  relief,  or 
even  a  curative  effect,  may  be  secured  by  local  means,  as  the  application 
of  equal  parts  of  belladonna  and  iodin  ointments  until  mild  counter- 
irritation  is  produced.  Ichthyol  ointment  is  also  serviceable.  After 
all,  however,  little  is  to  be  gained  from  therapeutic  measures,  and  it  is 
to  surgery  that  we  must  look  for  fresh  triumphs  in  the  treatment  of 
this  truly  distressing  complaint.  Cases  of  chronic  localized  peritonitis 
with  adhesions  have  been  operated  upon  successfully  by  AV.  E.  Ashton, 
H.  A.  Kelly,  and  others.  Instances  of  chronic  generalized  peritonitis, 
whether  tuberculous  or  not,  in  which  the  fluid  effusion  reaccumulates 
rapidly  after  repeated  tappings,  also  furnish  adequate  indications  for 
operative  procedures. 


ASCITES. 
{Hydrops  Periioncei ;  Dropsy  of  the  Peritoneum.) 

Definition. — An  accumulation  of  serum  in  the  peritoneal  cavity, 
resulting  from  stasis  (obstruction)  in  the  branches  of  the  portal  vein. 

Pathology. — The  quantity  of  liquid  contained  in  the  peritoneal 
cavity  is  (^uite  variable,  though  it  often  amounts  to  several  gallons.  It 
is  clear  and  transparent,  or  slightly  opalescent,  especially  on  standing. 


ASCITES.  971 

and  the  specific  gravity  ranges  from  1010  to  1014.  In  color  it  often 
has  a  faint  lemon-yellow  tint;  it  may,  however,  be  either  distinctly 
yellow,  brownish  (in  cirrhosis),  bile-stained  (as  when  jaundice  is  present), 
or  slightly  blood-stained.  In  reaction  it  is  usually  alkaline  ;  very  rarely 
it  is  either  acid  or  neutral. 

The  ascitic  fluid  usually  contains  much  albumin,  resembling  in  this 
respect  blood-serum,  as  would  be  expected  from  its  source.  The  per- 
centage of  albumin  may  be  approximately  ascertained  by  noting  the 
specific  gravity  of  the  fluid  by  the  urinometer.  Thus,  in  true  ascites 
the  specific  gravity  ranges  from  1010  to  1014,  and  the  variation  in  the 
percentage  of  albumin  is  from  1  to  2.  In  effusions  due  to  peritonitis 
the  percentage  of  albumin  ranges  higher  (2.5-6  per  cent.) ;  hence 
the  specific  gravity  ranges  correspondingly  higher  (1015-1024).  The 
standing  specimen  may  show  to  the  unaided  eye  a  minute  coagulum 
of  fibrin.  In  the  lowest  layer  of  the  fluid  the  microscope  discloses  leu- 
kocytes, red  blood-corpuscles  (in  abundance  when  ascites  is  due  to  gen- 
eral venous  stasis),  fat-cells,  endothelium,  and  cholesterin-crystals.  In 
ascites  the  microscopic  appearances  of  the  peritoneum  are  usually  normal, 
while  in  instances  of  peritonitis  the  membrane,  including  the  subperito- 
neal fibrous  tissue,  is  opaque  and  slightly  thickened. 

In  the  so-called  chylous  ascites  the  fluid  resembles  milk  ;  it  contains 
fat-droplets,  a  few  lymphocytes,  and  sugar  (Hodlmoser  ^).  This  condition 
may  be  associated  with  a  collection  of  milky  fluid  in  the  left  pleural  sac, 
when  there  is  thrombosis  of  the  subclavian  vein  at  the  point  at  Avhich 
the  thoracic  duct  enters.  The  term  ascites  adiposus  is  applied  to  a 
milky  fluid,  in  which  the  origin  of  the  fat  is  the  debris  of  degenerated 
epithelial  cells,  with  few  fat-droplets  and  no  sugar  (Quincke  and  Sena- 
tor), to  the  exclusion  of  other  morphologic  elements. 

In  long-standing  cases  the  abdominal  and  the  thoracic  organs  become 
atrophied  from  pressure  exerted  by  the  dropsical  fluid. 

Htiology. — Among  the  chief  causal  factors  are  those  that  hinder 
or  arrest  the  return  of  venous  blood  from  the  peritoneal  membrane, 
as  the  following :  {a)  Pressure  upon  the  branches  of  the  portal  vein 
within  the  liver,  due  to  contraction  of  surrounding  tissues,  as  in  hepatic 
cirrhosis  (including  malarial  atrophy — De  Brun),  syphilis  of  the  liver, 
and  cancerous  infiltration,  {h)  Numerous  conditions  in  the  course  of 
which  pressure  may  be  made  upon  the  portal  vein  external  to  the  liver, 
as  enlargement  of  the  glands  in  the  fissure,  carcinoma,  hydatids,  or 
abscesses  of  the  liver.  Tumors  of  any  adjacent  organs  (e.  g.,  pancreas) 
may  produce  it.  {c)  Thrombosis  of  the  portal  vein,  {d)  Pressure  upon 
the  inferior  vena  cava  after  it  receives  the  hepatic  trunk  (Roberts),  or 
upon  the  latter  itself,  or  the  lymphatics,  (e)  The  portal  circulation  is 
also  impeded  in  chronic  pulmonary  affections  (cirrhosis  and  emphysema) 
and  heart  diseases  (e.  g.^  ascites  due  to  "  pericurditic  pseudocirrhosis  of 
the  liver  " — Pick).  (/)  A  new  growth  in  the  })eritoneum  may  compress 
the  smaller  veins  or  the  root  of  the  mesentery.  ((/)  Diminished  resist- 
ance of  the  walls  of  the  portal  vessels,  due  1o  chronic  affections  that 
diminish  the  albuminous  constituents  of  the  blood  and  impair  the  nutri- 
tion of  the  peritoneum,  as  Bright's  disease,  carcinoma,  syphilis,  chronic 
malaria,  pernicious  anemia,  leukemia,  amyloidosis.  (A)  Chylous  ascites 
^  Wiener  klin.  Woch.^  11  Jahrg.,  No.  49. 


972  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

is  caused  either  by  a  leakage  of  the  hicteals  (due  to  uleeration,  in- 
juries, or  the  presence  of  tihiriis)  or  by  the  obstruction  of  the  thoracic 
duct  (due  to  thrombosis,  cicatrices,  compression).  Cases  of  hictescent 
ascites  in  Avhich  the  liuid  is  milky  (not  chylous)  have  recently  been 
reported.  The  nature  of  the  fluid  is  as  yet  unknown.  (^)  Adipose 
ascites  has  for  its  direct  cause  fatty  cellular  degeneration,  such  as  is 
found  in  carcinoma  and  tuberculosis  of  the  peritoneum. 

Leyden  has  (1897)  described  an  ameboid  organism. 

Symptoms. — Slight  peritoneal  dropsy  gives  rise  neither  to  symp- 
toms nor  to  abnormal  physical  signs.  When  the  sac  contains  1  (juart 
(1  liter)  of  fluid  or  over,  however,  the  first  subjective  symptoms  that  are 
due  to  the  mechanical  eff'ect  of  the  fluid  appear.  They  are  a  sense  of 
weight  and  fulness,  with  slight  uneasiness.  As  the  proportion  of  trans- 
uded serum  becomes  gradually  increased  these  symptoms  become  more 
pronounced.  There  may  in  addition  be  a  dragging  pain  m  the  loins, 
gastro-intestinal  disturbance  (meteorism,  constipation),  and  dyspnea 
(owing  to  the  resistance  opposed  to  the  descent  of  the  diaphragm, 
resulting  in  compression  of  the  lungs).  The  latter  symptom  is  much 
increased  upon  exertion  or  on  assuming  the  recumbent  posture.  Since 
the  heart  is  displaced  upward,  an  embarrassment  of  its  action  (rapidity 
and  irregularity)  would  be  expected.  Syncope  is  not  infrequent  for 
similar  reasons.  Frequent  inieturition  from  pressure  upon  the  bladder 
is  common,  and  the  kidneys,  owing  to  compression  of  the  renal  vessels, 
secrete  an  albuminous  urine,  which  is  greatly  lessened  in  amount. 

Physical  Signs. — After  the  serum  has  collected  in  considerable  amount 
the  physical  signs  afford  characteristic  evidence  of  the  condition.  From 
inspection  Ave  learn  many  valuable  jjoints:  (a)  The  belly  is  uniformly 
prominent  (the  degree  depending  upon  the  amount  of  serum  present), 
giving  it  a  rounded  form.  Changing  the  posture  of  the  patient  shifts  the 
point  of  greatest  pouching,  [b)  The  skin  is  seen  to  be  tense,  smooth, 
and  shining,  and  sometimes  shows  line;^  albicantes  ;  the  umbilicus  com- 
monly bulges  forward  ;  less  frequently  it  is  obliterated,  and  tlie  surface- 
veins  are  often  enlarged,  (e)  The  thorax  appears  small,  except  at  the 
base,  where  it  is  distended,  and  the  ensiform  cartilage  is  sometimes 
abruptly  curled  up.  {d)  The  respirations  are  hurried  and  are  of  the 
thoracic  type,  the  abdominal  movements  being  slight  or  entirely  want- 
ing. As  soon  as  the  belly-walls  become  moderately  tense  fluctuation  is 
elicited  by  placing  the  palm  of  the  left  hand  vertically  upon  one  side  of 
the  abdomen,  and  then,  with  the  finger-tips  of  the  right  hand,  tapping 
lightly  the  opposite  side ;  impulses  thus  sent  through  the  fluid  will  be 
distinctly  felt  by  the  hand  in  contact  with  the  abdomen.  When  the 
dropsical  fluid  is  small  in  ((uantity  the  patient  should  assume  the  erect 
posture  during  the  examination.  In  palpating  the  solid  organs  (liver, 
spleen,  abdominal  tumors)  when  ascites  is  present,  the  tips  of  the  fingers 
only  are  placed  upon  the  skin,  and  then  are  suddenly  '^dipped,"  dis- 
placing ihe  fluid,  thus  touching  the  solid  organ  or  new  growth.  Per- 
cussion gives  flatness  over  the  fluid,  although  some  degree  of  resonance 
may  be  transmitted  from  the  subjacent  bowel.  The  upper  level  of  dul- 
ness,  in  the  recumbent  posture,  is  not  represented  by  straight  transverse 
lines,  but  presents  a  concavity  that  is  pointed  to  the  head.  The  dulness 
is  extremely  movable,  shifting  with  change  of  posture.     When  the  decu- 


ASCITES.  <)T:>j 

bitus  is  supine  the  most  dependent  portions  of  the  abdomen  give  dulne.ss. 
Again,  if  the  patient  b(!  made  to  lie  on  either  side,  the  opposite  or  upper- 
most flank  will  be  found  clear,  the  ascitic  fluid  always  gravitating  to  the 
bottom  of  the  sac.  Tyson  has  observed  that  the  flanks  are  tympanitic 
with  considerable  frequency  in  ascites,  and  my  experience  has  been  similar, 
tympany  over  the  head  of  the  colon  being  almost  constant,  except  in 
pronounced  cases.  Moreover,  to  obtain  reliable  results,  if  the  layer  of 
fluid  be  thin,  the  pleximeter  finger  is  pressed  lightly  upon  the  surface, 
and  the  gentlest  percussion  only  is  allowable.  'J'he  patient  should  be 
placed  on  the  hands  and  knees  if  the  fluid  be  small  in  amount,  when  a 
zone  of  dulness  will  be  found  around  the  umbilicus.  The  cardiac  re'^'ion 
may  present  percussion  resonance  as  high  as  the  fourth  rib,  and  occasion- 
ally a  murmur  is  heard  at  the  base.  The  condition  should  be  regarded 
as  the  counterpart  of  hydrothorax  and  not  of  pleuritis. 

Diagnosis. — In  order  to  arrive  at  a  positive  diagnosis  a  clear  his- 
tory of  one  or  the  other  of  the  known  causative  conditions  is  requisite, 
joined  with  distinct  evidence  of  the  presence  of  fluid — viz.  fluctuation 
and  movable  dulness.  For  the  early  diagnosis  of  ascites  the  patient 
should  be  placed  in  the  knee-elbow  position,  when  dulness  can  be  readily 
elicited  in  the  umbilical  region. 

The  diagnosis  of  chylous  ascites  and  ascites  adiposus  rests  upon  inse- 
cure ground  unless  aspiration  be  resorted  to,  although  the  presence  of 
the  causative  conditions  in  the  case  may  afford  a  basis  for  suspicions. 

Diflferential  Diagnosis. — Ascites  is  most  apt  to  be  mistaken  for  an 
ovarian  cyst.  The  accompanying  table  presents  the  principal  points  of 
discrimination : 

Ascites.  Ovarian  Cyst. 

Clinical  Histon/. 

General  health   is   bad  prior  to  the  ap-  General  health  is  good  before  the  devel-- 

pearance  of  the  enlargement.  opment   of  the  tumor  ;    failure  after- 
ward. 

History  of  disease  of  liver,  lungs,  heart,  Frequent  history  of  dysmenorrhea,  neg- 

kidneys,  or  other  organ.  ative  as  to  organic  affections. 

Swelling  begins  below  and  gradually  ex-  Swelling  is  unilateral  at  first,  gradually 

tends  higher  ;    more  noticeable  when  becoming  more  central. 

sitting  than  in  the  standing  posture. 

Physical  Signs. 

Enlargement  is  symmetric,  the  abdomen  Enlargement  is  asymmetric  or  irregular, 

being   rounded   and    most    prominent  unless  the  tumor  be  very  large,  when 

about   the   umbilicus  ;    in   the   supine  it  may  fill  the   entire  abdomen.     The 

posture  the  abdomen  flattens,  with  lat-  greatest    circumference    is    below    the 

eral  bulging  ;    the  umbilicus  is  often  umbilicus,  which  never  bulges, 
pouched  and  thinned. 

Fluctuation  is  general  from  side  to  side  Fluctuation  is  circumscribed,  correspond- 

and  in  a  vertical  direction.  ing  to  the  limits  of  the  tumor. 

No  aortic  pulsation  felt.  Aortic  pulsation  is  sometimes  evident. 

Vaginal  examination    often    shows    the  Vaginal  examination  shows  the  uterus  to 

uterus  to  be  movable.     A  pouch  may  be  displaced.     A  cyst  may  be  felt  and 

project  into  the  vagina,  but  no  cyst  is  outlined  in  the  pelvis, 
detectable. 

When  standing,  the  upper  line  of  dul-  When  standing,  the  upper  line  of  duLiess 

ness  presents  a  concavity  ;  rarely  shows  is  generally  a  convexity, 
irregularities  due  to  fluid  running  up 
into  "  bays  "  between  coils  of  intestine. 


974  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Ascites.  Ovarian  Cyst. 
Physical  Siffns. 

In   the    supine   position    the   flunks  are  In  the  supine  position  dulness  is  still  in 

especially  dull  with  tympany  in  front.  front  and  the  tlanks  are  resonant. 

Percussion-dulness  shifts  its  position  with  Percussion-dulness  not  movable. 

that  of  the  patient. 

Ascitic  fluid   has   a   specific   gravity  of  Ovarian  fluid   has    a  specific   <rravity  of 

1010-1014.  and  is  usually  clear.     It  is  1018-1024.     It  is   of  a   thick,  turbid 

of  a  pale  straw  color.  character,  and  the  color  is  variable. 

Large  cysts  may  also  spring  from  the  pancreas  and  Hver  :  the  elimi- 
nation of  tlie  latter  conditions,  however,  does  not,  as  a  rule,  offer  marked 
difficulty.  Ascites  must  be  distinguished  in  practice  from  tlie  exudation 
due  to  chronic  peritonitis,  and  the  points  of  differentiation  have  been 
arranged  thus : 

Ascites.  Curonic  Peritonitis. 

A  previous  history  of  organic  disease  of  There  is  a  previous  history  of  acute  peri- 

the  liver,  heart,  kidneys,  or  other  organ  tonitis,   tuberculosis,   or   inflammatory 

is  obtainable.  diseases  of  the  female  pelvic  organs ; 

sometimes  a  history  of  injury. 

No  pain  is  exp«rienced.  Pain  is  a  prominent  symptum. 

The  abdomen  is  symmetrically  enlarged.  Abdomen  is  irregularly  prominent,  and 

rarely  flat. 

Fluctuation  is  general  in  the  transverse  Fluctuation  is  often  limited  to  circum- 

or  vertical  directions.  scribed  areas  due  to  loculation  of  fluid. 

Palpation  detects  no  hard  masses  of  ir-  Palpation  often  detects  resistant,  uneven 

regular  prominence.  orominences. 

Percussion-dulness   is   always   movable  Dulness  often  not  changeable  on  varying 

upon  altering  the  position  of  the  pa-  the  position  owing  to  adhesions, 
tient. 

Fluid  serous,  limpid,  specific  gravity  of  The  fluid  is  either  sero-fibrinous,  sero- 

1010-1014,    is    pale   straw-yellow    in  purulent,  or  milky  in  nature.     It  is 

color,  greenish  tinge  at  times.     Con-  often  viscid,  its  specific  gravity  is  1018- 

tains  1   to   3    per   cent,  of  albumin.  1024,  and  its  color  variable;  3  to  6 

Few   cellular   constituents    (lympho-  per    cent,     of    albumin.      Cytologic 

cytes,  endothelial  cells,  erythrocytes).  studies  show  more  polynuclear  neu- 

Cryoscopy,  freezing-point  higher.  trophilic  leukocytes.     Freezing-point 

lower. 

Overfilling  of  the  bladder  has  been  confused  with  ascites,  and  this 
organ  has  been  tapped  under  the  mistaken  notion  that  the  condition  Avas 
one  of  dropsy  of  the  peritoneum.  Catheterization  of  the  patient  before 
tapping  for  ascites  will  obviate  this  error.  Ascites  may  be  mistaken  for 
a  deposit  of  fat  in  the  abdominal  wall.  It  is  to  be  distinguished  by 
pinching  up  the  belly  wall  within  the  grasp  of  the  hand. 

Prognosis. — The  duration  of  ascites  may  be  many  months  or  even 
years.  In  most  instances  the  prognosis  is  unfavorable,  though  modified 
by  the  character  of  the  causal  condition  in  individual  cases.  The  imme^ 
diate  cause  of  death  may  be  either  syncope,  asphyxia,  pulmonary  atelec- 
tasis, or  it  may  be  the  primary  disease. 

Treatment. — Dietetic. — The  diet  should  be  largely  nitrogenous, 
light,  nutritious,  and  given  at  stated  periods  with  a  view  to  maintaining 
the  normal  proportion  of  albuminous  material  in  the  blood. 

Medicinal. — By  means  of  therapeutic  measures  we  should  aim  to 
accomplish  two  things :  First,  the  improvement  or  cure  of  the  original 
disease ;  and  secondly,  to  relieve  the  chief  symptoms  by  removing  the 


CABCINOMA    OF  TJfE  PERITONEUM.  975 

ascitic  fluid  on  -wliich  they  depend.  Thougli  tlie  causative  affection  is 
usually  chronic  and  incurable,  every  effort  should  ho  made  to  remove  or 
mitigate  its  pernicious  activity  in  accordance  with  the  principles  laid 
down  in  appropriate  portions  of  this  work.  Of  medicines  used  to  re- 
move the  transudation,  hydragogue  cathartics  are  most  potent  for  good, 
and  particularly  when  the  ascites  is  due  to  cardiac  or  renal  disease. 
Calomel  and  jalap  in  combination,  or  salines  in  full  doses,  administered 
after  the  MatthcAV  ITay  method,  should  be  tried.  Diuretics  are  recom- 
mended, but  are  often  disappointing  in  their  eff'ects.  Rolleston  points  out 
that  they  sometimes  appear  to  succeed  after  paracentesis.  English  authors 
greatly  praise  copaiba  and  its  resin.  The  bitartrate  and  other  salts  of  pot- 
ash, either  alone  or  in  combination  with  juniper  and  digitalis,  are  of  value 
Equally  important  with  the  exhibition  of  the  above  remedies  is  the  use 
of  tonics,  including  hematinics,  to  promote  the  general  nutrition  of 
the  patient.  I  have  reported  one  instance,  occurring  at  the  Philadel- 
phia Hospital,  in  which  a  cure  was  effected  perhaps  solely  as  the  result 
of  measures  intended  to  assist  the  nutritive  processes.  Based  upon  the 
experiments  of  Fleischer  and  Loeb,  which  indicate  that  adrenalin  injected 
intraperitoneally  hastens  absorption  from  the  peritoneal  cavity,  T.  M. 
Tyson  and  H.  D.  Jump^  employed  such  injections  in  two  cases  with 
encouraging  results.  On  the  other  hand,  autoserotherapy  is  said  to  re- 
tard transudation  into  the  peritoneum  and  produce  lasting  polyuria. 
The  fluid  is  to  be  withdrawn  from  the  peritoneal  cavity  with  a  sterile 
hypodermic  syringe  and  at  once  reinjected  subcutaneously.  The  dose 
should  be  progressively  larger  {e.  g.,  3,  5,  8,  and  10  c.c),  and  repeated 
at  six-day  intervals  for  two  months.  In  ascites  due  to  cirrhosis  of  the 
liver  recourse  should  be  had  to  paraceyitesis  abdominis,  not  as  a  last 
resort  only,  but  "as  a  systematic  method  of  treatment"  (Roberts).  A 
single  tapping  is  rarely  sufficient,  and  a  repetition  of  the  measure  from 
time  to  time,  until  the  collateral  circulation  is  established,  is  to  be 
advised  and  encouraged.  In  cases  in  which  the  transuded  serum  has 
rapidly  re-formed  after  its  removal  by  tapping,  Southey's  tubes,  by 
means  of  which  permanent  drainage  is  secured,  have  been  used  with 
good  results.  Drummond  affirms  that  ascites  due  to  liver-cirrhosis  can 
be  cured,  and  has  proposed  an  operation  whereby  adhesions  between  the 
abdominal  contents  and  its  parietes  are  secured,  in  which  new  blood- 
vessels are  formed,  thus  establishing  a  collateral  circulation. 


NEW  GROWTHS  IN  THE  PERITONEUM. 

The  most  frequent  and  important  of  the  new  growths  of  the  perito- 
neum are  (a)  carcinoma  and  (6)  tuberculous  deposit  and  tuberculous 
peritonitis,  the  latter  two  having  been  already  considered. 

CARCINOMA   OF   THE   PERITONEUM. 

There  occur  the  usual  varieties — scirrhous,  encephaloid,  and  colloid 
— the  latter  most  frequently  involving  the  omentum.     Primary  carci- 

^  Therapeutic  Gazette,  January,  1911. 


976  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

noma  of  the  peritoneum  is  rare.  Primary  endotlielioma,  however,  is 
occasionally  met  with.  It  resembles  true  carcinoma  in  macroscopic  as 
well  as  in  microscopic  appearances,  though  it  is  in  reality  to  be  ranked 
with  the  sarcomata  on  account  of  its  origin.  Carcinoma  of  the  perito- 
neum is  almost  always  seconilary  to  carcinoma  of  the  stomach,  liver, 
or  pelvic  organs.  The  peritoneum  may  either  be  the  seat  of  numerous 
small  round  miliary  tumors,  or.  less  commonly,  of  larger  nodular  masses, 
the  most  extensive  development  being  presented  by  the  colloid  varietv- 
Cancerous  peritonitis  is  often  found  to  be  an  associated  condition,  and 
the  retroperitoneal  lymph-glands  may  show  cancerous  development. 

Htiology. — More  cases  occur  in  the  female  sex  than  in  the  male. 
Age  has  also  a  potent  influence,  most  cases  appearing  late  in  life.  Trauma 
may  operate  as  an  influential  causative  factor. 

Symptoms. — When  prima rij,  carcinoma  of  the  peritoneum  is  ob- 
scure during  the  early  part  of  its  course.  Local  ^'rt/u  and  discomfort  are 
complained  of,  and  clinical  evidences  of  the  rancerouii  cachexia  develop 
early,  but  these  symptoms  are  not  at  first  striking  enough  to  be  entirely 
characteristic.  Later,  however,  the  nodules  can  often  be  plainly  felt 
(unless  the  liquid  effusion  be  too  marked),  and  the  ascites  (blood-stained), 
loss  of  flesh.,  weakness,  and  anemia  are  now  sufficiently  developed  for 
diagnosis.  In  the  colloid  variety  ascites  is  often  absent,  the  abdominal 
cavity  being  the  seat  of  a  large,  semisolid,  non-fluctuating  mass. 

The  secondary  form  usually  follows  carcinoma  of  the  stomach  or  the 
ovaries,  and  the  cachexia  will  have  been  developed  before  the  peritoneum 
is  secondarily  involved  in  consequence  of  the  presence  of  the  primary 
growth.  Hence,  any  symptoms  referable  to  the  general  abdominal  cav- 
ity are  strongly  suspicious.  Among  other  constitutional  symptoms, 
apart  from  those  already  mentioned,  is  fever  (rarely  absent),  which  may 
be  due  in  small  measure  to  the  anemia,  though  in  a  greater  measure  to 
the  associated  peritonitis. 

Physical  Signs. — The  abdomen  protrudes  if  effusion  be  present  or  if 
the  carcinoma  be  of  the  colloid  form,  though  not  invariably.  Even 
when  the  tumor  is  large,  dropsy  of  the  peritoneum  may  make  its  detec- 
tion impossible.  On  practising  palpation  after  tapping,  however,  the 
nodules  can  be  made  out,  either  extending  from  side  to  side  or  being 
more  or  less  localized  and  not  ailherent  to  underlying  structures. 

Differential  Diagnosis. — It  will  be  remembered  that  an  oblong 
tumor  lying  transversely  across  the  abdomen  below  the  stomach  is  met 
in  certain  forms  of  chronic  perito7iitis.  This  offers  the  same  physical 
signs  that  are  presented  by  peritoneal  carcinomata,  unless  the  tumor- 
masses  in  the  latter  affection  be  of  considerable  size.  Carcinoma,  how- 
ever, is  most  apt  to  occur  in  persons  past  middle  life,  while  nodular 
tuberculous  peritonitis  appears  almost  exclusively  in  children  and  young 
adults.  Evidences  of  tuberculous  disease  elsewhere,  past  or  present, 
and  particularly  suppuration  about  the  umbilicus,  would  point  to  tuber- 
culous peritonitis.  Moreover,  in  all  forms  of  abdominal  carcinoma  the 
inguinal  glands  are  ajit  to  be  indurated  and  enlarged.  Cyto-diagnosis 
might  serve  to  distinguish  carcinoma  from  tuberculosis  of  the  peritoneum. 
Proliferative  peritonitis  usually  gives  a  history  of  chronic  alcoholism.  The 
differentiation  of  hydatid  cysts  of  the  peritoneum  from  carcinoma  depends 
upon  the  history  of  the  case,  the  presence  of  hydatid  fremitus,  the  find- 


OTHER  TUMORS  OF  THE  PERITONEUM.  ^Ml 

ing  of  the  booklets  in  the  fluid,  the  less  rapid  growth  of"  the  tumor,  and 
the  lessened  amount  of  pain,  fever,  and  cachexia  in  the  Matter  disease. 
Qarcinoma  of  the  intestine  may  simulate  somewhat  tl  e  dires^e  under 
consideration,  but  the  signs  of  increasing  stenosis,  as  eviJ triced  by 
the  colicky  pain,  the  discharge  of  blood  and  pus  with  the  ftools,  and 
the  ribbon-like  character  of  the  feces,  will  serve  to  separate  the  con- 
ditions. Retroperitoneal  tumors  (sarcomata)  are  discriminated  with  the 
greatest  difficulty.  As  pointed  out  by  J.  D.  Steele,  in  tunujis  behind 
the  peritoneum  the  signs  of  intestinal  obstruction,  coupled  with  neu- 
ralgic pains  or  edema  of  the  lower  extremities  from  pressure  upon 
their  nervous  and  venous  supply,  are  important  discriminating  features. 
Moreover,  tumors  of  the  peritoneum,  whether  of  the  omentum  or  mesen- 
tery, are  movable,  while  those  behind  the  peritoneum  are  generally 
fixed.  In  retro-peritoneal  sarcoma  "  the  tumor  may  fluctuate  and 
may  move  with  respiration,  or  be  movable  by  palpation."  Omental 
tumors  lie  in  front  of  the  intestines  (as  can  be  shown  by  inflation  of  the 
bowel) ;  mesenteric  now  growths  sometimes  have  a  coil  of  intestine  in 
front  of  them.  On  the  other  hand,  retro-peritoneal  tumors  are  always 
crossed  by  loops  of  intestine  (colon).  Peritoneal  tumors  (particularly 
the  omenta])  follow  the  movements  of  respiration,  while  the  retro-peri- 
toneal are,  as  a  rule,  immobile.  The  latter  always  cross  the  central  long 
axis  of  the  body,  while  the  former  may  be  confined  to  one  or  the  other 
side.  Finally,  the  only  sure  method  of  determining  the  character  of 
tumors  behind  the  peritoneum  is  by  an  exploratory  celiotomy. 

The  prognosis  is  always  unfavorable. 

Treatment  can  accomplish  nothing  beyond  a  more  or  less  com- 
plete relief  from  the  distressing  symptoms. 

Other  Tumors  of  the  Peritoneum. — Primary  sarcoma  produces 
larger  or  smaller  areas  of  thickening  of  the  peritoneum.  Secondary 
sarcoma,  the  commoner  variety,  assumes  the  form  of  large  nodular  masses 
or  of  numerous  miliary  growths.  The  symptomatology  has  been  given 
under  Carcinoma  of  the  Peritoneum. 

Fibromata  and  lipomata — the  former  as  fibroid  nodules  varying  in 
size  from  a  millet-seed  to  a  split  pea,  the  latter  as  localized  overgrowths 
of  fatty  tissue  showing  great  variation  in  their  size — are  among  peritoneal 
and  retro-peritoneal  neoplasms.  The  lipomata,  however,  are  the  more 
frequent.  Mr.  Anderson  points  out  that  fibromata  may  merge,  on  the 
one  hand,  into  the  lipomata  [fihro-Upomata) ;  on  the  other,  into  the 
myomata  {jihro-myomata).  It  is  probable  that  lipomata  usually  spring 
from  the  retro-peritoneal  tissue  in  the  neighborhood  of  the  kidneys  and 
iliac  fossa.  Less  commonly,  however,  they  "  originate  in  the  subperi- 
toneal tissues  of  the  mesenteric  or  omental  folds,  where  general  fatty 
overgrowth  in  varying  degree  is  frequently  observed  '"  (Allchin). 

Peritoneal  lipomata  may  be  associated  Avith  extreme  obesity,  but  this 
is  by  no  means  invariably  the  case.  The  diagnosis  is  rarely  made, 
particularly  in  the  female,  owing  to  the  close'  resemblance  of  these 
growths  to  ovarian  cysts  and  other  tumors  found  in  connection  with  the 
female  genitalia.  They  have  been  mistaken  also  for  ascites,  which  is 
not  rarely  a  symptom  of  fibromatous  and  lipomatous  neoplasms.  The 
prognosis  is  unfavorable,  although,  if  early  recognized,  the  tumors  may 
be  successfully  removed. 
62 


PART   VIII. 

DISEASES  OF  THE  URINARY  SYSTEM. 


I.    DISEASES  OF  THE   KIDNEY. 


MOBILITY  OF   THE   KIDNEY. 

(Movable  Kidney;  Dislocated  Kidney;  Floating  Kidney;    Wandering  Kidney ; 
Ren  Mobilis ;  Nephroptosis.) 

Definition. — A  distinction  is  made  between  two  common  varieties 
of  mobile  kidney,  according  to  the  degree  of"  displacement,  as  follows : 
(1)  Movable  kidney^  the  upper  end  of  which  can  be  felt  during  deep 
inspiration,  and  which  can  be  pushed  down  in  the  retro-peritoneal  space 
to  the  level  of  the  umbilicus ;  (2)  Floating  kidney,  which  is  freely  mov- 
able below  or  beyond  this  point — i.  e.  possessing  a  larger  arc  of  mobility. 
In  the  so-called  palpable  kidney  the  lower  edge  of  the  organ  can  barely 
be  felt  on  deep  pressure. 

Ktiology. — The  condition  may  be  congenital  (rare).  An  abnormally 
long  renal  artery  may  predispose  to  the  development  of  a  movable  kidney. 
Emaciation  with  a  marked  wasting  of  the  fatty  capsule  in  which  the 
kidney  is  imbedded  is  a  frequent  underlying  cause  of  movable  kidney. 
Women  are  oftener  affected  than  men,  and  relations  from  multiple 
pregnancies,  tight  lacing  and  girdling,  and  traumatism  (falls,  heavy 
lifting,  and  the  like)  have  frequently  caused  displacement  and  mobility 
of  the  kidney.  Suckling  ^  observed  that  a  number  of  girls  who  served 
beer,  and  were  therefore  obliged  to  stoop  and  immediately  stand  upright 
with  considerable  frequency,  were  likely  to  have  movable  kidney.  Heavy 
tumors  of  the  organ,  the  pressure  of  adjacent  tumors  (as  of  the  liver), 
and  the  traction  of  hernias  may  likewise  cause  the  condition.  Watson's^ 
series  of  experiments  proved  that  the  structures  vital  to  the  restric- 
tion of  the  kidneys  mobility  within  its  normal  excursion  are  those  which 
form  the  attachments  along  its  posterior  surface  and  upper  pole. 

In  enteroptosis,  or  Gl^nard's  disease,  in  which  there  is  a  downward 
displacement  of  all  the  viscera,  mobility  of  the  kidney  is  often  asso- 
ciated. Although  either  kidney,  or  even  both  kidneys,  may  be  abnor- 
mally mobile,  the  right  one  is  usually  affected.  Sometimes  a  floating 
kidney  becomes  fixed  by  peritoneal  adhesions  in  an  abnormal  position,  as 
in  the  right  iliac  fossa ;  an  instance  of  this  occurred  in  a  seaman,  under 
my  care,  admitted  to  the  Medico-Chirurgical  Hospital  of  Philadelphia. 

"  The  body  form  is  an  important  etiologic  factor  of  movable  kidney, 

'  Edinburgh  Med.  Jour.,  Sept.,  1898. 

'■'  Boston  Med.  and  Surg.  Jour.,  vol.  cxlv.,  No.  12. 

978 


MOBILITY  OF  THE  KIDNEY.  979 

and  not  only  explains  the  greater  frequency  in  women  than  in  men,  hut 
also  the  reason  why  the  right  organ  is  more  often  disphicfid  tlian  the 
left"  (Ashton).  The  body  cavity  is  subdivided  into  tlireo  zones  by  two 
transverse  planes,  and  in  women  the  middle  zone  is  linble  to  be  contracted 
in  various  directions  with  a  consc(juent  displacement  downward  of  the 
organs  occupying  this  region.  The  right  kidney  is  pushed  downward, 
owing  to  backward  compression  of  the  liver,  which  tilts  its  superior  pole 
forward.  Becker  and  Lenhoff,  from  a  study  of  the  relation  between  the 
length  and  circumference  of  the  body  cavity,  found  that  the  greater  the 
contraction  of  the  middle  zone,  the  higher  will  be  the  body  index  ;  this 
is  arrived  at  as  follows  : 

Distance  from  suprasternal  notch  to  symphysis   w    iaa  _  i     i     •    ^ 
Circumferenceof  body  at  lower  border  of  tenth  rib 

They  concluded  that  when  the  body  index  was  below  75  no  displacement 
occurred,  but  when  the  index  was  above  77  the  kidney  was  almost  in- 
variably situated  abnormally  low. 

Symptoms. — Movable  kidney  may  exist  without  any  symptoms  what- 
ever. It  may  be  discovered  accidentally  by  physical  examination,  and 
not  infrequently  it  is  found  postmortem  in  a  similar  manner. 

The  symptoms  of  movable  kidney  are  local,  reflex,  and  general,  the 
local  and  reflex  symptoms  being  the  most  prominent  in  the  average  case. 
The  reflex  symptoms,  though  usually  abdominal,  may  become  general. 
The  local  symptoms  are  most  marked  in  extreme  mobility  of  the  kidney 
(floating  kidney),  although  many  of  the  symptoms  are  due  to  the  associ- 
ated sagging  of  other  organs,  while  in  moderate  mobility  the  reflex  symp- 
toms usually  predominate  over  the  local. 

Most  frequently  there  is  a  troublesome  dragging  pain,  or  a  sense  of 
weight  or  pressure  in  the  loins  or  abdomen,  especially  after  long  walking 
or  standing  or  hard  labor ;  this  may  be  referred  to  the  sacral  region. 
Sometimes  the  pain  may  be  quite  sharp  and  colicky  in  nature.  Pain  in 
the  kidney  itself  is  seldom  complained  of,  due  to  congestion  by  pressure 
or  traction  upon  the  renal  veins  or  obstruction  of  the  ureter. 

Reflex  g astro-intestinal  disturbances  are  common.  Indigestion  is 
usually  complained  of,  and  occasionally  vomiting  and  nausea  are  noted. 
Dilatation  of  the  stomach  may  possibly  be  caused  by  a  dislocated  kidney 
pressing  upon  the  duodenum.  Pressure-jaundice  is  also  an  unusual  con- 
comitant of  the  floating  kidney,  and  J.  Hutchinson,  Jr.,  records  two  cases 
that  caused  both  hepatic  colic  and  obstructive  jaundice.  Cardiac  paljnta- 
tion,  constipation,  flatulence,  and  edema  of  the  lower  extremities  (from  pres- 
sure on  the  inferior  vena  cava)  may  attend,  and  disturbances  of  the 
pelvic  viscera  have  also  been  noted  occasionally  (dysmenorrhea,  abortion^ 
and  irritable  bladder).  Improvement  is  usually  considerable  in  preg- 
nancy. Some  cases  of  displaced  kidney  are  characterized  by  sudden 
and  severe  attacks  of  nephralgic  or  gastralgic  pains,  chills,  fever,  ver- 
tigo, nausea  and  vomiting,  and  general  collapse.  These  attacks  are 
often  periodic,  occurring  sometimes  at  the  menstrual  period,  and  are 
known  as  ^^  Dietl's  crises"  or  '•^incarceration  symptoms."  They  may 
be  excited,  also,  by  a  too  free  indulgence  in  eating  and  drinking.  It  is 
most  probable,  as  Dietl  himself  suggested,  that  these  cases  are  due  to  a 
twisting  or  bending  of  the  renal  vessels  or  of  the  ureter,  or,  perhaps,  to 
circumscribed  inflammation  of  the  mobile  kidney.     An  acute  hydrone- 


980  DISEASES  OF  THE   URINARY  SYSTEM. 

phrosis  may  thus  develop.  The  urine  is  concentrated,  and  may  contain 
uric  acid  or  oxalates  in  excess.  After  three  or  four  days,  as  the  attack 
subsides,  micturition  becomes  free,  the  kidney  becoming  movable  once 
more.  These  attacks  of  traftsitioyial  h^(/ro}n'j>hroi<is  may  occur  intermit- 
tently (vide  Hydronephrosis).  Pyonephrosis  has  also  been  noted  and  in 
rare  instances  may  result  in  gangrene  by  occlusion  of  blood-vessels. 
When  a  loose  kidney  causes  rigidity  of  the  muscles  of  the  abdominal  vail 
(■'splint-belly  "),  it  may  produce  gastric  hyperacidity,  congestive  appen- 
dicitis, or  parenchymatous  nephritis. 

Floatimj  kidney  Q.moc'vAiQA  Avitli  Gldnard's  disease,  in  which  the  trans- 
verse colon,  pancreas,  stomach,  intestines,  and  other  viscera  are  pro- 
lapsed, gives  rise  to  symptoms  similar  to  those  stated  above,  only  with 
the  addition  of  greater  discomfort  and  nutritive  and  nervous  disturb- 
ances.     Sometimes  there  is  albuminuria  and  rarely  hematuria. 

The  (/enf-ral  si/mptoms  of  movable  kidney  are  those  of  neurasthenia  or 
hysteria.  Mental  anxiety,  leading  to  melancholia,  sometimes  follows  the 
discovery  of  a  movable  abdominal  tumor.  Cephalalgia,  backache,  pares- 
thesias, neuralgias,  nervous  dyspepsia,  hypochondriasis  (in  men),  and  hys- 
teric manifestations  may  arise  and  prove  a  perpetual  annoyance.  The  con- 
dition, however,  may  arise  in  a  previously  neurasthenic  or  hysteric  subject. 

The  physical  signs  of  movable  or  floating  kidney  are  highly  import- 
ant and  diagnostic.  Palpation,  especially  bimanual,  as  by  Israel's 
method.  The  patient  lying  in  a  semi-recumbent  position,  counter- 
pressure  (the  left  hand  being  placed  over  the  lumbar  region,  the 
right  next  the  skin  in  front,  manipulating  the  abdomen  from  above 
downward)  may  detect  a  firm,  movable  tumor  of  renal  size  and 
shape  in  either  Hank  (usually  the  right)  just  below  the  ribs  (movable 
kidney),  or  in  the  inguinal  or  umbilical  regions  (floating  kidney). 
Or,  the  patient  may  stand  and,  grasping  the  back  of  a  chair,  may  lean 
slightly  forward,  while  the  examiner,  at  the  patient's  side,  presses  with 
one  hand  over  the  loin,  and  with  the  other  feels  over  the  abdomen  be- 
low the  ribs.  Though  comparatively  easy  to  outline,  the  tumor  is  never- 
theless hard  to  grasp ;  it  is  often,  however,  readily  pushed  into  place. 
Deep  breathing  may  affect  a  palpable  or  movable  kidney,  but  has  no 
effect  upon  one  that  freely  wanders  about  the  abdomen  (floating  kidney.) 
Pulsation  of  the  renal  artery  may  be  felt  in  the  last-named  cases. 

Inspection  and  percussion  of  the  lumbar  region  in  movable  kidney  are 
uncertain,  and  therefore  unreliable.  Visible  depression  here  is  rarer 
than  a  visible  tumor  anteriorly.  I  have  noted  increased  tympany  over 
the  affected  side  as  compared  with  the  opposite  side. 

A  diagnosis  is  possible  only  after  a  careful  and  thorough  physical 
examination.  When  this  is  made,  an  abnormally  mobile  kidney  is 
usually  discovered  without  difficulty.  The  size  and  shape  of  the  organ, 
its  right-sided  position,  and  its  mobility,  associated  with  a  train  of  local, 
reflex,  or  general  nervous  disturbances,  especially  in  a  thin,  emaciated 
woman,  are  quite  distinctive.  A  knee-elbow  posture  is  sometimes  more 
favorable  than  the  recumbent  position  for  determining  a  movable  kidnev. 

Differential  Diagnosis. — Floating  kidney  is,  of  course,  more  easily 
diagnosticated  than  the  movable  type,  and  partly  because  of  the  fact 
that  in  instances  of  the  latter  tumors  of  the  gall-bladder  especially 
and  wandering  spleen  must  first  be  excluded.  The  absence  of  a  well- 
defined   splenic   notch,   the    presence  of  pulsation   of  the   renal  artery. 


MOBILITY  OF  THE  KIDNEY.  -981 

a  tympanitic  note  over  the  usually  intervening  colon,  and  an  unchanged 
area  of  splenic  dulness  will  assist  in  the  diagnosis;  in  addition  there  is 
the  fact  that  wandering  spleen  is  a  comparatively  rare  affection. 

Tumors  of  tlie  gall-bladder  are  frequently  mistaken  for  movable  kid- 
ney ;  occasionally  the  opposite  error  is  made ;  sometimes  both  conditions 
may  exist.  They  are  both  common  to  women  ;  they  both  may  present 
as  tumors  in  the  right  hypochondriac  and  umbilical  regions;  they  are 
more  or  less  movable,  firm,  smooth,  slightly  tender,  round  or  oval  in 
shape,  with  variable  percussion-signs  and  dyspeptic  symptoms ;  and 
either  may  give  rise  to  paroxysms  of  severe  colic  or  to  jaundice.  Jaun- 
dice, however,  is  rare  in  movable  kidney,  while  emaciation  and  general 
nervous  disorders  are  more  common  ;  the  floating  tumor  may  vary  in  size 
(hydronephrosis),  the  diminution  being  accompanied  by  a  marked  increase 
in  the  flow  of  urine.  If  the  gall-bladder  be  filled  with  calculi,  the  con- 
sistence is  firmer  than  that  of  the  kidney,  and  fremitus  may  be  felt. 
Moreover,  the  movements  of  the  gall-bladder  are  usually  lateral  within  a 
short  arc  of  a  circle,  the  center  of  which  is  a  point  beneath  the  edge  of 
the  right  lobe  of  the  liver ;  while  those  of  floating  or  movable  kidney 
may  be  either  vertical,  oblique,  or  lateral  in  arcs  of  a  much  larger  radius. 
Again,  tumors  of  the  gall-bladder  descend  with  inspiration,  as  is  not  the 
case  with  wandering  kidney. 

In  some  cases  h  is  necessary  to  distinguish  between  "  Dietl's  crises" 
and  renal.,  hepatic,  or  intestinal  colic,  acute  intestinal  obstruction,  affec- 
tions of  the  genital  organs,  and  appendicitis.  Tumors  of  the  ovaries  and 
hoivel  are  rarely  confounded  with  wandering  kidney. 

Prognosis. — In  uncomplicated  cases  life  is  never  endangered,  and 
a  cure  may  be  effected  in  numerous  cases  in  which  suitable  combined 
medical  and  surgical  treatment  is  pursued.  The  general  nervous  symp- 
toms are  usually  very  obstinate,  but  after  relief  is  afforded  from  the  ac- 
companying local  symptoms,  they  subside  or  cease  altogether. 

Treatment. — Since  emaciation  and  loss  of  perirenal  fat  is  a  fre- 
quent cause  of  wandering  kidney,  it  is  often  advisable  to  resort  to  meas- 
ures that  will  tend  to  increase  the  weight  and  fat  of  the  body.  The 
"rest-cure,"  with  its  forced  feeding,  may  be  all  that  is  necessary  in 
highly  nervous  subjects  having  but  a  slightly  movable  kidney.  In  all 
cases  more  or  less  prolonged  intervals  of  rest  (lying  doAvn)  throughout 
the  day  aid  markedly  in  ameliorating  the  symptoms.  Other  hygienic 
measures,  as  the  avoidance  of  over-exertion,  extreme  bodily  movements, 
straining — as  at  stool — and  so  forth,  should  also  be  enjoined. 

For  several  years,  and  until  recently,  the  operation  for  anchoring  the 
mobile  kidney  has  been  advised  as  appropriate  in  nearly  all  cases.  This 
is  now  perhaps  wisely  deprecated  ;  and  a  reversion  to  the  careful, 
patient,  and  constant  use  of  suitable  abdominal  pads  and  binders  in  cer- 
tain cases  is  meeting  with  much  success.  Watson  states  that  from  90  to 
95  per  cent,  of  movable  kidney  producing  symptoms  can  be  relieved  by 
a  suitable  corset.  Gallant  ^  recommends  a  corset  as  long  in  front  as  can  be 
worn  ;  specially  made  or  straight-front  corsets  being  chosen.  It  must  be 
at  least  two  inches  less  than  that  formerly  worn,  and  laced  at  the  back  from 
top  to  bottom  as  an  open  V.  Having  put  the  corset  around  the  waist, 
*  Saunder^  American  Year  Bock,  1903,  p.  453. 


982  DISEASES  OE  THE  URINARY  SYSTEM. 

the  patient  lies  down,  draws  up  the  knees,  and  then  fastens  the  corset 
from  below  upward,  drawing  the  lax  abdominal  wall  up  at  each  step.  In 
severe  cases  of  renal  displacements,  in  which  recurring  attacks  of  hydro- 
nephrosis, strangulation-crises,  pain  with  marked  gastro-intestinal  disturb- 
ances, profound  nervous  and  mental  disturbances,  or  other  grave  renal 
complications  occur,  some  such  surgical  procedure  as  nephrorrhaphy 
should  be  strongly  urged.  This  may  prove  an  effectual  cure,  although 
the  anchorage  is  often  torn  loose  by  a  sudden  or  severe  physical  effort. 
Suckling  states  that  surgery  offers  the  only  cure  for  nephroptosis.  The 
hypodermic  injection  uf  morphin  and  atropin  and  tlie  external  appli- 
cation of  heat  are  indicated  in  the  crises  of  Dietl. 


CIRCULATORY  DISORDERS  OF  THE  KIDNEYS. 

ACTIVE   HYPEREMIA. 
{Acute  or  Active  Congestion.) 

Definition. — An  acute,  temporary  engorgement  of  the  vessels  of 
the  kidneys,  with  little  or  no  exudation. 

Pathology. — The  kidney  is  swollen,  deep-red  in  color,  and  en- 
gorged with  blood,  which  flows  freely  on  section.  Microscopically,  there 
may  be  seen  cloudy  swelling  of  the  oortical  epithelium. 

Ktiology. — Acute  renal  congestion  is  due  mainly  to  the  action  of 
irritants  present  in  the  circulation,  as  in  the  acute  infectious  (especially 
the  eruptive)  fevers.  The  stimulating  diuretics  and  certain  poisonous 
drugs,  as  copaiba,  squills,  cantharides,  potassium  chlorate,  and  car- 
bolic acid,  also  sudden  contraction  of  the  peripheral  blood-vessels  by 
exposure  to  cold  while  the  body  is  overheated,  act  as  causes.  Post- 
operative acute  hyperemia  (ether?)  is  freciuently  met  with.  When  pro- 
longed the  congestion  passes  into  an  acute  nephritis.  It  may  be  caused 
in  one  kidney  as  a  result  of  either  nephrectomy  of  its  fellow  or  blocking 
of  the  ureter  by  a  calculus,  clot,  etc.,  of  the  opposite  side. 

Symptoms. — There  may  be  a  dull  pein  in  the  lumbar  region,  with 
a  slight  elevation  of  the  temperature  and  pulse-rate.  The  urine  either 
is  scanty,  or,  as  in  cantharides-poisoning,  it  may  be  altogether  sup- 
pressed. It  is  dark,  the  specific  gravity  is  increased,  and  it  contains 
some  free  blood,  a  trace  of  albumin,  and  a  few  hyaline  tube-casts. 

Diagnosis. — The  absence  of  a  marked  quantity  of  albumin,  of  the 
numerous  and  various  casts,  of  dropsy,  and  of  uremic  symptoms  distin- 
guishes active  hy|)eremia  from  acute  nephritis. 

The  prognosis  is  quite  favorable  upon  the  removal  of  the  cause.  A 
frequent  repetition  of  the  attacks,  however,  may  lead  to  a  nephritis. 

Treatment. — Absolute  rest  and  a  liquid  diet  should  be  ordered. 
Cupping  over  the  loins  or  the  use  of  hot  fomentations  should  be  prac- 
tised, '^rhe  free  use  of  water  and  other  diluents  or  mucilaginous  drinks 
should  be  encouraged.  Saline  laxatives  to  freely  open  the  bowels,  and 
the  use  of  hot  air  or  a  hot  pack  to  promote  sweating,  are  important  aid^ 
in  relieving  the  congested  kidneys. 


EMBOLIC  INFARCTIONS.  983 

PASSIVE    HYPEREMIA. 

(^Chronic  or  Passive  Congestion.) 

Definition. — A  chronic  venous  engorgement  of  the  renal  vessels, 
generally  secondary  to  diseases  of  certain  other  viscera. 

Pathology. — There  is  in  the  later  stages  a  characteristic  condition 
of  the  kidneys  called  "  cyanotic  induration."  Earlier  in  the  case  the 
organs  are  enlarged,  firm,  and  of  a  dark,  bluish-red  color.  The  capsule 
is  usually  non-adherent.  On  section  the  medullary  substance  is  seen  to 
be  darker  red  than  the  cortex  and  coarsely  fibrous  in  appearance.  Micro- 
scopic examination  shows  the  capillaries  (both  glomerular  and  medullary) 
somewhat  dilated  and  the  walls  thickened.  The  epithelium  may  either 
be  unchanged  or  a  little  cloudy  and  swollen,  or,  later,  even  fattj  ;  the 
interstitial  tissue  may  be  slightly  increased. 

Ktiology. — Most  commonly  the  renal  congestion  is  a  part  of  a  gen- 
eral venous  engorgement  due  to  chronic  cardiac,  pulmonary,  or  hepatic 
disease.  It  is  found  in  mitral  valvular  disease  with  ruptured  compen- 
sation of  the  heart  (common) ;  in  pulmonary  emphysema,  fibroid  phthisis, 
and  chronic  adhesive  pleurisy;  and  in  cirrhosis  of  the  liver.  Less  fre- 
quent causes  of  congested  kidneys  are  tumors,  the  pregnant  uterus,  and 
ascites,  all  of  which  bring  about  the  condition  through  pressure  upon  the 
renal  veins.  Again,  angulation,  as  in  nephroptosis,  kyphosis,  and  the 
like,  may  be  a  cause.  Only  rarely  may  passive  renal  congestion  be  due 
to  thrombosis  or  embolism  of  the  ascending;  vena  cava  or  of  the  renal 
veins. 

Symptoms. — These  are  accompanied  by  those  due  to  the  primary 
diseases  that  are  manifested  in  the  general  venous  congestion,  as  edema 
of  the  lower  extremities.  There  may  be  a  sensation  of  weight  in  the 
loins.  The  urine  is  diminished  in  quantity,  of  a  higher  specific  grav- 
ity, and  darker  in  color  ;  it  contains  a  little  albumin,  some  blood-cor- 
puscles, and  a  few  hyaline  casts  and  epithelial  cells,  depending  upon  the 
chronicity  and  intensity  of  the  congestion.  Urates  may  be  deposited 
in  the  standing  urine. 

Diagnosis. — From  nephritis  passive  renal  congestion  may  be  difier- 
entiated  by  the  comparative  absence  of  albumin,  casts,  general  dropsy- 
and  uremia,  and  by  the  undiminished  quantity  of  urea. 

Prognosis. — This  depends  upon  the  primary  cause.  Chronic  con- 
gestion may  pass  into  chronic  nephritis  with  fluctuation  of  the  oliguria 
and  albuminuria  according  to  the  functional  activity  of  the  heart. 

Treatment. — Rest  and  a  light  and  easily  assimilable  diet,  together 
with  cardiac  tonics  and  diuretics,  are  indicated.  The  infusion  of  dig- 
italis serves  a  good  purpose  by  increasing  the  quantity  of  urine  and 
clearing  it  of  albumin.     Basham's  mixture  is  a  useful  adjuvant. 

EMBOLIC   INFARCTIONS. 

Anemic  and  hemorrhagic  infarctions  of  the  kidney  are  of  pathologic 
rather  than  of  clinical  significance.  Cicatrices  may  result  from  these 
infarctions — "  embolic  contracted  kidney."  Very  rarely  the  sudden 
appearance  of  a  slight  amount  of  Mood  in  the  urine,  associated  with  car- 
diac disease,  and  tenderness  of  the  kidney,  and  possibly  with  a  sudden 
severe  pain  over  the  loin,  may  point  to  hemorrhagic  infarction. 


984  DISEASES  OF  THE   miyARY  SYSTEM. 

SPECIAL  PATHOLOGIC   STATES  OF  THE  URINE. 

HEMATURIA. 

Definition. — The  presence  of  blood  in  the  urine. 

Htiology. — (1)  Local  or  renal  <-ausei<  of  hematuria  include  conges- 
tion (including  that  due  to  torsion  of  the  renal  vessels  in  certain  cases 
of  floating  kidney),  acute  inflammation  of  the  kidneys,  and  acute  ex- 
acerbations of  chronic  nephritis,  embolic  hemorrhagic  infarction,  renal 
calculi  and  pyelitis,  tuberculosis,  malignant  renal  disease,  diffuse 
myxangiomatous  condition  of  the  pelvic  submucous  tissue  (Myles), 
actinomycosis  (U.  Israel),  hydatids,  traumatism,  and  parasites  (the 
filaria  sanguinis  hominis  and  distoyna  lunnatohium  (Billliarz). 

(2)  Affections  of  the  Lrinary  Tract. — In  the  ureter,  calculi  or  lacera- 
tions due  to  traumatism,  as  in  protracted  abdominal  sections ;  in  the 
bladder,  calculi,  malignant  tumors,  acute  cystitis,  ulceration  and  rupture 
of  varicose  veins  at  the  vesical  neck  ;  and  in  the  urethra,  gonorrhea,  cal- 
culi,  parasites,  and  traumatism — may  all  cause  hematuria. 

(3)  General  Diseases. — Acute  specific  fevers  and  certain  blood-dys- 
crasifB  (purpura,  gout,  scurvy,  hemophilia,  malaria,  and  leukemia)  may 
produce  hematuria.  Malarial  hematuria  in  mild  form  is  not  an  uncommon 
feature  of  paludism  in  the  Middle  States  of  this  country,  and  may  occur 
after  the  manner  of  intermittent  malarial  paroxysms.  That  due  to  the 
renal  congestion  of  chronic  heart-,  lung-,  or  liver-disease  is  not  a  marked 
condition,  and  has  not  been  of  frequent  occurrence  in  my  experience. 

(4)  Essential  Hematuria. — Senator  describes  a  form  of  hematuria  that 
is  sometimes  seen  in  young  persons  whose  health  may  be  quite  fair,  the 
blood  often  appearing  paroxysmally  and  without  apparent  cause  ("  renal 
hemophilia").  The  view  is  gaining  ground,  Avith  added  experience,  that 
so-called  symptomless  bleeding  from  the  kidney  is  usually  due  to  localized 
disease  in  the  cortex.  There  is  an  idiopathic  (family)  or  congenital  hema- 
turia.    Hematuria  may  be  also  a  manifestation  of  vicarious  menstruation. 

(5)  Endemic  hematuria  is  that  variety  found  in  some  of  the  tropical 
regions  where  the  distoma  hoematobium  (a  trematode  worm)  abounds. 

Diagnosis. — This  has  for  its  object  the  discovery  (1)  of  blood  in 
the  urine,  and  (2)  of  the  source  of  the  hemorrhage.  Bloody  urine 
varies  in  color  according  to  the  (juantity  of  blood  present,  to  its  condi- 
tion (coagulability),  disposition,  and  the  length  of  time  present  in  the 
urine.  A  light  reddish  tinge  or  ''smoky"  hue  may  indicate  a  slight 
([uantity  of  blood.  A  dark  coagulum  may  be  at  the  bottom  as  a  sediment, 
with  small  clots  floating  above  in  a  deep-red,  turbid  layer,  above  which, 
again,  the  urine  may  show  but  the  slightest  tint  of  red.  Microscojneally, 
the  blood-corpuscles  are  readily  discovered,  establishing  the  diagnosis 
from  hemoglobinuria,  in  which  condition  they  are  absent.'  When  red 
corpuscles  are  associated  with  tube-casts,  renal  hemorrhage  may  be  posi- 
tively diagnosed.  In  ammoniacal  urine  the  corpuscles  are  very  pale  and 
shadowy  (dissolved  hemoglobin).  After  remaining  in  ordinary  acid  and 
diluted  urine  they  lose  their  disk-like  shape  and  swell  into  spheres  of  a 
smaller  diameter.  Crine  containing  blood  always  shows  the  presence  of 
albumin.     According  to  Newman"  a  ratio  of  albumin  to  hemoglobin  in 

'  Hutchinson  and  Rainy,  Clinical  Method.",  p.  8.S7,  point  out  a  source  of  fallacy:  "In 
alkaline  urinen,  especially  if  they  have  stood  for  some  time,  the  red  cells  are  apt  to  swell 
up  and  disappear." 

=*  The  Lancet,  July  9,  1898. 


HEMOGL  OB  IN  UlilA .  985 

excess  of  1  to  1.6  indicates  not  only  an  independent  albuminuria  but 
also  a  renal  affection  as  the  cause  of  the  liematuria. 

Chemically,  the  blood-i)ij^ment  may  he  detected  by  J  teller's  test, 
which  consists  in  adding  liquor  potassae,  boiling  the  urine,  and  observing 
the  flakes  of  precipitating  phosphates,  which  become  reddish-yellow  or 
brown  from  the  added  heinochromogen.  The  guaiacum  test  is  also  used. 
The  spectroscope  is  sometimes  employed  to  discover  the  bands  of  alkaline 
hematin  in  the  precipitate  which  is  conclusive.  Leede  recommends  the 
accumulation  of  as  many  erythrocytes  as  possible  by  filtering  a  large 
amount  of  urine  and  applying  the  guaiac,  or  other  chemical,  tests  to  the 
residue  left  on  the  filter. 

The  source  of  the  hlood  in  hematuria  is  of  great  diagnostic  and  thera- 
peutic importance.  In  renal  hemorrhage  the  blood  is  thoroughly  mixed 
with  the  urine,  giving  a  uniformly  red,  "smoky,"  or  brown  color  (due  to 
methemoglobin),  as  in  hemorrhagic  nephritis.  Blood-casts  and  leuko- 
cytes may  also  be  found.  The  disease  causing  hematuria  may  be  traced 
sometimes  by  a  study  of  the  urine;  thus,  in  valvular  cardiac  disease  the 
sudden  appearance  of  hematuria  would  indicate  infarction  of  the  kidney. 
The  discovery  of  a  few  red  blood-corpuscles  in  a  concentrated  urine  would 
point  to  renal  congestion.  In  profuse  renal  hemorrhages  clots  represent- 
ing moulds  of  the  renal  pelves  and  of  the  ureters  may  be  discharged. 
Hemorrhage  due  to  calculus  is  usually  small  in  amount  and  appears  at  more 
or  less  prolonged  intervals.  Tubercular  hemorrhages  may  occur.  Blood 
from  the  ureters  is  usually  moulded  in  clots  in  the  shape  of  curved  cylinders, 
and  appears  like  small  dark  worms  in  the  urine.  Casts  from  the  ureters  are 
often  secondary  to  hemorrhages ;  in  such  cases  the  hematuria  may  alter- 
nate with  the  passage  of  clear  urine,  owing  to  temporary  hemorrhages  or 
to  the  blocking  of  the  ureter  on  the  diseased  side.     (See  also  Fibrinuria.) 

Vesical  hemorrhages  may  be  copious.  The  blood  and  ui'ine  are  not 
intimately  mixed,  and  large  clots  settle  on  standing.  The  first  portions 
of  urine  discharged  may  not  be  bloody,  while  the  last  may  consist  of  pure 
blood.  Urethral  blood  is  discharged  before  the  urine,  and  either  comes 
away  freely  or  may  be  "  milked  out  "  independently  of  urination. 

The  enaoscope  has  been  used  successfully  to  determine  the  source  of 
the  hemorrhage  (which  kidney  ?).     It  is  especially  useful  in  women. 

Prognosis. — This  varies  with  the  primary  source  of  the  hematuria. 

The  treatment  consists  primarily  in  rest  in  bed.  The  application 
of  dry  cold  to  the  loins  is  useful,  and  the  hypodermic  injection  of  ergotol 
is  to  be  recommended  for  trial.  Internally,  such  hemostatics  as  the  ex- 
tract of  hamamelis  virgrnica,  the  extract  of  hydrastis  canadensis,  gallic 
acid,  lead  acetate,  calcium  chlorid,  ergot,  and  opium  may  be  used. 
Cantharides  tincture  in  2-  to  5-drop  doses  has  been  tried  with  good 
results  in  hematuria  due  to  renal  congestion.  The  good  results  follow- 
ing the  use  of  a  10  per  cent,  solution  (a  pint  daily)  have  attracted  some 
attention  recently. 

HEMOGLOBINURIA. 

Definition. — ^The  presence  of  blood-pigments,  especially  methemo- 
globin, in  the  urine. 

;^tiology. — The  direct  cause  of  hemoglobinuria  is  a  condition  of 
the  blood  in  which,  as  a  result  of  the  dissolution  of  the  red  corpuscles, 
the  hemoglobin  is  set  free  and  is  excreted  by  the  kidneys. 


986  DISEASES  OF  THE   URINARY  SYSTEM. 

(1)  The  causes  of  the  hemolysis  are  principally  toxic,  and  include  the 
following:  (a)  Poisons  (carbolic  and  pyrogallic  acids,  potassium  chlo- 
rate, naphtol,  phosphorus,  arseniuretted  hydrogen,  and  carbon  dioxid). 
(b)  The  ingestion  of  poisonous  fungi  or  of  tainted  edible  mushrooma 
(llelveUa  escuhnta).  (c)  The  poisons  of  certain  infectious  diseases 
(scarlatina,  typhus  and  typhoid  fevers,  yellow  fever,  syphilis,  scurvy, 
purpura),  (d)  Extensive  burns,  the  absorption  of  hemorrhagic  eftusions, 
and  the  transfusion  of  animal  blood,  (e)  Rarely  it  may  be  due  to  ex- 
posure to  cold  and  to  violent  physical  exertion.  (/)  The  so-called  epi- 
demic Jiemoijlohi)iuria  (Winckel's  disease)  occurring  in  the  newborn. 

(2)  Paroxysmal  hemoglobinuria,  a  rare  variety,  may  occur  without  any 
apparent  cause  in  persons  enjoying  otherwise  good  health.  It  appears 
as  an  independent  disease  and  the  pigment  present  in  the  urine  consists 
largely  of  metheraoglobin.  Houiolytic  experiments  by  Ruziezka  and 
Levadet  show  that  the  phagocytes  attack  the  erythrocytes,  in  consequence 
of  the  union  of  an  intermediary  body  (toxin)  Avith  the  red  corpuscles  in 
this  disease.  The  toxin  is  driven  into  the  blood  during  or  before  the 
paroxysm  by  marked  exertion  or  chill.  It  is  held  by  some  to  be  a  mani- 
festation of  Raynaud's  disease,  uricemia,  and  by  others  to  be  due  to  syphilis. 

(3)  It  appears  as  a  symptom  of  malaria  in  the  southern  part  of  thii 
country.  This  is  termed  malignant  malarial  hemoijlobinuria  or  hemo- 
glohinuric  fever.     In  Africa  it  is  called  hlack-ioater  fever. 

Symptoms. — These  are  generally  the  symptoms  of  the  condition 
that  accomjianies  hemoglobinuria.  In  paroxysmal  hemoglobinuria  the 
attacks  are  usually  sudden,  brief  in  duration,  and  sometimes  intermit- 
tent, especially  when  of  malarial  origin.  An  anemic  condition  seems  to 
be  essential  to  the  production  of  malarial  hemoglobinuria.  Jaundice 
may  be  an  associated  symptom.  The  hemoglobinuria  seldom  lasts  for 
more  than  two  days,  though  very  grave  cases  take  on  the  aspect  of  a 
pernicious  malarial  attack.  There  may  be  lumbar  ))ains,  chills  and  fever, 
and  gastric  disturbances.  Urticaria  and  purpura  have  also  been  noted, 
as  has  anemia  in  cases  in  which  frequent  attacks  have  taken  place. 

Diagnosis. — This  is  made  by  an  examination  of  the  urine.  Macro- 
scopicall}",  it  is  of  a  red-brown  color,  slightly  turbid,  with  a  reddish- 
brown  or  brownish-black  sediment.  The  reaction  is  usually  acid,  and 
the  specific  gravity  slightly  lowered.  The  microscopic  features  that 
distinguish  hemoglobinuria  from  hematuria  are  variable.  In  the  former 
condition  few  or  no  red  corpuscles  are  present,  and  the  few  that  may  be 
seen  are  usually  colorless  (''  shadows  ")  or  fragmentary.  Small  flakes  or 
granules  of  disintegrated  hemoglobin  are  found*,  and  are  brownish-black 
in  color.  There  may  be  also  brown-tinged  casts  and  epithelium. 
Chemically,  the  urine  is  found  to  contain  albumin,  for  the  discovery 
of  Avhich  Heller's  and  the  guaiac  tests  for  blood-pigment  may  be 
tried.  The  former  has  been  described  in  the  preceding  discussion 
of  Hematuria.  The  guaiac  test  consists  in  overlaying  with  urine  a 
mixture  of  the  tincture  of  guaiac  and  hydrogen  peroxid  or  the  oil  of 
turpentine  (equal  parts).  When  the  blood-coloring  matter  is  present, 
an  indigo-blue  ring  is  formed  above  a  white  resinous  deposit.  When 
shaken  a  lighter  blue  color  develops  throughout  the  contents.  By 
means  of  the  spectroscope  the  three  absorption-bands  of  methemoglobin 
may   be  seen   (red,   green,    and  yellow).      Th&  blood-serum   in    hemo- 


ALBUMINURIA.  987 

globinuria  may  be  somewhat  red-tiriffed  on  account  of  the  dissolved 
hemoglobin.  The  hemoglobinuria  is  further  marked  by  the  aplasticity 
of  the  red  corpuscles,  by  tiieir  pallor,  by  poikilocytosis,  and  by  the 
presence  of  the  irregular  flakes  of  hemoglobin. 

The  prognosis  is  favorable  in  the  ordinary  paroxysmal  form.  Malio'- 
nant  malarial  hemoglobinuria,  however,  is  often  fatal. 

Treatment. — Hemoglobinuria  is  rather  intractable.  During  the 
paroxysms  external  warmth  is  needed,  along  with  hot  drinks  to  encour- 
age perspiration.  In  malarial  cases  quinin,  and  in  syphilitic  the  iodids, 
should  be  administered ;  although  by  some  it  is  believed  that  quinin 
may  aggravate  the  syndrome  in  particular  cases. 

ALBUMINURIA. 

Definition. — The  presence  of  albumin  in  the  urine. 

Pathology  and  !^tiology. — The  immediate  cause  is  the  escape  of 
the  normal  blood-constituents,  serum-albumin  and  serum-globulin,  from 
the  vessels  into  the  renal  tubules.  This  transudation  of  albumin  indi- 
cates either  a  transient  and  slight  or  a  permanent  and  grave  nutritional 
disturbance  of  either  the  epithelium  lining  the  glomeruli  or  of  that  of 
the  contained  tufts  of  capillaries,  or,  possibly,  of  the  memhrana  propria 
or  the  epithelium  of  the  uriniferous  tubules.  These  changes  induce  and 
offer  an  abnormal  perviousness  to  the  albumin  of  the  blood. 

The  principal  causes  of  albuminuria  are — (1)  Those  associated  with 
definite  lesions  of  the  kidney  ;  nephritis,  acute  and  chronic  ;  renal  con- 
gestions, active  and  passive  (the  latter  being  secondary  to  chronic  liver-, 
heart-,  and  lung-disease,  pregnancy,  or  tumors) ;  and  certain  toxemias. 
Among  the  last-named  are  included  scarlet  fever  (scarlatinal  nephritis) 
and  gout.  Other  causes  are — amyloid  and  fatty  degeneration  of  the 
kidney,  suppurative  nephritis,  and  renal  tumors  (cystic  kidney). 

Albuminuria  occurs  also  in  conditions  in  which  (2)  the  renal  lesions 
are  either  slight  or  undemonstrable :  (a)  Thus,  it  is  present  in  blood- 
changes,  as  in  chronic  lead-,  mercury-,  and  arsenic-poisoning,  scurvy, 
purpura,  syphilis,  leukemia,  or  extreme  anemia,  and  in  cases  in  which 
urobilin  or  bile-pigment  and  sugar  (glucose)  circulate  in  the  blood. 
Again,  slight  albuminuria  may  be  pi^esent  in  pregnancy,  in  saccharin  dia- 
betes, and  after  etherization.  In  certain  affections  of  the  nervous  system 
albumin  is  found  in  small  quantity,  as  after  an  epileptic  paroxysm,  in 
tetanus,  apoplexy,  and  exophthalmic  goiter. 

(6)  The  so-called  accidental  or  spurious  albuminuria  is  due  to  the 
presence  of  pus  or  blood ;  in  such  cases  the  condition  is  not  a  true 
renal  albuminuria,  since  it  is  commonly  associated  with  cystitis,  pyelitis, 
urethritis,  or  is  the  result  of  hemorrhage  from  the  pelvis  of  the  kidney, 
from  the  ureters,  bladder,  or  urethra.  Chemical  injury  of  the  bladder 
may  cause  a  reflex  albuminuria  (Evans,  Wynne,  and  Whipple). 

(c)  Febrile  albuminuria  is  of  rather  frequent  occurrence  in  diseases 
accompanied  by  pyrexia,  especially  when  long  continued.  Among  these 
are  typhoid  fever,  small-pox,  yellow  fever,  diphtheria,  and  even  influenza, 
follicular  tonsillitis,  and  pneumonitis.  The  renal  changes  in  these  cases 
are,  I  believe,  merely  a  transitory  cloudy,  swelling  in  the  glomeruli, 
which,  together  with  the  albuminuria,  rarely  lasts  longer  than  the  fever. 

(d)  Other  forms  of  albuminuria  have  been  styled  physiologic  or  func- 
tio^ial,  transient,  dietetic,  neurotic,  intermittent,  and  cyclic  :  in  these  no 


988  DISEASES  OF  THE   URINARY  SYSTEM. 

definite  lesions  of  the  kidney  are  found,  and  are  denied  by  some  to  exist. 
Recent  observers  are  inclined  to  believe  that  trivial,  non-progressive 
renal  changes  occur  in  these  cases.  Slight  albuminuria  certainly  does 
occur  in  some  cases  after  a  heavy  meal  rich  in  albumin,  after  marked 
and  prolonged  muscular  exertion,  intense  emotion,  and  cold  bathing. 

((')  Cyclic  albuminuria  has  come  to  be  of  greater  interest  and  impor- 
tance in  later  years,  particularly  as  it  bears  upon  the  prognosis  and  upon 
life-insurance  risks.  In  this  variety  there  are  a  periodic  appearance  and 
absence  of  albumin  in  the  urine.  The  albuminuric  paroxysms  are  very 
variable,  recurring  usually  after  meals  or  on  exertion,  according  to 
some,  largely  the  result  of  the  assumption  of  the  upright  posture  upon 
rising  from  bed,  but  generally  being  absent  during  rest  at  night  and 
during  the  evening  hours.  The  albumin  is  present  in  but  small  quan- 
tity, and  only  rarely  are  casts  (hyaline)  found.  The  accompanying  signs 
and  symptoms  common  to  nephritis  are  absent.  Cyclic  albuminuria  is 
most  common  in  adolescent  anemic  males  of  poor  nutrition  (ga*>tro-into8- 
tinal  auto-intoxication  ?),  dyspeptic,  neuralgic,  often  neurotic,  and  even 
hysteric.  Under  careful  management  these  cases  ordinarily  recover. 
There  is,  however,  a  class  of  cases  in  which  the  albuminuria  is  persistent 
even  after  fasting,  though  but  a  mere  trace  of  albumin  may  be  detected. 
After  the  administration  of  a  diuretic  or  on  stimulating  the  heart  the 
albumin  may  decrease  in  amount  (Edel).  However,  an  insidious  degen- 
eration of  kidney-structure  may  manifest  itself  many  years  later.  Albu- 
minuria may  rarely  be  hereditary  (Renault).  Slight  senile  albuminuria, 
without  evidence  of  renal  disease,  is  not  uncommon. 

Orthostatic  Albuminuria. — This  is  a  variety  of  albuminuria  caused  by 
the  upright  posture  (Aubertin).  It  appen.rs  onl}'^  after  standing.  Aubertin 
reports  4  cases,  and  he  concludes  that  orthostatic  albuminuria  represents 
the  terminal  stage  of  a  nephritis,  oi'  some  disturbance  of  the  renal  circu- 
lation. Engel  ascribes  orthostatic  albuminuria  to  an  existing  nephritis, 
in  which  the  cells  of  the  kidney,  however,  recuperate  when  the  patient 
lies  down.  Gillett  has  well  said  the  majority  of  cases  of  cyclic  albu- 
minuria are  also  orthostatic.  Lordosis,  with  or  without  movable  kidney, 
may  be  responsible  for  the  development  of  the  albuminuria  (Jehle). 

Diagnosis. — This  rests  upon  the  discovery  of  albumin  in  the  urine. 
For  the  diagnosis  of  cyclic  albuminuria,  specimens  of  urine  passed  at 
different  times  of  the  day  must  be  examined. 

Diflferential  Diagnosis. — Inquiry  and  careful  inference  concerning  the 
etiology  of  a  given  case  must  be  made,  lletial  alhuniinuria  is  persist- 
ent and  of  considerable  quantity,  except  in  chronic  interstitial  nephritis. 
Tube-casts  are  usually  present.  Functional  albuminuria  is  slight  and 
inconstant.  Tube-casts  are  usualW  absent  in  the  latter.  Again,  in  the 
former  variety,  general  symptoms,  as  dropsy,  cardiac  hypertrophy,  anemia, 
and  uremic  prodromes,  are  present.  It  is  true  that  slight  edema  is  some- 
times found  in  cyclic  albuminuria,  but  this  is  probably  due  to  the  marked 
aneuiia  that  is  so  often  seen.  Such  conditions  as  gleet  and  leukorrhea 
must  also  be  excluded. 

Tests  for  Albumin. — Two  samples  of  urine,  one  of  the  morning  before 
any  food  is  taken,  and  one- of  the  evening  before  the  patient  retires, 
should  be  examined.  The  smallest  quantity  can  be  detected  only  by  its 
coagulum  rendering  the  urine  turbid;  hence  any  turbidity  present  before 
the  given  test  is  made  should  be  removed  by  filtration,  unless  this  tur- 


ALBUMINURIA.  989 

bidity  be  due  to  urates,  when  a  little  warming  of  the  tube  will  render  the 
urine  clear. 

(1)  Boiling  Test. — This  is  the  comnionest  and  F  think  the  most  reli- 
able practical  test  for  albumin.  The  tube  is  filled  about  two-thirds  full 
of  urine.  If  alkaline  or  neutral  in  reaction,  a  drop  of  acetic  or  nitric 
acid  is  added ;  an  excess  of  acid  must  be  carefully  avoided,  lest  the 
albumin  (if  present)  be  converted  into  a  non-coagulable  form.  The  tube, 
held  aslant,  is  then  applied  to  the  flame,  and  slowly  revolved  with  the 
fingers,  so  that  the  upper  portion  of  the  column  of  urine  is  brought  to 
the  boiling-point.  A  comparison  of  this  with  the  lower  portion  of  the 
urine  is  made.  Any  turbidity  is  due  to  albumin  or  phosphates.  If 
albumin,  adding  a  few  drops  of  nitric  acid  will  increase  and  thicken  the 
coagulum ;  if  phosphate,  the  opaqueness  will  be  cleared  at  once. 

(2)  Heller  s  Nitric-acid  Test. — This  is  both  delicate  and  satisfactory. 
About  1  c.cm.  of  nitric  acid  is  poured  into  a  tube,  and  some  urine  is 
allowed  to  flow  slowly  from  a  pipet  and  settle  upon  the  acid.  The  pres- 
ence of  albumin  is  indicated  by  a  white  ring  at  the  point  of  contact  of  the 
two  liquids.  Uric  acid,  urates,  and  certain  urinary  coloring-matters 
form  a  pink  or  deep-red  ring  or  zone ;  this  forms,  as  a  rule,  above  the 
juncture  of  the  acid  and  urine.  Hemialbumose  also  gives  a  white  zone, 
but  does  not  respond  to  the  boiling  test  as  does  serum-albumin. 

Boston  s  Pipet  Method.^ — "  Reagents  :  (1)  concentrated  nitric  acid,  or 
(2)  nitric  acid  1  part  and  saturated  solution  of  magnesium  sulphate  9  parts. 

"  Albumin  causes  a  white  cloud  to  appear  in  the  form  of  a  ring  at  the 
zone  of  contact  of  the  two  liquids  (reagents  and  urine),  and  this  test, 
when  carefully  applied,  must  be  regarded  as  one  of  great  value. 

"  1.  A  pipet  is  filled  for  a  distance  of  from  one  inch  to  one  and  one- 
half  inches  with  the  urine  to  be  tested.  The  urine  is  then  removed  from 
the  surface  of  the  pipet  by  washing  or  by  wiping. 

"  2.  The  pipet,  with  its  contained  urine,  is  then  placed  near  the 
bottom  of  a  bottle  containing  nitric  acid,  when  the  pressure  of  the  index- 
finger  is  lessened  and  the  acid  allowed  to  flow  gradually  up  into  the  pipet. 

"  3.  When  the  pipet  is  seen  to  contain  about  equal  amounts  of  acid 
and  virine,  the  finger  is  again  pressed  firmly  upon  the  top  of  the  pipet, 
which  is  then  removed  from  the  bottle  and  held  toward  the  light  on  a 
level  with  the  eye.  If  albumin  is  present,  a  distinct  white  ring  of  coagu- 
lated albumin  appears  at  the  junction  of  the  urine  and  the  reagent." 

(3)  Johnson  s  Picric-acid  Test. — To  filtered  urine  in  a  test-tube  are 
slowly  added  a  few  drops  of  a  saturated  watery  solution  of  picric  acid. 
Immediate  turbidity  indicates  albumin.  Some  authorities  prefer  that  a 
dram  or  two  (4.0-8.0)  of  the  yellow  fluid  be  placed  gently  on  the  surface 
of  the  urine,  when,  if  albumin  is  present,  a  white  zone  at  once  is  appa- 
rent, together  with  a  haziness  that  spreads  downward  with  the  difi'usion 
of  the  liquids.  Heating  emphasizes  the  evidence  of  the  test,  which  is 
extremely  sensitive. 

(4)  Roberts'  nitric-magnesium  test  is  also  very  delicate.  It  consists 
in  using  the  following  mixture,  just  as  in  Heller's  test:  one  volume  of 
concentrated  nitric  acid,  added  to  five  volumes  of  a  saturated  solution 
of  magnesium  sulphate. 

(5)  Tricliloracetic-acid  Test. — This  will  discover  minute  traces  of 
albumin,  but  has  the  disadvantage  that  it  responds  to  nucieo-albumin 

1  Medical  Diagnosis,  Andera  and  Boston,  p.  606. 


990  DISEASES  OF  THE   URINARY  SYSTEM. 

as  well  as  to  serum-albumin.  A  few  crystals  may  be  dropped  into  the 
urine,  or  a  saturated  solution  may  be  used  after  the  "contact  method," 
when,  if  albumin  be  present,  a  white  coagulum  forms.  This  and  the 
Geisler  test-papers  (Vierordt)  constitute  portable  and  handy  tests. 

(6)  The  acttie-acid  and  potassiuni-ferroci/cDiid  test  is  minutely  sensi- 
tive, but  gives  a  precipitate  with  other  albuminoid  bodies.  The  urine  is 
first  acidulated  with  acetic  acid.  A  few  drops  of  a  freshly  prepared 
solution  of  potassium  ferrocyanid  are  then  added,  and  if  either  albumin 
or  hemialbumose  be  present,  it  will  be  precipitated. 

(7)  Quantitative  Test. — Usbach's  Album  in  oineter. — This  consists  in 
usinff  a  graduated  test-tube,  into  Avhich  definite  amounts  of  urine  and  a 
reagent  composed  of  10  parts  of  picric  acid,  20  of  citric  acid,  and  enough 
water  to  make  1000  parts  are  carefully  mixed  by  reversing  several  times 
the  stoppered  tube.  After  allowing  this  to  stand  about  twenty-four 
hours,  the  height  of  the  precipitated  albumin  is  read  off  on  an  etched 
scale,  which  will  indicate  approximately  the  parts  per  thousand.  Not 
less  than  0.5  part  per  thousand  can  be  estimated  correctly,  however. 
Tsuchiya  has  suggested  the  use  of  a  solution  of  phosphotungstic  acid  as 
follows:  Phosphotungstic  acid,  1.59  grams;  hydrochloric  acid  (conct.), 
5  c.c.  ;  ethyl  alcohol,  q.  s.  ad  100  c.c.  This  solution  is  substituted  for 
the  picric  acid  solution,  and  is  used  in  Esbach  tubes.  Should  there  be  a 
hematuria,  if  the  percentage  of  albumin  by  Esbach's  method,  divided 
into  the  number  of  red  cells  per  cubic  centimeter  of  urine,  is  less  than 
30.000,  it  suggests  a  purely  hematuric  albuminuria;  if  greater,  it  sug- 
gests an  independent  albuminuria  (Goldberg). 

Prognosis. — Etiologic  considerations  bear  heavily  in  this  matter. 
The  febrile,  hemic,  cyclic,  and  paroxysmal  varieties  usually  clear  up  with 
convalescence  and  with  advancing  years  (in  the  latter  case).  The  per- 
sistence of  albumin  in  these  cases,  however,  even  in  slight  amounts  or  at 
variable  periods,  should  cause  suspicion.  Personal  observation  leads  me 
to  believe  that  in  many  cases  the  function  of  the  renal  epithelium  has 
suffered.  Especially  is  this  true  when  there  is  associated  a  gradually  in- 
creasing arterial  tension.  The  presence  of  tube-casts  is  conclusive  of 
structural  change  in  the  kidneys. 

PROTEINURIA. 

[AlhiiiiKi.^iiria. ) 

Protein  may  appear  in  the  urine  as  a  result  of  pathologic  condi- 
tions, especially  myeloma,  and  is  dependent  upon  the  decomposition  of 
organized  pruteids!^  It  is  a  body  more  or  less  closely  allied  to  peptones, 
globin,  histon.  and  tlie  digestion  albumoses,  but  it  disi)lays  certain  charac- 
teristics unknown  to  these  substances.  The  nature  of  the  exciting  cause 
is  unknown  ;   it  may  be  bacterial  or  chemical  (phosphorus). 

Anders  and  Boston^  have  reviewed  all  the  cases  of  albumosuria  avail- 
able in  the  literature — 30  in  number — and  gave  an  account  of  three 
examples  that  fell  under  their  observation.  These  studies  appear  to 
warrant  the  following  inferences :  Nearly  all  cases  of  albumosuria  mani. 
fest  themselves  after  forty  years  of  age.  Males  are  affected  in  80  per 
cent,  of  the  cases.  Multiple  myeloma  figured  in  80  per  cent.,  hence 
albumosuria  is  suggestive  of  myeloma  and  may  be  diagnostic. 

1  Transactions  of  (he  VoUeye  oj  Physicians,  vol.  xxiv.,  The  Lancet,  January  10,  1903. 


INDWANURIA.  991 

SymptoniH. — Proteinuria  may  be  persistent,  transitory,  or,  less  com- 
monly, remittent,  and  it  occurs  in  variable  degrees  at  different  hours 
during  the  day.  The  urine  may  show  the  presence  of  combined  serum- 
albumin,  but  tube-casts  are  present  in  rare  instances  only.  Pain  is  an 
almost  constant  feature  and  is  aggravated  on  pressure  over  the  affectfd 
bones.  Bence-Jones  protein  (myelopathic  albumosuria  ;  Kahler's  disease) 
is  symptomatic  of  certain  infections  (tuberculosis,  pneumonia).  Of  interest 
is  the  proteinuria  of  pneumonia,  in  view  of  the  recent  theory  that  reso- 
lution in  this  disease  is  the  result  of  the  action  of  certain  ferments. 
Proteinuria  is  absolutely  diagnostic  of  disease  of  the  marrow  of  the 
bones,  but  it  only  points  toward  multiple  myeloma  when  other  symptoms 
of  the  latter  condition  are  present.  It  is  distinguishable  from  ordinary 
albuminuria  by  the  production  of  cloudiness  in  the  urine  when  heated  to 
50°  or  60°  C,  and  by  solution  of  the  precipitate  at  higher  temperatures.  It 
is  of  grave  prognostic  significance  and  runs  a  fatal  course  within  two  years. 

INDICANURIA. 

Definition. — The  presence  of  a  pathologic  quantity  of  indican  in 
the  urine.  Indican  occurs  in  the  urine  in  health  in  very  small  quanti- 
ties, and  is,  chemically  speaking,  indoxyl-potassium  sulphate. 

Pathology  and  Ktiology. — Indican  is  increased  abnormally  in 
the  urine  by  any  disorder  whereby  large  quantities  of  albuminous  mat- 
ters *are  decomposed.  Thus,  it  occurs  in  ileus,  which  produces  a  stag- 
nation of  the  contents  and  a  consequent  decomposition  from  bacterial 
action.  Under  such  circumstances  indol  and  phenol  are  formed.  The 
former,  being  absorbed  and  oxidized  into  indoxyl,  finally  appears  in  the 
urine  in  combination  with  potassium  sulphate.  Acute  and  chronic  peri- 
tonitis, wasting  diseases,  and  cachectic  conditions  in  which  there  is  a 
considerable  destruction  of  albuminoids  (as  in  Addison's  disease,  neo- 
plasmata,  cholera  Asiatica,  and  empyema)  usually  have  an  associated 
indicanuria.  Increased  indicanuria  occurs  when  there  is  an  impediment 
to  peristalsis  of  the  small  intestine,  hence  is  not  seen  in  simple  uncom- 
plicated constipation.  Since  the  pancreatic  secretion  peptonizes  the  pro- 
teids  from  which  arise  leucin  and  tyrosin,  and  these  in  turn  are  decom- 
posed into  skatol,  indol,  and  phenol,  it  is  stated  (Piseuti)  that  any 
obstruction  preventing  the  flow  of  the  pancreatic  juice  into  the  bowel 
would  be  reflected  in  a  diminished  quantity  of  indican  in  the  urine.  An 
increased  indicanuria  is  encountered  when  anachlorhydria  or  hypochlor- 
hydria  exists  (e.  ^.,  gastric  carcinoma — Simon). 

Diagnosis. — This  depends  upon  the  demonstration  of  indican  by 
adding  strong  oxidizing  agents,  which  decompose  this  product  and  set 
the  indigo  or  pigment  free.  At  times  the  urine  may  present  a  cloudy, 
bluish,  or  even  blue-black  appearance.  This  may  be  seen  in  urine  that 
has  been  standing  for  some  time,  the  sediment  giving  a  bluish  reflection, 
or  there  may  be  a  blue  turbid  film  on  the  surface.  Porter  ^  holds  that  a 
decidedly  bluish-black  color  shows  an  intense  type  of  putrefactive  fer- 
mentation with  the  production  of  highly  toxic  substances,  capable  of 
giving  rise  to  severe  toxemia.  A  reddish  shading  of  the  blue  or  a  red- 
dish-green color  shows  obstruction  to  the  fi'ee  flow  of  bile  through  the  duct. 
A  greenish  tinge  indicates  an  obstruction  to  the  internal  or  intrahepatic 
branches  of  the  bile-ducts.    These  patients  bear  surgical  interference  badly. 

^Archives  of  Diagnosis,  April,  1908. 


992  DISEASES  OF  THE   URISAEY  SYSTEM., 

Tests. — Jaffe's  well-known  test  consists  in  mixing  equal  volumes  of 
urine  and  liydrocliloric  acid,  and  then  adding,  drop  by  drop,  a  concen- 
trated solution  of  chlorinated  lime,  shaking  the  tube  after  each  addition.. 
A  strong  indigo-blue  color  appears  if  there  is  much  indican. 

A  good  modified  test  is  the  use  of  fuming  nitrohydrochloric  acid 
and  urine  (equal  parts)  and  a  saturated  solution  of  chlorinated  potash, 
used  as  in  the  above  method.  A  blue-black  cloud  or  ring  appears  below 
the  suriace.  If  a  few  drops  of  chloroform  are  then  added  and  the  mix- 
ture is  ajritated  slightlv,  a  blue  color  settles  at  the  bottom,  owing  to  the 
chloroform  carrying  with  it  the  oxidized  indican.  H.  Strauss'  gives  a 
new  and  convenient  clinical  method  for  the  quantitative  determination 
of  indican  in  the  urine.  A  correct  interpretation  of  indican  reactions 
serves  as  a  guide  both  as  regards  diagnosis  and  prognosis. 

PYURIA. 

Definition. — The  presence  of  pus  in  the  urine. 

Ktiology. — Pyuria  is  due  to  (1)  suppurative  inflammation  along  some 
portion  of  the  genito-urinary  tract,  or  (2)  to  the  rupture  of  adjacent  ab- 
scesses into  the  tract. 

Pyelitis  and  Pyelo-nephritis. — Pus  from  the  pelvis  of  the  kidney  may 
be  due  to  calculous,  tuberculous,  or  other  irritation.  It  is  associated  at 
times  Avith  the  ''railed'  or  transitional  epithelium  usually  seen  early  in 
the  case.  In  pyelo-nephritis  casts  may  indicate  renal  involvement, 
although  it  should  be  borne  in  mind  that  in  abscess  of  the  kidney  pus 
may  be  discharged  continuously  without  the  appearance  of  any  casts  in 
the  urine  whatsoever.  One  such  case  came  to  necropsy  under  the  ob- 
servation of  H.  S.  Anders,  in  Avhich  small  uratic  calculi  were  dis- 
charged now  and  then  for  several  years.  Later,  several  larger  stones 
were  removed  from  the  bladder  by  AVillard  by  suprapubic  cystotomy. 
The  abdominal  opening  healed  in  a  few  months,  but  pyuria  persisted. 
Death  occurred,  and  it  was  found  j^ostmortnn  that  a  large  abscess  occu- 
pied the  loAver  third  of  the  left  kidney,  which  was  filled  with  small,  dark, 
and  irregularly-shaped  calculi.  A  thick  pyogenic  menibiane  surrounded 
the  purulent  and  calculous  contents.  No  casts  were  found  at  any  time 
during  life,  and  renal  symptoms  were  altogether  absent. 

The  pyuria  is  sometimes  intermittent,  one  ureter  becoming  tempor- 
arily occluded  (on  the  side  of  the  disease),  the  clear,  normal  urine  from 
the  healthy  kidney  passing  until  the  ureteral  obstruction  is  relieved,  w  hen 
pus  again  appears.  Purulent  urine  from  the  kidney  is  usually  aCid  in 
reaction,  except  when  the  pyelo-nephritis  is  secondary  to  cystitis,  Avhen 
it  is  more  apt  to  be  alkaline  and  to  contain  a  decided  quantity  of  mucus. 
Cystitis. — Pyuria  in  this  affection  is  fetid  in  most  cases.  Bladder- 
symptoms  are  marked.  The  urine  is  alkaline,  and  a  stringy,  tenacious 
muco-pus  comes  with  the  last  portions.  Triple  phosphates  are  often  found. 
The  pus  and  urine  are  not  so  intimately  mixed  as  in  pyelonephritis. 

Urethritis. — The  pus  is  in  small  quantities,  is  passed  in  advance  of 
the  urine,  and  can  be  "milked  out."  There  is  a  history  of  gonorrheal 
infection,  and  the  gonococcus  may  be  demonstrated  in  most  cases. 

Rupture  of  contiguous  abscesses  into  the  urinary  tract  is  accompanied 
with  a  sudden  discharge  of  a  large  quantity  of  pus  in  the  urine,  preceded 
by  symptoms  of  abscess  elsewhere,  as  in  the  jielvis  or  right  iliac  fossa 
1  Deutsche  med.  Woch.,  \\n-i\  17,  1902. 


CHYLVRIA.  993 

(suppurative  appendicitis)  or  perinephric  abscess.  The  jtyuria  disappears 
as  abruptly  as  it  came  on,  or  lasts  but  a  few  days.  1'he  strongyluH  gigas 
in  the  pelvis  of  the  kidney  causes  pyuria  as  well  as  hematuria. 

Diagnosis. — Pus  gives  a  greenish-yellow  or  yellowish-white  tinge 
to  the  urine  and  sediment,  the  hitter  very  often  becoming  very  tenacious 
or  jelly-like  from  the  presence  of  mucus.  It  may  resemble  a  phosphatic 
precipitate,  as  in  cystitis;  the  latter,  however,  is  white,  lighter,  more  gran- 
ular, and  not  so  thick  or  tenacious.  Microscopically^  a  positive  diagnosis 
is  made  by  the  discovery  of  pus-corpuscles  (or  leukocytes)  with  their 
granular  protoplasm,  which  has  the  faculty  of  clearing  up  and  showing 
one  or  more  nuclei  upon  the  addition  of  acetic  acid.  The  corpuscles  are 
either  more  or  less  swollen  and  clear,  or  opaque,  granular,  or  even 
nucleated,  according  to  their  number,  the  length  of  time  in  the  urine, 
and  the  degree  of  alkalinity  or  acidity  of  the  latter.  A  few  phosphatic 
crystals  and  epithelium  may  be  seen. 

Chemically,  there  is  slight  albuminuria,  a  marked  amount  of  albu- 
min usually  indicating  renal  disease.  Reinecke  has  proposed  a  method 
for  determining  whether  all  the  albumin  can  be  accounted  for  by  the  pus. 
After  shaking  up  the  twenty-four-hour  specimen  to  diffuse  the  pus  evenly 
through  it,  he  counts  the  cells  present  by  means  of  a  hemocytometer. 
He  finds  that  100,000  pus-cells  per  c.mm.  should  correspond  to  1  per 
cent,  of  albumin  (Esbach).  It  is  obvious  that  this  method  falls  short  of 
accuracy,  although  approximately  reliable.  Nephritis  may  be  diagnosed 
in  connection  with  pyuria  by  the  discovery  of  casts.  On  the  addition 
of  liquor  potassae  to  urine  containing  pus  the  latter  is  converted  into  a 
clear  gelatinoid  substance ;  mucus,  on  the  other  hand,  becomes  thin  and 
flocculent.  Mucus  may  also  be  distinguished  from  pus  by  its  failure  to 
react  to  cold  nitric  acid,  whilst  the  albumin  of  purulent  fluid  coagulates. 

CHYLURIA. 

Definition. — The  presence  of  chyle  in  the  urine. 

l^tiology. — This  interesting  condition  may  be  either  parasitic  or 
non-parasitic  in  origin.  The  former  type  is  more  common  in  the  tropics, 
and  is  caused  by  an  engorgement  and  rupture  of  the  bladder  or  renal 
lymph-vessels,  due  to  obstruction  of  the  larger  branches  of  the  thoracic 
duct  or  in  the  duct  itself,  by  the  filaria  sanguinis  hominis  (vide  Filaria- 
sis).  It  is  held  to  follow  injuries  to  the  lymphatic  ducts,  and  may  be 
associated  with  pregnancy. 

Diagnosis. — The  urine  is  increased  in  quantity,  and  has  a  milky 
turbidity  {galacturia)  due  to  the  emulsified  fat.  After  standing  for  a  time 
a  light  coagulum  settles  to  the  bottom  and  a  creamy  pellicle  of  fat  rises 
to  the  surface.  The  sediment  contains  also  the  fibrin  of  the  chyle.  Some- 
times as  much  as  2  or  3  per  cent,  of  fat  is  present  {lipuria) ;  this  may 
be  tested  by  agitating  a  portion  of  the  urine  with  ether,  whereupon 
the  turbidity  disappears.  Owing  to  the  serum-albumin  in  the  chyle,  the 
various  tests  for  that  substance  would  show  traces  of  its  presence  in 
chyluria.  Hematuria  may  be  associated  with  chyluria,  especially  in 
parasitic  cases,  and  both  the  blood  and  urine  should  be  carefully  ex- 
amined for  filaria.  Microscopically,  chyle-containing  urine  resembles 
milk  in  its  millions  of  fine  granules  and  fat-droplets. 
63 


994  DISEASES  OF  THE   URINARY  SYSTEM. 

Prognosis. — Chyluria  is  intermittent  in  its  appearance,  correspond- 
ing to  the  times  of  rupture  of  the  vesical  lymphatics,  and  may  last  for 
years.  The  prognosis  of  non-parasitic  chyluria  is  good  as  to  life,  but 
unfavorable  as  to  cure. 

CHOLURIA. 

Definition. — Tlie  presence  of  bile-pigment  in  the  urine. 

Ktiology. — Choluria  may  be  caused  by  any  disease,  local  or  general, 
in  \\\nA\  Jdionh'cr  is  a  symptom. 

Diagnosis. — Bile-stained  urine  has  a  color  varying  from  a  green- 
ish-yellow to  a  brownish-green  or  brown-black,  resembling  porter.  When 
shaken  its  foam  assumes  a  characteristic  yellow  or  greenish-yellow  color. 
White  filter-paper  dipped  in  the  urine  is  stained  yellow. 

Tests. — The  chloroform  test  consists  in  adding  this  substance  to  the 
urine  and  allowing  it  to  settle  to  the  bottom  of  the  tube.  If  bile  or 
pigment  be  present,  the  gravitated  chloroform  will  be  colored  yellow. 

G-melins  test  is  most  commonly  employed,  though  it  is  not  the  most 
delicate.  A  few  drops  of  urine  and  nitric  acid  are  allowed  to  run 
together  on  a  white  porcelain  plate ;  if  bile-pigment  (bilirubin)  be  con- 
tained in  the  urine,  a  play  of  colors  ensues,  the  green  predominating,  fol- 
lowed by  the  blue,  violet,  and  red,  each  shade  representing  a  new  form 
of  pigment.  The  first  color  noticed  (green)  corresponds  to  the  biliver- 
din  or  normal  bile-pigment  of  herbaceous  animals.  This  oxidation  of 
bilirubin  into  biliverdin  is  better  accomplished  by  nitric  acid  containing 
a  little  nitrons  acid.  Hence,  the  test  may  be  improved  by  adding  enough 
fuming  nitric  to  ordinary  nitric  acid  to  form  a  yellow  trace  of  the  nitrous 
acid.  This  may  be  placed  in  a  test-tube,  and  some  of  the  urine  added 
gently  from  a  pipet.  Bile-pigment  will  be  indicated  by  successive  rings 
of  green,  blue,  violet,  and  red  from  above  downward ;  this  occurs,  how- 
ever, only  Avhen  considerable  bile-pigment  is  present. 

Mosenbach's  test  is  a  modification  of  Gmelin's,  and  is  more  distinct. 
The  urine  is  first  filtered,  and  a  drop  or  two  of  the  nitric-nitrous  acid  is 
then  poured  upon  the  filter-paper,  when  the  characteristic  colored  rings 
will  appear  if  bile  be  present.  According  to  Penzoldt,  the  Gmelin- 
Rosenbach  test  is  made  more  distinct  by  acidulating  the  filtrate  with 
acetic  acid  and  pouring  a  thin  layer  into  a  white  shallow  dish.  The 
acetic  acid  assumes  a  greenish-yellow,  and  later  a  green,  or  even  a  blue- 
green,  shade  if  bile  be  in  the  urine.  This  reaction  is  quickened  or  in- 
tensified by  the  application  of  heat  to  the  liquids. 

In  the  3Iarec1ial-Romi  test  a  mixture  of  one  part  of  the  tincture  of 
iodin  and  ten  parts  of  alcohol  is  spread  in  a  deep  layer  over  the  suspected 
urine  in  a  test-tube  or  glass.  A  grass-green  ring  forms  at  the  point  of 
contact  in  choluria. 

Bile-acids. — These  are  principally  the  glycocholic  and  taurocholic 
acids.  Traces  are  found  in  normal  urine,  and  their  clinical  significance 
or  diagnostic  importance,  as  far  as  is  known,  is  practically  nil. 

When  testing  for  bile-acids  the  Stranburger  modification  of  Petten- 
kofer's  method  may  be  used,  as  follows :  "  After  isolation  cane-sugar  is 
added  to  the  extract,  which  is  then  filtered.  A  drop  or  two  of  strong 
sulphuric  acid  is  spread  on  the  dried  filter ;  a  violet  or  purple  color 
appears"  (Musser). 


GLYCOSURIA.  995 

Other  constituents  of  the  urine  in  choluria  of  long  standing  are 
slight  quantities  of  albumin  and  icteric  or  yellow  bile-stained  hyaline 
or  finely-granular  casts. 

A  point  in  differential  diagnosis  should  be  noted.  Certain  drugs,  as 
rhubarb  and  santonin,  when  given  internally,  may  produce  a  discolora- 
tion of  the  urine  similar  to  that  caused  by  the  presence  of  bile.  On  agi- 
tation, however,  there  will  be  no  yellow  foam  and  no  reaction  to  the 
tests  for  bile,  while  the  addition  of  liquor  potassae  causes  a  red  color. 

UROBILINURIA. 

Definition. — The  presence  of  pathologic  quantities  of  urobilin  in 
the  urine.  Urobilin  is  the  principal  coloring-matter  of  the  urine,  and 
hence  is  present  in  normal  urine  in  small  quantity.  It  is  derived  from 
bilirubin  as  a  product  of  the  reduction  of  this  substance. 

When  present  in  large  quantities  urobilin  gives  to  the  urine  a  red- 
brown  color.  This  is  seen  in  fevers,  varying  in  depth  of  shade  according 
to  the  degree  of  pyrexia ;  also  in  diseases  of  the  liver,  after  hemorrhagic 
effusions  (;due  to  resorption),  in  the  hemorrhagic  diathesis,  in  purpura, 
and  in  progressive  pernicious  anemia.  Cavazza^  has  examined  20 
cases  of  urobilinuria  in  chlorosis.  He  found  a  temporary,  marked  increase 
in  acute  chlorosis  and  in  exacerbations  of  the  disease. 

When  deposited  in  the  tissues  it  gives  rise  to  a  form  of  jaundice  in 
which  there  is  a  brownish  skin — called  urohilinicterus. 

Diagnosis. — The  presence  of  urobilin  is  best  detected  by  a  spectro- 
scopic examination.  A  marked  absorption-band  between  traunhofer's 
lines  (f  and  b),  fading  off  from  the  green  into  the  blue,  is  characteristic. 
Chemically,  the  addition  of  a  few  drops  of  a  watery  solution  of  zinc 
chlorid  to  the  urine  will  cause  the  peculiar  red-green  fluorescence  of 
urobilin  to  appear. 

GLYCOSURIA. 

Definition. — The  presence  of  sugar  (glucose)  in  the  urine.  Nor- 
mally, a  trace  of  sugar  is  present  in  the  blood  (glykemia),  but  it  may 
be  doubted  whether  any  is  excreted  in  the  urine  in  health,  except  after 
the  ingestion  of  an  excess  of  food  rich  in  saccharine  or  starchy  sub- 
stances.   Uric  acid  may  give  the  same  reactions  as  glucose  in  the  urine. 

Htiology. — The  causes  of  glycosuria  may  be  enumerated  as  follows : 
(1)  Diabetes  mellitus — the  most  common.  (2)  Certain  diseases,  like 
gout  {intermittent  glycosuria),  cholera,  typhoid,  typhus,  and  scarlet 
fevers,  whooping-cough,  diphtheria,  malaria  (^paroxysmal  glycosuria), 
tetanus,  phthisis,  hepatic  cirrhosis,  and  organic  nervous  diseases,  espe- 
cially those  affecting  the  medulla  and  involving  the  floor  of  the  fourth 
ventricle.  Glycosuria  may  also  result  from  psychic  causes,  as  excessive 
mental  exertion,  extreme  emotional  activity  (grief,  worry,  and  shock), 
from  injuries  and  after  operations,^  as  cerebral  concussion  and  hemor- 
rhage, and  fracture  of  the  skull,  from  apoplexy,  cerebro-spinal  menin- 
gitis, and  after  epileptic  paroxysms.  (3)  Pregnancy  (40  per  cent,  of  the 
cases — Wormmiiller).     (4)  Certain  toxic  agents  cause  a  transient  glyco- 

*  Centralbl.f.  innere  Med.,  Marcla  15,  1902. 

=*  T.  R.  Brown,  Johm  Hopkins  Hosp.  Bvll,  May,  1900. 


996  DISEASES  OF  THE  URINARY  SYSTEM. 

suria,  among  these  being  carbon  monoxid,  raorphin,  atropin,*  hydro- 
cyanic acid,  amyl  nitrite,  curare,  chloral,  alcohol,  mercury,  arsenic,  tur- 
pentine, copaiba  (Bettman),  adrenalin,  phloridzin,  and  various  coal-tar 
derivatives,  as  salicylic  acid  and  salol.  This  source  of  glycosuria  has 
been  experimentally  demonstrated  in  dogs  by  Paul  Gii)ier.  (5)  Obesity 
and  thyroidisums  may  cause  a  temporary  glycosuria  (lipogenic).  (6) 
Pancreatic  disease  (chronic  interstitial  pancreatitis  and,  less  commonly, 
pancreatic  calculi,  carcinoma,  and  cysts).  (7)  Glycosuria  may  occur  in 
exophthalmic  goiter,  and,  according  to  Lyman,  may  be  present  for  a  short 
time  in  (8)  diabetes  insipidus.  (9)  Heredity  probably  plays  a  part  in 
predisposing  to  glycosuria  in  certain  cases,  particularly  in  the  permanent 
affection.  (10)  Dietetic  or  alimentary  glycosuria — due  to  ingestion  of 
alcohol,  carbohydrates,  or  glucose. 

Diagnosis. — The  daily  quantity  of  the  urine  of  typical  glycosuria — 
i.  e.,  when  masking  saccharine  diabetes — is  greatly  increased  (60  fluid- 
ounces — 2  liters — and  over  per  diem)  ;  it  is  of  high  specific  gravity  (1025 
and  over),  of  a  clear,  pale-yellow  color,  a  "ripe-fruit"  odor,  a  sweetish 
taste,  and  an  acid  reaction  that  is  intensified  on  standing,  owing  to  the 
fermentation  of  the  sugar.  Albuminuria  may  be  associated  with  glyco- 
suria, and  the  albumin  should  be  removed  before  testing  for  sugar. 

Tests. — The  most  impoi'tant  of  these  depend  mainly  upon  the  peculiar 
property  of  glucose  in  reducing  the  blue  oxid  of  copper  to  the  orange  or 
red  suboxid. 

(1)  Fehling's  Test. — Two  solutions  are  used,  equal  parts  being  mixed 
to  form  the  Fehling's  solution,  as  follows  : 

Solution  I.  contains  34.64  gm.  of  cupric  sulphate,  dissolved  in 
enough  water  to  make  500  c.cm.  Solution  II.  :  173  gm.  of  Rochelle 
salt  are  dissolved  in  480  c.cm.  of  sodium  hydroxid  (sp.  gr.  1.14) ;  this 
is  then  diluted  with  water  up  to  500  c.c. 

Application  :  Dilute  1  c.c.  of  Fehling's  solution  (about  10  drops 
of  each  of  the  above  solutions)  with  about  1  dram  (4  c.c.)  of  water  in 
a  test-tube,  and  heat  to  the  boiling-point.  If  the  clear  blue  color  re- 
mains, the  solution  is  ready  for  use  ;  should  it  change  color,  however, 
the  solution  is  unfit  for  use  and  should  be  discarded.  The  suspected 
urine  is  added,  drop  by  drop,  heating  occasionally,  when,  if  glucose  be 
present,  the  blue  color  will  be  discharged  by  a  yellow  turbidity,  which 
increases  until  finally  a  deep-yellow  or  orange  red  precipitate  falls. 
Bluish-white  flakes  and  a  greenish  discoloration  of  the  mixture  simply 
indicate  cupric  hydroxid,  and  not  glucose.  This  test  serves  for  the 
detection  of  .001  per  cent,  of  glucose  (Wormley).  It  cannot  be  applied 
to  strongly  ammoniacal  urine. 

(2)  Trommers  Test. — To  about  5  c.c.  of  urine  in  the  tube  add 
one-third  or  one-half  its  volume  of  potassium  or  sodium  hydroxid, 
and  then,  drop  by  drop,  add  a  10  per  cent,  solution  of  cupric  sul- 
phate. If  a  bluish-white  precipitate  falls,  either  filter  or  agitate  the 
liquid  until  it  assumes  a  slight  and  uniform  turbidity  ;  then  heat,  and, 
if  sugar  be  present,  a  yellow  or  red  deposit  of  cuprous  oxid  falls:  .01 
per  cent,  of  glucose  may  be  detected  in  this  way. 

There  are  certain  other  substances  which  wlien  present  in  urine  make 
the  copper  tests  fallacious  by  reducing  the  cupric  to  cuprous  oxid  (mucin, 
'  F.  Raphael,  DeuUche  me<l.  Woch.,  July  13,  1899. 


OLYCOSIJIUA.  997 

lactose,  pyrocatechin,  hydrochinon,  bile-pigments,  glycosuric  acid,  the 
products  of  elimination  after  the  ingestion  of  chloral — urochloric  acid — 
and  benzoic  and  salicylic  acids).  Among  normal  constituents  that  can 
reduce  cupric  oxid  are  uric  acid,  creatinin,  and  hippuric  acid.  "Alkap- 
ton  "  urines  also  reduce  Fehling's  solution. 

(3)  Bottgers  Bismuth  Teat. — This  may  be  performed  as  a  counter  to 
the  copper  tests.  Albumin,  however,  interferes  with  the  test  on  account 
of  the  contained  sulphur,  which  forms  a  black  bismuth  sulphid  :  hence, 
if  present,  it  must  first  be  removed.  This  may  be  done  by  acidulating 
the  urine  with  acetic  or  nitric  acid,  boiling,  and  then  filtering.  Bott- 
ger's  test  is  then  made  by  adding  to  the  non-albuminous  urine  or  to  the 
filtrate  from  one-half  to  an  equal  quantity  of  liquor  potassse  and  a  few 
grains  of  bismuth  subnitrate.  Boil  for  several  minutes,  and  if  glucose 
be  present  black  metallic  bismuth  will  be  precipitated. 

(4)  Nylanders  reagent  may  be  employed.  This  consists  of  2  parts 
of  basic  bismuth  nitrate  and  4  parts  of  sodium  tartrate  to  100  parts  of 
an  8  per  dent,  solution  of  caustic  soda.  One  part  of  the  reagent  is 
boiled  with  10  parts  of  the  urine  for  a  few  minutes,  when  a  change  from 
the  original  to  a  brown  or  black  color  will  indicate  the  presence  of  glu- 
cose. This  test  is  quite  distinct,  but  has  the  fallacy  that  is  common  to 
all  the  bismuth  tests,  of  forming  a  black  precipitate  with  the  sulphur 
compounds. 

(5)  Fermentation  Test. — Though  not  always  convenient  to  apply,  this 
is,  nevertheless,  a  most  reliable  test.  It  depends  upon  the  action  of 
yeast  in  breaking  up  glucose  into  alcohol  and  carbonic-acid  gas  (carbon 
dioxid).  It  is  performed  easily  by  adding  a  small  piece  of  compressed 
yeast  to  the  urine  in  a  test-tube,  inverting  the  latter  in  a  dish  of  the 
same,  and  standing  aside  for  twelve  to  twenty-four  hours,  the  temper- 
ature being  kept  at  about  80°  to  100°  F.  (26.6°-37.7°  C).  The  evo- 
lution of  gas  resulting  from  the  fermentation  of  the  sugar  takes  place, 
with  a  consequent  reduction  of  the  specific  gravity  of  the  urine.  •  The 
yeast  may  be  tested  simultaneously  for  its  purity  and  strength  by  pla- 
cing one  portion  in  a  test-tube  containing  about  two-thirds  mercury  and 
filling  with  normal  urine,  and  a  similar  portion  in  a  second  tube  with 
mercury  and  a  thin,  watery  solution  of  sugar  or  glucose ;  the  fermenta- 
tion test  of  the  suspected  urine  may  be  made  at  the  same  time,  and  all 
three  tubes  inverted  over  a  dish  of  mercury.  Obviously,  the  first 
tube  should  not  show  the  presence  of  carbon  dioxid  if  the  yeast  was 
free  from  sugar  ;  but  the  second  tube  should  show  this  gas  to  be  present 
or  the  yeast  was  inert. 

Other  tests,  such  as  Moore's  liquor-potasice-and-boiling  test,  Johnson's 
picric-acid  test,  and  the  phenyl-hydrazin  test,  are  more  intricate. 

The  quantitative  estimation  of  sugar  may  be  made  with  Fehling's 
solution  in  two  parts,  as  recommended  above  for  the  qualitative  test. 
This  method  is  based  upon  the  fact  that  the  cupric  oxid  of  1  c.c.  of 
Fehling's  solution  will  be  reduced  by  not  less  than  0.005  gm.  of  glucose. 
Place  1  c.c.  of  the  solution  in  a  test-tube  and  dilute  with  4  c.c.  of 
water  (5  c.c.  dil.  sol.).  Heat  to  the  boiling-point,  and  add  1  c.c.  of 
urine,  and  heat  the  liquid  again.  If  reduction  has  taken  place.  0.005 
gm. — 0.5  per  cent,  or  more — glucose  is  present ;  if  no  reduction  has 
occurred,  less  than  0.5  per  cent,  is  present.     If  2  c.c.  urine  are  used 


99S  DISEASES  OF  THE   URINARY  SYSTEM. 

before  the  color  of  the  Fehling  solution  is  discharged,  there  will  be 
0.25  per  cent,  glucose.  If  .1  c.c.  is  used,  1  per  cent,  is  present.  If 
■j^c.c.  urine  is  all  that  is  recjuired  (about  2  drops),  then  5.0  per  cent,  of 
glucose  is  present. 

Roberts'  diffcrential-densiti/  method  depends  upon  a  loss  in  the 
specific  gravity  of  the  urine,  due  to  the  fermentation  of  glucose.  Ac- 
cording to  Roberts,  each  degree  in  specific  gravity  lost  is  equivalent  to 
1  grain  of  glucose  in  1  imperial  fluidounce  (437.5  gr.)  of  urine,  or  one 
degree  represents  0.23  per  cent,  glucose.  Pavy's  method  is  also  conve- 
nient for  clinical  purposes.     (See  -works  on  Urinalysis.) 

Circumpolarization. — Finally,  sugar  may  be  determined  by  the  sac- 
charimeter  or  polariscope.  Glucose  polarizes  light  to  the  right.  The 
percentage  may  be  calculated  by  reading  the  vernier  scale  indicating  the 
degree  of  reflection,  and  multiplying  the  number  read  by  the  factor  of 
the  apparatus  used,  after  making  any  required  corrections. 

ACETONURIA,    DIACETONURIA,    AND    OXYBUTYRIA. 

Acetonuria,  diacetonuria,  and  /9-oxybutyria  are  so  closely  allied  with 
glycosuria,  and  especially  with  diabetic  coma  (acetonemia),  that  they  may 
be  considered  together.  In  the  first-named  condition  the  urine  contains 
acetone ;  in  the  second,  diacetic  or  aceto-acetic  acid ;  and  in  the  last, 
^-oxybutyric  acid. 

Acetonuria  may  exist  to  a  minute  degree  in  health,  the  acetone 
being  a  jjroduct  of  the  normal  nietamor])hosis  of  albumin.  It  may  be 
present  also  in — (1)  diabetes  ;  (2)  carcinoma ;  (3)  febrile  conditions  ;  (4) 
inanition  ;  (5)  psychoses  :  (6)  auto-intoxication,  especially  with  fatty  acids 
in  the  stomach  and  intestines  (enterogenous  acetonuria) ;  (7)  pregnancy ; 
(8)  after  anesthesia ;  and  (9)  in  cyclic  vomiting.  Urine  that  contains 
acetone  in  pathologic  quantities  has  a  fruity  (apple-like)  odor  or  one 
resembling  that  of  chloroform. 

Tests. — (1)  Gerhardt's  original  test  consisted  in  the  addition  of  a  few 
drops  of  the  tincture  of  the  chlorid  of  iron,  which  produced  a  Burgundy- 
red  color  with  acetone,  or  rather  with  the  aceto-acetic  acid. 

(2)  Nitro-jjrussid  Test. — To  a  fluidounce  (32.0)  of  the  urine  add  a 
dram  or  two  (4.0-8.0)  of  a  solution  of  sodium  nitro-prussid  (gr.  v  to  3j 
— 0.324  to  32.0)  and  a  few  drops  of  sti-ong  aqua  ammonige.  On  stand- 
ing a  rose-violet  color  appears.  According  to  Legal,  proportionately 
smaller  quantities  of  urine  and  the  reagent  may  be  used,  and  strong 
liquor  potassse.  A  bright-red  color  develops,  and  fades  rapidly,  but 
upon  adding  acetic  acid  this  changes  to  purple  or  violet-red  (Vierordt). 
This  is  a  better  test. 

(3)  Perhaps  the  most  accurate  and,  at  the  same  time,  satisfactory 
test  for  acetone  is  the  following  :  Distil  the  urine  with  a  little  phosphoric 
acid,  and  add  to  the  distillate  a  few  drops  of  sodium  hydroxid  and  of 
Lugol's  solution.  If  acetone  be  present,  yellow  crystals  of  iodoform 
will  form,  with  the  characteristic  odor. 

Diacetonuria  and  oxybutyria  never  occur  normally.  They  are 
often  associated  with  acetonuria  in  diabetes,  and  sometimes  in  fever,  or 
occur  as  an  independent  disease  (V.  Jaksch).  It  is  believed  /3-oxy- 
butyric  acid  is  the  immediate  cause  of  diabetic  coma.      "  The  persistent 


LITHURIA.  999 

excretion  of  more  than  2r>  grams  of"  /9-oxyTjutyric  acid  indicates  impend- 
ing coma"  (Simon).  Stadelmann  affirms  that  of  like  value  in  diabetes 
is  the  determination  of  a  marked  and  increasing  amount  of  ammonia  in 
the  urine  (1  gram — gr.  xv — and  more  per  diem),  as  indicating  the  im- 
minence of  diabetic  coma.  Diacetonuria  is  found  to  occur  in  certain 
acute  diseases  of  children,  accompanied  with  convulsions. 

Tests. — The  presence  of  diacetic  acid  is  demonstrated  by  the  chlorid- 
of-iron  reaction,  as  in  the  case  of  acetone,  except  that  the  urine  is  boiled 
previously.  This  is  done  to  avoid  fallacy,  since  in  unboiled  urine  acetic, 
formic,  and  oxybutyric  acids  may  strike  a  Burgundy -red  also ;  in  urine 
that  has  been  previously  boiled  these  do  not  react,  while  the  diacetic 
acid  does,  if  present.  Diacetic  acid  is  usually  present  simultaneously 
with  acetone  and  /9-oxybutyric  always,  and  is  formed  first.  Tests  for  the 
latter,  therefore,  need  not  be  detailed  here  [vide  Tests  for  Acetone). 

* 

LITHURIA. 

Definition. — A  persistent  excess  of  uric  (lithic)  acid  and  urates 
(lithates)  in  the  urine.  Uric  acid  occurs  in  the  urine  in  combination  with 
alkalies,  but  may  become  free,  separating  out  as  a  crystalline  deposit. 

Normal  urine  contains  about  0.4  part  of  uric  acid  to  1000  parts  of 
urine  (about  gr.  x — 0.648 — per  diem),  or  it  exists  in  the  proportion  of 
about  1  to  45  of  urea,  the  principal  solid  constituent. 

Ktiology. — The  causes  of  lithuria,  as  seen  in  certain  conditions  in 
which  this  metabolic  change  occurs,  may  be  put  down  to  be  chiefly  as 
follows :  (1)  Lithemia  (uricemia ;  uric-  or  lithic-acid  or  gouty  diathesis) ; 
(2)  gout  and  rheumatism ;  (3)  fever ;  (4)  leukemia  and  pernicious  an- 
emia ;  (5)  pulmonary  affections  in  which  the  interchange  of  gases  is  in- 
terfered with  ;  (6)  a  highly  nitrogenous  diet.  Certain  other  conditions 
of  the  urine  may  diminish  its  power  of  dissolving  the  uric  acid  shortly 
after  voidance,  and  may  cause  a  deposit  that  should  not  be  mistaken  for 
an  excess.  Such  are — (a)  temporary  increase  in  the  quantity  of  uric 
acid  from  an  over-indulgence  in  nitrogenous  food ;  {b)  temporary  high 
acidity ;  (e)  deficiency  in  mineral  salts. 

Diagnosis. — The  urine  has  a  high  specific  gravity,  a  deep  red-yel- 
low color,  and  a  marked  acid  reaction,  although,  rarely,  uric  acid  is 
formed  in  neutral  or  alkaline  urine  (Vierordt).  Albumin  may  be 
present  in  small  amount  at  the  same  time.  On  standing  the  uric 
acid  is  deposited  in  yellowish-red  or  "Cayenne  pepper"  grains,  com- 
posed of  microscopic  uric-acid  crystals.  Chemically  pure  uric  acid  is 
colorless,  but  that  deposited  from  urine  has  a  yellowish-red  appearance, 
both  to  the  naked  eye  and  under  the  microscope.  Examination  with  the 
latter  shows  a  great  variety  of  rhombic  prisms — "'  whet-stone-shaped," 
"crosses,"  "lozenges,"  and  others — single  and  in  agglomerations. 

Test. — The  murexid  reaction  may  be  obtained  by  evaporating  a  little 
urine  in  a  watch-glass  or  porcelain  dish,  adding  a  few  drops  of  strong 
nitric  acid,  and  heating  to  dryness  again ;  this  is  allowed  to  cool,  and 
a  drop  of  liquor  ammonise  added,  when  a  beautiful  purple  shade  of 
murexid  will  appear  if  uric  acid  be  present.  Martinet  gives  the  follow- 
ing simple  and  reliable  method  of  estimating  the  acidity  of  the  urine  as 
a  basis  for  treatment  in  various  conditions :  To  20  drops  of  decinormal 


1000  DISEASES  OF  THE   URIXAEY  SYSTEM. 

sodium  Lyilrate  solution  are  added  2  drops  of  a  1  per  cent,  alcoholic 
solution  of  jihenoli)litlialein  and  the  ■whole  heated  to  boiling.  Urine  is 
then  added,  drop  by  droj),  until  the  distinct  pink  color  vanishes  entirely. 
The  total  acidity  is  expressed  in  terms  of  sulphuric  acid,  IlgSO^,  by 
dividing  08  by  the  number  of  drops  of  urine  required  for  decoloration. 

Reference  should  here  be  made  to  the  ^'"^luelchis"  or  xanthin  bases. 
They  result  from  the  disintegration  of  nuciein,  as  does  uric  acid,  but 
diifer  from  the  latter  in  being  more  strongly  basic.  Along  witli  uric 
acid,  these  substances  are  often  spoken  of  under  the  term  "  alloxuric 
bodies."  There  is  great  variability  in  the  behavior  of  the  xanthin  bases 
as  compared  Avith  that  of  uric  acid,  although  they  are  usually  increased 
in  conditions  in  which  uric  acid  is  present  in  excess. 

Urates. — These  are  increased  in  pathologic  conditions  that  give  lise 
to  uric  acid  in  excess,  and  are  usually  present  Avith  the  latter  in  some 
quantity.  It  is  not  rare,  however,  in  healthy  individuals  for  a  deposit 
of  urates  to  occur  in  concentrated  urine  exposed  to  a  cool  atmosphere. 
Urates  appear  also  in  the  scanty  urine  from  any  cause,  e.  g.,  pi'ofuse  per- 
spiration, diarrhea,  fever,  and  after  a  meal  rich  in  albuminous  elements. 

Urates  occur  principally  as  acid  sodium  urate,  calcium  urate,  and 
ammonium  urate.  They  appear  macroscopically  as  a  flesh-colored  or 
'"brick-dust"  (lateritious)  sediment;  this  is  usually  abundant  and  very 
finely  granular  in  appearance,  while  the  urine  above  is  cloudy.  Upon 
heating  such  urine  it  becomes  clear,  the  urates  being  completely  dis- 
solved. 3Iicros<;opicaUi/,  the  sodium  and  calcium  salts  of  uric  acid  occur 
as  needle-  or  dumb-bell-like  crystals  or  as  fine,  dark,  amorphous  granules. 
Ammonium  urate  is  found  in  alkaline  urine,  often  Avith  triple  phosphates 
■when  some  putrescence  has  ensued.  It  is  seen  in  dark-broAvn  or  green 
spiculated  spherules;  these  are  sometimes  called  "hedge-hog  "  or  "thorn- 
apple"  crystals.  On  the  addition  of  a  drop  of  hydrochloric  acid  under 
the  cover-glass  uric-acid  crystals  may  be  seen  to  develop. 

OXALURIA. 

Definition. — A  persistent  excess  of  calcium  oxalate  in  the  urine. 
A  few  crystals  may  occur  in  normal  urine  (about  one  urine  out  of  every 
three),  especially  after  standing  for  a  long  time. 

Transient  oxaluria  may  follow  the  ingestion  of  sub-acid  fruits,  as 
pears,  or  of  vegetables  containing  oxalates  (tomatoes,  asparagus). 

Pathology.— Oxaluria  has  been  described  by  some  English  i)hys- 
icians  as  an  inde})endcnt  disease  or  special  diathesis  in  which  marked 
dyspepsia  and  hypochondriasis  or  neurasthenia  are  associated.  The 
condition  is  better  explained,  probably,  as  one  of  a  disturbed  metabolism 
• — particularly  of  the  fats  and  carbohydrates — in  which  the  oxaluria  and 
the  nervous  symptoAs  are  manifestations  analogous  to  the  lithuria  and  the 
irregular  gouty  symptoms  of  lithemia.  Oxalates  and  lithates  are  not 
infrequently  found  together  in  the  urine  of  those  subject  to  the  gouty 
habit.  Uric  acid  may  be  oxidized  to  oxalic  acid.  The  ultimate  source 
seems  to  be  the  nucleins  and  nucleo-albumins.  Oxaluria  is  also  present 
in  wasting  diseases,  as  in  tuberculosis  and  diabetes  mellitus,  and  in  the 
cancerous  cachexia  ;  it  may  appear  in  catarrhal  jaundice,  spermator- 
rhea, also  wnth  the  "mulberry  calculi,"  and  in  general  paresis  of  the 
insane.      Slight  albuminuria  is  not  infrequently  associated. 

Diagnosis. — ()xalate-of-lime  crystals  appear  in  the  urine  in  two 


PHOSPHATURIA.  1001 

forms — most  commonly  as  minute,  regular,  highly-refracting  octahedra, 
or,  more  rarely,  as  hour-glass-  and  dumb-bell-shaped  crystals. 

The  octahedral  crystals  have  two  crossed  axes,  giving  a  star  or  enve- 
lope-like appearance.  Oxalates  sometimes  give  a  glittering  and  scintil- 
lating effect  to  floating  mucus  in  urine  that  has  undergone  fermentation. 
The  finding  of  calcium  oxalate  in  the  urine  does  not  necessarily  imply 
an  increased  excretion  of  this  salt.  The  precipitation  is  due  to  the 
absence  of  the  sodium  phosphate  which  keeps  it  in  solution. 

The  prognosis  is  usually  favorable. 

Treatment. — Nitro-hydrochloric  acid  in  2-drop  doses  is  a  useful  agent. 

PHOSPHATURIA. 

Definition. — A  persistent  excess  of  phosphates  in  the  urine. 

Phosphoric-acid  salts  may  be  precipitated  in  normal  urine  that  has 
become  temporarily  alkaline.  These  acid  sodium  and  potassium  phos- 
phates in  normal  acid  urine  are  derived  from  the  alkaline  phosphates 
(neutral  sodium  and  potassium  phosphates)  of  the  blood.  In  normal 
urine  1.2  parts  of  alkaline  phosphates  per  1000  and  0.8  part  of  earthy 
phosphates  are  appreciable. 

l^tiology  and  Pathology.^-Conditions  that  produce  an  alkaline 
fermentation  of  the  urine  cause  a  deposit  either  of  amorphous  earthy 
phosphates  (of  calcium  and  magnesium)  or  of  alkaline  phosphates  (of 
potassium,  sodium,  and  ammonium).  They  are  also  found  in  the  de- 
composing urine  of  chronic  cystitis,  of  phosphatic  vesical  calculi,  of 
paralysis,  and  in  undue  retention  of  urine.  In  this  alkalinity,  due  to 
the  ammoniacal  fermentation  of  urea,  ammonium  carbonate  reacts  with 
the  phosphates  of  magnesium  to  form  the  triple  ammonio-magnesia  phos- 
phatic crystals,  the  commonest  variety  of  phosphaturia.  Here  the  phos- 
phates are  deposited  before  or  immediately  after  the  urine  is  passed, 
giving  a  milky  appearance  to  the  last  portion.  Deposits  of  phosphates, 
and  especially  of  triple  phosphates,  however,  do  not  indicate  an  actual 
phosphaturia.  This  must  be  determined  by  chemical  analysis.  Amor- 
phous carbonate  of  lime  in  small  quantity  may  be  present  also  if  the 
urine  is  strongly  alkaline  and  ammoniacal  (Beale).  The  calcium  phos- 
phates are  generally  more  abundant  than  the  magnesium,  and  may  be 
found  in  cases  of  nervous  or  atonic  dyspepsia,  neurasthenia,  and  other 
debilitated  conditions.  The  alkaline  phosphates  (which  represent  three- 
fourths  of  the  phosphoric  acids),  being  easily  soluble,  do  not  form  a 
deposit. 

A  quantitative  estimation  of  the  daily  output  of  phosphates  shows  a 
decided  increase  in  wasting  diseases,  as  tuberculosis,  leukemia,  chronic 
articular  rheumatism,  and  acute  yellow  atrophy  of  the  liver.  The  phos- 
phoric acid,  however,  is  not  increased.  The  so-callad  "  phosphatic  dia- 
betes "  is  characterized  chiefly  by  excessive  phosphaturia. 

Diagnosis. — Phosphatic  urine  has  usually  a  stale,  ammoniacal 
odor,  a  whitish  turbidity,  and  a  copious  light-colored  granular  sediment 
falls  on  standing.  Microscopically,  the  calcium  phosphate  crystals  appear 
singly  as  "knife-blade,"  "arrow-head,"  or  "slender  wedge-shape,"  or 
in  stellate  clusters.  Acetic  acid  dissolves  them.  The  ammonio-mag- 
nesium  phosphate  crystals  are  transparent  rhombic  or  triangular  prisms, 


1002  DISEASES  OF  THE   URINARY  SYSTEM. 

large  aud  small — "  coffin-lid-sbaped."     These  also  are  soluble  in  acetic 
acid  ;  oxalate-of-lime  crystals  are  not  so. 

On  heating  phosphatic  urine  an  increased  cloudiness  is  produced  that 
simulates  albumin,  but  on  acidifying,  as  with  a  drop  of  nitric  acid,  this 
is  cleared  up  at  once. 

LEUCINURIA   AND   TYROSINUEIA. 

Definition. — The  presence  of  leucin  and  tyrosin  in  the  urine. 
These  are  strictly  pathologic  substances,  and  are  usually  found  together. 
Thev  are  products  of  the  decomposition  of  albumin. 

Htiology. — The  principal  causes  of  leucinuria  and  tyrosinuria  are 
acute  yellow  atrophy  of  the  liver,  acute  phosphorus-poisoning  (in  both 
of  which  fatty  degeneration  is  conspicuous),  specific  infectious  diseases, 
as  typhoid  fever,  small-pox,  and  yellow  fever,  and  pernicious  anemia. 

I)iagnosis. — Leucin  is  the  more  soluble,  hence  is  rarely  found  in  the 
urinary  sediment.  Tyrosin,  on  the  other  hand,  may  be  discovered  some- 
times as  a  fine  greenish-yellow  deposit.  Bile-pigment  and  a  trace  of  al- 
bumin may  be  found  not  infrequently  in  urine  containing  leucin  and 
tyrosin.  Urea  is,  as  a  rule,  markedly  diminished.  Leucin  and  tyrosin  may 
be  detected  by  evaporating  a  few  drops  of  urine  on  a  glass  slide  and 
examining  microscopically.  Leucin  appears  in  the  form  of  slightly 
glistening,  greenish-yellow  spheres  that  may  show  radiating  lines  and 
concentric  rings.  Tyrosin  is  recognized  by  the  slender  tufts  of  fine, 
needle-like  crystals  arranged  in  star-  or  cross-like  fashion. 

If  the  residuum  after  evaporation  be  heated  with  a  drop  of  nitric  acid, 
slowly  evaporated  to  dryness,  and  then  touched  with  a  drop  of  sodium 
hydroxid,  the  leucin,  if  present,  will  assume  a  yellowish-brown  hue. 
Tyrosin  becomes  red  in  color  when  boiled  with  Millon's  reagent  of 
mercurous  nitrate,  and  a  violet  color  when  warmed  with  a  little  sul- 
phuric acid,  and  then  treated  with  a  drop  of  the  solution  of  phenic 
chlorid. 

CYSTINURIA. 

Definition. — The  presence  of  an  excess  of  cystin  in  the  urine. 
This  is  rare,  "  but  when  it  occurs  it  may  be  copious,  and  is  not  unlike  a 
sediment  of  fawn-colored  urates  "  (Hutchison  and  Rainy).  The  causes 
of  cystinuria  have  not  been  well  made  out,  though  liereditary  influences 
seem  to  have  an  important  bearing  on  the  etiology.  Insufficient  nitrogen 
metabolism,  as  occurs  similarly  in  such  allied  conditions  as  gout  and 
obesity,  seems  to  give  rise  to  cystinuria. 

Brieger  points  out  a  probable  significance  in  the  discovery  of  the 
associated  presence  of  ptomains  with  cystinuria.  Thus,  in  certain  infec- 
tious diseases,  as  intestinal  mycosis,  a  ptomain-cystinic  product  is  sup- 
posed to  be'formed,  then  to  be  absorbed,  and  finally  decomposed  in  the 
urine,  thus  setting  free  the  cystin.    Cystitis  may  be  caused  by  ptomains. 

Diagnosis. — The  sediment  is  light,  and  not  very  unlike  that  of  the 
amorphous  urates.  It  is  not  dissolved  by  heat,  however,  though  soluble 
in  ammonia.  Under  the  microscope  cystin  occurs  in  the  form  of  thin, 
transparent,  hexagonal  crystals.  Care  should  be  exercised  in  forming  a 
diagnosis  of  cystinuria  that  a  contamination  with  iodoform  be  excluded, 


VARIOUS  OTHER  CONDITIONS.  1003 

since  the  microscopic  appearance  of  that  substance  is  similar  to  that  of 
cystin.  On  account  of  the  sulphur  contained  in  cystin,  a  test  may  be 
employed  by  which  hydrogen  sulphid  is  liberated,  as  by  boiling  the  sus- 
pected urine  with  a  solution  of  lead  oxid  and  sodium  hydroxid,  black 
lead  sulphid  resulting  from  the  reaction  if  cystin  be  present. 

VARIOUS    OTHER   CONDITIONS. 

Urea. — This  occurs  in  solution  in  the  normal  urine  as  a  product  of 
the  perfect  decomposition  of  the  nitrogenous  elements  of  food  and  tis- 
sues. In  1000  parts  of  urine  about  20  parts  are  constituted  of  urea  (2 
per  cent.,  equivalent  to  about  gr.  450 — 30.0 — daily).  The  quantity  of 
urea  is  increased  in  the  urine  after  the  ingestion  of  a  considerable  quan- 
tity of  proteid  food  ;  sometimes  after  exertion  ;  in  acute  inflammation 
and  in  fevers — either  relatively  or  absolutely,  as  in  pneumonitis ;  in 
diabetes  and  other  morbid  conditions  in  which  metabolism  is  accom- 
panied by  an  increase  in  the  tissue-waste.  In  febrile  states  its  excretion 
increases  or  diminishes  with  the  exacerbations  and  remissions  of  tem- 
perature respectively. 

Urea  is  diminished  in  quantity  in  all  forms  of  nephritis,  and  markedly 
so  in  uremia ;  in  organic  liver-diseases ;  in  cachectic  and  anemic  states ; 
and  in  dropsy,  inanition,  and  allied  conditions. 

The  quantitative  estimation  of  urea  may  be  made  according  to  one  or 
more  of  several  methods  :  Fowler's  hypochlorite  test  (with  Labarraque's 
solution)  is  perhaps  the  most  practical  for  ordinary  clinical  purposes.^ 
Fowler's  method  is  based  upon  the  loss  of  specific  gravity  upon  the  liber- 
ation of  the  nitrogen  of  the  urea.  The  mean  specific  gravity  of  a  mix- 
ture of  1  part  of  urine  and  7  parts  of  the  solution  of  sodium  hypochlorite 
is  taken  while  quiescent,  and  is  then  subtracted  from  the  specific  gravity 
of  the  mixture  taken  after  agitation  several  times  during  about  two  hours. 
The  difference  which  is  due  to  the  liberation  of  the  nitrogen  (as  is  shown 
by  the  effervescence),  multiplied  by  the  factor  0.77,  gives  the  approximate 
percentage  of  urea  in  the  urine. 

Urine  evaporated  to  a  syrupy  consistence  and  then  treated  with  nitric 
acid  shows  crystalline  quadratic  plates  of  urea  nitrate. 

Chlorids. — About  10  parts  of  the  chlorids  of  sodium  and  potassium  in 
1000  parts  of  urine  are  excreted  daily.  They  are  increased  in  the 
urine  after  muscular  exertion,  during  the  resorption  of  mechanical  or 
inflammatory  transudations  and  exudations,  and  in  intermittent  fevers, 
owing  to  the  destruction  of  the  red  corpuscles. 

Pathologic  diminution  in  the  quantity  of  chlorids  occurs  in  fevers,  in 
the  nephritides,  in  cachectic  conditions,  and  especially  in  such  diseases 
as  pneumonitis,  pleuritis,  and  rheumatism.  In  the  last-named  class  the 
chlorids  diminish  as  exudation  continues,  and  may  even  totally  disap- 
pear from  the  urine  in  extensive  pneumonic  consolidations,  to  reappear 
again  with  the  resorption  of  the  exudate. 

Test. — The  chlorids  may  be  detected,  after  first  removing  any  albu- 
min that  may  be  present,  by  acidulating  with  a  few^  drops  of  nitric  acid 
(to  keep  the  phosphates  in  solution),  and  by  then  adding,  drop  by  drop, 
a  strong  solution  of  argentic  nitrate.     According  to  the  abundance  of 

^  See  works  on  Urinalysis. 


1004  DISEASES  OF  THE   URINARY  SYSTEM. 

the  resultant  white,  curdy  precipitate  of  argentic  chlorid  a  rough  esti- 
mate may  be  made  of  the  total  cjuantity  of  chlorids  in  the  urine. 

Lipuria  is  a  term  applied  to  the  presence  of  fat  in  the  urine.  It  may 
result  from  the  steady  use  of  cod-liver  oil  or  of  fatty  food,  or  it  may  be 
found  in  pyonephrosis  (Ebstein) ;  in  phosphorus-poisoning;  in  pro- 
longed suppuration:  in  the  lipemia  of  diabetes  mellitus ;  in  the  "large 
white  kidney  "  with  fatty  degeneration  of  chronic  Bright's  disease;  in 
beer-drinkers  ;  and  in  chyluria.  Fatty  urine  becomes  clear  upon  agitat- 
ing after  the  addition  of  ether. 

Lipaciduria,  or  urine  containing  volatile  fatty  acids  (acetic,  butyric, 
and  propionic),  is  as  yet  without  diagnostic  significance. 

Melanuria,  or  urine  containing  the  pigment  melanin,  is  found  in  cases 
of  melanotic  sarcoma.  The  urine  is  dark,  either  just  after  being  voided 
or  after  some  exposure  and  oxidation. 

Hematoporphyrinuria  (Urospectrin). — This  term  implies  the  presence 
of  hematoporphyrin  (iron-free  hematin)  in  the  urine.  It  occurs  after 
long-continued  use  (even  in  small  doses — Muller)  of  saffron  and  certain 
coal-tar  products  (sulfonal,  trional).  Stockton  found  it  in  acute  ascend- 
ing paralysis.^  In  addition  to  the  gastric  and  nervous  symytoms  in 
poisoning  from  these  substances  is  a  cherry-colored  or  dark  blue-red 
urine,  the  abnormal  appearance  of  the  latter  being  due  to  the  presence 
of  hematoporphyrin  resulting  from  the  destruction  of  the  red  blood- 
corpuscles.  The  condition  has  pi'oved  fatal  in  cases  in  which  the 
kidneys  were  diseased.  The  urine  is  always  quite  acid.  According 
to  Garrod,  hematoporphyrin  is  a  scanty  though  constant  ingredient  of 
normal  urine.  He  extracts  it  by  adding  100  c.cm.  of  urine  to  20  c.cm. 
of  a  10  per  cent,  solution  of  sodium  hydroxid.  This  precipitates  the 
phosphates,  which  are  washed  with  water  and  redissolved  with  rectified 
spirits.  After  acidulation  with  hydrochloric  acid  the  solution  shows 
spectroscopically  bands  of  acid  hematoporphyrin.  The  treatment  con- 
sists in  the  withdrawal  of  these  drugs  and  the  administration  of  alkalies. 

Pneumatinuria,  or  gas-formation  in  the  bladder,  rarely  occurs.  Heyse^ 
records  a  case  of  myelitis  in  which  this  condition  was  present. 

Fibrinuria. — In  certain  conditions  of  the  genito-urinary  tract,  partic- 
ularly pyelitis  and  ureteritis,  fibrinous  (and  mucous)  shreds  are  found  in 
the  urine.     Fibrinuria  may  follow  nephro-lithiasis  (v.  Jaksch). 

Typhoid  bacilluria  occurs  probably  in  about  25  per  cent,  of  the  cases 
of  typhoid  fever  (Horton   Smith,  Gwyn). 

Bacteriuria. — There  are  probably  few  specimens  of  urine  that  do  not 
contain  bacteria.  Engel  has  found  a  great  variety  of  organisms  in  the 
nephritides,  and  believes  a  special  coccus  to  be  responsible  for  many  in- 
stances of  the  sort  beo;inning  as  mibl  forms  of  '^bacterial  albu7)iinuria." 
Warburg  ^  reported  a  case  of  chill  and  fever  with  turbid  urine  due  to 
the  Bacillus  lactis  aerogenes.  The  tubercle  bacillus  is  not  uncommon  in 
the  advanced  stage  of  pulmonary  and  in  renal  or  vesical  tuberculosis. 

Lactosuria. — Lactose  is  found  in  the  urine  of  some  puerperae. 

Inosituria. — Inosite  occurs  in  the  urine  in  diabetes  mellitus,  diabetes 
insipidus,  and  chronic  interstitial  nephritis. 

'  Amer.  Jour.  Med.  Sciences,  July,  1900. 

'  Zeit.  f.  klin.  Med,  1894,  xxiv.,  p.  130,  quoted  in  The  American  Year-Book  of  Medicine 
and  Surgery  for  1896. 

»  Miinchener  Med.  Wochen.,  July  18,  1899. 


THE  NEPHRITIDES.  1005 

Alkaptonuria. — Alkapton  is  an  obscure  substance  (so  called  by 
Bredeker)  that  is  sometimes  found  in  the  urine  of  phthisical  cases,  or 
at  times  in  that  of  patients  witliout  any  apparent  local  or  general  dis- 
ease. Alkaptonuria  is  congenital  in  a  few  cases.  On  exposure  the  urine 
darkens  in  color  from  above  downward,  nlso  ii])on  the  ;iddif  ion  of  liquor 
potassae.  It  gives  the  suffar  reaction  with  Fehling's  solution  fOsler).  It 
gives  a  dark -brown  ring  in  Ehrlich's  diazo-test  (U.  MitchelP). 

Urine  as  affected  by  the  administration  of  drugs — as  carbolic  acid, 
salol,  antipyrin,  and  potassium  iodid — responds  to  certain  chemical  tests, 
for  the  study  of  which  the  reader  is  referred  to  works  on  urinalysis. 

Cholesteriyiuria  has  been  found  in  cases  of  pyonephrosis,  hydro- 
nephrosis, renal  hydatids,  epilepsy,  and  severe  dyspepsia. 


THE  NEPHRITIDES. 

Before  considering  the  several  varieties  of  nephritis,  and  especially 
the  clinical  history  peculiar  to  each  variety,  it  may  be  well  first  to  de- 
scribe certain  general  manifestations  of  renal  diseases  that  are  more  or 
less  common  to  all.  Reference  to  these  symptoms  under  the  different 
forms  of  nephritis  will,  it  is  hoped,  thus  make  possible  a  clearer  appre- 
hension of  their  significance  and  clinical  importance,  as  well  as  render 
unnecessary  any  further  elaboration. 

One  of  these  conditions  has  already  been  described — viz.,  (1)  Albu- 
minuria. It  remains  to  speak  of  (2)  the  Morphologic  constituents  of  the 
urine  in  nephritis,  (3)  Edema  (a^iasarca,  dropsy),  and  (4)  Uremia. 

THE  MORPHOLOGIC  CONSTITUENTS  OF   THE  URINE  IN  RENAL  DISEASE  : 
CASTS,  EPITHELIUM,  ETC. 

1.  Tube-casts. — These  are  undoubtedly  the  most  important  morpho- 
logic elements  in  the  urine  of  a  nephritic.  Albuminuria  is  coincident- 
ally  present,  and  the  occurrence  together  of  these  two  pathologic  con- 
stituents furnishes  indisputable  evidence  of  renal  disease.  Although, 
on  the  other  hand,  hyaline  casts  may  occur  in  many  pathologic  states 
minus  albuminuria.  According  to  the  nature  and  number  of  the  casts 
also  may  be  determined  the  character  and  variety  of  the  affection  of  the 
kidneys  in  most  instances.  Casts,  as  their  name  implies,  are  simply 
cylindric  bodies  moulded  in  the  renal  tubules,  and  composed  essentially 
of  the  coagulable  substances  in  the  blood-serum.  The  coagula  of  the 
tubules  are  mostly  albuminous.  Other  morphologic  elements  may  be 
mixed  with  casts — epithelium,  red  blood-cells,  pus-cells,  and  the  granular 
matter  and  fat-droplets  due  to  degeneration  of  the  renal  epithelium. 

Singly,  the  casts  are  invisible  to  the  naked  eye,  but  in  acute  nephritis 
they  may  be  so  abundant  as  to  form  a  cloudy  sediment. 

(a)  Microscopically,  the  unmixed  or  hyaline  cast — the  commonest — ■ 

appears  either  long  or  short  and  narrow  or  broad,  of  a  clear,  homogeneous 

substance,  delicate  in  outline,  and  often  showing  ends  with  a  cheesy  or 

wax-like  fracture.     They  may  be   straight  or  slightly  curved  and  tor- 

1  Medical  Record,  May  21,  1910. 


1006  DISEASES  OF  THE   i'BiyARY  SYSTEM. 

tuous.  Rarely,  a  cast  may  be  found  equal  to  a  millimeter  in  length. 
The  so-called  narrow  easts  are  about  equal  in  width  to  the  diameter  of  a 
leukocyte,  while  the  medium  and  broad  casts  are  from  three  to  four  times 
this  size.  Hyaline  casts  are  usually  associated  with  other  varieties  of 
casts,  though  in  fevers,  renal  congestion,  chronic  interstitial  nephritis, 
and  in  amyloid  kidney  they  may  occur  unassociated  Avitli  other  forms. 
Burrys  India-ink  method  of  staining  for  the  detection  of  casts  is  highly 
recommended  by  Stovesandt.' 

{b)  Crranidar  casts  are  nothing  more  than  hyaline  casts  with  fine  or 
coarse  granules  superadded.  The  granules  represent  minute,  opaque 
particles  of  urates,  albumin,  fat,  cellular  debris,  and  even  bacteria 
[bacterial  casts).  It  should  be  remembered,  however,  that  granular  casts 
may  be  simulated  by  casts  of  coagulated  albumin  covered  with  particles 
of  hematoidin  or  of  urates,  especially  in  acute  nephritis.  The  hema- 
toidin  can  be  recognized,  however,  by  the  brown-yellow  coloration. 

(e)  Epithelial  casts  are  hyaline  casts  more  or  less  covered  with  renal 
epithelium,  indicating  desquamative  nephritis  (Fig.  67).  The  epithelial 
cells  may  show  evidence  of  granular  or  fatty  change. 

{d)  JBlood-casts  consist  of  soft  hyaline  casts  having  red  blood-cells 
imbedded  in  them.     These  are  present  in  acute  hemorrhagic  nephritis. 

(c)  Waxy  casts  are  similar  in  appearance  to  hyaline  casts,  though 
better  defined,  broader  as  a  rule,  and  of  an  opaque,  slightly  yellowish 
tint.  They  often  show  broken  ends  (Fig.  67).  They  do  not  necessarily 
indicate  amyloid  disease  of  the  kidney,  as  was  formerly  held.  They  may, 
however,  sometimes  show  the  amyloid  reaction  with  iodin  and  potassium 
iodid,  and  are  always  suggestive  of  serious  renal  disease. 

(/)  Fatty  casts  are  such  as  have  left  upon  and  in  them  fat-droplets 
or  granules  (Fig.  QQ),  which,  if  abundant,  are  indicative  of  fatty  degen- 
eration of  the  kidney.      Cells  shoAving  granulation  may  be  seen. 

Rolled  casts  ox  pseudo-easts  (sometimes  made  by  sliding  a  cover-glase 
over  a  specimen  of  urine)  of  urates  should  not  be  mistaken  for  genuine 
tube-casts.  Blood-casts  (due  to  hemorrhage),  consisting  of  fibrin  and 
epithelial  pseudo-casts  (hollow),  in  cases  of  desquamative  nephritis,  also 
belong  in  this  category.  Cylindroids  are  distinguishable  from  hyaline 
casts-  by  their  greater  length,  tapering  ends,  and  by  being  at  times  beset 
with  leukocytes,  red  corpuscles,  epithelial  cells,  and  certain  crystals. 
Cylindroids  are  met  in  renal  congestion  and  are  related  to  true  casts. 

2.  Epithelium. — Renal  cells  are  found  in  the  urine  of  those  forms  of 
nephritis  that  are  characterized  by  a  catarrhal  or  des(|uaniative  and 
exudative  process  in  the  tubules.  Epithelial  cells  from  the  kidney  are 
polygonal  or  spheric  in  contour,  with  an  indistinct  cell-wall ;  they  have 
a  large  oval  nucleus,  and  are  either  abundantly  granular  or  show  a  fatty 
change.      These  cells  are  about  the  size  of  the  white  corpuscle. 

3.  Leukocytes. — Only  when  attached  to  casts  can  it  be  positively 
affirmed  that  leukocytes  are  of  renal  origin  (Striimpell).  The  pus-cells 
are  frequently  seen  to  be  without  nuclei  in  marked  or  chronic  pyuria. 

4.  Red  Blood-corpuscles  {vide  Hematuria,  p.  084). — In  acute  hem- 
orrhao-ic  ncpiiritis  and  in  severe  renal  congestion  free  red  blood-cor- 
puscles are  generally  to  be  found. 

5.  Fat-globules  and  fatty  degenerated  cells  are  seen  especially  in  sub- 

^  Practical  Medicine  Series,  1911,  vol.  i.,  p.  384. 


DROPSY  OF  RENAL  JJl.SEASE.  1007 

acute  and  chronic  nephritis  with  fatty  degeneration  of  the  proliferated 
epithelium,  or  in  the  fatty  stage  of  large  white  kidney. 

DROPSY   OF  RENAL   DISEASE. 

Since,  as  in  other  conditions,  renal  droj)sy  or  edema  is  an  al^normal 
accumulation  of  watery  fluid  transuded  from  the  hlood-vesscls  into  the 
cellular  tissues  and  lymph-spaces,  the  question  arises,  "What  is  the 
rationale  of  its  development  in  nephritis?"  On  the  ground  that  in  most 
forms  of  nephritis  the  urine  is  diminished,  it  was  foimerly  held  that  the 
dropsy  was  due  to  the  saturation  of  the  tissues  with  the  water  that  was  not 
excreted  by  the  'kidneys.  This  theory  is  not  tenable,  however,  for  there 
are  some  cases  of  edema  unaccompanied  by  any  diminution  in  the  daily 
quantity  of  urine ;  on  the  other  hand,  certain  instances  of  renal  disea.se 
in  which  there  is  a  state  of  almost  anuria  show  no  evidence  of  dropsy 
whatever.  Landerer  holds  that  the  relaxation  of  the  tissues  (which  may 
be  caused  by  the  increased  transudation  of  stasis,  or  by  hyponutrition 
from  hydremia),  and  their  consequent  loss  of  elasticity,  prevent  that 
forcing  of  the  lymph  into  circulation  that  exists  in  the  normal  state,  and 
as  a  result  a  watery  infiltration  of  the  tissues  is  permitted.  From  recent 
experiments  edema  is  due,  at  least  in  part,  "  to  toxic  substances  accumu- 
lating in  the  blood  and  exciting  an  injurious  action  on  the  endothelium 
of  the  capillaries"  (Edsall).  Pearce  ^  concludes  that  plethoric  hydremia 
and  vascular  injury  have  equal  value  with  nephritis  in  the  production  of 
edema,  and  that  none  of  these  three  factors  acting  alone,  and  no  combi- 
nation of  two  acting  together,  is  sufficient  to  cause  edema.  The  chloride 
retention  theory,  namely,  that  there  is  an  abnormal  amount  of  sodium 
chloride  in  the  tissues  of  persons  manifesting  renal  dropsy  (in  consequence 
of  which  an  accumulation  of  water  in  order  to  keep  the  chlorides  in  solu- 
tion occurs),  is  widely  accepted  at  the  present  day. 

The  dropsy  of  the  nephritides  may  be  either  slight  or  marked,  local 
or  general  (anasarca),  and  sudden  or  slow  in  onset.  It  is  purely  renal 
in  origin  perhaps  only  in  acute  Bright's  disease  or  in  the  earlier  stages 
of  chronic  Bright's  disease.  In  all  forms  of  chronic  nephritis  the  dropsy 
may  be  due,  in  part,  to  the  venous  stasis  of  cardiac  incompetency.  In 
chronic  interstitial  nephritis,  especially,  edema  is  slight,  and  usually  is 
the  result  of  weakness  and  dilatation  of  the  heart.  I  desire  to  mention 
here  those  rare  cases  of  dropsy  that  simulate  Bright's  disease  in  which  no 
satisfactory  causative  lesion  is  apparent  or  discoverable,  and  also  those 
cases,  rarer  still  perhaps,  that  have  a  peculiar  family  or  congenital  origin. 

Physical  Signs. — The  recognition  of  edema  is  made  possible  by  both 
inspection  and  palpation.  Benal  dropsy  is  manifested  first  by  puffiness 
of  the  skin  of  the  face,  and  especially  of  the  eyelids.  At  other  places 
where  there  is  loose  subcutaneous  cellular  tissue,  and  in  particular  where 
the  parts  are  dependent,  dropsy  is  most  apt  to  be  seen  early,  as  under 
the  malleoli  of  the  ankles,  the  dorsum  of  the  foot,  and  the  scrotum. 
Later,  the  limbs  and  the  lower  part  of  the  back  become  swollen,  and 
the  whole  body  is  involved  in  severe  cases.  The  skin  has  a  peculiar 
waxy  pallor  and  a  glossy  appearance.  When  vascular  or  cardiac  changes 
exist,  so  as  to  permit  of  increased  dropsy  from  engorgement,  as  in  cir- 
rhotic kidney,  a  cyanotic  or  muddy  color  of  the  skin  may  prevail.  Pal- 
pation detects  pitting  due  to  loss  of  elasticity  in  edematous  tissues. 

1  Archives  of  Internal  Medicine,  Chicago,  Junej  1909. 


1008  DISEASES  OE  THE   URINARY  SYSTEM. 

Pathologic  Features. — Dropsy  i.s  most  constant  and  most  persistently 
decided  in  the  large  kidney  of  subacute  or  chronic  nephritis ;  it  is  most 
uncommon  and  irregular  in  chronic  interstitial  nephritis  (contracted 
kidney).  There  is  also  a  doughy  or  putty-like  consistence.  In  very 
marked  cases  of  dropsy  the  deeper  parts,  such  as  the  muscles,  become 
aflected.  The, serous  cavities  also  in  general  anasarca  show  evidences  of 
effusion,  and  thus  give  rise  to  hydro-thorax,  hydro-peritoneum,  and 
hydro-pericardium.  Less  frequently  there  may  be  edema  of  the  larynx, 
uvula,  conjunctiva,  and  other  mucous  membranes.  Edema  of  the  brain, 
either  local  or  general,  may  be  the  cause  of  grave  uremic  symptoms  in 
chronic  nephritis,  or  of  unilateral  convulsions  or  paralysis  and  apoplectic 
seizures.  The  dropsical  liquid  is  chemically  similar  to  a  diluted  blood- 
serum.     A  minute  quantity  of  albumin  and  urea  is  present. 

UREMIA. 

Definition.* — Uremia  is  the  term  applied  to  a  group  of  manifestations, 
mainly  nervous  and  either  acute  or  chronic,  resulting  from  a  toxemia  due 
to  the  retention  in  the  body  of  certain  products  of  urinary  or  renal  origin. 

Although  most  common  in  Bright's  disease,  uremia  may  arise  also  in 
other  diseases,  as  in  gout  (gouty  kidney),  scarlet  fever  (scarlatinal  nephri- 
tis), typhus  fever,  yellow  fever,  and  cholera,  in  which  the  kidneys  and 
blood  may  be  seriously  affected.  Kidneys  which,  on  account  of  marked 
structural  changes,  fail  to  eliminate  the  normal  quantity  of  solid  constit- 
uents are  directly  or  indirectly  responsible  for  uremia. 

Our  present  knowledge  of  the  pathology  and  etiology  of  uremia, 
as  of  renal  edema,  is  based  solely  upon  theoretic  views.  The  theory  that 
attributes  uremic  symptoms  to  the  retention  of  the  excretory  products 
appears  to  have  the  strongest  proofs  to  support  it ;  but  the  positive  nature 
of  these  substances,  or  which  is  the  most  toxic,  or  whether  several  are 
concerned  in  the  causation  or  not,  remains  to  be  determined. 

Not  only  some  of  the  solid  urinary  constituents  accumulate  in  the 
blood  in  uremia,  but  the  water  also  is  only  partly  eliminated,  and  its 
presence  in  the  blood  renders  the  latter  hydremic  and  of  lower  specific 
gravity.  Notwithstanding  the  fact  that  most  cases  of  uremia  may  be 
traced  to  a  marked  simultaneous  diminution  in  the  quantity  of  urine 
passed,  there  remain  still  certain  instances  of  renal  disease  in  which 
uremic  symptoms  appear  without  any  such  perceptible  diminution. 
Even  more  frequent  perhaps  are  those  perplexing  cases  of  anuria  now 
and  then  reported  in  which  no  uremic  symptoms  appear.  In  the  latter 
instances  it  is  probable  that  the  elimination  of  products  normally  ex- 
creted by  the  kidneys  may  be  accomplished  through  other  channels,  as 
by  the  skin  and  bowels;  in  the  former  it  is  still  likely  that  the  solid 
urinary  constituents  are  retained. 

Traube's  theory  of  the  cause  of  uremia,  particularly  of  the  nervous 
or  cerebral  manifestations,  was  that  it  is  an  acute  edema  of  the  brain — 
local  or  general — witli  cerebral  anemia.  This  Avould  seem  to  explain 
certain  cases  of  nephritis,  as  already  mentioned,  in  which  a  fair  amount 
of  urine  and  solid  constituents  are  passed  ;  also  cases  of  anuria  due  to 
urethral  obstruction  in  which  no  uremic  symptoms  appear ;  and  certain 
cerebral  disturbances.     Hughes  and  Carter,  from  an  experimental  study, 


UREMIA.  1009 

reached  the  conclusion  that  uremia  is  caused  by  an  albuminous  product 
unlike  anything  found  in  natural  urine.  Strauss  found  both  the  ammonia 
in  the  blood  and  the  retention  nitrogen  in  the  hydremic  serum  markedly 
increased  in  uremia.  According  to  Croftan,  metabolic  disturbances  de- 
pendent upon  an  acid  intoxication  must  be  incriminated  with  producing 
many  of  the  fulminating  signs  of  uremic  coma.  "In  general  terms, 
however,  it  may  be  assumed  that  interference  with  albuminous  metabolic 
processes,  followed  by  disturbed  hepatic  function  and  renal  function,  ex- 
plains the  etiology  of  uremia  most  satisfactorily."  ^  Delafield  attributes 
the  sudden  violent  motor  symptoms  of  acute  uremia  to  a  contraction  of 
tlie  arteries  from  some  unknown  cause. 

The  symptoms  of  uremia  may  be  either  acute  or  chronic  in  onset, 
severity,  and  course.  In  acute  uremia  the  severest  nervous  symptow.H 
come  on  suddenly ;  they  last  but  a  comparatively  short  time,  and  termi- 
nate fatally,  with  convulsions  and  coma,  dyspnea,  feeble  cardiac  action  and 
pulse,  fever,  and  pulmonary  edema.  These  acute  symptoms,  however,  are 
not  infrequently  preceded  by  mild  uremic  prodromes,  as  headache,  som- 
nolence, nausea,  malaise,  slight  dyspnea,  and  uneasiness.  Curschmann  - 
claims  that  in  threatened  uremia  the  Babinski  reflex  often  becomes  posi- 
tive before  either  mental  disturbance  or  an  increase  of  the  tendon  reflexes 
appear. 

Chronic  uremia  is  characterized  by  the  absence  of  the  marked  symp- 
toms referred  to  above,  the  milder  manifestations  alone  appearing  and 
lasting  over  a  considerable  length  of  time.  Here  the  general  prostration, 
the  feeble  cardiac  and  arterial  states,  the  occasional  stupor  and  delirium, 
transient  dimness  of  vision,  anorexia  and  nausea,  irregularly  hurried 
breathing,  and  muscular  twitchings,  indicate  the  grave  condition  of  the 
patient.  To  gain  a  more  thorough  knowledge  of  this  condition  a  divi- 
sional study  of  the  symptomatology  is  necessary. 

Cerebral  Symptoms. — These  vary  from  a  slight  headache,  tremors,  and 
the  restlessness  of  anxiety  to  the  most  violent  maniacal  delirium  and  con- 
vulsions ;  from  somnolence,  low  muttering,  and  mental  stupor  to  profound 
coma ;  and  from  slight  visual  disturbances  to  complete  amaurosis.  The 
onset  of  a  noisy  delirium,  and  less  commonly  of  a  marked  mania,  is  often 
abrupt,  and  may  be  the  first  manifestation  of  Bright's  disease  in  an  indi- 
vidual. Delusional  insanity  (^folie  Brightique)  is  seen  in  a  few  cases. 
Bischoff  has  observed  only  two  cases  of  purely  uremic  psychoses  among 
3000  cases  of  insanity.  Melancholia  and  the  delusion  of  persecution, 
with  suicidal  and  homicidal  tendencies,  may  occur.  The  most  character- 
istic symptom  of  uremia,  however,  is  the  convulsion  (uremic  eclampsia). 
Uremic  convulsions  are  epileptiform  in  type,  although  they  may  be 
either  unilateral  or  local.  They  are  supposed  to  be  due  to  a  local 
or  general  edema  of  the  brain,  and  are  probably  allied  to  the  apoplexia 
serosa  of  early  writers  (Osier).  The  convulsions  of  uremia  may  come 
on  suddenly  or  may  be  preceded  by  headache,  vertigo,  dropsy,  nausea, 
and  vomiting.  As  in  the  epileptiform  convulsion,  after  the  early 
tonic  rigidity  there  may  follow  at  short  intervals  the  clonic  spasm,  with 
cyanosis,  fever,  and  contracted  arteries,  and  the  intervening  periods  of 
unconsciousness,    shallow   or    noisy  respiration,   and    slow,    hard   pulse. 

1  "Uremia,"  The  Therapeutic  Gazette,  November  15,  1907,  by  the  writer. 

2  Miinch.  vied.  Woch.,  1911,  Iviii.,  205-1. 

64 


1010  DISEASES  OF  THE   URiyARY  SYSTEM. 

Coma  may  come  on  «xradually  as  Avell  as  during  the  convulsive  attacks. 
It  may  be  preceded  by  headache,  apatliy,  and  insomnia,  and  continue 
progressively  to  deepen.  A  fi//>/ioid  state  not  infrerjuently  accompanies 
uremic  coma.  The  temperature  is  usually  lowered,  and  moderate  dilata- 
tion or  contraction  of  the  pupils  may  be  evidenced. 

Uremic  Amaurosis. — Blindness  may  follow  uremic  convulsions,  or, 
rarely,  it  may  come  on  without  motor  disturbances.  It  is  of  purely 
centric  origin  (the  cortex  of  the  occipital  lobe),  and  its  duration  is  short, 
lasting  but  a  few  days  in  most  instances.  Retinal  hemorrhage  may 
occur.  Uremic  deafness,  which  is  probably  also  of  centric  origin,  is  a 
less  common  manifestation.  Other  nervous  phenomena,  as  hemiplegia, 
monoplegia  (from  cerebral  or  spinal  congestion  or  edema),  contractures, 
aphasia,  pruritus,  paresthesife,  and  cramps  in  the  calf-muscles  are  not 
so  frequent  in  occurrence. 

Circulatory  Disturbances. — The  pulse  is  moderately  slow,  tense,  and 
fiill  in  uremia,  but  with  the  onset  of  acute  and  severe  symptoms,  as  con- 
vulsions, it  usually  becomes  accelerated,  small,  and  feeble.  The  heart's 
action  is  labored  and  feeble.  Indican  has  been  demonstrated  in  the 
blood  in  uremia;  this  is  absent  in  health  and  other  pathologic  states.' 

Respiratory  Symptoms. — Renal  dyspnea,  which  is  sometimes  called 
"uremic''  or  "renal  asthma."  is  a  marked,  and  often  an  early  symp- 
tom, of  uremia.  I  believe  that  it  is  the  most  constant  symptom  of  this 
serious  condition.  The  respirations  are  deep  and  often  stertorous  in 
coma,  or  they  may  be  irregular,  accelerated,  and  shallow,  sometimes  as- 
suming the  Cheyne-Stokes  type.  Dyspneic  attacks  are  especially  apt  to 
occur  at  night.  In  chronic  uremia  slight  dyspnea  may  be  continuous  for  a 
long  time.  Again,  alternating  paroxysmal  exacerbations  may  arise.  The 
uremic  dyspnea  is  probably  due  in  most  cases  to  the  toxemia  affecting  the 
respiratory  nervous  centers.  It  may,  however,  be  the  result  of  cardiac 
weakness  or  of  dropsy  or  pulmonary  edema. 

Q- astro -intestinal  Symptoms. — Uremic  stomatitis  is  generally  seen. 
The  breath  is  foul,  the  tongue,  lips,  and  gums  are  red,  swollen,  and  pain- 
ful, and  the  saliva  is  increased.  Uremic  vomiting  is  also  usually  of  cen- 
tric origin,  though  it  may  be  provoked  by  the  irritation  of  the  gastric 
mucosa,  caused  by  the  vicarious  elimination  of  the  urea  and  the  decom- 
position of  the  latter  into  irritating  ammonium  carbonate.  The  vomiting 
may  come  on  suddenly  and  be  persistent.  Uncontrollable  hiccough  and 
sometimes  uremic  diarrhea  may  be  associated.  The  irritant  action  of  the 
ammonium  carbonate  on  the  intestinal  mucous  membrane  may  produce  a 
catarrhal  or  diphtheritic  inflammation,  and  ulceration  even  (Grawitz). 
Uremic  diarrhea  may  also  exist  apart  from  any  gastric  disturbances. 

General  Symptoms. — The  shin  of  the  face  is  usually  pale  in  uremic 
coma.  Urea  may  be  excreted  by  the  sweat-glands,  and  may  be  seen  as 
minute  glistening  crystals  in  some  of  the  cutaneous  furrows  after  the 
evaporation  of  a  free  sweat.  The  skin  is  often  harsh  and  dry,  as  in 
chronic  interstitial  nephritis.  Uremic  pruritus  is  probably  the  result  of 
the  peripheral  irritation  of  the  cutaneous  nerves  by  crystals  of  urea.  The 
temperature  is  generally  lowered,  but  uremic  fever  frequently  accompanies 
the  convulsions  or  they  may  be  preceded  by  "uremic  chills."  In  some 
cases  the  temperature  rises  to  105°-107°  F.  (40.5°-41.6°  C.)  just  before 

1  For  test,  see  Zeniralblatt  fur  Innere  Medizin,  Dec.  23,  1911,  by  W.  von  Moraczewski 
and  E.  Herzfeld. 


UREMIA. 


1011 


death,  whilst  in  other  cases,  characterized  by  coma  that  deepens  into  col- 
kpse,  the  temperature  may  be  so  h)w  as  91^  or  O?/-'  V.  ('42.7''-.i?,.H''  C). 

There  is  not  infrequently  an  ammoniacal  odor  about  a  uremic  patient. 
The  urine  is  diminished  in  quantity,  is  generally  highly  albuminous,  and 
deficient  in  urea.  A  previous  dropsy  is  sometimes  markedly  reduced 
upon  the  appearance  of  acute  uremic  symptoms. 

Duration  iand  Prognosis. — Acute  uremia  is  manifested  by  coma 
and  convulsions,  seldom  lasting  more  than  a  few  days.  Chronic  uremia, 
in  which  milder  nervous  symptoms,  nausea  and  vomiting,  and  dyspnea 
are  more  prominent,  may  persist,  however,  for  many  weeks.  While  a 
grave  condition,  uremia,  even  in  its  most  acute  and  violent  forms,  is  not 
at  once  necessarily  fatal,  for  under  proper  treatment — as  by  venesection, 
for  instance,  followed  by  judicious  hygienic  measures — life  may  be  con- 
siderably prolonged.  Sooner  or  later,  however,  barring  a  possible  death 
from  some  intercurrent  affection,  a  fatal  result  is  inevitable. 

Diagnosis. — Uremia  may  be  recognized  by  the  history,  the  marked 
arterial  tension,  and  the  accentuated  second  sound  of  the  heart ;  also  by 
the  albuminuria  (the  urine  has  to  be  withdraAvn),  the  temperature,  and 
the  odor  of  the  breath.  The  presence  of  dropsy  in  some  cases  is  a  valu- 
able indication  of  the  nephritic  origin  of  uremic  manifestations. 

Differential  Diagnosis. — Uremic  unconsciousness  coming  on  suddenly, 
as  in  chronic  interstitial  nephritis,  may  simulate  alcoholism,  cerebral 
hemorrhage  {apoplexy),  cerebral  tumor,  or  meningitis.  The  points  of 
dissimilarity  between  the  first  two  conditions  and  uremia  are  here  tabu- 
lated (Herrick) : 


Cerebral  Hemorrhage. 
Pupils  unequal  or  dilated. 

Stertorous,    puffy    breath- 
ing, and  flapping  cheek. 
No  odor. 

Paralysis  ;  hemiplegia. 
Unconsciousness  absolute. 

Pulee  slow  and  strong  or 
irregular  ;  arteries  often 
atheromatous. 

Coma  sudden  and  deep. 
Convulsions  late  •,  may  be 

unilateral. 
Urine  generally  negative. 
Apoplectic    habit ;     heart 

may  show  hypertrophy. 


Alcoholic  Narcosis. 

Pupils   contracted    or    di- 
lated ;  eyes  injected. 
No  stertorous  breathing. 

Odor  of  alcohol. 

No  paralysis,  usually. 
May  be  aroused. 

Pulse  frequent  and  feeble. 


Coma  gradual. 
No  convulsions. 

Urine  generally  negative. 
Red  face  and  nose,  heart 

often  weak,  dilated,  my- 

ocarditic. 


Uremia. 

Pupils   generally   dilated  ; 

albuminuric  retinitis. 
Sharp,  hissing  stertor. 

No  odor,  unless  urinous. 

No  paralysis. 

May  or  may  not  b  e 
aroused. 

Pulse  at  first  strong,  later 
weak  and  rapid  ;  tension 
strong  ;  arterio-scle- 
rosis. 

Coma  gradual  or  sudden. 

Preceded  by  general  con- 
vulsions,  headache,   etc. 

Urine  albuminous. 

Edema  and  pallor  ;  heart 
hypertrophied. 


In  meningitis  the  mode  of  onset,  the  rigidity  of  the  neck,  incoherence  or 
mild  delirium,  photophobia,  and  pronounced  fever  point  to  the  distinction. 

Uremic  coma  must  also  be  differentiated  from  opium-poisoning  and 
diabetic  coma.  Chronic  uremia  must  not  be  confounded  with  the  asthenic 
state  of  typhoid  fever  and  acute  miliary  tuberculosis.  In  opium-poisoning 
the  pupils  are  contracted  and  do  not  respond  to  light.  Again,  in  opium- 
poisoning  the  respirations  are  slow,  deep,  and  full,  and  the  patient  may 
answer  rationally  when  aroused.    In  uremic  coma,  it  will  be  remembered, 


1012  DISEASES  OF  THE    TiJ/XlA'!'  SYSTEM. 

consciousness  is  abolished.  In  diahetic  coma  the  history  must  be  learned, 
the  harsh,  dry  skin  and  emaciation  noted,  and  especially  are  the  ethereal 
odor  and  the  Burtrundy-red  reaction  of  the  urine  (acetone)  with  the  tincture 
of  the  chlorid  of  iron  to  be  observed  ;  sugar  is  also  present. 

The  prog^nosis  is  grave,  but  guarded ;  it  is  even  favorable  in  many 
cases,  so  far  an  inimodiate  results  are  concerned. 

Treatment. — This  will  be  detailed  in  the  discussion  of  the  various 
forms  of  nephritis.  Suffice  it  to  say  that  the  supreme  indication  is  the 
prompt  elimination  of  the  poisons  in  the  blood.  When  diaphoresis  and 
catharsis  fail,  venesection  should  be  employed:  the  latter  measure  is  also 
probably  the  most  reliable  in  urgent  cases  of  uremic  convulsions  or  coma. 
The  counter-injection  (intravenous)  of  normal  salt  solution  may  be  indi- 
cated in  cases  of  profound  weakness  threatening  collapse.  Biiumler  ad- 
vises against  the  introduction  of  salt  solution  and  the  use  of  salt  in  the 
diet.  Frey  reconimends  luml)ar  puncture  to  evacuate  toxins  and  reduce 
pressure  on  the  brain  in  the  cerebral  type. 

Bozzoli  recommends  the  subcutaneous  injection  of  sterilized  serum 
because  of  the  gratifying  results  secured  in  a  number  of  cases  of  uremia. 


AMYLOID  KIDNEY. 


Definition. — Amyloid  (waxy  or  lardaceous)  degeneration  of  the  kid- 
neys is  usually  coexistent  with  a  similar  degeneration  of  other  viscera. 

Pathology. — Macroscopically,  the  amyloid  kidney  appears  pale, 
greenish  or  yellowish-white,  firm,  and  uniformly  enlarged,  and  the  surface 
is  smooth,  glistening,  and  often  mottled,  owing  to  the  prominence  of  the 
stellate  veins.  On  section  a  homogeneous,  anemic,  or  "  bacon-like  " 
surface  presents  itself,  particularly  in  the  cortical  region.  The  cortex 
is  wider  than  normal ;  the  pyramids  may  be  red  in  color  and  slightly 
infiltrated  ;  and  the  glomeruli  may  show  an  infiltration  by  the  glistening, 
translucent  amyloid  (albuminoid)  material.  On  the  application  of  Lugol's 
solution  of  iodin  to  the  amyloid  areas  a  mahogany-red  color  is  produced. 
Brushing  over  the  amyloid  substance  with  a  solution  of  iodin,  and  then 
with  dilute  sulphuric  acid,  gives  a  blue  or  violet  tint.  Similarly  used, 
a  1  per  cent,  solution  of  methyl-violet  strikes  a  red  color.  The  capsule 
of  the  kidney  is  thickened,  though  not  always  adherent. 

Microscopically,  the  amyloid  change  is  generally  found  in  the  early 
stages  to  affect  the  walls  of  the  cajjillaries  of  the  Malpighian  tufts.  The 
walls  are  swollen  with  the  homoircneous  material  and  the  vessel-lumen  is 
diminished  or  obliterated.  The  straight  urinifcrous  tubules  are  also  in- 
filtrated later  perhaps,  the  deposit  occurring  primarily  in  the  membranae 
propriae.  A  diffuse  nephritis  is  nearly  always  an  associated  condition. 
The  tubules  generally  contain  hyaline  casts.  Fatty  degeneration  of 
the  epithelium,  glomerulites  or  waxy  glomeruli,  and  a  thickening  of 
Bowman's  capsule  are  common  in  markedly  amyloid  kidneys.  In  ad- 
vanced cases  most  of  the  secretory  structure  becomes  atrophied.  Amy- 
loid infiltration  of  the  smaller  granular  kidney  is  less  common  than  of 
the  large  white  kidney,  with  intense  parenchymatous  changes. 

Hypertrophy  of  the  heart  is  not  always  present  in  amyloid  disease  of 


AMYLOID   KIDNEY.  1013 

the  kidneys.  Amyloid  infiltration  of  other  organs,  however,  as  of  the 
liver  and  spleen,  is  usually  associated  with  waxy  kidneys. 

!^tiology. — The  causes  of  amyloid  kidney  are  tliose  of  the  amyhjid 
change  affecting  (either  simultaneously  or  nearly  so)  other  organs,  as  the 
spleen,  liver,  and  intestines. 

Commonly,  amyloid  disease  is  marked  also  in  the  other  solid  organs 
named  above  ;  it  is  secondary  to  wasting  diseases,  cachexise,  and  the  like. 
Perhaps  the  most  frequent  cause  of  the  waxy  kidney  is  tuberculosis,  espe- 
cially of  the  lungs  ("chronic  ulcerative  phthisis"):  tuberculosis  of  the 
intestines  also  is  often  associated.  Next  in  order  are  the  prolonged  sup- 
purations, particularly  of  the  bones,  as  in  osteitis  of  the  vertebrae  and 
hips  (usually  tuberculous).  Chronic  empyema,  intestinal  ulcers,  vesico- 
vaginal fistulae,  and  other  purulent  affections,  chronic  in  nature  also, 
have  the  same  etiologic  effect.  Amyloid  kidney  is  often  present  in 
syphilis,  especially  in  the  tertiary  stage,  when  ulceration  of  the  mucous 
surfaces  and  of  the  bones  is  present.  Rarely,  gout,  malaria,  leukemia, 
cancer,  and  chronic  valvular  endocarditis  with  insufficiency  seem  to  pro- 
duce amyloid  disease. 

Sjrmptoms. — These  vary  greatly  according  to  the  extent  to  which 
the  amyloid  degeneration  has  encroached  upon  the  normal  kidney-struc- 
ture, and  may  be  overshadowed  partially  or  completely  by  those  of  the 
dominant  causal  aff'ection. 

The  urine  is  pale  yellow,  clear,  and  variable  in  quantity,  and  the 
amount  passed  in  twenty-four  hours  is  sometimes  normal  or  may  be 
slightly  diminished.  More  frequently,  perhaps,  it  is  increased,  and  espe- 
cially in  marked  or  advanced  cases.  The  specific  gravity  is  apt  to  be 
low  (1015—1005),  and  there  is  seldom  any  sediment. 

Serum-albumin  and  globulin  may  both  be  present  in  the  urine ;  but  a 
highly  significant  condition,  and  one  that  is  seemingly  diagnostic,  is  the 
high  proportion  of  globulin  as  compared  with  the  serum-albumin  (Sal- 
kowski,  Senator).  Tube-casts  may  be  found,  but  their  presence  may  be 
only  temporary ;  they  are  usually  wide,  hyaline,  fatty  and  granular, 
and  very  few  in  number  (Fig.  67).  The  amyloid  reaction  may  be  elicited 
with  the  hyaline  casts ;  symptoms  referable  to  the  kidney  are  often 
absent  in  comparison  with  those  of  the  nephritides.  Dropsy  is  not  in- 
variably present,  and  when  present  is  but  moderate  in  degree  and  gen- 
erally in  the  legs  only.  It  is  proportionately  prominent  with  the  in- 
crease in  the  anemia,  circulatory  depression,  and  wasting  of  flesh  and 
strength.  The  latter  manifestations,  constituting  a  cachectic  appearance, 
are  quite  commonly  observed  in  amyloid  kidney. 

The  associated  enlargement  and  the  firm,  sharp  outlines  of  the  liver 
and  spleen  are  of  diagnostic  significance.  3Iarked  diarrhea  may  be  due 
to  coexisting  amyloid  infiltration  of  the  intestines  or  to  tuberculous  intes- 
tinal ulcers,  and  is  often  seen  in  advanced  cases. 

Diagnosis. — This  can  seldom  be  made  upon  the  urinary  manifesta- 
tions alone.  Important  and  often  necessary  adjuncts  are  the  histories  of 
causation  and  of  the  associated  symptoms  and  physical  signs.  Thus, 
there  will  be  evidenced  in  most  cases  tuberculosis,  chronic  bone-suppura- 
tions, or  syphilis,  while  coexisting  hepatic  and  splenic  enlargements,  wast- 
ing, and  cachexia  are  usually  present.  In  any  of  the  diseased  conditions 
mentioned  amyloid  kidney  may  be  diagnosticated  with  reasonable  cer- 


1014  DISEASES  OF  THE   URINARY  SYSTEM. 

tainty  upon  the  development  of  an  increased  quantity  of  pale  clear  urine 
of  low  specific  gravity  and  containing  a  large  amount  of  albumin,  or  even 
with  slight  albuminuria. 

From  parencJtymatoiis  nephritis  amyloid  kidney  is  to  be  differentiated 
by  the  history,  by  the  more  marked  and  generally  distributed  dropsy, 
and  by  the  albuminuric  retinitis  that  characterize  the  former.  In  chronic 
interstitial  nephritis  there  are  less  marked  albuminuria  and  dropsy,  and 
there  are  present  arterio-sclerosis,  cardiac  hypertrophy,  and  a  pronounced 
tendency  toward  uremic  sy^mptoms. 

Prognosis. — This  varies  with  the  cause.  Incipient  bone-disease  or 
tuberculosis,  with  only  slight  evidences  of  amyloid  change  in  the  kidneys, 
may  be  controlled.  As  a  rule,  however,  the  structural  alterations  are  so 
far  advanced,  and  the  constitutional  powers  of  resistance  so  much  ener- 
vated, before  the  amyloid  infiltration  can  be  distinctly  apprehended  that 
in  the  majority  of  instances  the  prognosis  is  entirely  unfavorable.  In 
decided  cases  death  ensues  in  from  several  weeks  to  as  many  months. 

Treatment. — This  also  depends  upon  the  causal  affection.  Hygienic 
and  dietetic  measures  are  always  useful,  however,  with  a  view  to  improving 
the  general  nutrition.  The  iodid  of  iron  has  been  recommended  as  an 
alterative,  and  easily  assimilable  and  palatable  fats  and  tonics  may  also 
be  tried.  Tuberculous  cases  require  creasote  or  allied  preparations  :  syph- 
ilitics  require  mercurials  and  iodids ;  while  malarial  subjects  do  best 
under  the  systematic  use  of  arsenic,  iron,  and  quinin. 


NEPHROLITHIASIS. 

(Renal  Calculi;  Pyelitis  Calculosa ;  Renal  Colic;   Gravel.) 

Definition. — A  condition  characterized  by  the  formation  of  fine  or 
coarse  concretions  in  the  kidney-substance  or  in  the  renal  pelvis  by  the 
precipitation  of  certain  of  the  solid  urinary  constituents. 

Varieties. — According  to  their  size,  renal  concretions  are  variously 
termed — (1)  Renal  sand,  of  which  the  particles  are  fine  and  pulverized; 
(2)  Renal  gravel,  consisting  of  coarse  grains  or  even  of  pea-sized  concre- 
tions ;  (3)  Renal  stone,  or  calculus,  when  larger  masses  than  the  preceding 
exist,  either  more  or  less  rounded  or  as  stony  casts  or  moulds  of  the  pelvis 
of  the  kidney,  its  infundibula,  and  calyces  {dendritic  or  coral  calculi). 

According  to  their  composition,  the  chemical  varieties  of  renal  concre- 
tions are — (1)  Uric-acid  calculi,  the  most  frequent  in  occurrence.  Urates 
are  often  associated  in  the  calculus  with  uric  acid,  thus  producing  strati- 
fication. These  concretions  may  occur  as  sand,  gravel,  or  large  stones ; 
they  are  usually  quite  hard,  reddish-brown  or  black  in  color,  and  have  a 
smooth  though  irregularly  shaped  surface.  The  fracture  is  crystalline. 
Pure  uratic  stones  may  occur  in  children.  Mackarell,  Moore,  and 
Thomas  have  shown  that  uric  acid  is  not  the  most  common  constituent 
of  renal  calculi,  but  calcium  oxalate  and  calcium  phosphate. 

(2)  Calcium-oxalate  concretions  occur  more  rarely  in  the  kidney. 
They  constitute  the  so-called  ''mulberry  calculi,"  from  a  fancied  resem- 
blance to  the  mulberry,  owing  to  their  dark-brown  or  black  color  and 
very  irregular  and  nodulated  or  prickly  appearance.  They  are  also  quite 
dense;  lamination,  however,  is  not  common,  although  they  are  sometimes 
formed  about  a  uric-acid  nucleus. 


NEPHR  OLITIIIA  SIS.  1015 

(3)  Phosphatic  calculi  of  the  kidney  arc  still  less  common  tlian  the 
oxalate,  but  they  are  more  common  in  the  bladder.  They  may  consist  of 
calcic  phosphate  or  ammonio-magnesic  phosphate,  and  may  possibly  be 
associated  with  calcic  carbonate.  Phosphatic  salts  are  most  often  depos- 
ited secondarily  about  uric-acid  or  oxalate  calculi  in  the  alkaline  urine  of 
a  cystitis  set  up  by  the  irritation  of  the  true  renal  stones.  Phosphatic 
calculi  are  grayish-white  in   color  and  are  comparatively  soft. 

(4)  Renal  stones  composed  of  cystin,  xanfhin,  carhonate  of  lime,  fatty 
or  saponaceous  matters  (urostealith),  indigo,  z.n(i  fibrin,  though  of  extreme 
rarity,  have  been  occasionally  reported.  Cystin  calculi  have  a  pale-yellow 
color  and  a  waxy  luster. 

Pathology. — The  anatomic  changes  of  the  kidney  vary  with  the 
degree  and  persistence  of  the  irritation,  the  size  of  the  calculi,  and  their 
passage  or  retention.  Sometimes  numerous  granular  and  pea-sized  con- 
cretions are  found  in  the  renal  pelvis,  with  desquamated  epithelium  and  a 
turbid  urine.  Interesting  cases  are  those  in  which  a  dendritic  stone 
occupies  a  great  portion  of  the  atrophied  kidney-substance,  as  well  as 
the  entire  pelvis  of  the  organ.  In  one  of  my  own  patients  the  left  kidney 
was,  apparently,  nearly  twice  the  normal  size,  owing  to  the  presence  of  a 
large  coral-calculus  (uric  acid  and  urates),  connected  by  an  isthmus  with 
a  rounded  stone  in  the  inferior  portion  quite  as  large  as  a  large  walnut. 
The  pelvis  of  the  right  kidney  also  contained  a  dendritic  calculus. 

Secondary  Lesions. — Perhaps  the  most  usual  result  of  renal  concre- 
tions is  a  pyelitis  :  this  may  be  simple  catarrhal,  diphtheritic,  or  purulent, 
with  or  without  hemorrhages,  depending  upon  the  intensity  of  the  mechan- 
ical irritation.  A  pyelo-nephritis  may  follow  in  severe  cases,  as  may  even 
a  general  suppuration  (pyonephrosis)  or  perinephric  abscess  and  perfora- 
tions. Renal  pus-cavities  are  sometimes  found  2:)ostmortem  containing 
numerous  small  stones.  Hydronephrosis  is  another  important  pathologic 
sequel,  in  which  the  cause  is  to  be  attributed  to  the  blocking  of  the 
ureter  by  an  erstwhile  passing  stone  or  by  the  closing  of  the  aperture  of 
a  ureter  from  within  the  pelvis.  Pressure-necrosis  and  perforation  may 
thus  be  induced.  Owing  to  the  prolonged  pressure  of  a  dendritic  calculus, 
there  is  commonly  a  distinct  and  marked  atrophy  of  the  renal  parenchyma, 
resulting  in  chronic  diffuse  nephritis  with  little  or  no  exudation. 

Etiology. — The  definite  causation  and  the  exact  manner  of  formation 
of  renal  concretions  are  still  unestablished.  We  may  infer  not  a  little, 
however,  with  some  good  reason,  since  the  predisposing  causes  are  rather 
distinct.  Thus,  in  children  and  in  advanced  life  (before  15  and  after 
50  years  of  age)  the  occurrence  of  calculi  is  most  common,  the  uratic 
variety  being  most  frequent  in  the  former  and  the  uric  acid  in  the 
latter.  Men  are  subject  to  nephrolithiasis  more  often  than  are  women. 
The  uric-  or  lithic-acid  state  (lithemia),  gout,  and  the  various  influences 
that  induce  these  conditions,  as  an  excessive  meat  (proteid)  diet  or  a 
sedentary  life,  seem  to  predispose  to  stone.  Heredity,  I  believe,  plays 
a  prominent  part  in  many  cases. 

Broadly  speaking,  any  habit  of  the  system  that  encourages  the  pre- 
cipitation of  insoluble  abnormal  ingredients  or  of  normal  ingredients  in 
excess,  owing  to  chemical  changes  in  the  urine,  tends  to  the  formation 
of  calculi.  It  should  be  stated,  however,  that  the  primary  causes  of  cal- 
culus-formation is  the  presence  of  some  substance  in  the  urinary  tract 


1016  DISEASES  OF  THE  UBIXARY  SYSTEM. 

that  aftbinls  ii  nucleus  about  Avhicli  the  successive  layers  of  crystals  may 
deposit  ami  adhere,  such  as  bits  of  mucus,  colloid  material,  eiiitlielial 
shreds,  parasitic  ova,  bacteria,  blood-clots,  and  tube-casts. 

It  is  generally  believed  that  the  requisite  conditions  for  the  formation 
of  a  uric-arcid  renal  calculus  are — a  highly-acid  urine,  a  low  percentage 
of  salines,  and  deficiency  of  the  normal  urinary  coloring-matters. 

Symptoms. — These  may  be  slight,  progressive,  and  chronic,  or  they 
may  be  intensely  acute  and  comparatively  short  in  duration,  though  sub- 
ject to  repetition — /.  c.  renal  colic.  It  is  not  unusual  for  patients  to 
pass  uric-acid  sand  and  gravel  for  years  -without  much  complaint.  A 
sudden  blocking  of  a  ureter,  however,  or  a  slowly-passing  stone  of  dis- 
tending dimensions  produces  great  agony  at  times.  A  smooth,  snugly- 
fitting  dendritic  calculus  in  the  pelvis  may  not  cause  any  symptoms  for 
years  until  the  destruction  of  tissue  by  its  weight  and  mechanical  irritation 
ensues ;  there  is  then  a  progressive  failure  of  health,  a  constantly  increas- 
ing pain  in  the  back,  occasional  hematuria,  tenderness  on  pressure  over 
the  diseased  kidney,  both  anteriorly  (deep)  and  posteriorly,  and  finally 
uremia  and  death. 

The  characteristic  symptoms  of  stone  in  the  kidney  appear  as  an  attack 
of  renal  colic.  This  happens  when  a  calculus  in  its  passage  down  the 
ureter  acts  as  a  mechanical  irritant,  or  when  it  is  caught  and  stopped  in 
the  passage.  The  large  "gravel"  or  pea-sized  and  more  or  less  rough 
stones  usually  cause  the  attack,  which  comes  on,  as  a  rule,  quite  suddenly, 
although  it  may  be  preceded  by  a  chill  and  some  general  uneasiness  or 
by  slight  pain  in  the  region  of  the  kidney.  It  may  be  excited  by  a  sud- 
den muscular  effort.  The  pain  is  tearing  in  character,  and  rapidly 
reaches  an  agonizing  maximum  of  severit}^  starting  from  the  lumbar  re- 
gion and  extending  down  along  the  ureter  into  the  groin,  and  often  into 
the  testicle  and  inner  side  of  the  thigh.  The  paroxysm  may  appear  in 
the  form  of  a  diffuse  abdominal  and  lumbar  pain  in  some  instances.  There 
is  local  tenderness  on  pressure,  and  nausea  and  repeated  vomitings  are 
frequent.  The  patient  is  often  collapsed,  and  perspiration,  a  rapid,  small, 
and  feeble  pulse,  trembling,  anxiety,  bodily  twistings  about,  convulsions 
even,  and  syncope  may  ensue.  There  may  be  moderate  fever.  The  urine 
is  scanty  or  may  be  suppressed  for  a  time,  and  is  often  bloody.  Frequent 
and  painful  attempts  at  urination  are  made,  with  the  passage  of  but  a  few 
drops  at  a  time,  owing  perhaps,  in  part  at  least,  to  a  reflex  spasm  of  the 
vesical  sphincter  (vesical  tenesmus).  The  presence  of  pus  and  of  pelvic 
epithelium  in  the  urine  indicates  a  pyelitis.  When  a  large  fiuantity  of  clear 
urine  is  passed  it  maybe  looked  upon  as  having  come  from  a  healthy  kidney. 

The  paroxi/S7n  of  renal  colic  ends  when  the  impacted  stone  passes  out 
of  the  ureter.  This  may  occur  within  a  few  hours  or  it  may  take  several 
days ;  or  colic  may  be  intermittent. 

Recovery  is  not  always  complete  upon  the  evacuation  of  the  stone. 
The  previously  retracte<l  testicle  may  remain  painful,  and  there  are  apt 
to  be  aching  and  soreness  over  the  affected  kidney  and  ureter. 

In  certain  severe  cases  of  mechanical  irritation  the  symptoms  of  pye- 
litis, pyelo-nephritis  with  abscess,  or  hydronephrosis  may  be  superadded. 
Anuria  and  uremia  may  result. 

Nephrolithiasis  as  a  chronic  affection  may  exist  for  many  years,  with 
recurring  paroxysms  of  renal  colic.      I  observed  a  case  for  five  years 


NEPJIll  0 1 J  IT  J II A  ,S'/S'.  1017 

that  had  extended  over  a  period  of  thirty  years,  until  it  finally  came  to 
necropsy.  Between  the  attacks  of  colic  the  patient  may  be  entirely 
comfortable,  save  perhaps  an  occasional  burning  in  the  urethra  on  mic- 
turition, owing  to  a  highly-concentrated,  acid  urine  or  to  the  passage 
of  minute  uric-acid  granules.  There  are  apt  to  be  pain  and  tenderness 
over  a  kidney  containing  a  large  imbedded  stone.  A  smoky-hued 
urine,  due  to  slight  hematuria,  is  also  sometimes  present  in  long-stand- 
ing cases  of  renal  calculus,  particularly  after  exertion. 

A  renal  intermittent  fever  may  occur  in  nephrolithiasis,  and  is  analo- 
gous to  the  hepatic  intermittent  fever  of  cholelithiasis. 

Pyelitis — simple  or  purulent — with  late  involvement  of  the  kidney- 
parenchyma  (pyelo-nephritis)  is  a  frequent  concomitant  of  chronic  nephro- 
lithiasis. The  presence  of  pus  in  the  urine  is  constant,  with  an  absence 
of  renal  epithelium  in  cases  of  an  abscess-cavity  of  the  kidney.  In  ordi- 
nary pyelitis  the  pyuria  is  often  intermittent. 

The  general  health  of  patients  Avith  nephrolithiasis  is,  as  a  rule,  re- 
markably good.  Anorexia  is  not  only  seldom  present,  but  such  persons 
are  habitually  free  and  good  livers.  Persistent  headaches  with  nausea, 
however,  should  warn  one  of  uremia.  Splenic  and  hepatic  enlargement 
may  be  found  with  prolonged  suppurative  pyelo-nephritis,  indicating 
amyloid  disease. 

Diagnosis. — This  resolves  itself  into  a  study  of  the  diagnostic  cha- 
racters of  (a)  the  attacks  of  renal  colic,  (5)  of  the  underlying  systemic 
condition  in  general,  and  (c)  the  renal  condition  in  particular  that  renders 
these  attacks  possible.  The  latter  can  be  discovered  only  by  a  careful 
and  continuous  study  of  the  clinical  history  and  urinary  manifestations  as 
outlined  in  previous  paragraphs. 

Nephrolithiasis  may  be  positively  diagnosed  in  a  case  in  which,  after 
sudden,  agonizing,  colicky  pain,  referred  to  either  lumbar  region  and 
radiating  down  the  ureteral  course  to  the  testicle,  a  concretion  is  found  to 
have  passed  with  the  urine.  It  is  therefore  necessary  in  a  suspected  case 
of  renal  colic  to  pour  the  urine  through  a  fine  sieve  as  soon  as  passed. 
The  more  recent  improvements  in  the  operative  technic  for  producing 
the  Rbntgen  rays  enable  us  to  detect  renal  calculi  with  accuracy  as  to 
their  number,  size,  and  relative  position.  The  injection  of  collargol 
through  an  opaque  sound,  which  has  previously  been  introduced  into  the 
pelvis  of  the  kidney,  enables  an  a^-ray  picture  to  outline  the  pelvis  and 
calices.  In  the  case  of  urinary  calculi  consisting  of  uric  acid  alone,  how- 
ever, the  findings  are  totally  negative  on  Rontaenoscopy  (A.  Seelig  ^). 

Differential  Diagnosis. — Renal  colic  must  not  be  taken  for  biliary  or 
intestinal  colic.  The  antecedent  history  is  of  great  value  in  arriving  at  a 
diagnosis.  In  biliary  colic  there  may  be  jaundice,  and  pain  referred  to 
the  upper  rather  than  to  the  lower  abdominal  zone,  both  of  which  symp- 
toms are  absent  in  renal  colic  ;  while  in  the  latter  the  disturbance  of  mic- 
turition and  the  character  of  the  urine,  especially  the  hematuria,  are 
characteristic. 

In  intestinal  colic  the  griping  pain  is  usually  most  intense  in  the  um- 
bilical region,  is  often  relieved  by  pressure,  and  is  associated  with  tym- 
panites and  constipation ;.  it  has  usually  a  dietetic  origin,  while  the  renal 
and  urinary  symptoms  are  absent.  The  .exclusion  of  lumhodynia  and 
lumho-ahdominal  neuralgia  is  not  so  diflScult.  The  differentiation  of  the 
1  Zeitschrift  fiir  Vrologie,  Berlin,  April,  1912. 


1018  DISEASES  OF  THE   URINARY  SYSTEM. 

varieties  of  calculi  from  the  symptoms  is  not  positive.  It  has  been  sug- 
gested, however,  that  the  oxalate  stones  usually  cause  the  sharpest  pains 
and  the  hematuria.  Right-sided  ureteral  pain  felt  over  the  lower  abdom- 
inal region  may  be  confounded  with  aj>/H'mUccal  colic  Musser  has  found 
the  pain  of  renal  colic  to  bo  more  jiaroxysmal  and  less  uniform  in  location 
than  in  the  latter.  Early  reiud  tuberculosis  (vide),  with  its  hematuria  and 
pyuria,  must  be  dift'erentiated  from  renal  calculus  also.  Cases  of  supposed 
stone  in  the  kidney  with  most  of  the  typical  symptoms  in  which,  however, 
no  stone  was  found  at  operation  (false  stone),  have  been  reported  by  James 
Tyson.'  In  all  instances  adhesions  were  found  between  the  capsule  and 
the  kidney  itself,  and  all  were  relieved  by  operation. 

Prognosis. — This  should  always  be  guarded,  owing  to  the  possible 
dangers  and  complications  that  frequently  attend  nephrolithiasis  in  all 
of  its  forms.  Thus  the  passage  of  gravel  without  marked  symptoms 
tends  to  persist  or  recur — in  both  events  an  unfavorable  tendency,  since 
subsequent  formations  are  apt  to  be  larger  and  cause  serious  symptoms. 
An  attack  of  renal  colic  may  itself  be  fatal.  Large  latent  calculi  (den- 
dritic), of  long  standing,  are  nearly  always  incurable,  and  in  most  in- 
stances lead  to  such  grave  complications  as  pyelo-nephritis,  pyo-  and 
hydronephrosis,  perinephric  abscess,  and  uremia. 

Treatment. — Paroxysms  of  renal  colic  call  for  prompt  relief.  This 
is  best  aflbrded  by  hypodermic  injections  of  morphin  and  atropin, 
coupled  with  hot  baths  or  fomentations  applied  to  the  loins.  The  free 
use  of  hot  drinks,  as  lemonade,  soda,  or  plain  water,  is  also  helpful  in 
promoting  the  passage  of  the  stone.  Drinking  large  quantities  of  gly- 
cerin mixed  with  water  has  proven  of  service  in  some  cases.  Cases  of 
excessive  suffering  require  the  inhalation  of  chloroform. 

The  treatment  of  the  nephrolithiasis  without  or  betAveen  attacks  of 
renal  colic  is  most  important.  First  to  be  considered  are  the  hygienic 
and  dietetic  measures,  for  in  mild  and  uncomplicated  cases  much  can  be 
done  to  prevent  the  aggravation  of  the  disorder,  and  at  least  the  forma- 
tion of  larger  concretions  may  be  delayed.  When  the  tendency  is  to 
uric-acid  gravel  (the  commonest  variety),  the  patient  should  live  a  reg- 
ular, calm,  steady,  and  temperate  life.  Exercise  should  be  so  managed 
that  it  may  be  taken  rather  moderately  in  the  open  air,  and  Avith  a  view 
to  preventing  additional  weight  in  persons  of  fair  nutrition  and  to  pro- 
moting a  reduction  of  weight  in  the  obese.  In  short,  the  exercise  should 
be  sufficient  to  use  up  all  nitrogenous  food,  so  that  the  formation  and  elim- 
ination of  urea  may  be  increased  to  normal.  Hence  I  would  strongly  advise 
a  clinical  study  of  the  percentage  of  urea  in  the  urine  [vide  p.  1003). 

Over-indulgence  in  food,  particularly  in  red  meats  (liver,  sweetbread, 
and  similar  nuclear  food),  should  be  prohibited,  owing  to  tlie  ready  for- 
mation of  uric  acid  from  the  latter.  Alcohol  should  not  be  taken.  On 
the  other  hand,  since  the  urine  is  apt  to  be  scanty  and  highly  acid,  the 
patient  should  be  encouraged  to  drink  freely  of  plain  and  alkaline  waters. 
The  value  of  various  pure  spring-waters  as  diluents  is  undoubted,  the 
Buffalo,  Londonderry,  and  Otterburn  Lithia,  the  Saratoga,  Bedford,  and 
Poland  waters,  all  being  distinguished  for  their  purity.  More  marked 
and  more  generally  useful  for  their  alkilinity  are  the  Carlsbad.  Vichy, 
and  carbonated  waters.  In  cases  characterized  by  occasional  hematuria 
1  New  York  Medical  Journal,  May  26,  1906,  p.  llOd 


NEPITR  0  L  TTTJTA  SfS.  1019 

the  Rockbridge  alum-water  may  be  tried.  Plain  soda-water  and  lemonade 
may  be  used  as  adjuvants. 

The  medicinal  treatment  of  nephrolithiasis  is  aimed  to  secure  a  sol- 
vent and  disintegrating  action  upon  the  stones ;  it  is  symptomatic.  It  is 
extremely  doubtful  Whether  stones  once  formed  in  the  pelvis  of  the  kid- 
ney and  remaining  there  are  ever  dissolved,  though  certain  drugs  would 
seem  to  have  had  an  eroding  effect  in  some  instances,  and  they  are 
to  be  recommended  as  useful  in  preventing  the  formation  of  new  deposits. 
Lithium  citrate  or  carbonate  in  5-grain  (0.324)  doses  in  tablet  form, 
three  or  four  times  daily,  has  been  generally  employed  for  the  purpose. 
Sodium  phosphate  and  the  vegetable  salts  of  potash,  as  the  citrate,  acetate, 
and  tartrate,  are  useful.  Much  water,  especially  the  carbonated,  should 
be  drunk,  along  with  doses  of  the  above,  in  order  to  facilitate  the  solvent 
action,  and  in  this  way  relieve,  in  a  measure,  the  local  distress  and  pain. 
Recently  piperazin,  lycetol,  and  urotropin  have  been  brought  forward 
as  uric-acid-calculus  solvents  by  some  clinicians,  and  that  they  have 
such  action  as  is  claimed  has  been  proved  beyond  a  doubt  in  certain 
cases.  Whilst  they  deserve  a  farther  trial  in  nephrolithiasis,  it  is  too 
much,  however,  to  expect  successful  results  in  every  case. 

Recently,  Van  Noorden  and  Strause  have  recommended  calcium  car- 
bonate (gr.  x-xv — 0.648-0.972 — or  more  thrice  daily).  The  theory  is 
that  the  calcium  unites  with  the  acid  phosphates  in  the  intestines,  and 
thus  reduces  the  deuterophosphates  in  the  urine,  leaving  the  protophos- 
phates  to  dissolve  the  uric  acid.     They  report  excellent  clinical  results. 

The  reaction  of  the  urine  must  be  tested  at  stated  intervals  and  kept 
faintly  acid.  Should  the  urine  become  alkaline,  the  alkaline  treatment 
must  be  suspended  for  a  while,  or  a  secondary  deposit  of  phosphates  about 
the  uric-acid  stone  may  be  induced.  Nagging  lumbar  pains  may  be  re- 
lieved by  occasional  doses  of  such  analgesics  as  phenacetin,  belladonna, 
hyoscyamus,  codein,  and  indirectly  by  the  sweet  spirits-  of  niter,  buchu, 
and  uva  ursi.  Renal  hemorrhage  may  be  controlled  effectually  by  the 
use  of  the  fluid  extract  of  ergot,  or  by  alum  in  10-  or  15-grain  (0.648  or 
0.972)  doses,  or  by  gallic  acid  in  20-  or  30-grain  (1.29-1.94)  doses. 

Efforts  to  acidify  the  urine  are  indicated  when  the  calculus  happens 
to  be  composed  of  phosphates  or  of  calcium  carbonate.  This  is  more 
difficult  of  accomplishment  than  when  it  is  necessary  to  reduce  the  acidity. 
Saccharin  in  2-  or  3-grain  (0.129-0.194),  and  benzoic  and  boric  acids  in 
5-  to  15-grain  (0.324-0.972)  doses,  in  capsules,  seem  to  be  most  useful  for 
this  purpose.  It  is  claimed  for  calcium  carbonate,  again,  that  it  dimin- 
ishes the  phosphates  without  making  the  urine  alkaline. 

The  question  of  surgical  interference  must  be  decided  in  not  a  few 
cases ;  thus,  it  may  be  briefly  stated  that  in  protracted  and  obstinate 
cases  of  calculous  renal  disorder,  with  persistent  local  pain,  a  gradually 
decreasing  capacity  for  work,  and  evidences  of  severe  pyelitis,  pyelo- 
nephritis, or,  worse,  of  perinephric  abscess,  the  surgeon  must  operate.  In 
the  simplest  cases  a  nephrotomy  or  nephro-lithotomy  may  be  performed 
and  the  stone  removed.  Where  the  renal  structure  is  much  damaged  it 
may  be  necessary  to  do  a  nephrectomy.  To  avoid  the  increased  perils  of 
the  latter  operation,  however,  it  were  better  that  a  nephrotomy  were  done 
as  early  as  consistent  with  the  diagnosis  of  incarcerated  pelvic  stone  and 
the  condition  of  the  patient. 


1020  DISEASES  OF  THE   URrXARY  SYSTEM. 

ACUTE  NEPHRITIS. 

{Acute  Briffht's  Disease;  Acute  Diffu-^c  y<i)li,itU;  .Uute  J'tunicfiitmatous  Nephritis  ;  EriuhtiiH;, 
(yuarrhal,  Tubal,  Desquamative,  and  OlomenUo-nephritis  of  Acute  Course.) 

Definition. — An  acute  inflammation  of  the  kidneys,  more  or  less 
dift'iLSf  in  nature.  It  may  be  either  of  a  mihl,  severe,  or  grave  cha- 
racter. Dehitiehl  describes  three  varieties  of  acute  renal  inflammation 
under  the  common  synonym  of  acute  Bright's  disease,  as  follows  :  (1)  acute 
degeneration  of  the  kidneys,  (2)  acute  exudative  nephritis,  and  (3)  acute 
productive  nephritis.  At  present  writing  the  three  forms  foHowing  are 
recognized  by  many  writers;  (a)  Acute  tubular;  (6)  acute  glomerular 
and,  ((')  acute  diffuse  nephritis.  The  last-named  variety  manifests  the 
symptoms  of  the  first  two.  Moreover,  it  is  not  possible  to  recognize 
clinically  either  acute  tubular  or  acute  glomerular  nephritis  in  many  in- 
stances, but  I  shall  incidentally  give  a  brief  description  of  the  morbid 
changes  and  clinical  features  wrhich  they  present. 

Pathology. — From  the  very  mild  to  the  gravest  cases  of  nephritis 
there  is  an  intermediate  series  of  continuously  more  marked  pathologic 
changes  in  the  renal  tissues.  These  depend  greatly  on  tlie  amount  of 
poisonous  material  circulating  in  the  kidneys  and  eliminated  by  them. 

In  the  mildest  cases  the  macroscopic  appearances  of  the  kidneys  may 
present  nothing  distinctly  abnormal.  As  a  rule,  however,  the  organs  are 
slightly  enlarged,  swollen,  and  somewhat  softened.  These  conditions  are 
more  evident  when  the  interstitial  exudation  is  abundant  and  when  in- 
flammatory edema  is  evident.  The  kidneys  may  be  reddened  and  con- 
gested and  appear  bloody  on  section,  or  they  may  be  pale  and  mottled. 
In  examples  of  the  former,  hemorrhages  may  be  formed  beneath  the  cap- 
sule {acute  hemorrhagic  neph'itis),  though  it  is  more  common  to  see  red 
patches  of  hyperemia  alternating  Avith  opaque,  whitish  portions  on  both 
the  outer  and  cut-surfaces  of  the  kidneys.  The  cortex  especially  is 
swollen,  turbid,  and  pale,  or  slightly  congested  in  the  mildest  cases,  and 
is  deeply  mottled  (red  and  pale  glomeruli)  or  hyperemic  in  severe  in- 
stances. The  p3'ramids  usually  show  an  intense  redness.  The  surfaces 
are  smooth  and  the  capsule  non-adherent. 

Microscopically,  in  mild  cases,  there  is  simply  a  cloudy  swelling  or  a 
granular  (parenchymatous)  degeneration  of  the  epithelium  of  the  Mal- 
pighian  tufts,  Bowmans  capsule,  and  of  the  cortical  uriniferous  tubules 
{acute  tubular  nephritis).  These  changes  may  be  almost  exclusively  lim- 
ited to  the  glomeruli,  as  in  some  cases  of  scarlatina,  and  hence  the  term 
glomerulo-nephritis  (acute  glomerular  nephritis).  The  cells  are  swollen, 
opaque,  and  irregular  in  shape,  while  the  cell-contents  are  granular  (albu- 
minoid or  fatty).  A  further  advance  in  the  process  is  seen  in  cellular 
coagulation-necrosis  or  disintegration,  desquamation  of  the  cells,  and 
hyaline  degeneration  of  masses  of  them  in  the  tubules.  Acute  degen- 
erative changes  are  frequently  found  in  the  acute  infectious  diseases  or 
when  inorganic  poisons  have  been  introduced  into  the  bod}-.  In  phos- 
phorus-poisoning actual  fatty  degeneration  of  the  epithelium  may  be 
found.     A  rapid  necrosis  of  cells  is  also  met  with  in  severe  cases. 

True  acute  nephritis  is  not  only  characterized  by  changes  of  the  renal 
epithelium  (the  parenchyma),  described  above,  but  the  inflammatory  exu- 
date (serum,  leukocytes,  and  erythrocytes)  is  found  between  the  tubules. 
The  kidneys  show  different  stages  of  the  process  in  different  portions. 
In  some  places  there  is  only  a  slight  cellular  infiltration  of  the  intertubu- 


ACUTE  NEPIIJIITIS.  1021 

liir  tissues;  in  others,  besides  the  desquamation  of  necrotic  epithelial  cells 
and  the  presence  of  liyaline  casts  in  the  tubules,  the  interstitial  tissue  is 
swollen  by  the  coaguhited  sero-fibrinous  exudate,  abundant  leukocytes, 
and  some  red  blood-cerpuscles.  It  should  be  stated  that  the  inflammatory 
exudate  collects  also  in  the  Malpighian  bodies  and  tubules.  'I'he  epithe- 
lium lining  the  latter,  especially  the  convoluted  portion,  is  often  flattened, 
and  tlie  tubules  themselves  may  be  dilated  and  choked  with  degenerated 
cells  or,  more  frequently  in  the  straight  tubules,  with  hyaline  casts.  The 
white  blood-cells  that  are  found  infiltrating  the  stroma  of  the  kidney  are 
not  usually  equally  diffused,  but  are  collected  in  foci  in  the  cortex. 

In  most  cases  of  diffuse  exudative  nephritis  new  epithelium  appears, 
and  a  restoration  of  the  glomerular  function  takes  place.  In  the  pro- 
ductive variety  of  acute  diffuse  nephritis,  however,  according  to  Delaiield, 
the  lesions — consisting  of  a  cellular  growth  in  the  capsules  and  of  con- 
nective tissue  around  thickened  arteries — are  more  permanent  in  charac- 
ter from  the  first,  and  hence  the  increased  gravity  of  the  disease.  In  the 
more  intensely  acute  cases  the  new  tissue  between  the  tubules  is  largely 
cellular ;  in  those  of  a  subacute  type  it  is  relatively  dense  and  fibrous. 

Anasarca  and  pleural,  pericardial,  and  peritoneal  dropsy  are  also  found 
in  those  dying  of  acute  Bright's  disease.  Complicating  conditions  (lobar 
pneumonia,  meningitis)  are  sometimes  seen  postmortem. 

i^tiology. — Acute  nephritis  may  occur  at  any  time  of  life,  though  it 
more  often  makes  its  appearance  before  than  after  middle  life.  Males  are 
more  susceptible  than  females,  and  particularly  when  engaged  in  occupa- 
tions requiring  exposure  to  cold  and  wet.  The  habitual  use  of  alcoholics 
is  generally  a  predisposing  cause  of  acute  Bright's  disease. 

The  principal  exciting  causes  of  acute  diffuse  nephritis  are  the  follow- 
ing :  (1)  Those  acting  on  the  skin,  as  cold  and  dampness,  extensive  burns, 
and  chronic  skin-diseases.  In  many  cases  it  is  difficult  to  estimate  whether 
the  influence  of  alcoholic  intemperance  predominates  or  the  exposure  in- 
cident to  it.  Thus,  acute  intoxication  from  beer-drinking  itself  may 
cause'  an  attack  of  acute  nephritis.  The  disease  may  also  be  attributed, 
at  times,  to  exposure  to  cold  and  wet  irrespective  of  alcoholic  indulgence. 
It  may  be  presumed  with  reason  that  in  such  cases  there  is  some  inherent 
or  acquired  weakness  or  a  susceptibility  of  the  kidneys,  rendering  them 
the  weak  links  in  the  visceral  or  systemic  chain.  Watson  ^  states  that 
cold  is  a  factor  producing,  not  acute  nephritis,  but  the  onset  of  acute 
symptoms  in  an  already  existing  chronic  nephritis. 

(2)  Biologic  Toxic  Agents. — These  embrace  the  poisons  of  the  acute 
infectious  diseases,  though  in  the  majority  of  cases  scarlet  fever  is  the 
primary  affection.  Nephritis  may  supervene  during  the  height  of  scarla- 
tina, but  more  often  it  occurs  in  the  second  or  third  week  of  convales- 
cence. Other  infectious  fevers  may  also  cause  acute  nephritis  (small- 
pox, typhus,  typhoid,  relapsing  fever,  epidemic  influenza,  cholera,  diph- 
theria, yellow  fever,  measles,  chicken-pox,  erysipelas,  septico-pyemia. 
acute  lobar  pneumonia,  cerebro-spinal  meningitis,  dysentery,  acute  artic- 
ular rheumatism,  and  tuberculosis  :  syphilis  and  malaria  are  rare  causes). 
Acute  infectious  nephritis  may  also  occur  as  a  primary  disorder,  and  the 
brunt  of  the  aff"ection  may  fall  either  upon  the  kidney,  rather  than  upon 
any  other  part,  or  upon  the  organism  as  a  w^hole,  as  in  the  fevers. 

(3)  Chemical  Toxic  Agents. — Among  the  principal  irritants  of  this 

1  British  Med.  Jour.,  1912,  i.  822. 


1022  DISEASES  OF  THE    URINARY  SYSTEM. 

class;  are  turiH^itine.  cantliarides,  carbolic  and  salicvlic  acids,  iodoform, 
the  mineral  acids.  ])Otassium  chlorate,  and  such  inorjranic  poisons  as  phos- 
phorus, lead,  arsenic,  and  mercury.  The  excessive  ingestion  of  highly- 
acid,  spiced,  or  adulterated  foods  (as  from  salicylic  acid  and  lead  chromate) 
may  in  certain  individuals  cause  acute  renal  inflammation.  Ether  anes- 
thesia may  induce  acute  diffuse  nephritis. 

(4)  Pregnancy. — Here  the  nephritis  (gravidarum)  comes  on  in  prim- 
ipar;v.  usually  in  the  last  months  of  pregnancy.  It  is  probably  caused 
by  renal  engorgement  due  to  mechanical  pressure,  as  well  as  to  nutritive 
disturbances  in  the  kidney,  owing  to  the  altered  blood-condition. 

(5)  Latent  and  insidious  chronic  nephritis  may  be  the  cause  of  an  on- 
set of  a  manifest  acute  nephritis. 

(6)  Finally,  traumatism  to  the  kidney  may  cause  acute  nephritis, 
when  the  urine  may  contain  hematoidin  crystals. 

Symptoms. — The  onset  varies  with  the  cause  of  the  nephritis, 
though  generally  it  is  rather  sudden.  Chilliness,  nausea  and  vomiting, 
pain  in  the  back,  and,  Avithin  twenty-four  hours,  dropsy,  are  seen  in  some 
cases.  Children  may  be  seized  with  convulsions  (uremic),  and  adults  are 
not  less  liable  to  them  in  severe  attacks.  Fever  may  be  present,  although 
it  is  neither  constant  nor  high.  The  characteristic  symptom  is  the  early 
appearance  oi  edematous  puffiness  of  the  eyelids  and  face,  with  pallor  of  the 
skin.  Soon  (and  sometimes  at  first,  even)  a  swelling  is  noticed  about  the 
ankles  and  legs,  and  in  marked  cases  the  whole  body  becomes  dropsical,  so 
that  pitting  on  pressure  may  be  observed  pretty  much  all  over  the  bodily  sur- 
face. In  such  instances  the  scrotum  and  penis  or  the  labia  may  become 
enormously  distended,  the  skin  having  almost  a  translucent  appearance. 

Local  symp)toms.,  as  pain  and  tenderness  in  the  lumbar  region,  are  often 
wanting  and  are  never  marked.  There  may  be  a  desire  to  micturate  often, 
accompanied  by  slight  burning  and  vesical  tenesmus,  due  to  the  concen- 
trated urine.  In  very  severe  dropsy  the  tense,  dry  skin,  as  of  the  limbs, 
may  be  sensitive  or  even  painful  to  the  pressing  finger.  Movements  of 
the  body  are  often  difficult,  painful,  and  distressing  in  marked  anasarca. 
Intense  headache  and  backache  may  precede  the  onset  of  uremia.  In 
mild  cases  the  renal  condition  may  be  overlooked  unless  a  urinary  exam- 
ination is  made.  The  characteristics  of  the  urine  in  acute  nephritis  are 
all-important.  The  total  quantity  passed  in  twenty-four  hours  is  dimin- 
ished, and  may  be  very  scanty,  sometimes  amounting  to  not  more  than 
from  5  to  25  ounces  (150-740  c.c).  Suppression  occurs  in  some  cases  of 
toxic  origin,  when  an  acute  degeneration  or  necrosis  of  the  renal  epithe- 
lium takes  place,  and  in  the  most  severe  exudative  inflammations.  The 
specific  gravity  is  increased  to  1025  or  more,  early  in  the  case ;  later  it  may 
be  as  low  as  1010  or  1015.  The  color  is  darker  than  normally,  and  is 
usually  smoky-red  or  reddish-brown,  according  to  the  amount  of  blood 
passed.  If  the  morphologic  constituents  are  present  in  great  quantity,  a 
more  or  less  abundant  flocculent  sediment  appears  on  standing. 

Microscopically,  some  red  blood-corpuscles  and  renal  epithelium  are 
found,  along  with  the  characteristic  blood,  epithelial  and  granular  tube' 
casts  (Fig.  62).  Typical  casts  may  rarely  be  found  without  the  presence 
of  albumin.  Chemically  the  urine  is  acid,  and  on  boiling  a  thick,  curdy 
precipitate  of  albumin  forms.  The  percentage  of  the  latter  by  Esbach's 
method  varies  from  1  to  1.5  per  cent.  The  urea  and  gross  solids  are 
diminished.      The  molecular    concentration    or  osmotic  pressure  of  the 


ACUTE  NEPHRITIS.  1028 

urine  is  usually  reduced  (hyposthenuria),  so  that  the  freezing-point  (cry- 
oscopy)  is  1°  or  less  than  1°  C  (instead  of  the  normal  1.3°  to  2.3°  C.) 
below  that  of  distilled  water  (0°  C.)  (A.  0.  J.  KeDy). 

Other  symptoms  may  develop  during  the  course  of  acute  Bright's  dis- 
ease, li  great  general  edema  is  present,  physical  signs  of  hydrothorax, 
ascites,  and  hydropericardium  may  be  elicited.  The  first-mentioned  con- 
dition is  bilateral  and  causes  dyspnea ;  the  second  increases  the  dyspnea 
by  pressing  the  diaphragm  upward ;  and  the  last  impairs  the  heart's 
action.  Strlimpell  describes  a  form  of  pneumonia — a  "  stiff  inflamma- 
tory edema" — midway  between  lobar  pneumonia  and  broncho-pneumo- 
nia, that  sometimes  develops  in  severe  cases  of  acute  nephritis.  Edema 
of  the  conjunctivae,  soft  palate,  and  larynx  may  also  occur,  llecently, 
Lapinsky  reported  a  fatal  case  of  acute  parenchymatous  nephritis  in 
which  severe  bilateral  sciatic  neuritis  was  associated. 

The  pulse  is  often  hard  and  tense,  and,  though  slow  at  first,  it  may 
become  accelerated  later.  Cardiac  hypertrophy  of  a  slight  degree  may 
be  detected.  The  second  aortic  sound  is  accentuated.  The  arterial 
pressure  is  considerably  elevated.  Epistaxis  is  an  occasional  symptom 
and  subconjunctival  hemorrhages  are  sometimes  seen  as  a  result  of  uremic 
convulsions  that  may  not  have  been  witnessed.  A  very  constant  symptom 
is  the  dry,  anemic  skin.  Uremic  manifestations  may  ensue  at  any  time 
during  the  course  of  the  disease.  They  appear  early  in  the  most  severe 
cases,  with  intense  headache  and  backache,  vomiting,  and  convulsions. 

The  clinical  course  in  other  cases  differs  somewhat  from  the  above, 
which  may  be  considered  as  the  common  form  resulting  from  exposure. 
Acute  nephritis  occurring  as  a  complication  of  the  infectious  fevers,  except 
scarlatina,  may  be  characterized  by  the  very  slight  degree,  or  even  by 
the  absence,  of  dropsy.  Albuminuria,  hematuria,  anemia,  and  uremia 
supervene  in  the  graver  affections  ;  this  is  the  acute  tubular  nephritis.  In 
scarlatinal  nephritis  we  have  an  illustration  of  acute  glomerular  nephritis  ; 
anasarca  is  common,  and  slight  edema  at  least  is  quite  constant.  During 
the  period  of  convalescence  tube-casts  (granular  or  fatty  granular)  may 
be  found  in  the  urine  (Fig.  63).  In  mild  affections  simply  a  little  albu- 
min and  a  few  hyaline  casts  reveal  the  parenchymatous  degeneration. 
In  cases  of  degenerative  nephritis  due  to  mineral  poisoning  the  subsidence 
of  the  acute  toxic  symptoms  may  be  followed  by  the  typhoid  condition. 
In  the  so-called  nephro-typhoid  condition,  where  typhoid  fever  begins 
with  pronounced  symptoms  of  acute  nephritis,  hematuria  may  be  marked. 
The  nephritis  of  pregnancy  is  usually  gradual  in  its  onset,  and  the  albu- 
min increases  from  month  to  month.  Some  hyaline  or  faintly  granular 
casts  are  found  (Fig.  65),  and  erythrocytes  rarely  appear  in  the  urine. 
Danger  of  eclampsia  is  constant  until  the  albuminuria  has  subsided. 

Acute  productive  nephritis  (Delafield),  in  Avhich  there  is  a  ten- 
dency to  the  formation  of  patches  or  wedges  of  fibrous  tissue,  is  charac- 
terized by  higher  fever,  by  cerebral  and  circulatory  disturbances  of  a 
typhoid  nature,  and  by  anemia,  dropsy,  and  a  highly-albuminous  m*ine, 
even  though  blood  may  be  absent  and  casts  may  be  few.  The  dropsy  is 
most  apparent  in  the  legs.  Dyspnea,  vomiting,  diarrhea,  and  a  progres- 
sive and  rapid  loss  of  flesh  and  strength  ensue  until  convulsions  or  coma, 
sometimes  preceded  by  acute  maniacal  excitement,  end  in  death.  Milder 
cases,  lasting  from  two  to  four  weeks,  apparently  get  well,  albumin  and 
casts  persisting,  however,  until,   after  an  interval  of  weeks  or  months, 


1024  DISEASES  OF  THE   URIXARy  SYSTEM. 

anotlier  and  similar  attack  occurs.      In  short,  the  first  acute  attack  is 
liable  to  chronic  repetition  until  a  fatal  one  takes  place. 

Diagnosis. — The  condition  cannot  be  overlooked  when  the  urine  is 
cart'fidlv  examined  both  chemically  and  microscopically.  The  dreaded 
eclampsia  gravidaruni  can.  however,  be  recognized  only  by  repeated 
urinary  examination,  especially  during  the  last  months  of  pregnancy. 
AcuteBright's  disease  should  be  suspected,  and  the  urine  examined  in 
everv  case  showing  pallor  of  the  skin  and  puffy  eyelids,  whether  general 
prostration  of  the  health  is  apparent  or  not.  The  characteristic  symp- 
toms of  acute  diffuse  nephritis  are  the  following :  headache,  rest- 
lessness, muscular  twitching,  dysi)nea,  nausea  and  vomiting,  a  tense 
pulse,  moderate  fever,  dropsy,  and  anemia.  Tube-casts  and  albuminuria 
are  almost  constant,  except  in  rare  instances  of  puerperal  eclampsia  (J. 
Hirst).  It  should  be  borne  in  mind  that  slight  albuminuria  occurring 
in  the  course  of  pregnancy  or  during  any  of  the  acute  specific  fevers, 
without  cants,  is  not  a  true  nepliritis,  although  a  more  or  less  remote 
consequence  of  the  glandular  degeneration  of  the  renal  epithelium  asso- 
ciated with  the  febrile  albuminuria.  In  addition  to  the  presence  of  albu- 
min and  hyaline  and  cell-casts,  however,  a  diminished  quantity  of  sooty- 
looking  urine  and  the  discovery  of  red  and  white  blood-corpuscles  will 
render  the  diagnosis  positive.  The  history  of  the  case  and  the  causal 
factors  are  also  to  be  taken  into  consideration. 

The  diagnosis  of  the  particular  sub-variety  is  sometimes  possible. 
Thus  acute  tubular  nepliritis  commonly  results  from  an  intoxication,  or 
more  rarely  from  a  severe  infection  or  chilling.  The  urine  is  scanty, 
turbid,  and  often  reddish-brown  in  appearance,  and  the  sediment  is  com- 
posed largely  of  renal  epithelium  and  tube-casts.  Edema  is  absent. 
The  effects  of  the  toxic  agent  on  other  viscera  is  shown  by  the  presence 
of  jaundice,  myocardial  weakness  and  the  like.  In  acute  glomerular 
nepliritis  the  urine  is  scanty,  the  amount  of  albumin  large,  but  few,  if  any, 
tube-casts  and  renal  cells  are  found.    General  edema  is  commonly  present. 

Prognosis. — The  duration  of  ordinary  exudative  or  tubal  nephritis 
following  exposure  to  cold  and  wet  varies  from  a  few  days  to  three,  four, 
or  six  weeks.  The  albuminuria  steadily  decreases,  and  with  the  casts 
finally  disappears,  while  the  daily  quantity  of  urine  increases,  as  does 
the  excretion  of  urea.  The  prognosis  depends  much  upon  the  primary 
disease  or  causative  condition,  and  also  upon  the  intensity  and  char- 
acter of  the  renal  inflammation.  Scarlatinal  nephritis  is  less  likely 
to  be  recovered  from  than  nephritis  due  to  exposure  to  cold  after  alco- 
holic excesses.  The  acute  parenchymatous  degeneration  that  accom- 
panies typhoid  fever,  diphtheria,  and  other  infectious  fevers,  as  well  as 
pregnancy,  is  usually  a  mild  affection  and  recovery  takes  place  easily. 
But  in  acute  yellow' atrophy,  yellow  fever,  cholera,  and  in  severe  phos- 
phorus- or  mercurial  poisoning  death  may  occur  from  the  intense  and 
widespread  necrosis  of  renal  epithelium.  In  favorable  cases  of  ordinary 
exudative  nephritis  the  dropsy  and  albuminuria  gradually  diminish, 
while  the  color  of  the  skin  and  the  quantity  of  urine  and  urea  increase, 
so  that  in  the  course  of  from  three  to  four  or  six  weeks  recovery  is 
established.  After  the  disappearance  of  the  dropsy  the  albumin  may 
persist  for  some  time,  and  then  slowly  disappear ;  but  rarely,  in  unfavor- 
able cases,  even  when  dropsy  has  disappeared,  albuminuria  may  continue 
and  the  affection  become  a  chronic  parenchymatous  nephritis. 


Fig.  62,  Fig.  63. 


Fig.  64.  -Fio-  ^o- 


Fig.  66.  Fig.  67. 

P'lG  62. -A.  G.,  aged  fifteen,  male,  suffering  from  acute  nephritis.  Urine  showing  granular 
<=a«ts,^(Quee_n^ob^  il^'^l^  ^^_  Scarlatinal  nephritis,  third  week  of  convalescence.  Urine 
sho™g^ranular  c^a|ts(Quee^^  cancer  of  the  common  duct  and  head  of 

'^^^^^^f!^:^Z^^t^^e:!i^S'^l^^^'^A^^.    urine  showing 

'"'■^fw'^f^rrSerfiftySu^  m^^^      ^rtnTsho^.^ng  granular  and  fatty  casts;  post-mortem 
showed  chronic  parenchymatous  nephritis  (Queen  obj.  J  ;  eye-piece  iv.).  „^^i„,-^  i-a^„^v 

F?G   67  _C   C    a^ed  forty-two,  female,  suffering  from  septicopyemia  with  amyloid  kidney. 
Urine  showing  epithelial  and  (so-called)  amyloid  casts  (Queen  obj.  |;  eye-piece  ij.). 
uiiuc.  a  a    f  j-j^_  Napoleon  Boston.] 


ACUTE  NEFIIIUTI.S.  1025 

SerioiiR  and  often  dangerous  symptoms  of  iicuto  nephritis  are — severe 
general  edema,  dropsical  effusions  into  the  serous  sacs  (as  hydrothorax), 
uremia  (especially  when  beginning  with  cerebral  manifestations,  as  coma 
or  convulsions),  and  finally  inflammation  of  the  internal  organs,  as  pleu- 
ritis,  pneumonitis,  pericarditis,  peritonitis,  and  meningitis.  In  the  ab- 
sence of  uremia  recovery  in  cases  of  marked  general  dropsy  is  quite 
common.  Suppression  of  urine,  however,  lasting  more  than  twenty-four 
or  forty-eight  hours,  is  usually  a  fatal  symptom.  The  prognosis  is  un- 
favorable also  in  cases  in  which  the  nephritis  has  a  productive  character. 
Life  may,  on  the  other  hand,  be  prolonged  for  several  years. 

Treatment. — I  shall  not  include  here  the  management  of  the  pri- 
mary affection  of  which  the  nephritis  may  be  either  a  complication  or 
consequence.  Bland  liquid  foods  only  should  be  allowed  in  the  acute 
stage,  and  the  patient  should  be  encouraged  to  drink  freely  of  Avater 
(plain  or  distilled),  skimmed  milk,  or  buttermilk ;  these  are  especially  valu- 
able when  hot.     If  dropsy  be  present,  a  salt-free  diet  should  be  adopted. 

Since  the  renal  function  is  diminished  by  the  congestion  and  inflam- 
mation, the  first  object  in  the  treatment  is  to  relieve  these  conditions 
and  thus  restore  the  excretory  function.  The  single  or  combined  use 
of  diaphoretics  and  cathartics  is  practised,  therefore,  not  that  the  skin 
and  bowels  should  be  made  to  perform  the  work  normally  done  by  the 
kidneys,  but  in  order  to  restore  the  functional  equilibrium  by  the  anti- 
phlogistic effect  produced. 

Absolute  rest  in  a  warm  bed  and  in  a  warm  room  is  of  primary  im- 
portance. Woollen  underwear  and  blankets  should  be  provided,  so  as 
to  promote  a  constant  free  action  of  the  sweat-glands.  These  hygienic 
measures  should  be  carried  out  both  in  the  mild  and  in  the  severer  cases. 

Local  bloodletting,  as  by  leeches  or  cupping  over  the  loins,  I  seldom 
employ  ;  in  rare  cases,  however,  when  much  pain  is  complained  of,  it 
may  be  useful,  although  hot  fomentations  may  be  more  so.  Diminution 
of  the  edema  and  the  elimination  of  urea  and  other  urinary  constituents 
that  may  be  retained  in  acute  nephritis  are  best  obtained  by  ex- 
citing a  profuse  perspiration.  The  hot-air  or  hot-water  bath  and 
the  hot  wet-pack  may  be  used  to  accomplish  these  results,  and 
in  most  cases  the  last-named  method  suffices.  It  is  easily  applied  by 
wringing  a  blanket  out  of  hot  water,  wrapping  the  patient  in  it,  and 
then  with  a  dry  blanket,  and  finally  a  rubber-cloth  cover,  surrounding 
all.  This  furnishes  a  steam-bath  in  which  the  patient  may  remain  until 
copious  sweating  has  lasted  an  hour  or  so,  according  to  the  condition. 
Children  suffering  from  scarlatinal  nephritis  may  be  treated  thus,  or 
quite  readily  also  by  immersion  in«hot  water,  for  twenty,  thirty,  or  forty 
minutes ;  the  skin  should  then  be  lightly  dried,  and  the  child  wrapped 
in  warm  sheets  or  blankets  and  w'armly  covered  in  bed..  Hot  vapor  or 
air  may  be  generated  alongside  the  bed,  and  transferred  under  the  raised 
or  cradled  bed-clothes  by  means  of  a  tin  funnel  and  pipe.  The  sweating 
will  be  aided  by  the  drinking  of  hot  lemonade  or  soda-water  or  of  water 
containing  spirit  of  Mindererus.  Should  the  skin  fail  to  respond  to 
these  measures,  as  in  uremia,  perspiration  may  be  started  by  a  hypo- 
dermic injection  of  pilocarpin  (gr.  -|  to  \ — 0.008  to  0.0108),  after  which 
it  will  continue  to  pour  out  on  the  application  of  heat.  The  heart  and 
pulse  should  be  watched  after  the  injec-tiou  of  pilocarpin,  as  serious  col- 
lapse   sometimes    attends    its    use.      The   sw^eatings  should  be    repeated 

65 


1026  DISEASES  OF  THE   rRISARY  SYSTEM. 

until  the  dropsy  disappears  and  as  often  as  the  patient's  strength 
will  permit.  The  beneficial  effects  of  s^veat-baths  are  not  due  to  the 
removal  of  nitrogen  through  the  skin,  but  rather  of  sodium  chloride. 
A  useful  adjunct  to  the  above  is  the  administration  of  hydragogues,  as 
the  saline  cathartics,  elaterium,  and  compound  jalap  powder.  Elaterium 
e.xtract  (gr.  ^^ — 0.0108-0.0162)  is  prompt  in  action,  and  magnesium 
or  sodium  sulphate  (,^j — 4.0),  given  in  hot  concentrated  solution  every 
hour,  or  a  calomel  purge,  may  be  recommended.  It  may  be  necessary 
to  aid  in  relieving  the  tension  and  distress  of  extreme  edema  by  multi- 
ple punctures  or  by  the  use  of  a  small  trocar  and  canula,  with  a  drain- 
age-tube (Southey)  attached  to  the  latter  after  the  trocar  is  withdrawn. 
Aspiration  must  be  performed  if  either  hydro-thorax,  hydro-pericardium, 
or  ascites  assumes  serious  proportions.  Half-ounce  (16.0)  doses  of  the 
spirit  of  Mindererus  (li([.  ammon.  acetat.)  in  Avater  may  be  added  to  the 
diaphoretic  treatment ;  this,  combined  with  aconite,  aids  in  controlling 
the  fever  that  may  be  present  and  in  preventing  the  vaso-constriction 
that  is  often  premonitory  of  uremic  symptoms. 

Uremic  convulsions  that  do  not  soon  yield  to  prompt  diaphoresis  and 
catharsis  should  be  treated  by  venesection.  As  much  as  a  pint  or  two 
(.5-1  liter)  of  blood  may  be  withdrawn  and  life  saved  thereby.  Some- 
times chloroform-inhalations  are  needed  to  subdue  the  very  violent  con- 
vulsive seizures,  as  in  eclampsia.  Their  return  may  be  prevented  by 
rectal  injections  of  potassium  bromid  and  chloral,  consisting  of  1  dram 
(4.0)  of  the  former  and  h  dram  (2.0)  of  the  latter.  Contraction  of  the 
arteries  with  increased  tension  and  beginning  muscular  twitchings  calls 
for  the  use  of  nitroglycerin,  chloral  hydrate,  or,  possibly,  morphin. 

Diuretics  other  than  the  simple  diluent  drinks  mentioned  have  very 
little  use  in  the  therapy  of  acute  diffuse  nephritis,  at  least  early  in  the 
disease.  Later,  as  adjuvants  to  the  diuretic  properties  of  water,  potas- 
sium bitartrate  or  acetate,  sodium  benzoate,  and  cardiac  stimulants,  as 
caffein  citrate  and  the  infusion  of  digitalis,  may  be  given,  well  diluted. 

During  convalescence  care  must  be  exercised  that  the  patient  does 
not  catch  cold.  The  diet  must  not  be  increased  to  solids  too  sud- 
denly nor  too  rapidly,  and  particularly  in  the  matter  of  meats.  Light 
watery  vegetables,  fruits,  and  cereals  may  be  gradually  added  to  the 
diet-list,  although  milk  should  be  mainly  used.  Ferruginous  tonics 
are  indicated  for  the  anemia,  and  Basham's  mixture  is  an  admirable 
preparation  at  this  stage. 

A  change  of  locality  to  a  Avarmer,  drier,  and  more  equable  climate, 
and  careful  habits  of  dress,  diet,  and  exercise,  are  necessary  in  cases  of 
recovery  from  the  very  serious  forms  of  nephritis,  in  which  the  renal 
parenchyma  is  shown  to  have  been  somewhat  damaged  by  the  per- 
sistence of  slight  albuminuria  at  intervals. 


ACUTE  INTERSTITIAL  NON-SUPPURATIVE  NEPHRITIS. 

("  Lymphomaious  Nephritis  "' —  Wagner.) 

Increasing    interest    and    importance    attach  to    the    etiologic    and 
pathologic  features,  principally,  of  this  affection. 

Definition. — -An  acute  "inflammation  of  the  kidneys,  character- 


CHRONIC  NEPURITTS.  1027 

ized  by  cellular  and  fluid  exudation  into  the  interstitial  tissue,  accom- 
panied by  but  not  dependent  upon  degeneration  of  the  epithelium  ;  the 
exudation  is  not  purulent  in  character,  and  tlie  lesions  may  be  both 
diffuse  and  local  "  (Councilman). 

Pathology. — The  kidney  is  enlarged,  pale,  and  somewhat  mot- 
tled. The  essential  lesion  consists  in  an  acute  proliferation  of  the  cells 
in  the  intertubular  tissue,  with  but  little  change  in  the  parenchyma. 
The  proliferation  takes  place  mainly  from  the  venous  and  capillary 
endothelium.  The  cells  are  found  chiefly  in  the  intermediate  zone  of 
the  kidney,  between  the  pyramids  and  the  cortex.  Howard '  noted  the 
occurrence  of  the  following:  (1)  plasma-cells,  lymphocytes,  polymorpho- 
nuclear leukocytes  in  the  exudation ;  (2)  lymphocytes  and  plasma-cells 
in  the  dilated  vessels  ;  (3)  mytosis  and  evident  ameboid  activity  of 
plasma-cells  in  both  blood-vessels  and  tissues.  A  special  observation 
was  the  discovery  of  large  numbers  of  typical  eosinophilic  leukocytes  in 
the  interstitial  exudation  and  in  the  blood-vessels. 

Ktiology. — Most  of  the  cases  of  acute  interstitial  nephritis  occurred 
in  children  suffering  from  diphtheria  and  scarlet  fever.  The  first  case 
described,  by  Biermier  in  1860,  occurred  in  a  case  of  scarlatina.  Other 
acute  infectious  diseases,  as  typhoid  fever,  lobar  pneumonia,  measles, 
and  epidemic  cerebro-spinal  meningitis,  may  have  acute  interstitial  neph- 
ritis present.  The  Bacillus  coli  and  pus  streptococci  have  been  found 
in  some  of  the  kidneys ;  and  a  general  streptococcus  infection  following 
abortion  has  been  noted  in  several  cases  of  this  form  of  nephritis. 
Bacteria  may  play  no  part  in  the  etiology  of  this  aff"ection,  and  the 
powerful  toxins  of  the  mixed  infection  commonly  met  with  are  possibly 
responsible  for  the  chemotactic  cellular  proliferation. 

ij^mulsion-albuminuria. — The  urine  is  chylous  in  appearance, 
and  upon  microscopic  study  it  presents  a  faint  haze,  caused  by  minute 
globules  of  fat.  No  volatile  liquid  results  from  destructive  distillation  (acro- 
lein test),  but  a  questionable  reaction  is  obtained  with  Fehling's  solution. 

Boiling  causes  a  heavy  precipitate :  while  artificial  peptic  digestion 
removes  the  turbidity. 


CHRONIC  NEPHRITIS  (EXUDATIVE). 

{Chronic  Brighfs  Disease;  Chronic  Parenchymatous  Nephritis;  Chronic  Diffuse 
Nephritis  with  Exudation;  Chronic  Tubal  and  Chronic  Desquamative  Nephri- 
tis; Chronic  Glomerido-nephritis ;  Large  White  Kidney;  Secondary  or  Fatty 
and  Contracted  Kidney.) 

Definition. — A  chronic  diffuse  inflammation  of  the  kidneys,  at- 
tended with  epithelial  degeneration,  exudation  from  the  blood-vessels, 
and  permanent  connective-tissue  changes  in  the  stroma.  •  According  to 
Delafield,  this  is  the  chronic  productive  {or  diffuse)  nephritis  with  exu- 
dation— one  of  two  varieties  of  chronic  Bright's  disease. 

Pathology. — Although  there  are  several  types  of  pathologic  kidney 
in  this  disease,  the  anatomic  diff"erences  depend  upon  the  causation  and 
duration  of  the  nephritis. 

The  first  type  of  kidney  to  be  mentioned  is  the  large  white  kidney 
(without  waxy  degeneration).  It  is  either  enlarged  or  normal  in  size, 
^  Amei:  Jour.  Med.  Sciences,  Feb.,  1901. 


1028  DISEASES  OF  THE   URIXARY  SYSTEM. 

and  pale  or  yell()^visll  in  color.  Tlio  surface  is  smooth,  and  the  capsule 
is  easily  stripped  oft".  On  section  the  cortex  is  hroader  tlian  nornially, 
yellowish-white  throu>rhout,  or  it  may  present  opaque  yellowish  or  whi- 
tish areas  with  mottlings  of  red.  The  pyramids  are  congested  in  some 
cases.  Microscopically  the  renal  epithelium  is  swollen,  hyaline,  granular, 
or  fattv,  and  more  or  less  disintegrated  or  flattened  :  the  glomeruli  are 
enlarged  from  the  growth  of  the  capsule-cells  and  of  the  cells  covering 
the  capillaries,  and  in  some  cases,  owing  to  the  connective-tissue  thicken- 
ing of  the  capsule,  the  tuft  of  capillaries  is  found  to  be  atrophied.  The 
interstitial  tissue  shows  some  thickening  of  the  arterial  walls  and  a  mod- 
erate growth  of  connective  tissue  in  patches  around  the  glomeruli  and 
tubules :  the  latter  contain  hyaline  and  granular  casts. 

The  small  white  kidneri,  or  secondary  contracted  kidney,  in  most  in- 
stances is  probably  a  later  stage  of  the  preceding,  in  which  the  degen- 
eration of  e{)ithelium  is  more  advanced  and  the  growth  of  connective 
tissue  and  resultant  cicatricial  contraction  are  prominent  features.  The 
surface  is  slightly  granulated,  and  the  capsule  is  proportionately  adherent. 
While  this  kidney  is  usually  grayish  or  yellowish  in  color  {pale,  granular 
kidney),  there  may  be  some  mottling  due  to  red  spots.  The  consistence 
is  firm  and  the  cut-surface  shows  yellowish-white  foci  of  the  fatty  degen- 
erated epitlielinm  in  the  narroweil  cortex,  ''small,  granular,  fatty  kidney." 
Under  the  microscope  we  find  extensive  degeneration  and  disintegration 
of  the  epithelium  of  the  glomeruli  and  convoluted  tubules,  with  atrophy 
of  the  parenchyma,  and  a  corresponding  increase  of  the  interstitial  con- 
nective tissue.     Waxy  degeneration  may  be  associated-. 

Another  variety  is  the  large  red  or  variegated  kidney  of  chronic  hoii- 
orrltagic  nephritis.  The  organs  are  usually  enlarged,  swollen,  red,  and 
congested-looking  or  mottled,  and  frequently  "  bumpy  "  or  slightly 
bossellated.  The  capsule  is  slightly  adherent  to  the  depressions  between 
the  bosses.  Red  spots,  due  to  small  hemorrhages,  may  be  noticed. 
The  section  shows  also  congested  portions  and  gray  or  yellow  spots  cor- 
responding to  the  anemic  and  fatty  degenerated  portions.  Small  cortical 
hemorrhagic  areas  or  striations.  brownish-red  in  color,  are  distinctive  of 
the  kidney.  The  microscopic  appearances  are  those  of  the  large  white 
kidney  plus  those  of  acute  nephritis.  Or,  there  ma}^  be  inflammatory 
edema  and  cellular  infiltration  of  the  intertubular  tissue,  and  dilated  tufts 
of  capillaries  with  surrounding  cellular  hyperplasia. 

Htiology. — The  disease  may  follow  either  the  acute  diffuse  nephri- 
tis, as  of  scarlet  fever  or  pregnancy,  or  simple  chronic  congestion  and 
chronic  degeneration  of  the  kidneys.  Watson  believes  that  acute  nephri- 
tis is  not  a  common  disease,  is  usually  due  to  the  direct  effect  of  some 
infection  and  that  the  majority  recover  completely.  More  often  chronic 
parenchymatous  nephritis  arises  insidiously,  in  a  subacute  manner 
and  without  any  previous  acute  manifestation.  Males  are  more 
frequently  subjects  than  females.  Children  affected  with  the  disease 
have  usually  had  scarlatinal  nephritis.  Young  adults  are  more  com- 
monly affected,  however,  with  the  usual  variety,  developing  subacutely. 
Drinkers  of  beer  and  other  malt  and  alcoholic  intoxicants  seem  to  be 
liable  to  the  disease.  It  is  not  improbable  that  some  toxic  or  infectious 
agency,  acting  slowly  and  persistently,  may  in  the  insidious  cases  be  the 
cause  of  the  nephritis,  although  manifestations  elsewhere  may  be  absent. 
I  have    observed  it  in  certain   individuals    living   in    malarial    regions. 


CHROMIC  NEPJIIUT/S.  1029 

Persons  working  under  exposure  to  cold  and  wet,  and  tliose  living  in 
humid  and  low,  marshy,  localities  are  more  liable  tiian  those  who  are 
better  protected  from  climatic  vicissitudes.  Tuberculosis,  sy[)l]ilis,  and 
chronic  suppuration  may  give  rise  to  the  "  parenciiymalous  '  form  of 
chronic  Bright's  disease,  and  it  is  usually  combined  with  amyloid  disease. 

Symptoms. — There  may  be  a  persistence,  in  a  lesscT  degree,  of  the 
symptoms  of  an  acute  parenchymatous  nephritis,  particularly  the  anemia, 
dropsy,  and  the  albuminuria,  until  the  affection  becomes  chronic.  In 
most  cases,  however,  the  disease  develops  slowly  and  gradually,  in  a 
subacute  manner,  though  the  earlier  symptoms  seldom  indicate  any 
renal  derangement.  There  may  be  simply  a  general  impairment  of 
health  and  strength,  loss  of  appetite,  nausea,  and  attacks  of  indigestion, 
headache,  dulness,  and  perhaps  some  pallor.  Soon  there  is  puflfiness 
of  the  eyelids  or  swelling  of  the  feet  or  ankles,  or  both,  and  the  com- 
plexion takes  on  a  blanched  appearance.  The  edema  gradually  extends 
up  the  legs,  and  is  often  worse  as  the  day  grows,  while  on  rising  in  the 
morning  it  may  be  found  to  have  disappeared  during  the  night's  rest 
and  recumbency.  The  quantity  of  urine  is  diminished  in  the  majority 
of  cases,  though  in  the  later  stages  it  may  be  nearly  or  quite  normal, 
and  even  slightly  increased  in  long-standing  instances  or  when  absorp- 
tion of  the  dropsy  is  taking  place.  Superadded  acute  nephritis  may  cause 
a  very  scanty  or  a  suppressed  secretion  of  urine.  The  specific  gravity  is, 
of  course,  increased  in  scanty  urine,  and  vice  versd.  Alhuminuria  is 
often  quite  marked.  The  amount  of  albumin  may  be  from  one-fourth  to 
three-fourths  of  the  volume  ot  the  urine,  or  from  1  to  3  per  cent,  by 
weight,  so  that  the  daily  loss  of  albumin  may  be  considerable.  The  nitro- 
gen coefficient,  i.  e.,  the  relation  of  the  urea  to  the  total  nitrogen,  is 
reduced  from  the,  normal  (80  to  82)  to  60.  The  color  of  the  urine  is 
turbid,  sometimes  smoky-yellow,  and  urates,  casts,  red  and  white  blood- 
cells,  epithelial  cells,  granular  debris,  and  fatty  granular  cells  are  found 
in  the  usually  abundant  sediment.  The  tube-casts  are  of  different  varie- 
ties, but  narrow  or  broad  hyaline,  fatty  granular  (Fig.  66),  and  epithelial 
casts  are  commonly  observed. 

The  edema  is  prominent  and  persistent.  It  gradually  extends  all 
over  the  body,  so  that  pitting  can  be  obtained  on  tbe  limbs,  chest,  abdo- 
men, and  back.  The  loose  subcutaneous  tissues,  as  of  the  penis,  scrotum, 
and  eyelids,  are  particularly  distended.  In  chronic  hemorrhagic  nephri- 
tis, only,  the  edema  may  be  absent  or  very  slight.  The  pasty,  pallid 
complexion  and  anasarca  are  most  characteristic  of  chronic  exudative 
nephritis,  especially  with  large  white  kidney.  The  dropsy  may  be  mod- 
erate and  about  stationary  for  several  months ;  then,  despite  all  treat- 
ment, it  becomes  insidiously  worse,  death  ensuing  in  a  month  or  two. 

Dropsy  of  the  serous  sacs,  with  its  attendant  distressing  symptoms, 
may  be  present  in  serious  cases,  and  edema  of  the  larynx  and  lungs 
may  come  on  suddenly  and  cause  death.  Dyspnea  may  be  toxic  and 
nervous,  as  well  as  mechanical  or  cardiac  in  origin.  Cardiac  dyspnea, 
due  to  failure  of  the  heart's  action,  as  seen  in  many  cases,  is  usually 
worse  on  lying  down.  It  may  be  provoked  by  vaso-constriction.  and  is 
then  a  danger-signal  of  uremia.  Catarrhal  bronchitis  may  be  associated 
Avith  cough  and  expectoration. 

There  is  moderate  hypertrophy  of  the  left  ventricle,  and  later  dila- 
tation of  both  ventricles.     The  aortic  second  sound  is  accentuated  and 


1030  DISEASES  OF  THE   UBiyARV  SYSTEM. 

tbo  puIse-teusion   incre<iscri.     The  blood-pressure  is  persistently  exalted 
prior  to  failure  of  the  left  ventricle. 

Uremic  »vw/'fo???.s  are  frecjuently  manifested,  exce]it  the  convulsions 
which  are  common  to  chronic  nejjhritis  without  exudation.  Headache, 
yertigo,  sleeplessness,  nausea  and  vomiting,  diarrhea,  and  stupor,  coma, 
or  delirium,  may  develop  and  precede  a  fatal  termination. 

Albiiminuric  neiiro-retinitis,  as  evidenced  by  dimness  of  vision  and 
field-defects,  occurs  in  quite  a  number  of  cases.  The  skin  of  the  legs 
becomes  subject  to  a  red  eczematous  eruption  in  some  cases  of  great 
dropsical  distention.  In  the  absence  of  complicating  inflammations, 
such  as  pericarditis,  endocarditis,  pneumonitis,  and  ulcerative  colitis, 
which  are  rare,  the  temperature  is  practically  normal. 

The  course  of  chronic  exudative  nephritis  may  either  continue 
from  bad  to  worse,  until  death  ends  all  in  a  year  or  two,  or  anemia, 
dropsy,  and  albuminuria  may  attack  one  who  for  years  previous  has  had 
apparent  good  health,  after  a  first  attack  the  second  proving  fatal  within 
a  few  months.  Again,  some  patients,  having  a  little  pallor,  slightly 
diminished  urine  of  high  specific  gravity,  with  albumin,  may  complain 
of  nothing  for  years,  until  decided  attacks,  lasting  for  several  months, 
may  occur,  with  intervals  during  which  the  dropsy,  dyspnea,  etc.  may 
be  absent,  although  some  albuminuria  persists. 

The  average  duration  of  the  disease  varies.  The  duration  of  chronic 
hemorrhagic  nephritis  may  be  somewhat  longer  (eight  months  to  two  or 
three  years)  than  that  of  the  large  white  kidney  (six  to  eighteen  months), 
but  it  is  shorter  than  the  secondary,  contracted  kidney,  Avhich  lasts  from 
one  and  a  half  to  three  or  even  five  years. 

Diagnosis. — The  diagnosis  of  the  disease  itself  is  not  difficult,  but 
of  the  stage  or  the  variety  of  kidney  it  is  almost  impossible  to  tell  cor- 
rectly in  some  instances.  The  urinary  examination,  coupled  with  the 
symptoms  of  dropsy  and  anemia,  is  sufficiently  diagnostic  of  chronic 
diffuse  nephritis  (with  exudation).  The  fact  that,  as  shown  by  Czyhlarz 
and  Donath,'  methylene-blue  is  retarded  in  its  elimination  from  the 
kidneys  in  nephritis,  may  have  diagnostic  value  in  some  cases. 

In  cases  of  large  white  kidney/  the  urine  passed  is,  as  a  rule, 
less  in  quantity  and  is  of  higher  specific  gravity  than  in  the  small, 
pale,  and  contracted  kidney.  Edema  is  usually  greater  in  the  for- 
mer also,  while  in  the  latter  cardio-vascular  changes  are  more  marked. 
The  transition  of  the  disease  from  the  earlier  to  the  later  stage  may 
be  thus  noted.  The  casts  in  the  latter  may  be  narrower  and  more  darkly 
granular  than  in  the  large  white  kidney.  The  existence  of  hemorrhagic 
kidney  may  be  inferred  from  the  history  of  alcoholism  and  the  persistent 
presence  of  erythrocytes  and  blood-casts  in  the  urine. 

Chronic  parenchymatous  is  distinguished  from  chronic  interstitial 
nephritis  by  the  following  points  of  difference : 

Chronic  Parenchymatous  Nephritis.  Chronic  Interstitial  Nephritis. 

Occurs  in  early  or  middle  life.  Occurs  later  in  life. 

There  is  a  previous  history  of  an  acute  A  previous  history  of  gout,  chronic  lead- 
attack,  of  scarlet  fever,  or  perhaps  of  poisoning,  syphilis,  excessive  eating 
acute  alcoholism.                                              and   drinking    (spirits),  nerve-strain. 

The  onset  is  gradual  or  markedly  mani-  Tlie  onset  is  very  slow,  insidious,  and 
fest.  indefinite. 

Dropsy  is  a  constant  symptom.  Dropsy  is  rare. 
1  Wien.  klin.  WocMn.,  June  15,  1899. 


CHRONIC  NEPULUTIS.  1031 

ClIBONIC    PARKNCHYMATOira    NEPItRITIH.  ClIRONIC    INTESTINAL    XkPHKITIH. 

Vaacular  changea  and  cerebral  symp-  Arteriosclorosi.s,    cardiac    hypertrophy, 

toms  are  comparatively  un(fommon.  and  cerebral  symptoms  are  common. 

Albuminuric  retinitis  common.  Retinal    hemorrhage    and    choking   of 

disc. 

Marked  albuminuria ;  many  tube-casts,  Very  slight  albuminuria  and  few  casts, 

chiefly  short,  thick,  granular.  chiefly  hyaline  (long,  narrow). 

Urine  but  little  increased  in  quantity,  Urine  of  very  low  speciflc  gravity  and 

often  diminished;  specific  gravity  is  excessive  in  quantity. 

increased  or  slightly  diminished. 

Anemia  occurs  earlier  and  is  marked.  Anemia    slowly    progressive    and    less 

marked. 

Uremic  symptoms  are  generally  less  se-  Uremic  symptoms  are  generally  severe 

vere — amaurosis,  vomiting,  diarrhea,  — coma  andconvulsions,  great  dyspnea. 

headache. 

Runs  a  shorter  course — from  two  to  six  Has   a  more  chronic  course — seven  to 

or  seven  years.  thirty  years. 

Progfnosis. — This  is  invariably  bad  as  to  cure,  though  life  may  be 
prolonged  in  certain  cases.  In  severe  cases  death  may  take  place  in  from 
three  months  to  a  year,  either  from  uremia,  dropsy,  cardiac  dilatation,  or 
complications.  Cases  of  a  year's  duration  almost  »ever  recover,  and, 
a  fortiori^  those  in  which  advanced  secondary  contraction  of  the  kidney 
may  be  inferred  are  incurable,  and  may  soon  terminate  fatally.  Com- 
plete recoveries  from  the  disease,  particularly  in  children  that  have  had 
scarlet  fever,  may  occur  but  rarely.  The  prognosis  depends  greatly  on 
the  quantity  of  urine  passed  daily,  the  excretion  of  urea  and  total  solids, 
and  upon  the  amount  and  persistency  of  the  albumin,  as  well  as  upon 
the  degree  of  cardio-vascular  and  retinal  changes.  F.  Widal  ^  reempha- 
sizes  the  importance  of  determining  the  amount  of  urea  in  the  blood, 
more  than  0.5  grams  per  liter  of  blood-serum  implying  nitrogen  retention, 
which  the  organism  cannot  tolerate. 

Treatment.— The  indications  for  treatment  are  similar  to  those  in 
acute  nephritis.  The  dropsy  and  uremia  must  be  treated  symptomatically, 
and  the  diet  is  of  importance.  Skimmed  milk  and  buttermilk,  or 
"  zoolak,"  with  dried  bread,  crackers,  and  zwieback,  perhaps,  should 
be  depended  on  as  much  as  possible  when  dropsy  is  pronounced. 
When  dropsy  is  slight,  more  solid  food,  meats  sparingly  and  vegetables, 
rice  and  other  light  cereals  and  fruits,  and  out-of-door  life  should  be 
recommended.  Until  recently  not  enough  proteid  food  was  allowed  in 
chronic  nephritis,  but  milk  is  still  the  best  article.  The  reduction  or 
complete  absence  of  salt  in  the  diet  has  a  strong  influence  in  reducing 
edema  (Rovighi).  The  output  of  water  and  salt,  however,  should  be 
recorded,  and  the  intake  of  the  latter  restricted  as  indicated.  A  patient 
with  edema  should  remain  in  bed.  Residence  in  a  warm,  dry  climate 
may  aid  in  prolonging  life.  Woolens  should  be  worn  next  to  the  skin, 
and  severe  exercise  should  be  forbidden. 

The  infusion  of  digitalis,  strophanthus,  spartein,  adonidin,  or  con- 
vallaria  may  be  needed  in  cardiac  weakness,  or  nitroglycerin  for  con- 
tracted and  tense  arteries  with  a  tendency  to  uremic  twitchings.  Unir- 
ritating  diuretics,  such  as  Trousseau's  diuretic  wine  and  Basham's  mixture 
for  the  anemia,  are  useful.  Strontium  lactate  in  doses  of  from  15  to  20 
grains  (0.972-1.29),  three  times  daily,  I  have  found  useful  in  some  cases. 
Diuretin  has  also  been  tried  lately  with  favorable  results.  Yon  Hbsslin 
states  that  sodium  bicarbonate  without  much  fluid  reduces  albuminuria. 
1  Bull,  et  mem.  Soc.  med.  d.  hop.  de  Paris,  1911,  3  s.,  xxxii.,  627. 


1032  DISEASES  OF  THE   URINARY  SYSTEM, 


CHRONIC   NEPHRITIS    i  NON-EXUDATIVE). 

(Chronic  Iiiterstitial  Xephiitis  ;  Chronic  Brit/ht's  Disease;  Primari/,  trr  Genuine, 
Contracted  Kidney;  Cirrhotic  Kidney  ;  Red  Granidar  Kidney;  Chronic  Pro- 
duct ire  [Diffuse)  Nephritis  without  Exudation  {DeJaJield)  ;    Gouty  Kidnq/.) 

Definition. — A  cbrouic  diffuse  inflammation  of  the  kidneys,  attended 
with  a  growth  of  connective  tissue  in  the  stroma,  degeneration  and 
atrophy  of  the  parenchyma,  and  marked  cardio-vascular  changes.  Two 
additional  varieties  are  recognized ;  the  arteriosclerotic  type  and  the 
secondary  contracted  kidney.  The  last  named  was  described  under 
chronic  ]iarenchymatous  nephritis,  of  Avhicli  it  is  a  sequel. 

Pathology. — In  genuine  primary  contraction  of  the  kidneys  there 
is  a  reduction  in  size  and  weight  about  equal  in  both  organs.  They 
may  be  only  one-half  or  one-third  the  size  of  normal  kidneys,  and  the 
two  kidneys  together  may  not  weigh  over  two  ounces.  They  are  often 
found  imbedded  in  thick  adipose  tissue,  the  capsule  being  thick,  opaque, 
and  very  adherent,  so  that  on  stripping  it  off  it  brings  away  portions  of 
the  renal  cortex.  The  surface  of  the  kidney  is  red,  irregularly  granular, 
or  finely  nodular,  and  occasionally  small  cysts  are  present.  The  con- 
sistence is  firm,  dense,  and  resistant  to  the  knife.  The  cut  surface  shows 
a  thin,  atrophied  cortex,  and  dark,  reddish  streaks  alternating  with  pale 
portions.  The  pyramids  are  also  diminished,  and  darker  than  the  cor- 
tex. In  the  gouty  kidney  the  pyramids  show  fine  striations  of  sodium 
urate  or  of  uric  acid,  or  crystals  representing  uric-acid  infarctions. 

Microseopioally,  the  essential  changes  are  an  increased  production  of 
connective  tissue,  especially  in  the  cortical  substance,  and  a  more  or  less 
proportionate  degeneration  and  atrophy  of  the  renal  parenchyma,  the 
ilestruction  of  which  is  due  to  the  circulation  of  noxious  agents,  but  which 
is  replaced  by  cicatricial  fibrous  tissue  (Weigert). 

The  new  tissue  occurs  in  irregular  masses  around  the  shrunken  glom- 
eruli or  between  the  tubules.  The  distribution  of  connective  tissue  in 
the  pyramids  is  diffuse.  In  the  earlier  cases  the  cells  of  the  tufts  and 
capsules  are  swollen  and  multiplied,  and  a  small-cell  infiltration  is  seen 
around  the  glomeruli  and  tubules.  Later  this  infiltration  of  ceils  becomes 
fibrillated  and  ends  in  fibrous  thickening.  Glomerular  atrophy  is  due 
partly  to  the  changes  in  the  capillary,  intracapilhiry  cells,  and  those 
around  the  tufts ;  partly  also  to  capsular  thickening  and  hyaline  or  waxy 
degeneration  ;  and  partly  to  the  thickening  and  occlusion  of  arterioles. 

The  tubules  show  marked  changes.  Some  are  included  in  masses  of 
connective  tissue,  so  that  there  is  compression-atrophy  and  even  total 
obliteration  of  the  lumen.  The  intertubular  connective  tissue  constricts 
the  tubules  in  certain  places,  so  that  the  lumen  is  elsewhere  increased. 
This  dilatation  is  especially  prominent  in  the  granules  seen  on  the  outer 
surface  of  the  kidney,  and,  owing  to  the  damming  back  of  urine  in  some 
of  the  tubules  thus  obstructed,  little  cysts  are  visible  to  the  naked  eye 
here  and  there.  The  epithelium  lining  these  tubules  shows  granular, 
fattv,  or  waxy  degeneration,  and  may  be  either  flattened,  cuboid,  or 
swollen.     The  tubes  may  contain  granular  or  fatty  ddbris  and  tube-casts. 

An  important  change  in  most  cases  is  the  growth  of  fibrous  tissue  in 
the  walls  of  the  arteries,  causing  sclerosis.  The  arteries  and  capillaries 
are   thus   mostly   occluded   by   the   obliterating   endarteritii.      Waxy   or 


CniiONJC  JSEPJUUTLS.  1033 

hyaline  degeneration  is  seen  also  {vide  Arteriosclerosis).  These  arterio- 
capillary  changes  may  be. the  primary  condition,  and  may  represent  the 
renal  effects  of  a  general  arteriosclerosis  or  fibrosis  forming  the  arterio- 
sclerotic type  of  the  disease.  Interstitial  nephritis  is  "  but  one  lesion  of 
a  generalized  process  of  fibrosis"  (Watkins).  An  almost  constant  ac- 
companiment of  chronic  productive  nephritis  is  cardiac  hyperthrophy. 
The  degree  of  the  latter  depends  upon  the  extent  of  the  renal,  and  also 
of  the  general,  arterial  sclerosis.  The  whole  heart  may  become  so  large 
that  the  term  cor  bovinum  has  been  fittingly  applied  to  it.  In  moderate 
enlargements  the  left  ventricle  only  is  hypertrophied. 

Complicating  lesions  that  may  be  mentioned  are  cerebral  hemorrhage, 
cirrhosis  of  the  liver,  pulmonary  emphysema,  chronic  endocarditis, 
chronic  endarteritis,   pericarditis,   bronchitis,   and  gastric  catarrh. 

Ktiology. — The  cause  of  the  slow  diffuse  degeneration,  atrophy,  and 
fibroid  contraction  of  the  kidneys  is  sometimes  quite  obscure,  (a)  In 
some  cases  it  would  seem  to  be  "  only  an  anticipation  of  the  gradual 
changes  which  take  place  in  the  organ  in  extreme  old  age"  (Osier) — the 
"  senile  kidney,"  (b)  Heredity  undoubtedly  plays  a  part  in  the  causation 
of  certain  cases,  even  to  the  third  or  fourth  generation,  (c)  Age  and 
Sex. — The  disease  is  more  common  in  males ;  it  is  seldom  manifested 
symptomatically  until  about  fifty  or  sixty  years  of  age,  and  is  therefore 
an  affection  of  advanced  life,  (d)  Individuals  having  a  special  tendency 
to  sclerotic  degeneration  of  the  arteries,  from  whatever  injurious  influ- 
ence, are  more  liable  to  chronic  interstitial  nephritis,  although  the  pro- 
longed irritation  of  deleterious  (especially  chemico-toxic)  agents  may 
give  rise  to  the  disease  in  those  whose  cellular  nutrition  is  usually  not 
defective.  Thus,  the  disease  has  been  attributed  to  the  following  causes  : 
alcoholism,  uric  acid,  and  lead,  giving  rise  to  chronic  poisoning.  Chronic 
syphilis  and  chronic  malaria  probably  are  also  causative  factors,  {e) 
Habitual  overeating  and  drinking,  owing  to  the  imperfect  metabolism 
of  the  substances  ingested,  cause  a  constant  excretion  of  irritating  prod- 
ucts by  the  kidney,  and  no  doubt  frequently  cause  granular  atrophy 
and  sclerosis  of  the  organ.  The  continuous  and  even  moderate  use  of 
alcohol  for  many  years,  especially  of  spirituous  liquors,  is  a  widespread 
cause  of  the  disease.  It  is  equally  likely  that  the  excessive  use  of  red 
meats  in  the  diet  leads  to  the  production  of  the  uric  acid  that  induces 
the  renal  disorder  (uricemia  ;  lithemia),  by  deranging  the  function  of  the 
liver  (Murchison).  (/)  Allied  to  the  above  is  gout,  which  causes 
chronic  Bright's  disease — in  England  perhaps  more  than  in  this 
country,  lithemia  and  nervous  dyspepsia  being  more  common  there. 
{g)  According  to  Striimpell,  severe  acute  articular  rheumatism  is  some- 
times followed  by  contracted  kidney,  {h)  Chronic  Bright's  disease  with 
renal  sclerosis  is  favored  in  origin  and  development  by  the  anxieties, 
worries,  and  high  nervous  tension  connected  with  modern  business  ac- 
tivity and  "social  functions,"  the  latter  particularly  acting  their  part 
among  elderly  ladies.  Associated  with  these  are  usually  over-indul- 
gence in  rich  foods  and  Avines,  and  sedentary  habits,  {i)  Emerson  ^  has 
presented  experimental  evidence  which  shows  the  influence  of  repeated 
disturbance  of   the  circulation  as  an  accessory  etiologic   factor   to  the 

^  Archives  of  Internal  Medicine,  June,  1908. 


1034  DISEASES   OF  THE    URIXAEY  SYSTEM. 

action  of  toxic  substances.  (,/)  The  cold,  moist  climate  of  New  England 
and  the  Middle  States  would  seem,  according  ro  Purdy.  to  predispose  to 
contracted  kidney,  {/c)  A  chronic  productive  nephritis  without  exudation, 
though  not  the  true  "  contracted  and  red  granular  "  kidney,  may  be  caused 
by  hydronephrosis,  chronic  pyelitis,  and  chronic  congestion  of  the  kidney, 
as  from  heart  disease. 

Symptoms. — These  may  be  latent  for  years,  while  the  morbid  pro- 
ductive changes  in  the  kidneys  are  slowly  effected.  The  first  symptoms 
may  not  appear  until  late  in  life,  although  the  kidneys  may  be  in  an 
advanced  stage  of  degeneration.  Or  some  complicating  or  intercurrent 
affection  may  set  in,  as  pneumonia  or  pericarditis,  and  cause  the  de- 
velopment of  grave  or  fatal  renal  symptoms.  More  commonly,  how- 
ever, there  is  an  attack  of  uremia,  with  headache,  stupor,  or  convulsions, 
dyspnea,  nausea  and  vomiting,  and  a  tense  pulse.  This  attack  may  be 
recovered  from.  Then  there  is  an  interval  of  variable  duration,  during 
which  the  health  is  more  or  less  impaired,  and  lassitude,  drowsiness, 
disordered  digestion,  headache,  failing  vision,  dyspnea,  and  frequent 
micturition  are  complained  of.  This  is  followed  by  another  uremic 
attack,  severer  than  the  first,  or  perhaps  fatal  ;  if  not  fatal,  the  general 
health  is  still  more  reduced,  and  confinement  to  the  house  or  bed  is 
necessary,  until  the  vital  forces  can  no  longer  compensate  for  the  destruc- 
tion of  the  renal  parenchyma. 

Spasmodic  dyspnea  (uremic ;  cardiac)  is  sometimes  the  first  manifes- 
tation of  contracted  kidney.  The  gradual  onset  of  periods  of  uncon- 
trollable drowsiness  during  the  day  is  often  marked.  An  attack  of 
hemiplegia  may  also  be  the  first  indication  of  renal  disease.  Sometimes 
progressive  loss  of  flesh  and  strength,  with  a  dry,  harsh,  twinkled  skin, 
may  be  from  the  beginning  the  only  clinical  features  of  the  affection 
until  death  results  from  sheer  feebleness  and  emaciation.  The  complex- 
ity and  variability  of  the  symptoms  make  it  best  to  describe  them  under 
the  heads  of  the  various  systems : 

Urinary  System. — The  daily  quantity  of  urine  is  usually  increased 
so  much  that  patients  are  troubled  with  a  desire  to  urinate  frequently, 
not  only  during  the  day,  but  two  or  three  times  during  the  night.  This 
complaint  may  be  aggravated  by  the  hyperacidity  of  the  urine  and  the 
irritability  of  the  prostate  (especially  in  advanced  age)  that  are  so  often 
associated  with  cases  of  renal  cirrhosis.  The  urine  voided  during  the 
twenty-four  hours  may  measure  several  quarts  (2  to  4  liters)  in  well- 
marked  cases  of  the  disease.  Early  in  the  attack,  when  the  incipient 
degeneration  and  destruction  of  the  parenchymatous  cells  is  taking 
place,  the  quantity  of  urine  may  be  slightly  decreased  ;  but  as  the 
•'  blood-flow  to  the  parts  that  remain  must,  cceteris  paribus,  be  as  great 
as  it  would  have  been  to  the  whole  of  the  organs  if  they  had  been  in- 
tact," excessive  pressure  is  brought  to  bear  within  the  capillaries  by  the 
compensating  hypertrophy  of  the  heart,  and  the  secretion  of  the  urine, 
especially  of  the  watery  elements,  becomes  more  active.  The  polyuria 
may  give  rise  to  a  suspicion  of  diabetes.  The  urine  is  clear  and  pale- 
yellow  in  color,  the  specific  gravity  being  seldom  above  1010  or  1012, 
and  it  may  be  as  low  as  1002  or  1005.  Albumin  is  found  only  in 
traces  or  it  may  be  absent  altogether  {glomerular  atrojyhy),  especially  in 
urine  voided  in  the  earlv  morning.     The  urea  is  diminished,  and  there  ia 


CHRONIC  NEPHRITIS.  1035 

little  or  no  sediment.  A  very  careful  microscopic  examination  may  re- 
veal a,  few,  usually  narrow,  hyaline  or  granular  casts,  perhaps  some  leuko- 
cytes, and  rarely  a  few  erythrocytes.  In  the  later  stages  of  the  disease 
or  upon  the  supervention  of  an  uremic  exacerbation  or  of  a  complicating 
inflammation  the  urine  may  be  decreased,  the  albumin  increased,  and 
numerous  casts  be  discovered  in  a  more  apparent  urinary  sediment. 
Hematuria  is  rare. 

Circulatory  System. — The  freezing-point  of  the  blood  is  lowered,  due 
to  the  retention  of  products  normally  eliminated  by  the  kidneys.  It  is 
to  be  recollected  that  the  freezing-point  in  health  is  — .56°C.,  and  in 
nephritis  it  may  be  found  to  be  — .58°  Cor  lower.  The  physical  sifjns 
of  cardiac  hypertrophy  are  present.  Symptoms  referable  to  the  heart 
are  absent,  unless  dilatation  and  feebleness,  sudden  arterial  contraction, 
cardiac  complications,  or  endocarditis  occur.  Inspection  and  palpation 
of  the  hypertrophied  heart  show  an  apex-beat  displaced  downward  and  to 
the  left,  and  an  increased,  heaving,  and  rather  circumscribed  apical  im- 
pulse. These  signs  may  be  less  evident  in  cases  of  coexisting  emphy- 
sema. The  left  border  of  the  deep  cardiac  dulness  extends  outside  the 
nipple-line  in  the  fifth  or  sixth  interspace.  The  first  sound  of  the  heart 
is  loud  and  may  be  duplicated.  A  distinctive  auscultatory  sign  is  the 
accentuation  of  the  aortic  second  sound,  indicating  increased  vascular 
tension.  In  quite  a  majority  of  the  cases  I  observe,  sooner  or  later,  a 
mitral  systolic  murmur ;  it  is  due  to  relative  insufficiency. 

The  pulse  is  increased  in  tension,  and  is  hard,  incompressible,  and 
pe^-sistent,  the  duration  of  each  pulse-wave  being  increased  [pulsus  tar- 
dus). The  radial  artery  itself — and  this  is  true  of  most  of  the  palpable 
arteries — feels  hard,  thickened,  and  often  tortuous,  on  account  of  the 
arteriosclerosis.  The  systolic  blood-pressure  is  decidedly  high,  often  ex- 
ceeding 200  mm.  Hg.  As  soon  as  compensation  of  the  heart  fails,  symp- 
toms of  breathlessness  (especially  on  exertion),  palpitation,  and  the  like, 
appear,  and  sometimes  in  paroxysmal  attacks  ("cardiac  asthma").  The 
resultant  stasis  gives  rise  to  transudation  into  the  lungs  (bronchorrhea ; 
pulmonary  edema),  and  later  to  edema  of  the  extremities. 

Respiratory  System. — Epistaxis  may  be  a  serious  symptom.  Sudden 
edema  of  the  larynx  may  also  occur,  and  is  always  grave.  Transuda- 
tions into  the  pleural  sac  (hydrothorax),  as  well  as  into  the  lungs  {vide 
supra),  may  precede  death.  Dyspnea,  which  is  either  cardiac  or 
uremic,  is  usually  worse  at  night,  and  a  true  orthopnea,  together  with 
Cheyne-Stokes  breathing,  may  be  observed  associated  with  uremic  stupor 
and  coma. 

Nervous  System. — Symptoms  referable  to  the  nervous  system  are  very 
important,  since  they  are  usually  indicative  of  grave  uremia.  Cephal- 
algia is  frequent,  and  neuralgic  pains  throughout  the  body,  and  insom- 
nia, may  be  complained  of.  Later  great  droivsiness  is  often  a  premo- 
nition of  uremic  coma.  Convulsions  may  be  preceded  by  muscular 
twitchings,  which  should  attract  attention  to  the  imminent  danger  of 
the  former.  Cerebral  apoplexy  with  hemiplegia  may  be  the  first 
symptom  of  conti'acted  kidney.  It  is  especially  apt  to  occur  in  cases 
of  marked  hardening  and  weakening  of  the  arteries.  There  may  be 
an  hemorrhagic  pachymeningitis,  as  well  as  a  hemorrhage  into  the 
brain-substance.  The  hemiplegia  may  persist  until  death ;  or  it  may 
disappear  in  a  short  time,  and  be  followed  by  subsequent  attacks  at  in- 


1036  DISEASES  OF  THE   URIXARY  SYSTEM. 

tervals  ("shifting  paralyses").  Formication,  numbness,  and  pallor  of 
one  or  more  fingers  (the  ''  dead  finger")  I  believe,  with  Dieulafoy,  to  be 
sometimes  the  earliest  symptoms  of  chronic  Briglit's  disease. 

Of  the  special  senses,  Nt'/i/rntic  retinitis  is  often  the  earliest  evidence 
of  chronic  Ihight's  disease.  The  patient  may  or  may  not  have  had 
slight  dimness  of  vision  (mistiness)  prior  to  the  ophthalmoscopic  exami- 
nation. The  loss  of  vision  affects  both  eyes,  and  is  usually  partial  {am- 
blyopia).  Sudden  and  complete  blindness  may  come  on  in  grave  cases 
— uremic  amaurosis — the  condition  being  due  to  neuro-retinitis.  The 
optic  papilla  is  swollen,  and  surrounded  by  retinal  hemorrhages  or  by 
white  dots  and  streaks  ("feather-splashes"').  Exoi)hthaliii()S  without  thy- 
roid eidargement  has  occasionally  been  noted  (Earlier  and  I  lanes, 
Gordinier).      Tinnitus  aurium,  deafness,  and  vcrtif/o  are  not  uncommon. 

Digestive  System. — Anorexia,  nausea,  and  annoying  dyspepsia  are 
often  complained  of.  Severe  vomiting  may  usher  in  an  uremic  attack. 
Catarrhal  gastritis  may  exist  for  some  time,  the  tongue  being  coated 
and  the  breath  heavy  and  urinous.      Uremic  diarrhea  may  also  occur. 

The  Skin. — Edema  is  usually  absent  in  renal  sclerosis ;  when  it  does 
occur,  however  (as  in  the  ankles  and  limbs),  it  is  due  to  dilatation  and 
failure  of  the  heart.  The  skin  is  dry,  and  minute  lustrous  scales  of  urea 
may  be  seen  around  some  of  the  pores.  A  certain  degree  of  pallor  is 
noticed,  and  often  the  skin  has  a  cyanotic  tinge.  Pruritus  and  trouble- 
some eczema  are  frequently  present,  and  muscular  cramps,  occurring 
especially  in  the  calves  of  the  legs  and  at  night,  may  also  be  associated. 
The  general  nutrition  gradually  fails,  so  that  in  advanced  cases  the 
debility  and   emaciation  are  extreme. 

Uremia  may  come  on  at  any  time  during  the  course  of  the  disease,  and 
may  be  the  first  symptomatic  manifestation  ;  it  may  either  be  sudden  and 
severe  in  its  onset  (acute  uremia)  or  mild,  insidious,  and  gradual  (clironic 
uremia).  Moderate  fever  may  attend  an  uremic  attack,  or  the  tempera- 
ture may  be  normal ;  in  chronic  uremia,  with  prostration,  coma,  delir- 
ium, and  feeble  pulse,  it  may  be  even  subnormal. 

Among  the  complications  that  may  occur  are  the  following :  pneu- 
monia, either  lobar  or  lobular ;  pleuritis,  pericarditis,  bronchitis,  gastritis, 
enteritis,  peritonitis,  meningitis,  endocarditis,  emphysema,  phthisis,  acute 
dermatitis  exfoliativa  (Duckworth),  and  hepatic  cirrhosis. 

Diagnosis. — This  depends  in  great  part  upon  the  ])hysical,  chemical, 
and  histologic  examination  of  the  urine.  Both  the  morning  and  evening 
urine  should  be  examined  repeatedly  for  albumin  and  casts,  since 
one  examination — and  especially  that  of  the  morning  urine — may  give 
negative  results,  owing  both  to  the  scarcity  of  these  two  pathologic 
elements  and  to  the  fact  that  one  or  both  may  be  altogether  absent 
in  some  instances.  The  mere  discovery  of  a  trace  of  albumin  or  of 
a  few  casts  is  not  always  positive  evidence  of  chronic  Bright's  disease, 
as  both  may  exist  in  other  conditions.  But  the  age,  habits,  and  symp- 
toms of  the  patient  must  be  studied  in  connection  with  frequent  urinary 
examinations;  and  a  persistent  slight  albuminuria,  with  casts,  and  the 
passage  daily  of  large  ({uantities  of  clear,  pale  urine  of  low  specific 
gravity,  afford  sufficient  grounds  for  making  the  diagnosis. 

Contracted  kidney  should  be  suspected  in  all  cases  in  which,  during 
middle  life,  either  one  or  more  of  the  following  sjmptoms  and  signs  may 
be  noticed:  frequent  headache,  congestive  disorders,  repeated  epistaxis, 


CHRONIC  NEJ'JIR/TW.  lO.'JT 

vertigo,  dimness  of  vision,  intractable  conjunctival  irritation  f  A  He- 
man),  impaired  strength,  .dyspneic  attacks,  gastro-intestinal  dyspep- 
sia, noises  in  the  ear,  itching  of  the  skin,  cramps  in  the  calves,  mus- 
cular twitchings,  growing  mental  dulness,  increasing  pulse-tension, 
and  rigidity  and  tortuosity  of  the  temporal  and  radial  arteries.  Sud- 
den coma,  convulsions,  amaurosis,  apoplexy,  vomiting,  or  dyspnea  in 
persons  in  the  middle  period  of  life,  with  or  without  a  history  of  poly- 
uria, should  create  the  suspicion  of  chronic  Bright's  disease.  It  will  be 
found  in  such  cases  that  there  has  been  a  diminution  in  the  urinary  flow 
before  the  attack.  Persons  of  lithemic,  gouty,  rheumatic,  or  alcoholic 
habits,  with  evidences  of  cardiac  hypertrophy,  an  accentuated  aortic  sec- 
ond sound,  and  a  hard  pulse  are  often  readily  diagnosed  as  subjects  of 
contracted  kidney  when  an  examination  of  the  urine  is  made. 

If  the  first  examination  of  the  patient  is  made  during  a  sudden 
uremic  or  apoplectic  attack,  catheterization  should  be  done  if  neces- 
sary, and  the  detection  of  albuminuria  will  then  clear  the  diagnosis. 
To  determine  accurately  the  permeability  of  the  kidneys,  Schapira  ^  rec- 
ommends the  hypodermic  administration  of  phloridzin  or  indigo  carmine, 
followed  by  ureter  catheterization. 

In  order  to  differentiate  between  primary  renal  affection  with  second- 
ary cardiac  hyperthrophy  and  primary  heart  disease  with  a  secondary 
congested  kidney  oceurring  late  in  the  case,  the  general  features,  course, 
symptoms,  and  signs  must  be  carefully  and  judiciously  balanced.  Prom- 
inent cardio-vascular  changes  would  indicate  an  arteriosclerotic  kidney. 
The  presence  of  a  diastolic  murmur  would  tend  to  exclude  primary  con- 
tracted kidney  of  toxic  origin;  on  the  other  hand,  an  albuminuric  retinitis 
would  point  to  a  primary  renal  complaint.  The  symptoms  of  ordinary 
non-inflammatory  senile  kidney  may  not  be  unlike  those  of  chronic  inter- 
stitial nephritis,  though  not  so  severe ;  and  yet,  from  excessive  eating  and 
drinking  at  times,  uremic  attacks  may  supervene  to  cloud  the  diagnosis. 

Prognosis. — The  duration  of  chronic  interstitial  nephritis  varies. 
In  uncomplicated  cases  it  may  last  for  five,  ten,  twenty,  or  possibly  thirty 
years.  Complications  or  intercurrent  affections  may,  however,  shorten 
the  duration  very  much.  The  postmortem  examination  may  show  the 
characteristic  kidneys  in  one  who  during  life  had  no  symptoms  indicating 
renal  disease,  and  whose  death  was  caused  by  some  intercurrent  disease. 
The  gradual  destruction  of  the  renal  parenchyma  and  its  replacement 
by  scar-tissue  cause  irreparable  damage  to  the  organs.  On  the  other 
hand,  the  fact  that  the  process  is  usually  a  slow  one  and  its  duration 
long  is  compatible  with  the  preservation  of  life  for  many  years,  and  with 
comparative  comfort,  even,  in  many  instances.  The  prognosis  in  a  given 
case  depends  very  much  upon  the  general  constitutional  condition,  the 
cardio-vascular  state,  and  the  presence  or  absence  of  uremia  and  inflam- 
matory complications.  Cardiac  dilatation  and  insufficiency  indicate  a 
not  far  distant  end.  Convulsive  and  apoplectic  seizures  are  often  fatal, 
and  hemorrhages,  persistent  vomiting,  and  diarrhea,  retinitis  nephritica, 
coma,  and  delirium  render  the  prognosis  as  to  further  systemic  toler- 
ance of  the  degenerated  kidneys  exceedingly  grave. 

Treatment. — An  early  recognition  of  the  disease  and  the  steadfast 
practice  of  careful  hygienic  measures  will  prevent,  to  a  considerable 
degree,  the  advance  of  the  cirrhotic  changes.  Noxious  substances  enter- 
^Jour.  Amer.  Med.  Assoc,  Jan.  15,  1910. 


1038  DISEASES  OF  THE   UmXAEY  SYSTEM. 

ing  into  the  etiology  of  the  affection  must  be  avoided  and  removed  as 
far  as  possible.  The  formation  of  uric  acid  must  be  reduced  by  dietetic 
management,  alcoholics  must  be  interdicted,  and  lead — when  the  cause 
of  tile  condition — must  be  kept  from  further  poisoning  the  system  bv  a 
change  of  occupation.  By  diminishing  these  irritants  the  heart  and 
blood-vessels  ure  also  conserved — a  point  of  vital   importance. 

The  hygienic  treatment  nmst  embrace  a  regulation  of  all  the  habits 
of  body  and  modes  <»f  life.  The  patient  must  be  treated,  and  not  his 
malady,  since  that  is  incurable.  A  dietary  that  is  suitable  for  each  indi- 
vidual case  must  be  made  out ;  it  nmst  be  the  aim  tu  maintain  the  nutri- 
tive e(iuilibrium  of  the  patient,  without  producing  irritation  of  the  renal 
epithelium.  Vaughan  holds  that  a  salt-free  diet  protects  the  kidneys  by 
decreasing  their  labor.  Saundby's  rule  is  a  good  guide :  "  Eat  very 
sparingly  of  butcher's  meat ;  avoid  malt  liquors,  spirits,  and  strong 
wines.''  Red  meats  are  probably  no  more  injurious  than  white  in  their 
effects  in  this  disease ;  although  the  former  should  be  allowed  in  smaller 
quantities  than  the  latter.  An  exclusive  milk  diet  may  be  necessary  for 
short  periods  when  gastric  irritation  is  present,  but  in  such  a  chronic  dis- 
ease undue  weakness  would  result  from  a  restriction  to  milk  alone.  The 
larger  the  quantity  of  proteid  food  consumed,  the  greater  the  amount  of 
albumin  in  the  urine  and  also  the  greater  the  accumulation  of  urea  in 
the  circulation.  Vegetables,  greens,  fruits,  and  light,  well-cooked  fari- 
naceous articles  may  also  be  partaken  of,  and  tea,  coffee,  and  cocoa  may 
be  drunk.  The  use  of  natural  mineral  w^aters  aids  in  the  renal  circula- 
tion and  keeps  the  kidneys  flushed.  In  general  a  mixed  diet  will  be  of 
advantage ;  the  nitrogenous  and  carbohydrate  elements  (sugars  and 
starches)  are  used  in  limited  amounts,  while  pure  fats  and  fruits  (raw  or 
cooked)  are  to  be  recommended.  I  would  add  that  whole  milk,  diluted, 
should  make  up  a  considerable  portion  of  the  diet,  that  meats  be  al- 
lowed in  small  quantity  once  daily,  as  a  rule,  and  that  we  should  draw 
largely  upon  the  vegetable  kingdom  for  aliment.  Stout  persons  and 
those  leading  sedentary  lives  should  have  less  food  than  those  taking 
exercise,  and  gastric  disorder  requires  the  elimination  of  all  but  soft, 
bland  foods,  or  a  liquid  diet  until  digestion  is  restored.  As  elsewhere 
stated,  it  is  impossible  to  lay  down  a  dietary  that  would  be  suitable  for 
all  cases,  on  account  of  the  peculiarities  presented  by  the  individual 
cases.  The  effect  of  a  given  diet  is  to  be  noted  by  a  careful  observation 
of  the  bodily  weight  and  by  oft-repeated  examination  of  the  urine. ^  Ex- 
tremes of  bodily  and  mental  activity  should  be  avoided,  and  physical 
exercise  should  be  moderate,  regular,  and  taken  in  the  open  air,  provided 
the  latter  be  warm  and  dry. 

A  change  of  residence  to  a  warm,  mild,  and  dry  climate  is  often  of 
service.  The  variability  and  humidity  of  temperate  climates,  particu- 
larly during  winter,  aggravate  this  disease,  Avhile  a  sea  voyage  or  a 
sojourn  at  some  southern,  western,  or  European  resort,  where  the  soil  is 
dry  and  sandy  and  the  climate  equable,  may  be  very  beneficial. 

The  indications  for  medicinal  treatment  are  principally  as  follows  : 
The  bowels  should  be  kept  free  by  the  aid  of  laxatives  {e.  g.,  trituratio 
elaterini,  gr.  ^-j — 0.0162-0.0648)  or  laxative  alkaline  mineral  waters. 
Papoid,  peptenzyme.  and  other  digestants,  Avith  bitter  tonics,  are  useful 
in  some  cases  in  which  a  furred  tongue  and  indigestion  are  troublesome. 

'  American  Medicine,  October  31, 1903,  vol.  vi.,  No.  18,  pp.  697-699,  by  the  v^riter. 


CHRONIC  NErillUTIS.  1039 

Acids  or  alkalies,  according  to  special  indications,  may  also  be  used 
simultaneously.  An  increased  vascular  tension  (vaso-constrictionj,  such 
as  to  place  a  serious  strain  upon  the  heart ;  the  other  extreme,  of  a  very 
low  tension,  that  induces  dropsy;  and  complications,  usually  uremic  (con- 
vulsions, dyspnea,  headache),  also  call  for  therapeutic  assistance.  High 
tension  is  to  be  met  by  the  cautious  use  of  nitroglycerin  in  gradually 
ascending  doses,  beginning  with  1  minim  (0.066)  every  three  hours. 
Headache,  vertigo,  and  the  so-called  renal  asthma  (dyspnea)  are  also 
often  relieved  by  this  drug.  A  too  great  reduction  in  the  arterial  ten- 
sion is  undesii^able,  being  attended  with  danger  of  uremia  and  serous 
effusions,  owing  to  insufficient  urinary  excretion. 

Low  tension,  with  signs  of  cardiac  dilatation,  scanty  albuminous 
urine,  and  edema,  requires  heart-tonics  and  stimulants,  in  conjunction 
with  purgatives.  Digitalis  (preferably  in  infusion)  has  good  effects, 
especially  when  combined  with  strychnin  nitrate  or  with  caffein  citrate. 
Calomel  and  the  salines  should  be  given  for  the  dropsy. 

Uremic  symptoms  should  be  treated  as  in  acute  Bright's  disease  by 
causing  profuse  sweating  and  free  catharsis,  and  in  some  cases  by  phle- 
botomy. Inhalation  of  amyl  nitrite  or  chloroform,  or,  what  is  often  a 
useful  and  necessary  measure,  the  hypodermic  injection  of  morphin  (gr. 
^ — 0.0108),  may  be  tried  in  convulsions,  severe  headache,  or  dyspnea. 
White  and  Wilcox  ^  have  shown  that  morphin  does  good  in  nephritis  by 
diminishing  the  oxidizing  functions  of  the  body  metabolism.  Le  Fevre 
extols  chloral  for  its  more  lasting  action  than  chloroform. 

Contracted  kidney  of  a  probable  malarial  or  syphilitic  origin  may  be 
benefited  somewhat  by  the  use  of  arsenic  and  the  iodids  respectively ; 
but  no  drugs  can  possibly  restore  the  destroyed  renal  parenchyma  or 
transform  connective-tissue  cells  into  secreting  kidney-cells.  Renaut^ 
claims  to  have  treated  chronic  nephritis  successfully  with  a  maceration 
of  young  pigs'  kidneys.  The  dose  recommended  for  adults  is  two  kidneys 
per  day  (each  weighing  not  over  160  gm.).  The  maceration  has  an  ener- 
getic diuretic  action  and  an  unmistakable  antitoxic  property.  Spillmann 
claims  a  specific  effect  for  the  internal  secretion  of  the  kidney  as  obtained 
from  the  venous  blood  of  the  organ,  diuresis  being  greatly  increased. 

Certain  recent  writers  (Rose,  Ferguson,  Wolff)  had  observed  the  dis- 
appearance of  casts  and  albuminuria  after  the  operation  of  nephropexy  in 
which  a  portion  of  the  capsule  had  been  removed.  In  1898,  Edebohls 
first  proposed  the  cure  of  chronic  nephritis  by  operation — decapsulation. 
He  reports  18  cases  thus  treated,  and  in  each  operation  (except  2) 
stripped  off  about  one-half  of  the  capsule.  The  beneficial  and  curative 
effects  indicated  by  an  increased  flow  of  urine  and  the  disappearance  of 
dropsy  tube-casts  and  albumin,  do  not  show  themselves  usually  before 
the  tenth  day.  It  is  not  a  helpful  operation  in  advanced  cases  and  its 
precise  value  as  a  therapeutic  measure  in  chronic  nephritis  has  not  as  yet 
been  determined.  While  the  majority  of  the  cases  treated  surgically 
belong  in  the  category  of  chronic  interstitial  nephritis,  decapsulation  is 
quite  as  appropriate  in  suitable  cases  of  the  parenchymatous  variety. 

The  Rose-Bradford  Kidney. — In  1904  Rose-Bradford  described  a  form 
of  fibrotic  kidney,  inflammatory  in  origin,  and  quite  distinct  from  the  con- 
tracted kidney  of  advanced  life.  The  etiology  is  unknown.  Power  suggests 
an  underlying  blood-carried  toxin  as  the  cause.     '"  The  disease  occurs  in 

^  Internat.  Clin.,  vol.  ii.,  20th  Series.         ^  Revue  de  Med.,  last  indexed,  xliv.,  p.  140. 


1040  DISEASES  OF  THE    URrXARY  SYSTEif. 

young  subjects  and  is  markedly  latent.  Polyuria  with  much  albumin, 
absence  of  edema,  cardiovascular  and  fundus  oculi  changes,  with  a  fatal 
termination  from  an  acute  uremia,  complete  the  story  "  (Rose-Bradford). 

PYELITIS. 

{Pyelonephritis;  P!/onephriti&.) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney-  The  com- 
pound terms  above  represent  iuilammation  of  the  kidney-structure  as  a 
result  of.  and  combined  with,  pyelitis. 

Pathology. — In  the  mildest  varieties  of  pyelitis  (the  catarrhal)  the 
morbid  changes  consist  simply  of  a  reddened,  swollen,  and  turbid  mucous 
membrane,  covered  with  an  exudation  of  viscid  muco-pus  and  desqua- 
mated epithelium.  Ecchymoses  are  sometimes  seen.  The  urine  in  the 
pelvis  of  the  kidney  is  also  turbid  from  the  admixed  pus-covpuscles  and 
pelvic  epithelium.  In  calculous  pyelitis  purulent  inflammation  and  ulcer- 
ation prevail,  and  the  kidney  structure  is  also  involved  by  extension 
(pyelonephritis).  Renal  abscesses  are  thus  formed,  and  small  dark  cal- 
culi may  be  found  mingled  with  the  pus  in  small  abscess  cavities ;  or, 
perhaps,  as  noted  before  (vide  Nephrolithiasis),  one  large  abscess  cavity 
may  replace  the  destroyed  renal  parenchyma  [pyonephrosis). 

A  diphtheritic  inflammation,  Avith  the  formation  of  a  false  membrane 
and  sloughing  of  the  pelvis,  sometimes  follows  the  severe  acute  infections. 
Marked  hemorrhagic  areas  may  be  seen  also.  In  tuberculous  pyelitis 
there  is  usually  an  association  of  nephritis  with  areas  of  tuberculous 
softening  and  ulceration,  and  later  pyonephrosis.  In  very  chronic  cases 
the  pyelitis  may  be  followed  by  an  infiltration  of  the  kidney  structure 
with  cheesy  masses  that  may  become  the  seat  of  calcification. 

Persistent  obstruction  leading  to  pyelitis  is  associated  with  dilatation 
of  the  pelvis  from  retention  of  urine  or  of  pus  (pyonephrosis).  This,  in 
turn,  from  prolonged  pressure,  causes  marked  atrophy  of  the  secreting 
structure  of  the  kidney.  There  is  also  an  increase  in  the  interstitial 
tissue.  The  so-called  surgical  kidney  is  found  when  an  acute  bilateral 
pyelitis,  following  a  severe  cystitis,  has  excited  an  acute  suppurative  in- 
flammation of  the  kidney.  Acute  suppurative  or  interstitial  inflamma- 
tion of  the  kidney  due  to  metastatic  or  miliary  abscesses  is  considered 
under  the  heading  Pyemia  {vide  p.  170). 

l^tiology. — Pyelitis  rarely  is  primary  or  independent  in  origin,  as 
after  exposure  to  cold  and  wet.  The  secondary  causes  of  pyelitis  are 
as  follows:  (1)  renal  calculi  (the  most  frequent);  (2)  extension  upward 
of  urethritis,  cystitis,  or  ureteritis,  particularly  when  gonorrheal  in 
origin  ;  (3)  retention  of  decomposed  urine  in  the  pelvis  of  the  kidney ; 

(4)  renal     affections,    as    tubercle,    carcinoma,    and   acute    nephritis ; 

(5)  specific  fevers  ;  (6)  foreign  bodies,  other  than  stone  in  the  pel- 
vis ;  (7)  irritating  diuretics.  To  point  out  briefly  certain  additional 
facts  bearing  upon  the  causation  of  pyelitis  in  the  order  named,  it 
should  be  mentioned  that  calculous  pyelitis  may  result  from  the  irrita- 
tion of  the  constant  presence  and  passage  of  small  stones  ("gravel  "), 
or  even  of  uric-acid  "sand,"  as  well  as  from  the  large  dendritic  concre- 
tions that  send  offshoots  into  the  calyces.  Extensions  of  inflammation 
to  the  pelvis  from  lower  portions  of  the  urinary  tract  may  occur  in  pro- 
tracted cases  of  such  affections  as  gonorrheal  urethritis    and  puerperal 


PYELITIS.  1041 

and  calculous  cystitis.  Obstructive  pyelitis  sorrifttimes  follows  the  im- 
paction of  renal  calculi  or  of  other  foreign  bodies  in  the  ureter  wiien 
there  is  pre-existing  inflammation  of  the  tract,  or  when,  as  usually  hap- 
pens, there  is  chemical  irritation  from  the  decomposition  of  the  accumu- 
lated urine.  There  may  be  obstruction  in  the  bladder  and  urethra,  as 
from  enlarged  prostatic  tumors,  stricture,  phimosis,  and  paralysis  of  the 
sphincter  vesicae,  or  as  in  paraplegia.  Under  the  consideration  of  tuber- 
culosis and  carcinoma  of  the  kidney  is  included  the  involvement  of  the 
pelvis  by  these  conditions.  Infectious  pyelitis  may  result  from  small- 
pox, diphtheria,  typhoid  fever,  and  scarlatina,  and  it  depends  upon 
the  irritating  effect  of  certain  substances  eliminated  by  the  kidneys.  It 
is  usually  associated  with  more  or  less  nephritis  (pyelonephritis).  Para- 
sites, such  as  the  echinococcus  (hydatids),  distoma,  strongylus,  and  filaria, 
may  give  rise  to  pyelitis.  Cantharides,  cubebs,  copaiba,  turpentine,  and 
diabetic  urine  even,  may  rarely  excite  a  pyelitis. 

Symptoms. — These  are  frequently  overshadowed  by  those  of  the 
primary  causative  condition :  they  are  varied  also  for  the  same  reason. 
The  clinical  manifestations  of  a  simple  catarrhal  pyelitis  are  slight  pain 
and  tenderness  in  the  region  of  the  aff'ected  kidney  or  kidneys,  mild 
fever,  with  a  turbid  urine  of  acid  reaction,  showing  a  few  pus-cells,  a 
little  mucus,  rarely  some  red  blood  corpuscles,  and  a  trace  of  albumin. 

In  the  severer  varieties,  as  in  calculous  pyelitis,  especially  when 
there  are  attacks  of  renal  colic,  the  urine  frequently  shows  to  the  naked 
eye  the  presence  of  blood  and  a  marked  amount  of  pus,  some  mucus, 
and  at  times  the  transitional  caudate  epithelial  cells  from  the  middle 
layers  of  the  mucosa.  In  obstructive  pyelitis  the  urine  sometimes  flows 
freely  and  normally  for  a  while,  until  the  developing  pain  over  the  in- 
flamed kidney  ends  in  relief  by  the  expulsion  of  the  obstacle  and  the  pas- 
sage of  purulent  urine.  This  alternation  of  normal  with  py  oid  urine  is  indic- 
ative  of  aunilateral  pyelitis.  Am moniacal  urine  is  met  with  in  cysto-jjyelitis. 
Albuminuria  is  decidedly  shown  according  to  the  degree  of  pyuria. 

In  chronic  suppurative  pyelitis  or  pyelonephritis  the  pyuria  is  variable 
both  in  quantity  and  constancy,  hitermittent  pyuria  may  be  due  to  the 
temporary  blocking  of  the  ureter  by  a  stone  {vide  Obstructive  Pyelitis). 
The  pus  is  seldom  mixed  with  epithelium  in  chronic  purulent  pyelitis.  The 
associated  intermittent  fever  may  be  like  that  of  tuberculous  pyelitis,  and 
marked  prostration,  anemia,  and  emaciation  are  concomitants.  Evidences 
of  amyloid  change  may  be  revealed  in  long-standing,  chronic  cases. 

In  severe  pyelitis  the  pain  is  often  acute,  coursing  down  the  ureters. 
The  fever  is  moderate,  and  there  are  present  the  common  symptoms  de- 
scribed under  Nephrolithiasis  {vide  p.  1016). 

The  fever  in  purulent  pyelitis  (pyonephrosis)  and  pyelonephritis 
takes  on  a  hectic  or  typhoid  type.  Paroxysms  of  rigors  or  chills,  fol- 
lowed by  a  rapid  rise  in  temperature  and  ending  in  perspiration,  may 
be  observed ;  or  there  may  be  marked  prostration  and  feebleness  of 
circulation,  delirium,  and  stupor.  The  temperature-curve  runs  an  irreg- 
ular course,  Avith  marked  remissions,  in  pyemic  cases. 

The  term  ammoniemia  has  been  applied  to  that  complexus  of  nervous 
symptoms  that  is  supposed  to  arise  from  the  decomposition  and  absorption 
of  urinary  substances.  These  symptoms  may  be  similar  to  the  manifesta- 
tions of  diabetic  coma. 

Distinct  enlargement  and  fluctuation  of  the  diseased  kidney  may  be 

66 


1042  DISEASES  OF  THE   URINARY  SYSTEM. 

determined  in  some  cases  of  pyonephrosis.  This  may  also  be  intermittent, 
being  detectable  while  there  is  obstruction  to  the  flow' of  pus,  and  rice  verad. 
Accordintr  to  A.  II.  Smith,  at  the  menstrual  periods  pyelitis  may  be  sub- 
ject to  marked  exacerbations,  simulating  renal  colic.  In  chronic  pyelitis 
with  atrophy  of  the  kidney  the  onset  of  uremia  may  terminate  the  case. 

Diag^nosis. — This  embraces  the  discrimination  from  other  affections, 
and  the  })ossible  detection  of  the  variety — etiologically  considered — of  the 
pyelitis.  It  is  most  important  to  pay  attention  to  the  clinical  history  of 
any  case  with  a  view  to  the  discovery  of  the  cause;  also  the  urinary  con- 
dition must  be  carefully  studied.  In  the  very  nature  of  this  affection  it 
is  often  impossible  to  exclude  other  affections  of  the  urinary  tract,  as 
nephritis,  cystitis^  and  urethritis. 

Epithelium  from  the  pelvis  of  the  kidney  cannot  be  distinguished  from 
transitional  bladder-cells;  but,  given  the  indications  of  a  pyelitis,  its  cal- 
culous cause  is  at  once  made  clear  upon  the  passage  of  the  characteristic 
uratic  or  oxalatic  concretions.  It  may  happen  that  the  urine  from  one 
kidney  is  prevented  from  flowing  by  the  impaction  of  a  stone  in  the 
ureter.  The  urine  may  now  flow  clear  from  the  other  and  vicariously 
acting  kidney  until,  the  stone  having  given  way,  it  suddenly  increases 
in  quantity  and  changes  in  character,  owing  to  the  return  of  the  mor- 
phologic elements  of  the  pyelitis  (corpuscles,  desquamated  epithelium, 
crystals,  and  debris). 

Catheterization  of  the  ureters  and  renal  pelves,  as  described  and  prac- 
tised by  Pawlik  and  Kelly,  is  a  most  certain  method  of  determining  in 
doubtful  cases  from  Avhich  side  the  purulent  urine  arises.  Urine  from  the 
diseased  kidney  freezes  at  a  point  higher  than  does  that  from  the  healthy 
organ.'  Palpation  of  the  ureters  through  the  lateral  and  anterior  fornix 
of  the  vagina  will  sometimes  reveal  thickening  and  tenderness  in  cystopy- 
elitis,  and  ureteral  distention  sometimes  may  be  felt  in  pyelitis  calculosa. 

Casts  and  albumin  are  usually  present  when  the  kidney-structure  is 
involved  by  extension  of  the  pyelitis,  while  marked  pain  in  the  region 
of  the  kidney  indicates  predominant  pyelitis,  though  it  does  not  exclude 
the  possibility  of  coexisting  nephritis.  Marked  vesical  irritability  points 
to  associated  cystitis,  but  in  intense  pyelitis  with  much  pus  and  an  acid 
urine  vesical  tenesmus  may  also  be  troublesome.  Tuberculous  can  be 
discriminated  from  calculous  pyelitis  by  finding  tubei'cle  bacilli  in  the 
pus.  Tubercle  bacilli  Avere  found  by  Flick  and  AValsh  in  the  urine  in 
73.3  per  cent,  of  consumptives,  though  lesions  of  the  kidneys  were  often 
wanting.  The  presence  of  a  fluctuating  tumor  in  the  lumbar  region  is 
significant  enough  of  pus ;  but  it  may  be  difficult  to  determine  whether 
it  is  due  to  pyonephrosis  or  perinephric  abscess,  although  pyuria  and  the 
previous  history  of  pyelitis,  as  well  as  the  more  circumscribed  and  less 
edematous  character  of  the  swelling  of  the  former,  are  important  distin- 
guishing ))oints. 

Differential  Diagnosis. — The  hemorrhagic  pyelitis  of  Senator,  Dela- 
field,  and  others,  described  as  occurring  in  milder  forms,  and  particularly 
in  girls  of  neurotic  types,  may  be  distinguished  by  the  intermittent 
hematuria  and  the  occasional  lumbar  pain,  lasting  but  a  few  days  or  a 
week,  and  followed  uniformly  by  recovery. 

Difficulty  is  sometimes  experienced  in  diagnosticating  pyelitis  when 
coexistent  with  cystitis — pyelo-cyditis.  These  affections  will  not  be  con- 
^  Tinker,  Johns  Hopkins  HoRpilal  BuUetin,  June,  1903. 


HYnRONEriinosis.  1043 

founded,  however,  when  it  is  recollected  that  their  histories  differ.  There 
is  pain  in  one  lumbar  region  in  the  former,  and  in  thehhuldcr  in  tlic  latter. 

According  to  Rosenfeld  :  (1)  an  alkaline  reaction  is  not  found  in  un- 
complicated pyelitis;  (2)  the  limit  of  albumin  in  the  urine,  even  with 
severest  cystitis,  is  0.1  per  cent,  (maximum,  0.15).  Stress  is  laid  upon 
the  relation  of  the  albumin-contents,  which  is  from  two  to  three  times 
greater  with  pyelitis  than  with  cystitis. 

Prognosis. — Renal  complications  always  make  the  pyelitis  a  serious 
affection.  Catarrhal  cases  recover.  Calculous  pyelitis  tends  toward 
chronicity.  Pyelo-nephritis  and  pyonephrosis  are  apt  to  end  fatally  from 
exhaustion  or  uremia.  Perforation  and  the  discharge  of  pus  into  the  peri- 
toneal cavity,  pleural  sac,  intestine,  and  bronchi  even,  may  precede  death. 
The  gravity  of  all  cases  of  pyelitis  depends  upon  the  causes  and  upon  the 
tendency  to  consecutive  suppuration. 

Treatment. — This  varies  according  to  the  cause :  the  latter  needs 
to  be  removed,  its  effects  counteracted,  and  its  return  avoided.  The 
treatment  of  calculous  pyelitis  is  essentially  the  treatment  of  nephro- 
lithiasis. Primary  inflammation  of  the  lower  portions  of  the  urinary 
tract  must  be  combated ;  causes  of  retention  of  decomposed  urine,  as  an 
urethral  stricture  or  enlarged  prostate,  must  be  diminished ;  infectious 
fevers  must  be  judiciously  handled  and  irritating  diuretics  withheld. 

Local  measures  are  of  value  in  all  forms  of  pyelitis.  Hot-water 
bags,  fomentations,  poultices,  and  dry  cupping  are  often  of  great  service. 
Internally,  the  use  of  diluents  is  to  be  recommended,  especially  the 
alkaline  mineral  Avaters,  flaxseed  tea,  barley-water,  skimmed  and  butter- 
milk, and  lemonade. 

Potassium  citrate,  uva  ursi,  pichi,  buchu,  and  pareira  brava  are  some- 
times selected  for  their  soothing  properties.  But,  practically,  none 
of  the  remedies  named  nor  any  other  drug  is  of  any  avail  when  suppu- 
ration is  once  established.  Irrigation  by  means  of  Kelly's  ureteral 
catheter  may  be  practised  with  good  results  in  females.  Hypodermo- 
clysis  of  normal  salt-solution  may  be  of  sustaining  value  at  critical 
times  in  infectious  pyelonephritis.  In  chronic  pyelitis  salol  and  the  oils 
of  turpentine,  sandalwood,  juniper,  copaiba,  urotropin,  methylene  blue, 
and  erigeron  have  been  used  for  their  stimulating  and  alterative  effects 
upon  the  mucous  membrane.  Surgical  intervention  is  necessary  in  severe 
purulent  pyelitis,  pyelonephritis,  and  pyonephrosis. 


HYDRONEPHROSIS. 


Definition. — An  obstructive  accumulation  of  urinary  fluid  in  the 
pelvis  and  calyces  of  the  kidney ;  it  may  cause  dilatation,  pyelitis,  or 
inflammation  and  atrophy  of  the  renal  structure. 

Pathology. — Hydronephrosis  is  usually  unilateral.  The  pathologic 
changes  consist  of  a  dilation  of  the  pelvis  of  the  kidney,  associated 
with  a  degree  of  atrophy  of  the  renal  tissue  depending  upon  the  degree 
and  persistence  of  the  pressure.  The  accumulated  fluid  causes  flatten- 
ing and  atrophy  of  the  papillae,  and  gradually  of  the  tubules  and  glom- 
eruli, as  the  dilatation  and  distention  increase,  until  in  extreme  cases 


1044  DISEASES  OF  THE    URiyARY  SYSTEM. 

remnants  only  of  the  renal  structure  remain  in  the  walls  of  the  hydro- 
nephrotic  cyst.  The  mucous  membrane  lining  the  })elvis  and  calyces 
first  becomes  thinned,  and  later  thickened,  by  the  growth  of  connective 
tissue,  thus  forming  the  dense  sac-wall.  There  is  also  a  growth  of  con- 
nective tissue  in  the  renal  parenchyma,  medullary  and  cortical,  a  chronic 
nephritis  with  degeneration  and  atrophy  of  the  renal  cells  being  set  up. 

A  nephrydrotic  cyst  may  be  very  large,  containing  as  much  as  several 
gallons  of  liquid.  Sometimes  in  medium-sized  sacs  the  external  appear- 
ance of  the  walls  may  be  lobulated  ;  the  interior,  however,  usually  shows 
only  partial  septa  projecting  from  the  wall  into  the  cavity  of  the  sac. 
According  to  the  seat  of  obstruction  one  or  both  ureters  may  also  be 
dilated.     If  one  kidney  is  affected,  its  fellow  is  often  hypertrophied. 

The  fluid  contained  in  the  sac  varies  in  composition,  but  usually  is  a 
clear,  thin,  yellowish,  watery  urine.  The  specific  gravity  is  low,  and 
the  reaction  is  often  slightly  alkaline.  Traces  of  albumin,  urea,  uric 
acid,  and  salts  are  found.  Turbidity  may  be  present,  owing  to  admix- 
ture with  pus,  blood,  or  epithelium,  but  only  in  instances  in  which  pre- 
vious inflammatory  conditions,  as  a  calculous  pyelitis,  or  subsequent 
complications  of  like  nature  have  existed. 

Htiology. — Hydronephrosis — or,  better,  nejjJirydrosis — is  in  most 
instances  secondarily  produced  by  diseases — congenital  or  acquired — 
that  cause  occlusion  of  the  ureter.  Probably  from  20  to  35  per  cent, 
of  cases  are  congenital  (Roberts).  In  these  cases  the  causal  condition 
is  one  of  stricture,  due  to  obstruction  caused  by  a  defective  development 
or  malformation  in  the  urinary  passage  of  one  or  both  sides,  usually  the 
latter.  Thus,  there  may  be  a  valve-like  formation  or  a  very  acute  in- 
sertion of  the  ureter  into  the  kidney.  The  dilation  has  occasionally 
become  so  great  in  the  fetus  as  to  cause  considerable  mechanical  diffi- 
culty during  labor. 

Among  adults,  women  are  more  often  subject  to  hydronephrosis  than 
men,  and  especially  women  who  have  borne  children.  The  condition 
may  be  bilateral,  as  from  a  stricture  low  down  and  due  to  gonorrheal 
urethritis,  but  more  often  it  is  unilateral.  The  causes  of  these  acquired 
cases  are  as  follows :  (1)  Impacted  calculi  in  the  ureter  or  renal  pelvis. 
(2)  Disease  of  the  ureteral  walls,  as  inflammatory  thickening  and  cica- 
tricial stenosis  from  ulcers.  (3)  Flexion  and  twisting  of  the  ureter,  as 
from  movable  kidney.  (4)  Pressure  upon  the  ureter  from  without,  as 
by  tumors  and  constricting  bands  (pelvic  adhesions).  The  gravid  and 
retrodisplaced  uterus,  uterine  and  ovarian  neoplasms,  enlarged  and  pro- 
lapsed spleen,  and  similar  conditions  causing  compression  or  traction 
and  obliteration  of  the  lumen  of  the  ureter,  are  found  in  this  class.  (5) 
Calculus  of  the  lower  portion  of  the  ureter.  (6)  Diseases  and  tumors  of 
the  bladder  that  involve  the  ureteral  orifices,  particularly  carcinoma  and 
papilloma,  or  that  cause  retention,  as  prostatic  enlargement.  (7)  Ure- 
thral stricture. 

Symptoms. — These  depend  somewhat  upon  the  cause  and  extent 
of  the  hydronephrosis.  Marked  bilateral  disease,  when  congenital,  may 
render  the  fetus  inviable.  The  unilateral  variety  may  be  overlooked 
for  years,  and  no  symptoms  may  point  to  the  trouble  until  a  tumor  can 
be  made  out  by  inspection  and  palpation,  or  until  the  ureter  of  the  re- 
maining kidney  may  become  obstructed  and  symptoms  of  uremia  super- 


HYDRONEPHROSIS.  1045 

vene.  The  latter  are  more  apt  to  come  on,  and  earlier  too,  in  double 
hydronephrosis. 

Locally.,  the  patient  may  complain  of  frequent  and  severe  pains  that 
shoot  about  the  affected  loin  and  downward  toward  the  thigh.  Sensa- 
tions of  weight  and  a  dragging  discomfort  are  common.  Anorexia, 
nausea  and  vom-iting,  eructations,  and  irregularity  of  bowel-action  are 
associated  sometimes.  In  large  hydronephrotic  cysts  a  continuous  dull, 
aching  pain  only  may  be  felt,  or,  as  is  not  infrequently  the  case,  the 
tumor  may  be  absolutely  painless.  Obstinate  constipation  may  result 
from  compression  of  the  colon,  or  in  moderate  enlargements  diarrhea 
may  occur  from  the  pressure-irritation. 

Usually  a  swelling  is  detected  in  the  renal  region.  It  gradually  in- 
creases in  size,  and  in  marked  enlargements  distinct  bulging  may  be 
visible  in  the  hypochondriac  and  lumbar  regions.  Palpation  reveals  a 
rounded,  firm,  yet  somewhat  elastic  and  sometimes  fluctuating  tumor. 
There  may  be  slight  tenderness.  Dulness  on  percussion  is  found  over 
the  mass,  except  where  the  colon  overlies  it,  when  tympany  is  elicited ; 
this  is  a  characteristic  sign  of  kidney  tumors.  Moderate  enlargements 
generally  do  not  descend  during  inspiration. 

The  intermittent  form  of  hydronephrosis  (Landau)  is  interesting  from 
the  variations  that  occur  in  the  size  of  the  tumors.  A  marked  diminu- 
tion is  coincident  with  a  more  or  less  sudden  increase  in  the  quantity  of 
urine  passed ;  and,  on  the  other  hand,  as  the  tumor  gradually  enlarges 
the  flow  of  urine  decreases.  These  cases  are  in  most  instances  due  to 
movable  kidney.  Colicky  pains  often  usher  in  the  periods  of  greatest 
distention  preceding  the  sudden  increase  in  the  flow  of  clear  urine. 
This  variety  of  the  affection  occurs  most  frequently  in  women  that  have 
borne  children.  The  general  symptoms  scarcely  amount  to  more  than 
a  certain  loss  of  flesh  incident  to  the  associated  worry  and  anxiety. 
The  filling  of  the  nephrydrotic  cyst,  the  distention,  and  the  pain  and 
discharge,  with  subsidence  of  the  tumor,  recur  with  variable  frequency. 
Violent  exercise  inflicting  a  sudden  jar  may  precipitate  the  attacks.  The 
tumor  may  continue  to  develop  in  size  for  several  days  after  the  pain  has 
disappeared.  The  latter  may  last  from  several  hours  to  a  day.  During 
the  intervals,  and  after  the  urine  has  increased  in  quantity,  gradually 
or  quickly,  the  patient  may  feel  tolerably  comfortable  for  weeks  or 
months.  For  obvious  reasons  the  tumor  is  rather  mobile  in  intermittent 
hydronephrosis. 

The  occurrence  of  chills,  fever  and  sweats,  nausea  and  vomiting, 
abdominal  distention,  and  rapid  pulse  usually  indicates  suppuration  and 
pyonephrosis.  The  urine  will  then  be  cloudy  and  reveal  pus,  following 
both  discharge  and  aspiration.  A  lowered  specific  gravity  and  the 
presence  of  albumin  will  be  noted  when  a  chronic  nephritis  has  been  set 
up.  The  functional  kidney  test  which  is  most  practical  is  that  by  the 
employment  of  indigocarmin.^  Increased  arterial  tension  and  symptoms 
of  acute  febrile  or  chronic  afebrile  uremia  may  be  added. 

Hydronephrosis  paraplegica  is  a  form  of  the  disease  in  which  para- 
plegia develops  as  a  complication. 

The  course  of  nephrydrosis  is  usually  chronic,  with  variations  and 
exacerbations  depending  upon  the  cause  of  the  aff"ection. 

Diagnosis. — This  is  obviously  very  difficult  in  cases  in  which  th« 
*  Therapeu/ic  GavJte,  February,  1911. 


1046  DISEASES  OF  THE   VRiyARY  SYSTEM. 

accumulation  of  liquid  is  small.  Characteristic  signs  are  the  gradual 
development  of  a  tumor  in  either  flank,  as  described  above,  with  dimi- 
nution in  the  urinary  flow,  followed  by  a  more  or  less  sudden  free  dis- 
charge and  the  subsidence  of  the  tumor,  with  recurrences  (as  in  the 
intermittent  variety).  When  these  do  not  occur  and  the  tumor  continu- 
ously enlarges,  aspiration  may  be  practised  to  determine  whether  the 
mass  is  solid  or  liquid  ;  the  nature  of  the  latter  may  also  thus  be  ascer- 
tained, whether  urinary  or  not.  Ureteral  catheterization  is  of  great 
value  as  a  diagnostic  criterion. 

Differential  Diagnosis. — The  nephrydrotic  sac  must  be  distinguished 
by  exclusion  from  an  ovarian  cyst,  cystic  kidney,  and  tumors  of  the  sphen^ 
liver,  and  gaU-hladder.  Very  large  cysts  may  be  mistaken  for  ascites. 
Assurance  of  the  presence  of  the  colon  over  the  tumor  is  diagnostic, 
and  a  chemical  examination  of  the  fluid  obtained  by  the  use  of  the  ex- 
ploring needle  will  suffice  in  most  cases.  It  should  be  remembered, 
however,  that  a  slight  amount  of  urea  is  sometimes  found  in  ovarian 
cystic  fluid.  The  presence  of  pus-cells  in  abundance  in  the  aspirated 
fluid,  with  symptoms  of  suppuration,  is  significant  of  pyonephrosis. 
Sefjreiiration  and  catheterization  of  the  ureters  may  elicit  decisive  evi- 
dence  during  the  existence  of  the  tumor. 

Prognosis. — This  is  generally  unfovorable,  though  in  unilateral 
hydronephrosis  evidences  of  compensation  on  the  part  of  the  unaff'ected 
kidney  should  render  the  case  guardedly  favorable,  particularly  if  the 
cause  be  a  movable  kidney.  The  bilateral  aff"ection  is  always  grave, 
owing  to  the  danger  of  uremia.  Infection  of  the  cyst  with  pus-organ- 
isms is  usually  a  fatal  complication.  Recovery  may  ensue  in  rare  in- 
stances in  which  a  spontaneous  discharge  of  the  li([uid  takes  place.  Rup- 
ture of  the  sac  is  unlikely. 

Treatment. — The  removal  of  the  cause  is  seldom  feasible.  Symp- 
tomatic treatment  only  is  required  in  mild  cases,  though  sometimes  gen- 
tle massage  over  the  sac,  properly  directed  and  cautiously  applied  (to 
avoid  rupture),  may  cause  a  reduction  in  the  size  of  the  tumor.  Most 
often  surgical  measures  only  are  of  use.  These  embrace  puncture  and 
aspiration,  incision  (nephrotomy)  and  drainage,  nephrorrhaphy,  ne- 
phrectomy, and  the  formation  of  a  renal  fistula.  These  procedures,  how- 
ever, are  undertaken  only  when  successive  reaccumulations  of  the  fluid 
follow  those  measures  first  mentioned. 


PERINEPHRIC    ABSCESS. 

[rerinephritis.) 

Definition. — Suppurative  inflammation  of  the  connective  tissue 
surrounding  the  kidney. 

Pathology. — The  suppuration  attacks  the  lax  adipose  tissue  or 
the  fatty  capsule  in  which  tiie  kidney  is  imbedded  and  the  adjacent 
retroperitoneal  tissue.  The  starting-point  of  suppuration  is  usually  be- 
hind the  kidney.  There  may  be  several  small  abscesses  at  first,  but 
more  often  a  single  lai'ge  abscess  is  found.  The  walls  may  be  soft  and 
shreddy,  or  in  more  chronic  cases  thickened  and  fibrous.  A  bulging 
externally  over  the  afl'ected  lumbar  region  is  not  infrequent,  particularly 


PERTNEPHRIC  A BSOESS.  3  047 

in  large  and  extensive  accumulations  of  pus.  The  latter  lias  a  tendency 
at  a  given  point  to  burrow  into  the  surrounding  tissues,  and  especially 
downward  toward  the  iliac  fossa,  pointing  in  the  groin  near  Poupart's 
ligament.  It  may  extend  backward  and  open  upon  the  skin-surface. 
Sometimes  the  pus  perforates  the  diaphragm  and  discharges  tlirongh  the 
pleural  cavity  and  lungs,  or  the  colon,  vagina,  bladder,  or  peritoneum 
may  be  perforated.  The  pus  is  occasionally  quite  offensive,  and  may 
be  ichorous  from  an  admixture  of  infiltrated  urine.  Perirenal  abscess 
due  to  calculous  pyonephrosis  may  contain  calculi  that  have  ulcerated 
through  pelvic  or  renal  walls.  Thickening  of  the  adjacent  peri- 
toneum is  often  found.  In  certain  cases  of  perinephritis,  which  usually 
gave  no  symptoms  during  life,  the  postmortem  examination  has  revealed 
fibrous  adhesions  and  a  firm  and  thickened  and  fatty  capsule,  stripped 
with  difficulty  from  the  true  capsule  of  the  kidney. 

Ktiology. — Perirenal  abscesses,  when  not  traumatic  in  origin,  de- 
velop most  frequently  as  a  result  of  purulent  pyelo-nephritis  or  pyo- 
nephrosis. Hence  they  are  usually  secondary.  Other  primary  condi- 
tions that  may  cause  perirenal  suppuration  are  the  following  :  extension 
of  inflammation  from  the  ureter  or  pelvis  of  the  kidney,  pelvic  abscess, 
appendiceal  or  hepatic  abscesses,  spinal  caries  (psoas  abscess),  and  em- 
pyema. Sometimes  tuberculous  processes  in  the  kidney  and  suppurating 
new  growths,  as  carcinoma  and  cysts  (including  the  echinococcus),  are 
complicated  by  perirenal  abscess.  More  rarely  such  severe  infectious 
diseases  as  typhus  fever,  small-pox,  and  pyemia  lead  to  purulent  peri- 
nephritis.    Finally,  there  are  cases  for  which  no  cause  is  discoverable. 

S3niiptoiiiS. — Subjectively,  there  is  noted  a  dull,  throhhing  pain 
over  the  aff"ected  region  that  is  increased  by  motion ;  sometimes,  when 
the  abscess  is  large  and  presses  on  the  large  nerve-trunks,  the  pains  may 
become  shooting  in  character  and  be  felt  in  the  leg  on  the  same  side. 
Numbness  may  also  be  felt.  Pain  and  tenderness  on  palpation  are  com- 
mon. The  patient  is  prostrated,  weak,  and  often  quite  emaciated,  and 
flexure  of  the  thigh  on  the  aff"ected  side  is  frequent.  The  characteristic 
fever  of  suppuration  is  present  in  the  deeply  remitting  or  intermitting 
type,  with  alternating  chills  and  debilitating  sweats.  Pus  is  found  in 
the  urine  only  when  the  kidney  is  involved.  Sooner  or  later  evidences 
of  a  tumor  are  seen ;  the  areas  can  be  palpated,  and  a  gradual  bulging 
in  the  lumbar  area,  increasing  slowly,  with  smoothness  and  glistening 
of  the  skin  and  pitting  (edema),  may  be  observed.  Fluctuation  is  fre- 
quently apparent  in  advanced  cases,  and  in  favorable  cases  signs  of 
"  pointing  "  appear. 

Diagnosis. — Should  the  abscess  tend  to  burrow  downward,  the 
condition  may  be  somewhat  obscure  on  account  of  the  absence  of  dis- 
tinct local  symptoms.  Indeed,  involvement  of  the  psoas  may  give  rise 
to  symptoms  of  coxitis,  as  pain  referred  to  the  knee-joint.  The  diag- 
nosis is  usually  easy,  and  when  in  doubt  as  to  whether  the  tumor  is  an 
abscess  or  an  hydronephrosis  or  solid  mass,  the  exploring  needle  should 
be  used. 

Differential  Diagnosis. — An  important  point  in  diff'erentiating  peri- 
nephric abscess  from  suppurative  pyelitis  or  pyelo-nephritis  alone  is 
the  fact  that  in  the  latter  the  quantity  of  urine  is  usually  diminished, 
whilst  in  the  former  there  is  less  apt  to  be  any  interference  with  the 


1048  DISEASES  OF  THE   UHINARY  SYSTEM. 

renal  secretion.  Again,  Avhilst  in  the  latter  the  urine  usually  contains 
blood  and  pus,  in  the  former  the  urine  is  free  from  blood,  though  not 
necessarily  from  pus,  and  casts  are  apt  to  be  absent  here. 

Prognosis. — This  is  guardedly  favorable  if  the  abscess  points  ex- 
ternallv  in  the  lumbar  area.  Of  course  rupture  into  the  peritoneal 
cavity,  bladder,  bowel,  and  groin  is  always  a  serious  occurrence. 

The  treatment  is  surgical,  consisting  in  free  incision  and  drainage. 


CYSTIC  KIDNEY. 

{Renal  Cyst.) 


Pathology. — Congenital  cystic  kidneys  are  in  reality  collections  of 
cysts,  varying  in  size  from  a  pea  to  a  marble,  and  separated  from  each 
other  by  septa  of  compressed  renal  or  fibrous  tissue.  Either  one,  or  fre- 
quently both,  kidneys  may  be  affected  with  what  is  sometimes  termed 
congenital  cystic  degeneration  of  the  kidneys.  There  is  considerable  en- 
largement of  the  organs,  and  during  intra-uterine  life  they  may  attain  an 
enormous  size.  In  mild  cases  the  affection  may  be  tolerated  for  some 
years  after  birth.  The  cystic  fluid  may  be  either  clear,  turbid,  reddish- 
yellow,  or  dark-brown  in  color,  acid  in  reaction,  and  holds  in  solution 
urinary  salts,  blood,  cholesterin.  and  sometimes  uric  acid  and  urea.  A 
single  layer  of  flattened  epithelial  cells  lines  the  cyst-walls.  The  cysts 
themselves  seem  to  be  dilatations  of  the  renal  tubules  and  of  Bowman's 
capsules,  due,  in  some  instances,  to  an  obliteration  of  the  tubules  of  the 
papillne  or  to  stenosis  of  some  portion  of  the  urinary  tract. 

The  cystic  kidneys  usually  met  with  in  adult  life  (acquired)  are  of 
several  varieties :  (1)  One  or  perhaps  a  few  cysts  may  be  present,  larger 
usually  than  those  in  the  congenital  cystic  kidney,  which  seem  to  cause 
no  interference  with  the  normal  renal  functions.  Sometimes  a  reddish- 
brown  colloid  material  is  contained  in  these  cysts. 

(2)  Small  and  often  quite  minute  cysts  frequently  accompany  the 
chronic  nephritic  kidney  that  is  small,  contracted,  and  cirrhotic.  These 
result  from  dilated  tubules  and  capsules  when  the  former  are  narrowed 
by  the  hyperplasia  of  fibrous  tissue. 

(3)  Cystic  kidneys  in  adults  may  have  the  pathologic  characteristics 
of  the  congenital  variety — a  mere  aggregation  of  cysts  containing  clear 
or  colored  serum  or  a  cloudy,  dark,  thick,  colloid  liquid.  This  condition 
is  sometimes  associated  with  similar  cystic  disease  of  the  liver  and  spleen. 
It  may  be  a  late  manifestation  of  mild  congenital  defects.  The  kidneys 
have  been  found  converted  into  cysts  in  cases  in  which  the  presence  of 
calculi  (uric  acid)  in  the  tubules  has  probably  started  the  cystic  degene- 
ration. 

(4)  Solitary  cystic  adenoma  rarely  occurs.  It  is  in  the  form  of  a 
globular  tumor  projecting  from  the  surface  (usually  the  anterior)  of  the 
kidney.  It  may  be  as  large  as  an  orange,  and  may  be  enclosed  in  a  dis- 
tinct capsule.  On  section  the  mass  is  found  to  be  composed  of  various- 
sized  cysts  separated  by  septa  of  fibrous  tissue  lined  with  cuboid  or 
columnar  epithelium.  The  remainder  of  the  kidney  appears  to  be  quite 
healthy. 


NEW  GROWTHS  OF  THE  KIDNEY.  1049 

Symptoms. — These  may  be  absent  in  adults  until  the  sudden  de- 
velopment of  uremia.  Ordinarily,  the  clinical  picture  is  similar  to  that 
of  chronic  interstitial  nephritis.  There  is  an  increase  in  the  (quantity 
of  urine,  which  is  of  low  specific  gravity  ;  the  normal  solids  are  dimin- 
ished in  quantity  :  and  aceto-soluble  albumin  may  be  present  (Clifford 
Mitchell).^  Slight  albuminuria  maybe  present,  (^)n  palpation  a  large, 
rounded,  and  sponge-lihe  mass  may  be  felt  in  either  hypochondrium  or  on 
both  sides.  Cardiac  hypertrophy  and  increased  arterial  tension,  as  in 
chronic  cirrhosis,  are  also  frequently  met  with  in  cystic  degeneration 
of  the  kidneys.  Parker^  reports  a  case  which  was  followed  by  exfolia- 
tive dermatitis.      Cystic  disease  of  the  liver  may  be  associated. 

The  diagnosis  can  onJy  be  made  upon  the  presence  of  the  above 
symptoms  and  the  discovery  of  the  clear  physical  signs  of  the  tumor.  It 
should  be  pointed  out  that  a  possible  complication  of  perinephric  abscess, 
due  to  rupture  of  one  or  more  of  the  cysts  (as  has  occurred — Osier), 
would  of  course  render  a  diagnosis  wellnigh  impossible. 

Prognosis. — Bilateral  cystic  disease  of  the  kidney  must  eventually 
prove  fatal,  due  to  uremia  or  cardiac  failure.  Solitary  cysts  give  a  tol- 
erably favorable  outlook  under  proper  surgical  interference. 

Treatment. — The  unilocular  cysts  just  referred  to  above  may  be 
removed,  capsule  and  all,  and  the  kidney  sutured.  Bilateral  disease 
cannot  be  operated  upon  for  obvious  reasons ;  unilateral  cystic  degen- 
eration may  be  treated  by  nephrectomy,  with  narrow  chances  of  success. 


NEW  GROWTHS  OF  THE  KIDNEY. 

The  most  common  tumors  of  the  kidney  are  those  belonging  to  the 
class  of  adenomata  (benign)  and  those  that  are  either  sarcomatous  or  car- 
cinomatous (malignant). 

Adenomata  may  be  congenital  or  acquired.  They  grow  in  the 
cortex  of  the  kidney  in  the  form  of  small  nodular  masses,  which  in  some 
cases  may  increase  to  a  considerable  size  before  any  symptoms  are  pro- 
duced. A  cystic  growth  may  be  combined  with  adenoma  {cystic  ade- 
noma), and  lymphadenoma  is  also  occasionally  seen  as  a  secondary 
growth.  Other  benign  tumors  that  may  aifect  the  kidney  are  angioma, 
fibroma,  and  lipoma.  Very  large  vascular  adenomata  may  become 
malignant.  Grawitz,  Lubarsch,  Kelly,  and  others  have  described  a 
variety  of  tumor  (Jiypernephromd)  derived  from  aberrant  adrenal  tissue 
misplaced  in  the  kidney. 

Symptoms. — The  important  points  in  the  diagnosis  of  hypernephroma 
are  hematuria  at  long  intervals,  pain  and  tumor,  the  latter  giving  rise  to 
pressure  symptoms.  JT-ray  plates  are  of  value  in  differentiating  the 
hematuria  of  stone  (Mofiitt). 

Sarcoma  and  carcinoma  may  be  either  primary  or  secondary. 
Sarcoma  is  frequently  congenital  in  origin,  and  may  have  an  admixture 
of  striped  muscular  tissue.  The  presence  of  the  latter  in  the  kidney 
points  to  developmental  disturbances  during  embryonic  life  as  the  cause 
of  a  variety  of  tumor  known  as  rhabdomyoma.  Alveolar  sarcoma  is 
also  met  with.     Renal  sarcoma  is  not  uncommon  in  children. 

Renal  carcinoma  is  probably  of  less  frequent  occurrence  than  sar- 

>  PhUa.  Med.  Jour.,  Aug.  19,  1899.  ^  Amer.  Jour.  Med.  Sci.,  Sept.,  1899. 


1050  DISEASES   OF  THE    UEIXARY  SYSTEM. 

coma  ;  it  niav,  however,  be  found  in  cliildren  as  well  as  in  a<ied  persons, 
the  two  extremes  of  life.  Carcinoma  of  the  kidney  is  usually  of  the  soft 
medullary  or  encephaloid  variety.  As  a  primary  aft'ection  it  probably 
originates  in  the  renal  tubules.  Secondary  carcinoma  of  the  kidney, 
although  probably  more  frequent  than  the  primary  form,  is  seldom  of 
clinical  importance.  Renal  carcinoma  may  occur  as  a  diffuse  infiltration 
or  in  noiliilar  masses,  one  kidney  usually  being  afl'ected  in  primary  carci- 
noma. The  tumor  sometimes  reaches  an  enormous  size,  and  instances  are 
recorded  in  which  nearly  the  whole  abdomen  has  been  filled,  and  in  which 
the  growth  weighed  as  much  as  ol  lbs.  (14  kgms.,  Roberts).  Rhabdomy- 
omata  do  not,  as  a  rule,  attain  a  very  large  size,  though  sarcomata  may 
grow  quite  large.  Softening  and  hemorrhage  within  these  malignant 
growths  may  occur.  The  pelvis  of  the  kidney  may  be  invaded,  and 
metastatic  areas  may  form  in  the  liver  or  the  lungs,  though  this  occurs 
in  the  case  of  primary  renal  carcinoma  less  readily  than  from  carcinoma 
in  other  organs.  The  renal  parenchyma  is  either  partially  or  wholly 
destroyed,  the  pyramids  being  attacked  later  than  the  cortex. 

Symptoms. — Lumbar  pain  on  the  aftected  side  is  often  an  early 
symptom,  and  may  persist  throughout  the  course  of  the  disease.  It 
may  be  paroxysmal,  and  be  felt  extending  down  the  thigh,  or  it  may  be 
dull,  dragfjinff,  and  limited  in  character.  Pain  is  not,  however,  a  con- 
stant  symptom  in  a  certain  proportion  of  the  cases. 

Hematuria  may  occur  earh"  or  late,  and  often  appears  before  any 
tumor  is  palpable.  The  blood  may  be  in  a  fluid  state  or  in  clots,  the 
latter  not  seldom  taking  the  form  of  pelvic  or  urethral  casts,  the  passage 
of  which  may  give  rise  to  colicky  pains.  Casts  of  the  ureter  sometimes 
resemble  lumbricoid  worms.  The  hemorrhage  may  be  excessive  and 
cause  marked  weakness  and  a  symptomatic  anemia,  superadded  to  the 
cancerous  anemia  that  is  usually  present ;  on  the  other  hand,  it  may  be 
so  slight  as  to  be  discoverable  only  microscopically.  It  recurs  at  irreg- 
ular intervals  of  days  or  weeks.  Large  clots  may  accumulate  in  the 
bladder  and  cause  vesical  irritability.  The  urine  from  the  healthy  kid- 
ney may  be  quite  normal,  and  may  be  secured  for  observation  by  ureteral 
catheterization.  Anorexia,  nausea  and  vomiting,  progressive  loss  of  flesh 
and  strength,  increasing  pallor,  and  the  concomitant  symptoms  of  the 
cancerous  cachexia  are  seen  to  develop. 

Physical  Signs. — These  may  not  be  sufficient  to  reveal  the  presence 
of  the  tumor  for  some  time  after  the  above  symptoms  have  been  observed. 
The  appearance  of  a  palpable  tumor  in  either  flank  is  a  definite  aid  to 
diagnosis.  It  is  felt  between  the  ribs  and  pelvis  latero-anteriorly,  and 
at  first,  when  small  and  on  the  right  side,  it  may  be  movable.  Both 
sarcoma  and  carcinoma  of  the  kidney  may  assume  enormous  sizes.  The 
tumor  feels  dense  and  hard  (except  rapidly-growing  tumors,  as  encepha- 
loid), either  smooth  or  lobulated,  and.  when  not  too  large,  may  retain 
the  natural  position  and  form  of  the  kidney.  The  growth  extends 
downward  and  inward,  and  in  the  very  large  malignant  renal  tumors  of 
childhood  the  abdomen  shows  considerable  enlargement,  along  with  an 
abnormal  pulsation  and  a  prominence  of  the  veins.  Usually  the  tumor 
does  not  move  with  respiration.  Percussion  gives  dulness  over  the  mass, 
although  in  small  and  moderately  large  tumors  the  overlying  colon  may 
cause  a  tympanitic  note  to  be  heard. 


CYSTITIS. 


1051 


Diagnosis. — The  presence  of  a  tumor,  when  not  too  hirge  and  dis- 
tinctly occupying  the  lumbar  and  h)Wor  latcrel  ahdominal  region,  to- 
gether with  hematuria,  \y.i\n  of  a  local  nature,  and  progresnive  failure  of 
nutrition,  may  be  looked  upon  as  diagnostic  of  a  malignant  type  of 
renal  tumor.  The  relation  of  the  colon  to  the  tumor  and  immovability 
of  the  latter  during  respiration  are  also  diagnostic. 

Differential  Diagnosis. — This  is  a  very  difficult  subject.  Affec- 
tions such  as  hydronephrosis,  paranephritic  cyst,'  pyonephrosis,  cys- 
tic kidney,  hydatids,  ovarian,  splenic,  and  hepatic  tumors  and  (par- 
ticularly in  children)  retroperitoneal  sarcoma  must  bo  differentiated 
from  renal  growths.  Careful  bimanual  palpation  will  aid  in  the  diagno- 
sis, but  the  exclusion  of  other  lumbar  enlargements  must  be  made  by 
close  attention  to  the  history  and  to  the  development  and  course  of  the 
symptoms.  Hematuria  alone,  in  aged  persons,  is  suggestive  of  carcinoma 
when  no  tangible  cause  for  the  presence  of  the  blood  is  at  hand.  Hepatic 
and  splenic  tumors  are  usually  movable  during  deep  breathing,  whilst 
renal  tumors  are  not  so.  In  cases  of  hepatic  growths  also  the  area  of 
dulness  extends  higher,  whilst  in  renal  growths  on  the  right  side  a  tym- 
panitic area  generally  lies  between  the  liver  and  the  tumor.  The  cha- 
racteristic notch  and  edge  of  the  spleen,  and  the  absence  of  the  overlying 
colon-tympany,  are  points  that  distinguish  splenic  enlargements  from 
those  of  the  left  kidney.  Pelvic  growths  (ovarian  and  uterine)  enlarge 
from  below  upward,  and  are  readily  detected  by  vaginal  examination. 
In  children  Lobstein's  cancer  (retroperitoneal  sarcoma),  if  very  large,  is 
easily  mistaken  for  a  renal  tumor,  except  that  it  is  usually  more  cen- 
trally situated  and  more  firmly  fixed. 

Prognosis  and  Treatment. — The  termination  in  cases  of  renal  carci- 
noma is  inevitably  fatal,  and  children  succumb  more  quickly  than  adults. 
The  disease  may  last  from  a  few  months  to  sometimes  a  year  or  tAvo. 

If  the  kidney  be  removed  while  the  growth  is  still  small,  the  prog- 
nosis is  fairly  good ;  but  if  large  or  if  metastatic  tumors  have  formed, 
the  prognosis  is  always  bad.  Bloch  warmly  advocates  in  some  cases  the 
removal  of  small  sections  of  kidney-substance,  to  avert  the  necessity  of 
a  nephrectomy  by  proving  the  non-malignancy  of  the  growth.  The  treat- 
ment, aside  from  early  surgical  measures,  is  entirely  symptomatic  and 
supportive,  and  obviously  it  is  unsuccessful.  Renal  colic,  excessive 
hematuria,  and  a  gradually  lowered  vitality  may  be  met  by  the  use  of 
palliatives,  tonics,  and  by  nutritious  and  easily  digestible  diet.  Nueleirt 
may  be  tried  hypodermically  or  by  the  mouth. 


II.   DISEASES  OF  THE  BLADDER. 
CYSTITIS. 

Definition. — Inflammation  of  the  mucous  membrane  of  the  bladder. 
It  may  be  either  acute  or  chronic,  the  latter  being  clinically  the  much 
more  frequent  condition. 

^  Jour.  Amer.  Med.  Assoc,  June  27,  1903,  p.  1775. 


1052  DISEASES   OF  THE    UEINARY  SYSTEM. 

ACUTE    CYSTITIS.. 

Pathologfy. — Cystoscopic  examination  performed  according  to  Paw- 
lik's  or  Kellys  method,  hereafter  to  be  described,  reveals  an  intensely 
hyperemic  condition  of  the  vesical  mucosa,  Avhich  is  puft'y,  edematous, 
and  of  a  bright-red  color ;  this  may  be  more  intense  at  points,  especi- 
ally in  the  vicinity  of  the  trigone.  The  membrane  is  bathed  in  a  thick, 
tenacious  muco-pus,  and  here  and  there  may  be  noted  denuded  areas,  and 
the  exfoliated  epithelium  often  hanging  in  shreds  from  the  bladder-wall. 
Hemorrhagic  effusions  may  be  observed.  In  the  severer  iirades  of  the 
disease  the  intense  general  hyperemia  causes  a  disappearance  of  the  blood- 
vessels that  are  to  be  seen  in  the  normal  condition.  Occasioiuilly  small 
patches  of  ulceration,  due  to  abscess  formation  {phlegmonon*  ci/stitis), 
may  be  observed,  and  in  rare  and  fatal  instances  the  entire  bladder-wall 
is  involved  in  a  necrotic  process. 
^y  Ktiology. — ^Cases  of  acute  cystitis  may  be  grouped  according  to 
their  origin   into  four  main  classes,  as  follows  : 

(1)  Catarrhal. — Like  other  mucosa,  the  vesical  epithelium  is  very  re- 
sponsive to  systemic  circulatory  disturbances.  Thus,  sudden  exposure 
to  extremes  of  cold  or  heat  or  violent  atmospheric  changes,  thereby 
abruptly  suppressing  the  action  of  the  skin,  may  be  potent  influences  in 
tiie  etiology  of  the  disease.  An  intense  acute  catarrhal  inflammation 
may  follow  retention  of  the  urine  in  the  bladder,  with  or  without  its 
subsequent  decomposition  ;  it  may  also  be  the  result  of  pressure  from 
an  enlarged  prostate  or  other  tumor,  and  may  follow  cystocele,  urethral 
stricture,  or  paresis  of  the  bladder-wall.  In  overdistention  of  the  bladder, 
with  the  accumulation  of  a  gallon  (4  liters)  or  more  of  urine,  the  so-called 
acute  exfoliative  cystitis  may  result,  in  Avhich  the  entire  mucous  membrane 
of  the  bladder  may  be  shed,  and  the  symptoms  of  grave  uremic  intoxica- 
tion supervene.  The  prolonged  retention  of  urine  is  followed  by  decom- 
position of  the  fluid,  and  this,  by  its  irritant  action,  always  excites  a  cys- 
titis that  soon  assumes  the  chronic  type.    ^ ^ 

(2)  Septic. — This  may  result  either  from  the  direct  introduction  of 
pus-producing  germs  into  the  bladder  or  from  the  systemic  transmission 
of  these  micro-organisms  to  the  organ.  This  is  known  as  the  bac- 
terial origin  of  cystitis.  Under  the  first  class  may  be  mentioned  the 
passage  of  an  unclean  catheter  or  sound ;  this  is  a  cause  of  cystitis  in 
puerperal  women,  and  in  men  Avho  are  the  subjects  of  minor  grades  of 
urethral  stricture,  and  who  have  been  subjected  to  gradual  dilatation  by 
means  of  bougies.  Gonorrheal  cystitis  is  also  to  be  included  under  this 
heading.  There  is  a  condition  known  as  febrile  cystitis,  which  consti- 
tutes the  second  class  of  septic  cases.  This  comprises  the  vesical  in- 
flammation that  is  present  in  the  various  febrile  conditions,  and  which 
is  probably  a  direct  result  of  the  presence  in  the  urine  of  the  causal 
bacilli  or  their  toxins  (Fitz).  Thus,  in  all  of  the  infectious  diseases 
and  fevers  (typhoid  and  the  other  exanthemata,  rheumatism,  diphtheria, 
tuberculosis)  there  is  noted  a  cystitis  of  varying  degrees  of  severity 
that  can  be  accounted  for  onl}^  by  the  local  irritant  action  of  the  spe- 
cific germ  of  the  associated  disease,  or  its  eliminating  toxins.  1'he  so- 
called  (jouty  cystitis,  which  occurs  in  lithemic  individuals,  and  which  is 
due  to  the  irritating,  concentrated  urine,  may  also  be  here  included. 

i^^i)  Toxic. — Certain  drugs  when  introduced  into  the  system  manifest 


ACUTE  CYSTITIS.  lOo.'i 

an  irritant  action  upon  the  vesical  mucosa,  and  promptly  excite  a  severe 
grade  of  acute  cystitis.  Proniinont  amon^  these  may  he  mentioned 
cantharides  and  other  irritants  of  the  urinary  tract — cuh(;})H,  copaiha, 
and  sinapis.  Workers  in  coal-tar  dye-stuffs  are  sometimes  affected  with 
acute  cystitis. 

(4)  Traumatic. — Traumatic  inflammation  of  the  bladder  folhjws  the 
improper  and  careless  use  of  the  catheter,  sound,  or  other  instrument ; 
the  presence  in  the  bladder  of  calculi  or  other  foreif^n  bodies  ;  and  the 
pressure  of  the  fetus  in  parturition,  or  of  large  masses  of  impacted 
feces. 

(5)  From  Adjacent  Inflammation. — Irritation  with  consecutive  inflamma- 
tion may  result  from  the  extension  of  an  inflammatory  process  from  sur- 
rounding structures  either  by  continuity  or  contiguity  of  tissue.  Thus, 
a  cystitis  may  follow  a  urethritis — gonorrheal  or  otherwise  ;  it  may  re- 
sult from  an  extension  downward  of  a  ureteritis,  or  it  may  be  conse- 
quent upon  a  vaginitis,  a  malignant  neoplasm  of  an  adjacent  viscus,  a 
salpingitis,  pelvic  peritonitis,  or  pelvic  abscess  in  the  immediate  vicinity 
of  the  bladder,  as  in  the  vesico-uterine  pouch. 

Symptoms. — The  symptoms  of  acute  cystitis  are  very  marked. 
Pain.,  vesical  nr^itahility.,  vesical  and  rectal  tenesmus,  frequency  of  mic- 
turition, fever,  and  urinary  changes  are  all  pronounced.  Prominent 
among  these  is  pain,  which  may  be  most  intense  and  is  the  earliest  and 
most  persistent  manifestation  of  the  disease.  Its  seat  is  the  suprapubic 
region,  whence  it  may  radiate  to  the  sacral  region,  the  perineum,  the 
end  of  the  penis,  or  the  upper  portion  of  the  thighs  ;  it  is  most  con- 
stant, but  is  worst  just  before  micturition,  by  which  it  may  be  alleviated. 
It  is  considerably  relieved  by  the  recumbent  posture,  and  is  aggravated 
by  pressure  over  the  bladder. 

With  the  pain,  and  probably  ranking  second  in  severity,  is  the  rectal 
and  vesical  tenesmus,  or  strangury.  There  is  an  almost  constant  desire  to 
urinate.  The  urine  may  be  opaque  or  highly  colored.  It  is  often  bloody 
(in  very  acute  cases  the  vesical  contents  may  consist  of  a  small  quantity 
of  pure  blood  only),  is  of  a  specific  gravity  varying  from  1005  to  1030 
(in  the  febrile  cases),  and  contains  pus-corpuscles,  mucous  flakes,  shreds 
of  disintegrated  and  exfoliated  epithelium  (bladder),  and  micro-organ- 
isms. Thomas  R.  Brown, ^  in  a  bacteriological  study  of  26  cases,  found 
the  exciting  causes  as  follows :  bacillus  coli  communis,  57.7  per  cent. ; 
staphylococcus  pyogenes  albus,  19.2  per  cent.  ;  staphylococcus  pyogenes 
aureus,  7.7  per  cent. ;  and  B.  pyocyaneus,  B.  typhosus,  and  B.  proteus  vul- 
garis (Haiser),  each  3.8  per  cent. 

Gonorrheal  infection  may  invade  the  vesicle  mucosae  when  mixed  or 
pure  cultures  of  this  organism  are  recoverable  from  the  urine ;  fungous 
mycelial  threads  and  yeast-cells  have  even  been  found  in  certain  cases 
{mycotic  cystitis).  The  urine  is  commonly  acid  in  reaction,  though 
Brown  found  it  alkaline  where  the  excitant  was  the  B.  proteus  vulgaris. 
It  may  become  less  acid  or  alkaline  should  the  condition  become  modified. 
More  or  less  albumin  will  be  noted,  and  on  standing  a  dense  sediment 
forms  in  the  bottom  of  the  flask,  which  is  composed  of  all  the  foregoing 
substances,  as  shown  by  chemical  and  microscopic  examination.  The 
total  quantity  of  urine  voided  in  the  twenty-four  hours  may  be  normal 

*  Johns  Hopkins  Hospital  Btdleiin,  January,  1901,  p.  4. 


1054  DISEASES  OF  THE    URINARY  SYSTEM. 

in  amount  or  even  slightly  in  excess  of  the  normal.  On  the  other  hand, 
if  exfoliation  of  the  mucous  membrane  takes  place,  there  may  occur  par- 
tial or  even  total  suppression  of  the  urine. 

Fever,  with  or  without  an  initial  rigor,  persists  throughout  the  attack, 
but  is  not  of  a  severe  type,  save  in  the  septic  and  malignant  (diphthe- 
ritic) forms  of  the  disease,  when  it  may  reach  103°-105°  F.  (39.4*^- 
40.5°  C). 

Abscesses  may  form,  and  betray  themselves  by  localized  pain,  tender- 
ness, and,  in  some  cases,  by  a  circumscribed  induration  requiring  surgical 
treatment. 

In  the  variety  associated  with  extreme  exfoliation  of  the  vesical 
mucosa  grave  uremic  tnanifcstations  follow.  These  include  all  the 
features  of  the  typhoid  state  (dry.  brown  tongue,  mild  delirium,  ner- 
vous and  muscular  twitching ;  headache ;  gastric  disturbances ;  and 
coma).      There   is   also   some   degree   of   malaise   and   anorexia. 

It  must  not  be  forgotten  that  acute  cystitis  may  represent  an  acute 
exacerbation  in  the  chronic  form,  and  at  times  may  assume  a  severe 
type  of  the  disease. 

Diagnosis. — Cystitis  should  be  readily  recognized  from  the  history 
of  the  case  and  the  frequency  of  the  two  almost  pathognomonic  symp- 
toms— suprapubic  pain  and  vesical  tenesmus.  An  examination  of  the 
urine  will  reveal  the  characteristic  clinical  features.  The  percentage  of 
albumin  is  usually  much  larger  in  nephritis  than  in  irritability  of  the 
bladder.  The  differentiation  between  cystitis  and  vesical  irritability  will 
be  noted  under  the  latter  condition.  Urethritis  may  be  excluded  by 
means  of  the  two-glass  test.  For  example,  if  urination  into  two  glasses 
reveals  pus  in  both,  after  carefully  Avashing  out  the  urethra  as  far  as  the 
compressor  urethme  muscle,  it  is  "very  positive  proof  that  cystitis  or 
some  inflammation  further  up  the  canal  is  present  "  (Greene  and  Brooks). 

The  prognosis  of  the  milder  grades  of  cystitis  is  good :  the  septic 
and  malignant  cases  offer  a  much  graver  outlook.  Extension  of  the. 
process  upward  tov.ard  the  kidneys  is  always  serious. 

Treatment. — The  treatment  of  acute  cystitis  includes  prophylactic, 
hygienic,  and  medicinal  measures. 

Prophylactic. — Most  important  is  the  prevention  of  the  disease,  and 
this  includes,  in  addition  to  the  usual  care  of  the  body,  the  observance 
of  thorough   asepsis. 

Hygienic. — The  cause  of  the  disease,  if  evident  (calculus,  externa] 
pressure),  should  be  sought  and  removed.  The  patient  should  at  once 
be  placed  absolutely  at  rest  in  the  recumbent  posture.  The  diet  must  be 
regulated,  and  all  irritating,  highly  seasoned  articles  of  food  must  be  in- 
terdicted. Alcohol  in  any  form  is  prohibited.  An  absolute  milk  diet 
will  be  most  beneficial.  The  patient  should  be  instructed  to  drink  freely 
of  water  and  other  diluent  drinks.  The  free  action  of  the  skin  may  be 
secured  by  friction  and  warm  bathing. 
C>\^  Medicinal. — The  drugs  to  be  employed  are  the  saline  laxatives  and  the 
various  mild  diuretics  and  urinary  alterants. LA_The  reaction  of  the  urine 
will  indicate  the  variety  of  alterant  to  be  employed.  If  it  be  acid, 
alkaline  waters  are  serviceable,  as  the  soda-preparations.  Vichy,  or  the 
potassium  salts.  In  alkaline  conditions  of  the  urine  probably  the  most 
valuable  drugs  are  benzoic  and  boracic  acid  and  salol.     Benzoic  acid  is 


CHBONIC  CYSTITIS.  ]05."; 

best  administered  in  the  form  of  ammonium  benzoate,  which  may  bo 
given  in  10-grain  (0.G48)  doses  thrice  daily  in  the  compound  infusion 
of  buchu,  or  in  uva  ursi.  Hot  applic:i,tions  and  liot  local  bathing  (sitz- 
baths)  will  do  much  to  relieve  the  pain  and  tenesmus;  if  these  be  severe, 
a  rectal  suppository  of  opium  and  belladonna  or  an  enema  of  chloral 
hydrate  will  generally  give  prompt  relief.  Tincture  of  cannabis  indica, 
administered  internally,  may  answer  if  opium  be  contraindicated.  Under 
such  a  course  as  the  preceding  a  cure  may  be  expected  within  eight  or 
ten  days.  It  is  prudent  to  advise  the  patients  to  wear  flannel  or  silk 
binders  over  the  abdomen,  to  avoid  chilling  of  the  surface  and  subse- 
quent acute  attacks. 

CHRONIC    CYSTITIS. 

Pathology. — The  vesical  mucosa  is  not  so  hyperemic  as  in  the 
acute  variety,  but  is  of  a  peculiar  muddy  or  grayish-blue  (slate)  color, 
dotted  here  and  there  with  patches  of  erosion  or  of  actual  ulceration. 
Slight  hemorrhages  may  and  do  occur.  Owing  to  the  slow  course  of  the 
disease  there  follows  an  immense  thickening  of  the  bladder-wall  from 
hyperplasia,  conjoined  with  more  or  less  edema,  of  the  tissues.  The 
result  is  a  contraction  of  the  wall  with  a  proportionate  diminution  in  the 
vesical  capacity.  The  mucosa  may  become  polypoid  in  spots,  and  there 
rarely  follows  obstruction  of  the  ureteral  orifices,  with  consequent  dilata- 
tion of  the  ureters  and  renal  pelves  from  a  damming  back  of  the  secre- 
tion. In  the  majority  of  cases,  however,  the  changes  will  be  found  on 
cystoscopic  examination  to  be  limited  to  the  lower  portion  of  the  bladder. 
The  urinary  changes  are  about  as  in  the  acute  form,  save  that  the  reaction 
is  alkaline  and  the  amount  of  mucus  and  pus  is  proportionately  greater. 

Ktiology. — Chronic  inflammation  of  the  bladder  may  be  the  result 
of  a  neglected  or  oft-repeated  acute  attack.  It  may  occur  from  the  per- 
sistent action  of  an  exciting  cause,  as  the  presence  of  some  irritating 
substance  (calculus)  in  the  bladder,  or  of  some  excitant  external  to  that 
viscus,  as  a  localized  inflammation  or  a  displaced  uterus.  The  tubercu- 
lous variety  and  that  due  to  neoplasmata  are  insidious  in  development. 

The  symptoms  and  diag:nosiS  differ  but  slightly  from  those  of 
acute  cystitis,  although  the  pain  and  tenesmus  are  less  intense.  Oppo- 
sitely, the  am,ou7it  of  albumin  in  the  urine  is  comparatively  large.  The 
same  remark  applies  to  the  quantity  of  mucus  and  pus  (vide  Pathology) ; 
indeed,  the  last-named  ingredient  often  forms  a  thick  gelatinous  mass  in 
the  standing  urine  that  tends  to  adhere  to  the  receptacle.  According  to 
Brown's  researches  bacterial  flora  contribute  liberally  toward  chronic  cys- 
titis :  B.  coli  communis  was  present  in  the  urine  in  55.2  per  cent.  (50  per 
cent,  in  pure  culture,  and  once  combined  with  B.  tuberculosis) :  staphy- 
lococcus pyogenes  aureus,  10.3  per  cent. ;  staphylococcus  albus,  6.9  per 
cent.;  B.  proteus  vulgaris,  3.4  per  cent.  The  reaction  of  the  urine  is 
often  neutral  or  alkaline  where  infection  is  due  to  the  three  last-named 
organisms.  An  alkaline  reaction  exists  in  80  to  90  per  cent,  of  cases. 
The  cystoscope  is  an  invaluable  aid  to  the  recognition  of  chronic  cystitis. 
Chronic  cystitis  is  accompanied  by  debility  and  emaciation,  Avhich,  how- 
ever, are  of  slow  development. 

The  prognosis  is  always  serious,  and  the  course  of  the  disease  is  at 
the  best  protracted. 


1056  DISEASES  OF  THE   UEiyARY  SYSTEM. 

Treatment. — \cy\  generally,  the  treatment  set  down  for  the  acute 
disease  will  not  answer  in  the  ehronie  form.  Undoubtedly,  there  will 
follow  more  or  less  amelioration  of  the  symptoms,  but  the  tendency  is 
toward  a  prolonged  chronicity.  In  such  cases,  after  the  removal  of  the 
ascertainable  causes  so  far  as  practicable,  we  are  compelled  to  resort  to 
local  treatment  of  the  bladder.  This  includes — (1)  Vesical  irrigation; 
(2)  Topical  applications ;  (3)  Permanent  drainage  of  the  bladder. 

Vesical  irrigation  is  secured  by  means  of  an  aseptic  soft-rubber 
catheter  which  is  connected  with  a  graduated  glass  funnel :  a  siphonage 
is  produced  by  the  alternate  elevation  and  depression  of  the  funnel, 
which  contains  the  irrigating  fluid.  The  latter  may  consist  of  plain 
sterilized  (boiled)  water,  sterile  normal  salt-solution  (40-60  gr.  to  the 
pint — 2.59—4.0  per  ^  liter),  or  a  weak  solution  of  mercuric  chlorid  (1  : 
50,000-100,000).  The  irrigation  should  be  done  slowly,  and  not  more 
than  twice  or  thrice  daily  in  severe  cases,  and  much  less  frequently  in 
ordinary  cases,  according  to  the  exigencies  of  the  condition. 

Vesical  medication  may  be  secured  by  means  of  the  funnel  after  irri- 
gation, the  medicating  substances  being  dissolved  in  a  pint  of  water  and 
allowed  to  flow  slowly  in  and  out  of  the  bladder.  The  drugs  that  may 
be  used  in  this  manner  are  silver  nitrate  or  zinc  sulphate  (1-5  gr.  to  the 
ounce — 0.0648-0.324  to  32.0)  or  a  saturated  solution  of  boric  acid.  If 
the  salts  of  zinc  or  silver  are  used,  not  more  than  an  ounce  of  the  solu- 
tion should  be  allowed  to  enter  the  bladder,  and  much  less  than  this 
amount  will  generally  suffice.  In  cases  in  which  there  exist  patches  of 
ulceration  the  application  must  be  made  directly  to  these  areas  through 
the  endoscope  or  cystoscope.  Stronger  solutions  may  now  be  employed, 
as  silver  nitrate,  20-30  gr.  (1.29-1.94)  to  the  ounce.  This  application 
should  be  followed  by  a  slight  irrigation  of  the  bladder. 

When  this  local  medication  fails  to  eff"ect  a  cure,  permanent  drainage 
of  the  bladder  must  be  secured — in  the  male  by  a  suprapubic  or  perineal 
incision,  and  in  the  female  by  the  establishment  of  a  vesico-vaginal  fis- 
tula. This  places  the  bladder  absolutely  at  rest,  and  gives  the  inflamed 
mucosa  a  chance  to  heal  under  proper  medication. 
^  As  to  internal  remedies,  various  agents  that  possess  a  local  stimulating 
effect  upon  the  genito-urinary  tract  are  advised  by  most  authors,  but  I 
think  little  is  to  be  gained  from  their  employment  as  compared  with  the 
results  achievable  from  topical  treatment.  Most  efficacious  among  inter- 
nal remedies  are — oil  of  sandalwood,  terebene,  urotropin,  pichi,  buchu 
(fluid  extract),  and  the  oil  of  copaiba.  If  disinfection  of  the  bladder  in 
loco  is  not  practicable,  antiseptics  should  be  given  internally,  combined 
with  those  stated  above.  Salol  and  potassium  chlorate  are  excellent  for 
this  purpose.    G^^ 


NEOPLASMS  OF  THE  BLADDER. 

Primary  new-growths  of  the  bladder  are  exceedingly  rare,  occur- 
ring, however,  with  greater  frequency  in  males  in  about  the  proportion 
of  3  to  1 ;  they  may  be  either  benign  or  malignant.  On  the  other  hand, 
secondary  neoplasmata,  particularly  carcinomata,  are  relatively  common. 


VESICAL  HEMORRHAGE.  1057 

The  most  frequent  variety  of  new-growth  encountered  is  carcinoma,  par- 
ticularly the  so-called  villous  or  papillomatous  carcinoma,  Williams'  find- 
ing in  20  women  aflected  with  bladder-tumor,  carcinoma  in  IG.  Other 
growths  are  sarcomatous,  fibroraatous,  cystic,  and  papillomatous  in 
nature. 

The  symptoms  are  the  same  for  all  varieties,  and  include,  first  and 
most  commonly,  hemorrhage  (which  is  both  persistent  and  free),  together 
with  pain,  frequency  of  micturition,  and  occasionally  the  discharge  of 
detached  fragments  of  the  growth.  In  carcinomatous  cases  of  advanced 
standing  cachexia  will  be  marked.  By  means  of  the  cystoscope  the  nature 
of  the  complaint  is  disclosed.  In  the  case  of  secondary  growths  the 
primary  tumor  may  often  be  detected. 

The  prognosis,  of  course,  will  depend  upon  the  nature  of  the 
growth. 

The  treatment  is  purely  surgical. 


VESICAL  HEMORRHAGE. 

{Vesical  Hemorrhoids.) 

Hemorrhage  of  the  bladder  has  been  mentioned  as  a  symptom  of 
various  affections,  both  general  and  local,  among  the  former  being  leu- 
kemia and  malarial  hematuria,  and  among  the  latter  nephrolithiasis  and 
tuberculosis  and  carcinoma  of  the  bladder.  It  is  also  a  prominent  mani- 
festation in  stone  in  the  bladder,  and  not  infrequently  appears  in  preg- 
nancy (late).  Independently  of  the  operation  of  all  of  the  above-men- 
tioned etiologic  factors,  hemorrhage  has  been  known  to  occur  from  the 
bladder,  and  recent  precise  methods  of  exploring  the  viscus  (endoscopic 
examination)  have  shown  it  to  be  due  to  a  hemorrhoidal  state  of  the  ves- 
sels. The  hemorrhage  may  be  profuse,  and,  rarely,  even  fatal  in  its 
effects. 

The  diagnosis  is  based  in  part  upon  the  absence  of  the  more  obvi- 
ous causes  of  hematuria  and  the  presence  of  free  bleedings,  but  chiefly 
upon  the  result  of  a  careful  cystoscopic  exploration  of  the  bladder. 

The  prognosis^  so  far  as  my  experience  extends,  is  eminently  favor- 
able, though  a  few  fatal  cases  have  been  reported. 

Treatment. — This  is  mainly  local.  The  bladder  may  be  irrigated 
with  an  astringent  solution  (1  per  cent,  tannic  acid,  ^  per  cent,  alum), 
and  this  may  be  alternated  with  an  antiseptic  solution  (3  per  cent,  boric 
acid,  1  per  cent,  salicylic  acid).  I  have  recently  observed  a  case  in 
which  recovery  followed  the  internal  admission  of  the  extract,  hamamelis 
fluid.  (3J-4.0),  l.  i.  d. 

67  1  Brit.  Med.  Jour.,  1889. 


1058  DISEASES  OF  THE   URINARY  SYSTEM. 

NEUROSES   OF  THE  BLADDER. 

IRRITABILITY   OF   THE   BLADDER. 

Definition. — By  this  term  is  meant  a  condition  of  the  bladder  in 
■^\'hich  there  exists  an  hyperesthesia  of  the  organ,  especially  of  the  neck — 
that  portion  surrounding  the  urethral  and  ureteral  orifices  {vesical  trigone) 
— without  the  presence  of  any  tangible  cause  therefor.  This  must  be  dis- 
tinguished from  the  irritability  that  is  associated  with  true  organic  dis- 
ease of  the  bladder  itself,  as  in  the  presence  of  calculi,  tumors,  or  fissure 
of  the  neck,  or  with  disease  of  the  surrounding  structures. 

Pathologry. — Cystoscopic  examination  of  the  bladder  may  reveal  a 
slight  increase  in  the  vascularity  of  the  mucous  membrane.  The  condi- 
tion of  irritable  bladder  in  women,  which  has  previously  been  held  to  be 
a  purely  functional  derangement,  is  now  regarded  by  Dacheux  and 
Zuckerkandl  as  a  localized  hyperemia,  especially  at  the  bas  fond,  and 
less  often  at  the  beginning  of  the  urethra.' 

Etiology. — While  in  many  instances  no  well-defined  causal  relations 
can  be  determined,  it  is  very  generally  true  that  the  patients  who  are  the 
subjects  of  vesical  irritability  are  individuals  of  a  neurotic  temperament, 
very  often  manifesting  strong  hysteric  tendencies.  They  are  generally 
ill-nourished,  fretful,  irritable,  peevish,  suffering  almost  constantly  from 
vague  neuralgic  attacks  in  different  portions  of  the  body  (cephalalgia,  tic 
douloureux,  lumbo-sacral  pain),  and  in  a  chronic  condition  of  physical 
prostration.  Frequently  they  eventually  develop  a  true  hypochondriasis 
or  melancholia.  In  others  there  may  be  found  a  history  of  extreme  men- 
tal and  physical  tire,  overwork,  business  anxiety,  over-indulgence  in  ven- 
ery,  menstrual  irregularity,  dysmenorrhea,  ovarian  or  uterine  disorders, 
long-continued  gastro-intestinal  disturbance  (dyspepsia),  improper  hy- 
gienic surroundings,  improper  regimen,  indulgence  in  late  hours,  and  a 
general  lack  of  will-power.  It  must,  however,  be  remembered  that  sub- 
jects of  chronic  malarial  intoxication  very  often  manifest  all  the  symp- 
toms of  vesical  irritability,  marked,  it  may  be,  by  a  feature  of  more  or  less 
periodicity.  Lithemic  individuals  also  are  very  prone  to  develop  a  pro- 
nounced vesical  irritability,  the  affection  in  them  probably  resulting  from 
the  local  action  of  the  highly  concentrated  and  irritating  urine.  The  con- 
dition must  commonly,  however,  be  regarded  as  belonging  essentially  to 
the  large  group  of  neuroses. 

In  a  certain  percentage  of  cases  the  bladder-trouble  is  a  reflex  mani- 
festation of  some  disease  of  an  adjacent  organ,  as  the  urethra,  ureter,  va- 
gina, rectum,  anus,  or  the  internal  organs  of  generation.  These  are  not, 
however,  to  be  looked  upon  as  cases  of  true  neurotic  vesical  irritability. 

Symptoms. — The  symptoms  of  irritable  bladder  are  mainly  extreme 
painfulness  a,nd  frequencT/  of  mieturitioyi,  associated  with  marked  vesical 
and  rectal  tenesmus.  The  dysuria  is  not  always  or  altogether  relieved  by 
micturition  ;  indeed,  the  pain  may  be  'uat  as  severe,  or  even  worse  after, 
than  before,  the  voiding  of  the  urine.  Especially  is  this  true  when  there 
coexists  a  more  or  less  spasmodic  muscular  action  of  the  bladder-walls, 

*  The  American  Yenr-Book  of  Medicine  and  Surgery,  1897,  p.  576. 


NEUROSES  OF  THE  BLADDER.  1059 

the  hypersensitive  mucosa  then  being  squeezed,  and  the  patient,  suffering 
at  times  to  such  an  extent  as  to  be  thrown  almost  into  a  state  of  collapse. 
There  is  usually  a  sense  of  weight  or  pressure  in  the  pubic  region,  which 
is  largely  relieved  when  the  patient  assumes  the  recumbent  posture.  Uri- 
nation is  often  performed  spasmodically,  or  there  may  be  a  spasm  of  the 
urethra  and  neck  of  the  bladder  resulting  in  an  utter  inability  to  perform 
the  act.  The  urine  may  be  normal  in  appearance  and  amount.  Very 
often  it  is  increased  in  quantity  {hysteric  polyuria),  and  at  times  the  op- 
posite may  be  true  and  more  or  less  suppression  be  noted.  In  lithemic 
cases  the  urinary  characteristics  already  mentioned  under  that  condition 
will  be  present  {vide  p.  440). 

Diagnosis. — Very  frequently  will  simple  vesical  irritability  be  con- 
founded with  true  cystitis.  The  points  of  differentiation,  however,  are  as 
follows : 

Irritable  Bladder.  Cystitis. 

The   patient   is  of  a   neurotic   tempera-  May  occur  in  any  individual,  irrespective 

ment,  and  generally  gives  no  history  of  temperament.     It  frequently  follows 

of  organic  bladder-disease  nor  of  ope-  catherization,  sounding,  or  other  trau- 

rations  upon  the  bladder.  matism. 

Pain  is  severe,  and  often  worse  after  mic-  The  pain  is   usually  much  relieved  by 

turition.  micturition. 

The  constitutional  symptoms  are  those  of  The    constitutional    symptoms    are    not 

nervous  depression.  marked,  save  in  grave  cases. 

Never  results  fatally.  May  result  fatally. 

The  urine  does  not  present  any  marked  There  are   always  present   marked  and 

alteration  in  its  physical  or  chemical  characteristic  alterations  in  the  physi- 

qualities.  It  may  shoAV  hyperacidity,  cal  and  chemical  qualities  of  the  urine, 
or  extreme  concentration,  or  dilution. 

The  appearance  of  the  mucosa  is  negative  Cystoscopic  exploration  reveals  the  angry 

in  true  neurosis.  and   diseased  mucosa,  and  may  show 

the  cause  (calculus,  tumor). 

The  duration  is  always  protracted.  The  duration  of  acute  attacks  may  be 

short. 

Prognosis. — Good  as  regards  life ;  doubtful  as  regards  the  ultimate 
cure  of  the  patient. 

Treatment. — Since  the  condition  is  largely  one  of  neurotic  origin, 
the  attention  of  the  physician  must  be  directed  mainly  toward  a  bet- 
terment of  the  state  of  the  nervous  system.  Absolute  rest,  physical 
and  mental,  must  be  insisted  upon,  and  the  patient  must  be  subjected  to 
a  course  of  strict  moral  suasion  whenever  this  may  be  deemed  necessary. 
Any  cause  of  reflex  irritation  must  be  removed,  and  a  careful  search 
should  be  instituted  for  some  such  condition  as  cervical  stenosis,  uterine 
displacements,  anal  fissure,  hemorrhoids,  stricture  of  the  rectum,  vaginitis, 
urethritis,  tuberculous  infection  of  Skene's  glands  of  the  urethra,  chronic 
gastro-intestinal  catarrh,  and  the  like.  The  habits  of  the  patient  must 
be  inquired  into,  and  late  hours,  the  eating  of  improper  and  unwholesome 
articles  of  food,  masturbation,  or  the  reading  of  sensational  and  trashy 
literature  corrected.  In  many  instances  the  pronounced  neurasthenic 
condition  demands  a  course,  more  or  less  protracted,  of  the  Weir  Mitchell 
rest-treatment  {vide  Neurasthenia,  p.  1234).  The  urine  should  be  care- 
fully examined  for  lithemic  and  other  pathologic  features,  and  by  an  ap- 


lOGO  DISEASES   OF   TIIE    URINARY  SYSTEM. 

propriate  course  of  treatment  it  should  be  reiKlered  as  bland  and  unirri- 
tating  as  possible.  Large  draughts  of  diluent  drinks  may  be  of  benefit, 
and  if  these  be  combined  with  the  prolonged  administration  of  nerve- 
sedatives  and  antispasmodics,  a  marked  amelioration  of  the  patient's  con- 
dition may  be  secured.  In  cases  associated  with  spasmodic  muscular  con- 
traction it  may  become  necessary  to  employ  an  occasional  suppository  of 
opium  and  belladonna,  or  an  enema  of  chloral  hydrate.  Change  of  air 
and  scene,  regulation  of  the  diet,  the  institution  of  a  proper  course  of 
vTymnastics,  mental  and  physical,  and  the  observance  of  a  happy  and 
cheerful  atmosphere  will  generally  do  much  to  improve  the  patient's  con- 
dition. The  administration  of  tonics  (strychnin,  iron)  and  the  prevention 
of  constipation  are  very  essential.  Especially  must  it  be  remembered 
that  in  all  these  cases  of  simple  vesical  irritability  physical  exploration 
of  the  bladder  is  absolutely  contraindicated.  The  patient's  mind  must  be 
directed  away  from  the  bladder  in  order  to  secure  good  results. 

NEUROSES    OF   MICTURITION. 

1.  Incontinence    of   Urine    [Enuresis). — An    inability    to    retain    the 
urine.     This  may  arise  from  a  number  of  causes.     Frequently  it  is  the 
result  of  some  lesion  of  the  spinal  cord  involving  the  sphincteric  cen- 
ter of  the  bladder;  this  is  known  as  paralytic   incontinence,  and   is  to 
be  recognized  by  a  constant  dribbling,  alternating  with  spurts  of  urine 
when   voluntary   or  involuntary  muscular  action   is  brought  into  play, 
as  in  the  act  of  coughing,  sneezing,  or   bending  forward  of  the  body. 
It  may  be  the  result  of  a  general  bodily  weakness  or  after  prostrating 
diseases    (typhoid,   late    stages    of  pulmonary    tuberculosis).     Again,    it 
may  result  from  some  local  condition  in  the  bladder  or  urethra.      Here 
mav  be  mentioned  paralysis  of  the  urethra  from  over-dilatation  or  from 
traumatism,  or  that  due  to  pressure  of  the  fetal  head  in  a  prolonged  labor  ; 
imperfect  vesical  innervation  ;   over-distention  of  the  bladder,  producing 
a  paresis  of  its  walls ;  or  from  some  temporary  obstruction  at  the  urethra 
or  base  of  the  bladder,  such  as  a  tumor  or  a  sharply  retroflexed  uterus. 
It  may  be  a  result  of  over-distention  of  the  bladder,  with  partial  paral- 
ysis of  the  sphincter,  the  bladder  remaining  overfilled,  while  there  is  at 
constant  escape  of  a  few  drops  of  urine  (incontinence  of  retention).     It 
may  follow  some  local  causes  of  irritation,  as  the  presence  of  vesical  cal- 
culi, pressure  from  an  anteflexed  uterus  upon  the  fundus  of  the  bladder, 
cystitis,  and  parasites.     The  condition  known  as  spasmodic  incontinence 
is  that  due  to  an  over-action  of  the  compressor  muscle  of  the  bladder,  as 
a  consequence  of  which  there  is  a  diminution  of  the  vesical  capacity,  the 
urine  being   forcibly   and   involuntarily   ejected   at   irregular    intervals. 
Finally,  nocturnal  enuresis  is  that  variety  which  is  so  common  in  young, 
delicate,  and  often  neurotic  children  :  this  is  usually  noticed  in  the  early 
hours  of  sleep,  and  is  often  the  result  of  some  local  irritation  acting  upon 
a  hypersensitive  organism,  such  as  the  presence  of  oxyurias.  an  elongated 
prepuce,  contraction  of  the  urethral  meatus,  or  masturbation.     Bierhoff  * 
is  of  the  opinion  that  the  essential  or  ultimate  condition  is  hyperesthesia 
of    the    deep    urethra    or    sphincter    from    hyperemia    or    inflammation. 
Nocturnal  incontinence  may  be  a  manifestation  of  nocturnal  epilepsy  or 
^  PhUa.  Med.  Jour.,  May  2(5,  ;900. 


NEUROSKS   OF  MldTlIRlTlON.  1061 

of  incipient  ccnebral  or- spinjil  disoasc  (Fitz).  Adenoid  vof^otations  may 
bear  an  indirect  causiitive  relation  to  the  condition,  and  it  may  be  a 
symptom  of  thyroid  hypoplasia.  In  the  female,  uretliral  papiJl'miiita 
and  caruncles  have  been  assigned  as  causes.  The  hyperacidity  of  the 
urine  associated  with  podagra  may  also  excite  enuresis.  The  constant 
escape  of  urine  in  the  paretic  cases  is  apt  to  result  in  extensive  excoria- 
tion of  the  parts. 

The  treatment  varies  according  to  the  cause.  The  enuresis  of  chil- 
dren, if  left  alone,  will  eventually  cure  itself  as  the  age  and  strength  of 
the  patient  increases,  though  obvious  exciting  causes,  if  present,  should 
be  removed  if  not  impracticable.  Good  hygiene,  systematic  evacuation 
of  the  bladder,  elevation  of  the  hips  on  a  pillow  in  bed,  plenty  of  out- 
of-door  exercise,  a  change  to  the  seashore  or  mountains,  an  abundance 
of  suitable  and  strengthening  food,  mainly  vegetable,  so  that  a  large  pro- 
portion of  the  fluid  output  occurs  by  way  of  the  intestines,  Avith  a  mini- 
mum of  water,  and  milk,  especially  late  in  the  day,  and  the  administration 
of  tonics  (ii'on,  cod-liver  or  olive  oil,  and  strychnin),  will  generally  effect 
a  cure.  The  fluid  extract  of  rhus  aromatica  in  5-  to  15-drop  doses,  thrice 
daily,  has  been  very  beneficial  in  children.  Excellent  results  often  follow 
the  administration  of  minute  doses  of  atropin  or  tincture  of  belladonna. 
A  favorite  formula  of  my  own  in  cases  possessing  a  hypersensitive  nervous 
organization  has  long  been  as  follows  : 

:^^.   Tr.  belladounge,  3ss-j  (     2.0-4.0); 

Sodii  brom.,  3ij       (     8.0); 

Ac.  hydrobrom.  dil.,  sijss  (  10.0) ; 

Ext.  ergotse  fl.,  3ij      (     8.0); 

Glycerini,  3;j        (     4.0); 
Elix.  simplicis,  q.  s.  ad  liv      (128.0). 

M.  et  Sig.  3j  (4.0)  three  or  four  times  a  day  for  a  child  of 
five  years. 

In  very  delicate  or  feeble  children  suffering  from  enuresis  I  substitute 
a  motor  tonic  and  stimulant  (tr.  nucis  vom.)  for  the  bromids  or  nerve- 
sedatives.  In  cases  showing  marked  hyperacidity  the  alkalies  or  alkaline 
mineral  waters,  with  careful  rearrangement  of  the  diet,  are  indicated. 
Klotz  advises  to  raise  the  foot  of  the  bed  and  make  the  patient  sleep  on 
his  side.  Again,  the  little  sufferer  may  be  Avakened  prior  to  the  hour  fur 
the  occurrence  of  the  incontinence. 

Spasmodic  action  of  the  vesical  compressor  may  be  relieved  bv  the 
cautious  use  of  the  motor  depressants,  while  its  converse,  paresis,  de- 
mands the  exhibition  of  full  doses  of  strychnin  or  tincture  of  nux  vomica. 
The  judicious  and  careful  use  of  the  catheter,  followed  by  the  adminis- 
tration of  strychnin,  will  promptly  effect  a  cure  in  the  incontinence  of 
retention.  Any  local  cause  of  vesical  irritation  must  be  removed.  Gal- 
vanism in  the  paretic  cases,  applied  both  to  the  bladder  and  to  the  urethra, 
may  be  of  service.  Forchheimer  uses  the  faradic  current ;  in  girls  one 
pole  is  introduced  into  the  vagina,  in  boys  into  the  rectum,  while  the 
other  pole  is  placed  over  the  region  of  the  bladder.  The  current  must 
not  be  of  too  great  strength,  and  he  begins  Avith  the  Aveakest  induction 
current,  which  is  gradually  increased.  In  the  female  Sanger  suggests 
massage  of  the  urethra.    'Vibratory  massage  has  proved  succ^sful  in  a 


1062  DISEASES  OF  THE    URiyABY  SYSTE.V. 

few  cases.  Should  excoriation  occur,  bland  ointments,  as  of  zinc  o.xid 
and  lanolin,  should  be  used.  Kenioval  of  adenoid  vegetations  has  been 
recommended  in  cases  in  which  they  produce  conditions  of  malnutrition. 
For  cases  caused  by  thyroid  insufficiency,  the  use  of  thyroid  extract  will 
relieve  the  enuresis  and  also  bring  about  marked  improvement  in  the 
general  physical  and  mental  condition. 

'2.  Retention. — Nervous  retention  of  the  urine  is  occasionally  encountered 
in  hysteric  and  highly  neurotic  individuals.  Its  most  common  manifesta- 
tion is  an  inability  to  urinate  in  the  presence  of  others.  It  is  also  occa- 
sionally noted  after  childbirth,  when  it  may  be  due  to  nervous  reaction, 
to  edema  and  tortuosity  of  the  urethra,  or  to  a  temporary^  inability  of  the 
bladder-walls  to  contract  upon  their  contents,  thereby  permitting  a 
longer  retention  of  the  vesical  contents,  and  even  favoring  over-disten- 
tion  of  the  organ.  If  the  urine  be  allowed  to  remain  for  too  long  a 
period  in  the  bladder,  fermentative  changes  follow  and  a  secondary  cys- 
titis will  result.  Under  these  circumstances  an  exfoliation  of  a  portion  or 
even  of  the  entire  bladder-epithelium  may  be  noted. 

The  treatment  consists  in  the  aduiinistrati(»n  of  strychnin  and  other 
nerve-tonics,  in  building  up  the  general  constitution,  and  in  affording  a 
change  of  air  and  recreation.  In  that  variety  following  childbirth  the 
patient  should  be  urged  to  make  voluntary  efforts  at  micturition,  and 
these  may  be  seconded  b}^  the  firm  application  of  an  abdominal  binder 
and  compress,  or  of  hot,  moist  flannel  cloths,  kept  up  for  twenty  minutes 
or  a  half  hour.  The  sound  of  running  water,  as  when  pouring  water 
from  a  pitcher  into  the  basin,  often  causes  a  contraction  of  the  bladder 
and  excites  the  flow  of  urine.  It  may  become  necessary,  the  foregoing 
methods  failing,  to  resort  to  catheterization,  the  usual  antiseptic  precau- 
tions being  observed. 


PART   IX. 

DISEASES   OF    THE    NERVOUS    SYSTEM. 


The  central  nervous  system  is  generally  divided  into  two  parts — the 
brain  and  the  cord.  The  brain  consists  of  the  cerebral  hemispheres,  the 
basal  ganglia,  the  pons,  the  cerebellum,  and  the  medulla.  The  cerebral 
hemispheres  are  joined  together  by  the  corpus  callosum  and  the  anterior 
and  posterior  commissures.  They  are  united  to  the  pons  by  the  crura  cere- 
bri, and  the  pons  is  continuous  with  the  medulla,  which  in  turn  is  con- 
tinuous with  the  spinal  cord.  The  surface  of  the  cerebral  hemispheres 
is  divided  by  sulci  or  fissures  into  various  regions,  known  as  the  frontal, 
parietal,  temporo-sphenoidal,  and  occipital  lobes.  The  superior  longi- 
tudinal fissure  separates  the  two  hemispheres ;  the  fissure  of  Sylvius  is  be- 
tween the  frontal  and  parietal  lobes  above  and  the  temporo-sphenoidal  lobe 
below.  The  fissure  of  Rolando  divides  the  frontal  from  the  parietal  lobe, 
and  the  parieto-occipital  fissure  the  latter  from  the  occipital  lobe.  The 
continuation  of  the  last-named  fissure  upon  the  median  surface  forms  the 
upper  boundary  of  the  cuneus,  the  lower  boundary  of  which  is  the  cal- 
carine  fissure.  The  hippocampal  fissure  separates  the  fascia  dentata 
from  the  hippocampal  gyrus,  and  by  its  extension  inward  produces  an 
elevation  in  the  lateral  ventricle  known  as  the  hippocampus  major. 
Each  lobe  is  subdivided  by  secondary  fissures  into  a  number  of  lobules. 
The  topography  of  the  hemispheres  is  important  because  it  is  now  pos- 
sible to  map  out  with  considerable  accuracy  the  regions  in  which  vari- 
ous motor  impulses  originate,  and  with  less  accuracy  the  regions  in 
which  various  sensory  phenomena  are  perceived.  The  accompanying 
diagrams  illustrate,  more  satisfactorily  than  could  any  description, 
the  regions  that  have  been  hitherto  determined  (Figs.  68,  69,  and  70). 
There  is  some  discussion  in  regard  to  the  degree  of  individuality  of  these 
centers,  but  the  weight  of  evidence  inclines  to  the  belief  that  they  are 
not  sharply  delimited.  Ordinarily  speaking,  one  side  of  the  brain  inner- 
vates the  opposite  side  of  the  body  ;  but  certain  parts,  as  the  muscles  of 
the  trunk,  appear  to  receive  impulses  simultaneously  from  both  hemi- 
spheres, and  other  functions  seem  to  be  accomplished  exclusively  upon 
one  side  ;  thus  motor  speech  is  ordinarily  disturbed  only  when  the  lesion 
is  in  the  left  hemisphere. 

The  central  nervous  system  is  composed  practically  of  two  ele- 
ments— the  neuroglia,  or  supporting  substance,  and  the  neurons.  The 
neuroglia  consists  of  round  cells  with  radiating  processes,  lying  in  the 

1063 


1064 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


midst  of  a  tangled  network  of  fibers.  Its  function  appears  to  be  ex- 
actly similar  to  that  of  connective  tissue.  The  neuron,  or  nerve-unit, 
consists  of  a  ganglion-cell,  the  ])rotoplasmic  processes  springing  from  it, 
and  the  neuraxou,  or  axis-cylinder.  The  cell-body  consists  of  pro- 
toplasm and  nucleus.  The  latter  contains  a  nucleolus  and  a  small 
amount  of  chromatin;  the  former  is  composed  of  a  reticulum  of  fibril- 
lar ground-mass,  in  which  are  found,  in  certain  cells,  peculiar  bodies, 
that  take  the  basic  stain,  are  irregularly  spindle-shaped,  and  are  often 
arranged  concentrically  to  the  nucleus ;  they  also  extend  a  short  dis- 
tance into  the  protoplasmic  processes.  The  protoplasmic  processes 
branch  irregularly,  and  along  the  sides  of  the  finer  ramifications  are 
placed  short  lateral  offshoots,  the  buds  or  gemmules.  The  axis-cylinder 
is  a  single  process,  of  uniform  thickness,  usually  single,  but  sometimes 


CONCRETE  CONCEPT 

Fig.  C8.— Side  view  of  human  brain,  showing  localization  of  functions  (Charles  K.  Mills). 

brancbed,  and  srivinor  off  at  rej^ular  intervals  fine,  lone:  branches,  the 
collaterals  ;  it  terminates  either  as  a  tuft  of  fine  fibers  surrounding  a 
ganglion-cell,  or  in  a  motor  plate  in  the  muscles,  or  in  a  special  sense- 
corpuscle  in  the  skin.  It  cannot  be  too  frequently  reiterated  that  each 
neuron  constitutes  an  individual  unit  that  is  entirely  independent  of  all 
other  neurons  and  has  no  anatomical  connection  with  them  whatever.^ 
A  physiological  communication  must,  of  course,  exist,  that  perhaps  is 
analogous  to  electric  induction ;  and  it  has  been  suggested,  by  Dercum 
among  others,  that  during  life  the  protoplasmic  processes  move  about 
and  make  contact  with  the  surrounding  nervous  structures.  The  func- 
tions of  the  various  elements  of  the  neuron  are  as  yet  imperfectly  un- 
derstood.     The  cell-body  appears  to  exercise  a  trophic  action  over  the 

'  Ap&tliy,  and  more  recently  Bethe,  have  claimed  that  delicate  neuro-fibrils  pass  from 
one  neuron  to  another.     This  has  not  yet  been  confirmed. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1065 


other  parts,  especially  the  axis-cylinder.     It  probably  also  generates  the 
motor  impulses.     The  protoplnsmic   process   may   have    nutritive    func- 


FiG.  69.— View  of  the  mesial  surface  of  human  brain,  showing  localization  of  functions  (Charles 

K.  Mills). 

tions,  or  serve  to  conduct  impulses  to  the  cells  (cellipetal).      The  axis- 
cylinder  conducts  impulses  from  the  cells  (cellifugal),  except  in  the  case 


Fig.  70.— The  subdivisions  of  the  motor  cortex  (Mills  and  Frazier). 

of  the  peripheral  process  of  the  cells  of  the  spinal  ganglion.^     A  short 
*  Lenhossek  has  suggested  that  this  is  a  modified  protoplasmic  process. 


1066 


DISEASES  OF  THE  yERVOUS  SYSTEM. 


distance  from  the  cell  the  axis-rylimler  is  enveh^ped  by  the  myelin-sheath, 
giving  rise  to  the  nerve-fiber,  and  when  aggregated  together  these  fibers 
form  the  white  matter  of  the  nervous  system. 

It  has  been  possible  to  trace  more  or  less  accurately  the  course  of 
many  of  the  groujts  or  systems  of  fibers.  These  exist  because  cells 
havino-  the  same  functions  are  usually  grouped  together,  forming  cen- 
ters or  wano'lia,  and  the  fibers  from  these,  taking  the  same  course,  form  a 
bundle.  Three  classes  are  recognized  :  (1)  fibers  wholly  within  one 
hemisphere,  fibrite  propria,  uniting  adjacent  convolutions,  and  long  as- 
sociation-fibers, uniting  diff'erent  lobes;  (2)  fibers  passing  from  one 
hemisphere  to  the  other,  commissural  fibers  :  (3)  fibers  passing  from  the 
cerebrum  to  the  other  parts  of  the  central  nervous  system,  the  pro- 
jection-fibers, forming  the  corona  radiata. 


Fig.  71.— Section  of  spinal  cord  (after  Danaj,  showing  complete  subdivision  of  white  columns 


into- 

(DPy,  direct  pyramidal 
tract. 
AFC,  anterior   funda- 
mental column. 


Lateral 
columns. 


f  Column  of  Goll. 
T>»„*„_j„-«^i.,.„„=   J  Column  of  Burdach. 
Postenor columns,  i  ^^  rim-zoue,  or  Lissauer's 

\     column. 


f  LFC,  lateral  fundamental  column. 

i  LL,  lateral  limiting  layer. 

-I  CPyT,  crossed  pyramidal  tract. 

I  CT,  direct  cerebellar  tract. 

t  ALT,  antero-lateral  ascending  tract. 

f  ARZ.  anterior  root-zone. 
I  M/iZ,  middle  root-zone. 
I  OZ,  oval  zone, 
t  FEZ,  posterior  root-zone. 


The  columns  or  tracts  that  have  been  mapped  out  in  the  cord  may  be 
seen  in  the  accompanying  diagram  (Fig.  71).  In  the  antero-lateral  por- 
tion are  found  the  anterior  or  uncrossed  pyramidal  column,  the  antero- 
lateral column  of  Gowers,  the  cerebellar  column,  and  the  crossed  pyram- 
idal column.  In  the  posterior  region  are  the  columns  of  Goll  and  Bur- 
dach.   The  rest  of  the  white  matter  forms  the  so-called  ground-bundles. 

In  the  area  comprising  the  anterior  and  lateral  columns  both  ascend- 
ing and  descending  fibers  are  found. 

The  columns  tliat  transmit  ascending  impulses  are — 1.  The  direct 
lateral  cerebellar  column.  2.  The  antero-lateral  ascending  column  of 
Gowers.  3.  The  antero-lateral  ground-bundle  or  fundamental  column. 
4.  The  columns  of  Goll  and  Burdach.  Descending  impulses  are  trans- 
mitted chiefly  by  the  direct  and  crossed  pyramidal  tracts  and  the  antero- 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


]0f;7 


lateral  descending  tract.  '^Die  direct  lateral  cerebellar  tract  of  Fleclisig 
takes  origin  in  the  cells  of  the  column  of  Clarke,  and  first  appears  in  the 
lower  dorsal  region,  and  passes  through  the  restiform  body  to  the  cere- 
bellum. Gowers'  tract,  or  the  antero-lateral  ascending  column,  is  first 
seen  in  the  lumbar  cord,  and  arises  from  some  of  the  cells  of  the  pos- 
terior horn.  It  then  crosses  to  the  other  side  of  the  cord  through 
the  posterior  commissure  and  terminates  in  the  region  of  the  lateral 
nucleus. 


ellum 


Fig.  72. — A,  the  direct  sensory  tract :  ps,  Peripheral  spinal  nerves;  pg,  ganglion  on  posterior 
roots  of  spinal  nerves ;  qt,  Gower's  tract ;  cgt,  columns  of  GoU  and  Burdach ;  en,  nucleus  cune- 
atus ;  gn,  nucleus  gracilis ;  o,  cells  in  posterior  horn ;  pc,  peripheral  cranial  nerve ;  g,  gan- 
glion on  cranial  sensory  nerve;  n,  cells  of  cranial  sensory  nerves  in  medulla ;  /,  fillet ;  ol,  optic 
thalamus. 

B,  indirect  sensory  tracts  (Van  Gehuchten) :  dot,  Direct  cerebellar  tract.  The  numbers  repre- 
sent the  different  series  of  neurons. 

The  direct  and  crossed  pyramidal  columns  constitute  the  great  motor 
path  by  which  fibers  descend  from  the  cortex  and  end  in  the  motor  nuclei 
of  the  cranial  and  spinal  nerves — in  the  latter  case  in  the  multipolar  gan- 
glion-cells of  the  anterior  horns.  Their  origin  is  in  the  motor  region  of 
the  cerebral  cortex — i.  e.,  the  ascending  frontal,  the  paracentral  lobule, 
and  part  of  the  second  frontal  convolution  (Fig.  70);  they  then  approach 
one  another,  as  do  the  fibers  from  all  parts  of  the  cerebral  cortex  (known 
collectively  as  the  corona  radiata),  to  enter  the  internal  capsule.     This 


1068 


DISEASES  OF  THE  yERVOUS  SYSTEM. 


may  be  describetl  as  a  wtHl<:;e.  lioumled  in  front  and  to  tlic  inner  side  by 
the  caudate  nucleus  and  the  optic  thalamus,  and  on  the  outer  side  by  the 
lenticular  nucleus. 

All  of  the  fibers  of  the  corona  radiata  do  not  pass  through  the  internal 
capsule,  some  being  lost  in  the  gray  matter  of  the  basal  ganglia,  while 
others  take  Origin  in  the  ganglia.  The  angle  of  the  internal  capsule 
is  known  as  the  genu  or  knee,  the  part  anterior  to  it  as  the  anterior 
limb,  and  the  part  posterior  as  the  posterior  limb.  Through  the  anterior 
limb  pass  the  fibers  from   the  frontal  region ;   in  the  region  of  the  genu 


Hum 


Fig.  73.— a,  Diagram  of  the  direct  or  voluntary  motor  tract,  showing  the  center  of  the  motor 
impulses  from  the  cerebral  cortex  of  the  voluntary  muscles  (Van  Gehuchten):  m.  Muscles;  n,  cells 
of  nuclei  of  motor  criinlal  nerves  in  pons  and  medulla;  a,  motor  cells  in  anterior  horns  of  spina) 
cord  ;  dpi,  direct  pyramidal  tract;  cpt,  crossed  pyramidal  tract ;  pc,  peripheral  cranial  nerve;  ps, 
peripheral  spinal  nerve. 

B,  Diagram  of  the  indirect  or  involuntary  motor  tract. 

are  the  fibers  for  the  muscles  of  the  face  and  tongue  ;  and  in  the  pos- 
terior limb,  the  motor  fibers  to  the  extremities,  also  the  sensory  or  teg- 
mental fibers,  and  at  its  posterior  end  the  fibers  of  the  optic  radiation. 

The  crusta  consists  of  fibers  that  pass  through  the  pons  and  enter  the 
medulla,  constituting  its  pyramidal  tracts. 

The  tegmental  fibers  are  continuous  through  the  longitudinal  fibers  of 
the  pons  with  those  derived  from  the  formatio  reticularis  of  the  medulla. 
This  is  formed  by  fibers  from  the  superior  cerebellar  peduncles,  the  olivary 
body,  and  the  posterior  and  lateral  columns  of  the  cord,  which  are  rein- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  KMi'J 

forced  in  their  upward  course  by  fibers  derived  from  the  quadrigeminal 
and  geniculate  bodies. 

Tracing  the  pyramidal  fibers  through  the  medulla,  they  will  be  found 
to  divide  into  two  unequal  portions  at  its  lower  part.  The  larger  decussates 
at  this  point  (the  region  of  the  first  and  second  cervical  nerves),  constitut- 
ing the  decussation  of  the  pyramids  ;  it  then  crosses  to  the  posterior  part 
of  the  lateral  column  of  the  opposite  side,  in  which  it  runs  as  the  crossed 
pyramidal  tract. 

In  their  course  these  fibers  give  off  collaterals  at  right  angles  to  them- 
selves. These  pass  into  the  gray  matter,  and  terminate  in  arborizations 
about  the  root-cells  of  the  anterior  horn  of  the  same  side.  The  main  axes 
end  in  the  same  manner.  As  these  main  fibers  with  their  collaterals  pass 
into  the  gray  matter  at  various  levels  of  the  cord,  the  tract  becomes  more 
and  more  attenuated,  and  terminates  finally  in  the  lumbar  enlargement  of 
the  cord  in  the  neighborhood  of  the  third  or  fourth  sacral  nerve.  The 
smaller  division  of  the  medullary  pyramids  passes  directly  into  the  anterior 
region  of  the  cord  without  decussating,  and  is  known  as  the  direct  pyramidal 
tract,  or  the  column  of  Tiirck.  In  its  course  it  gives  oif  collaterals  at  right 
angles.  The-e  pass  through  the  anterior  commissure  at  different  levels  of 
the  cord,  and  end  in  relation  with  cells  of  the  anterior  hoi'n  of  the  oppo- 
site side.  The  main  fibers  terminate  precisely  in  the  same  manner 
(Fig.  73). 

Thus  it  will  be  observed  that  the  fibers  of  the  column  of  Tiirck  de- 
cussate in  the  anterior  commissure  of  the  cord  ;  like  the  tract  previously 
described,  it  becomes  gradually  smaller  from  above  downward,  and  ends 
in  the  lower  part  of  the  dorsal  cord.  The  axis-cylinders  of  the  multi- 
polar ganglion-cells  of  the  anterior  horns  pass  out  through  the  anterior 
roots  of  the  same  side  and  terminate  in  end-plates  of  muscles.  Dejerine, 
Oppenheim,  Monakow,  and  other  neurologists  believe  that  each  motor 
cortex  sends  fibers  to  both  sides  of  the  body,  and  that  the  decussation 
of  the  pyramids  is  not  a  complete  one,  a  small  number  of  the  fibers 
running  in  the  lateral  pyramidal  tract  on  the  same  side  as  the  lesion. 
This  is  borne  out  clinically  by  the  slight  paresis  and  the  plus  knee-jerk 
on  the  same  side,  neither  of  which,  however,  approaches  in  degree  the 
palsy  and  increased  knee-jerk  on  the  side  opposite  to  the  lesion. 

Pathologic  confirmation  of  this  view  has  been  obtained  by  several 
observers,  who  have  found  degeneration  in  both  latero-pyramidal  col- 
umns in  cases  of  a  unilateral  lesion  in  the  motor  cortex. 

Motor-fibers  from  the  nuclei  of  cranial  nerves  after  decussating 
join  with  motor  fibers  of  the  internal  capsule.  The  exact  course  of 
these  fibers,  however,  has  not  been  demonstrated  anatomically.  Since 
many  of  the  muscles  supplied  by  the  cranial  nerves  functionate  bilater- 
ally— e.  g.  the  eye-muscles  and  the  muscles  of  mastication — the  suppo- 
sition is  that  in  addition  to  fibers  from  its  own  nucleus  each  motor  cranial 
nerve  receives  fibers  from  the  corresponding  nucleus  of  the  opposite 
side.  It  was  Broadbent  who  first  pointed  out  that  parts  that  functionate 
bilaterally  are  supplied  from  both  sides  of  the  brain. 

The  course  of  the  fibers  of  the  posterior  column  is  as  follows  : 

The  ganglion-cells  on  the  posterior  roots  give  rise  to  two  fibers, 
fused  for  a  short  distance  from  the  cell,  but  soon  bifurcating.  The 
longer   of   the    two,    the    centrifugal    fiber,    extends    to    the    surface 


1070 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


former  may  be   either  long  or  short. 


and  terminates  in  pointed  or  bulbous  endings  in  the  epidermis,  or 
in  special  sensory  nerve-endings  in  tactile  cells,  tactile  corpuscles,  or 
end-bulbs.  The  centripetal  fibers  or  axons  penetrate  the  cord,  and 
divide  in  the  white  matter  into  ascending  and  descending  fibers.     The 

The  short  fibers  are  vertical  at 
first,  but  finally  bend  into  the 
gray  matter,  and  end  in  rela- 
tion "with  certain  cells  of  the 
anterior  cornua,  forming  per- 
haps a  part  of  the  reflex  arc. 
Their  collaterals  end  in  a  sim- 
ilar manner.  The  long  fibers 
extend  up  the  cord  to  the  me- 
dulla, ending  in  the  usual  man- 
ner in  the  gray  nuclei  of  the 
columns  of  Goll  and  Burdach  ; 
these  are  known  as  the  nucleus 
gracilis  and  nucleus  cuneatus, 
respectively.  They  also  give  off 
collatei"als  in  their  course.  The 
descending  fibers,  on  the  other 
hand,  are  all  short,  and  probably 
constitute  the  so-called  comina 
tract  of  Schultze. 

Since  fibers  continue  to  enter 
the  cord  at  different  levels, 
those  that  have  entered  belovr 
are  pushed  more  and  more  to- 
ward the  median  line.  It  will 
thus  be  seen  that  the  column 
of  Goll  is  made  up  almost  en- 
tirely of  long  fibers,  and  that 
the  column  of  Burdach  also  con- 
tains long  fibers,  although  it  is 
probable  that  the  short  ones  pre- 
dominate. The  long  fibers  are 
concerned  in  muscular  coordination  and  e({uilibrium.  It  is  likely  that 
the  fibers  of  pain  and  temperature  sense,  although  entering  by  the  pos- 
terior roots,  do  not  pass  up  through  the  posterior  columns,  but  rather 
through  the  tract  of  Gowers. 

The  skin  areas  innervated  by  the  different  segments  of  the  cord  are 
shown  in  Fig.  75. 

Since  the  post-natal  growth  of  the  vertebrae  is  more  rapid  than  that 
of  the  cord,  it  follows  that  the  spinal  nerves  assume  a  more  and  more 
oblique  position,  until  finally  the  spinal  segments,  each  of  which  con- 
sists of  an  anterior  and  posterior  nerve-bundle  with  a  transverse  plane 
of  white  substance,  lie  considerably  above  the  vertebrte  after  which  they 
are  named  (see  Fig.  74).  The  following  table  (Starr,  modified  by  Mills 
and  Dana  from  the  experimental  and  clinical  studies  of  Thorburn  and 
others)  shows  the  localization  of  function  (not  organs)  in  the  different 
segments  of  the  cord : 


Sacral 


Fk;.  74 — Diagram  showing  the  groupings  andplex 
usee  of  the  spinal  nerves  (redrawn  after  Baker). 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1071. 


Localization  of  the  Functions  of  the  Segmentif  of  thji  Spinal  Cord. 

Reflex  and  Centers.  Hensation. 


Segment 
First  cervical. 


Second  and  third 
cervical. 


Fourth  cervical. 


Fifth  cervical. 


Sixth  cervical. 


Seventh  cervical. 


Eighth  cervical. 


First  dorsal. 


Second  dorsal. 


Second  to  twelfth 
dorsal. 


Muscles. 
Rectus  latcrales. 
Rectus  capitis. 
Anticus  and  posticus. 
Sterno-hyoid. 
Sterno-thyroid. 
Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Omo-hyoid. 
Diaphragm. 

Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  iufra-spi- 
natus. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Brachialis  anticus. 

Supinator  longus. 

Supinator  brevis. 

Deep  muscles  of  shoul- 
der-blade. 

Rhomboid. 

Teres  minor. 

Pectoralis  (clavicular 
part). 

Serratus  magnus. 

Deltoid. 

Biceps. 

Brachialis  anticus. 

Subscapular. 

Pectoralis  (clavicular 
part). 

Serratus  magnus. 

Triceps. 

Pronators. 

Rhomboid. 

Latissimus  dorsi. 

Triceps  (long  head). 

Extensors  of  wrist  and 
lingers. 

Pronators  of  wrist. 

Flexors  of  wrist. 

Subscapular. 

Pectoralis  (costal  part). 

Serratus  magnus. 

Latissimus  dorsi. 

Teres  major. 

Triceps  (long  head). 
Flexors    of    wrist    and 

fingers. 
Intrinsic  hand-muscles. 

Extensors  of  thumb. 
Intrinsic  hand-muscles. 
Thenar  and  hypothenar 
muscles. 


Hypochondrium  (?).  Sud- 
den inspiration  prf>- 
ducc.il  by  Hiidden  pres- 
sure ln'uciiUi  the  lower 
border  of  the  ribs. 

Pupillary  (fourth  cervi- 
cal to' second  dorsal). 
Dilatation  of  the  pupil 
produced  by  irritation 
of  the  neck. 


Scapular  (fifth  cervical 
to  first  dorsal).  Irrita- 
tion of  skin  over  the 
scapula  produces  con- 
traction of  the  scap- 
ular muscles. 

Supinator  longus.  Tap- 
ping the  tendon  of  the 
supinator  longus  pro- 
duces flexion  of  fore- 
arm. 


Triceps  (fifth  to  sixth 
cervical).  Tapping  el- 
bow tendon  produces 
extension  of  forearm. 

Posterior  wrist  (sixth  to 
eighth  cervical).  Tap- 
ping tendons  causes 
extension  of  the  hand. 


Anterior  wrist  (seventh  to 
eighth  cervical).  Tap- 
ping anterior  tendons 
causes  flexion  of  wrist. 

Palmar  (seventh  cervical 
to  first  dorsal).  Strok- 
ing the  palm  causes 
closure  of  the  fingers. 


Muscles  of  back  and  ab- 
domen. 
Erectores  spinse. 


Epigastric  (fourth  to  sev- 
enth dorsal).  Tickling 
mammary  region 
causes  retraction  of 
the  epigastrium. 

Abdominal  (seventh  to 
eleventh  dorsal). 
Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Vaso-motor  centers.  Sec- 
ond dorsal  to  second 
lumbar. 


Back  of  head  to  vertex 
and  neck.  lOccipitalis 
major,  oeoipitalis  mi- 
nor, tturioilariH  mag- 
nus, superficialis  colli, 
and  supraclavicular.) 

Neck. 

Shoulder,  anterior  sur- 
face. 

Outer  arm.  (Supracla- 
vicular, circumflex, 
external  musculo-cu- 
taneous,  cutaneous.) 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  the  wrist. 
(Supraclavicular,  cir- 
cumflex, external  cu- 
taneous, internal  cu- 
taneous, posterior  spi- 
nal branches.) 


Outer  side  and  front  of 
forearm. 

Back    of    hand,    radial 
distribution. 

(Chiefly  external  cu- 
taneous, internal  cu- 
taneous, radial.) 


Radial  distribution  in 
the  hand. 

Median  distribution  in 
the  palm,  thumb,  in- 
dex, and  one  half  of 
the  middle  finger. 

(External  cutane- 
ous, internal  cutane- 
ous, radial,  median, 
posterior  spinal 
branches.) 

Ulnar  area  of  hand, 
back,  and  palm,  in- 
ner border  of  forearm. 
(Internal  cutaneous, 
ulnar.) 

Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 

(Chiefly  internal 
cutaneous  and  nerve 
of  Wrisberg  or  1  e  s  s- 
er  internal  cutane- 
ous.) 

Inner  side  of  arm  near 
10  ann  in  the  axilla, 
(Intercosto-humeral.) 

Skin  of  the  chest  and  ab- 
domen, in  bands  ruii- 
ning  around  and 
down  w  a  r  d,  corre- 
sponding to  spinal 
nerves. 

Upper  gluteal  region. 
(Intercostals  and  dor- 
sal posterior  nerves.) 


Eleventh    and    twelfth 
dorsal  testicle. 


1072 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Segment. 

First  Inmliar. 


Second  lumbar. 

Third  lumbar. 
Fourth  lumbar. 

Fifth  lumbar. 


First  and  second 
sacral. 


Third,  fourth.and 
fifth  sacral. 


Mi'scLEa. 


Kone. 


Vastus  intcrnus. 


Partorius;  adductors  of 

thigh. 
Flexors  of  thigh. 
Extensors  of  knee. 
Abductors  of  thigh. 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Cnlf-muscles. 

Glutei. 

Peronci. 

Extensors  of  ankle. 

Small  muscles  of  foot. 

Perineal. 

Muscles  of  bladder,  rec- 
tum, and  external 
genitals. 


Reflex  and  Centers. 

Oremaslrn'r  (first  to  third 
himtiiir).  Stinking  in- 
ner thigh  causes  re- 
traction of  scrotum. 

PaUllar.  Striking  pa- 
tellar tendon  causes 
extension  of  the  leg. 


Glulml  (fourth  to  fifth 
lumbar).  Stroking 
buttock  causes  dimp- 
ling in  fold  of  buttock. 

Achilk'g  (aidoii.  Over- 
extension causes  rapid 
flexion  of  ankle,  called 
ankle-clonus. 


Plantar  (fifth  lumbar  to 
second  sacraU.  Tick- 
ling sole  of  foot  causes 
flexion  of  toes  and 
retraction  of  leg. 

Genital  center. 

Vesical  center. 

.A.nal  center. 


Sess.vtion. 

Skin  over  groin  and 
front  of  scrotum.  (Ilio- 
hypogastric, ilio- in- 
guinal.)  Testicle. 

Outer  side  and  upper 
front  of  thigh.  Lum- 
bar region.  (Gonito- 
crural,  external  cuta- 
neous.) 

Front  and  outer  side  of 
thigh.  Inner  side  of 
leg  and  foot. 

Inner  side  of  thigh,  leg, 
and  foot.  (Internal 
cutaneous,  long  sa- 
phenous, obturator.) 

Back  of  thigh  and 
outer  side  of  leg  and 
ankle:  sole:  dorsum 
of  foot.  (External 
popliteal,  external 
saphenous,  musculo- 
cutaneous, plantar.) 

Back  of  buttock  and 
thigh,  side  of  leg  and 
ankle:  sole;  dorsum 
of  foot. 

Circumanal  region, 
anus,  rectum,  penis, 
urethra,  vagina,  per- 
ineum. 

(Small  sciatic,  pudic, 
inferior  hemorrhoidal, 
inferior  pudendal.) 


To  the  foregoing  table,  which  illustrates  spinal  localization,  should 
be  added  another,  showing  what  functions  reside  in  the  pons  and  medulla, 
as  follows : 


Nuclei. 
III. 

IV. 


VI. 


XII. 


Sphincter  iris.     Ciliary  muscles. 

Levator  palpebrge  superioris.     Rectus  internus  (in  convergence). 
Rectus  superior.     Rectus  inferior. 
Obliquus  inferior. 
Obliquus  superior. 
(Upper  facial  group.) 


V. 

Rectus  externus.  Rectus 
inter,  of  opposite  side 
in  lateral  movements. 


f  (Associated  movement  of  levator  palpebrae.) 
I  Muscles  of  lower  jaw. 


(Lower  facial  group.) 
Muscles  of  tongue. 


VII. — Facial  muscles. 

jY     r  Mu.«;cles  of  pharynx. 

y'    I   Muscles  of  esophagus. 
■j^t"    I   Muscles  of  larynx. 

'Motor  cortical  area,  see  p. 


1067. 


Sensory  Cortical  Area. — Owing  to  the  extensive  compensation  of  sen- 
sory fibers,  by  means  of  which  each  side  of  the  brain  sends  fibers  to  both 
sides  of  the  body,  it  is  impossible    to  map  out  the  center  with  precision. 

It  is  generally  believed,  for  reasons  already  stated,  that  the  ascending 
parietal  convolution  and  parietal  lobe  contain  muscular  and  tactile  sen- 
sory functions.  It  is  possible  that  the  sensory  zone  extends  to  the  mesial 
surface  of  the  hemisphere,  as  does  the  motor  area.  That  this  is  the  chief 
sensory  center,  as  claimed  by  some  observers,  is,  however,  very  question- 
able (Figs.  08  and  69). 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1073 


From  the  cuneus,  fibers  pass  to  the  pulvinar,  forming  the  optic  radia- 
tion of  Gratiolet.  From  the  pulvinar  tliey  apparently  pass  to  the  exter- 
nal geniculate  bodies,  and  thence  to  the  anterior  corpus  quadrigeminum. 
The  optic  tracts  arise  by  two  roots  that  curve  round  the  crusta  on  either 
side  and  unite  immediately  in  front  of  the  tuber  cinereum.  Fibers  from 
the  two  tracts  pass  to  the  homologous  sides  of  both  retinae ;  therefore  the 
lesions  posterior  to  the  chiasm  give  rise  to  blindness  of  half  of  each  retina 
on  the  same  side,  although  the  blind  fields  are  on  the  opposite  side — 
lateral  homonymous  hemianopsia  (Fig.  77). 


Fig.  75.— Showing  the  regions  innervated  by  the  different  spinal  roots  or  the  corresponding 
segments  of  the  cord.  It  should  be  remembered  that  the  limits  are  not  in  reality  so  sharply 
defined,  but  extend  into  one  another  (Kocher). 

Visual  Centers. — The  exact  center  for  ordinary  vision  is  in  the  cor- 
tex of  the  occipital  lobe  of  the  inner  surface  in  the  region  of  the  calca- 
rine  fissure.  A  higher  center  exists,  probably  located  in  the  angular 
gyrus,  a  lesion  of  which  produces  mind-blindness  ;  this  is  a  condition 
in  which  vision  is  not  lost,  but  the  objects  seen  are  not  recognized 
by  the  individual.  Ferrier  says  that  a  lesion  in  this  region  sometimes 
gives  rise  to  crossed  amblyopia.  The  eye  opposite  to  the  lesions  is  chiefly 
affected,  though  vision  is  also  restricted  in  the  eye  on  the  same  side  of 
the  lesion  (visual  tract). 

Olfactory  Center. — This  is  located  in  the  anterior  part  of  the  uncinate 
convolution,  on  the  inner  surface  of  the  temporal  lobe.     It  is  possible, 

Q8 


1074  DISEASES  OF  THE  XERVOUS  SYSTEM. 

too,  that  fibers  pass  from  this  region  through  the  anterior  commissure  to 
the  cortex  of  the  opposite  hemisphere. 

Auditari/  Center. — A  lesion  in  the  posterior  part  of  the  first  temporal 
convolution  produces  a  deafness  in  the  opposite  ear  that  is  transient  in  cha- 
racter, owing  to  compensation.  Bilateral  lesions  produce  complete  deaf- 
ness. Mind-deafness,  or  an  inability  to  understand  spoken  words,  has 
resulted  from  a  lesion  in  the  first  temporal  convolution  of  the  left  side. 

SpeeeJi  Center. — The  articulate  speech  center  is  located  in  the  poste- 
rior part  of  the  left  third  or  inferior  frontal  convolution,  and  in  the  ad- 
jacent part  of  the  ascending  frontal  in  right-handed  people  (but  on  the 
right  side  in  left-handed  persons). 

It  is  not  known  exactly  what  part  the  island  of  Reil  plays  in  articu- 
late speech.  Word-blindness  results  from  a  lesion  in  the  angular  gyrus. 
Word-deafness  results  from  a  lesion  in  the  posterior  part  of  the  first  left 
temporal  convolution.    (See  also  Aphasia.) 

Ta^tc  Ccnttr. — The  area  of  cortical  representation  is  probably  locate d 
in  the  uncinate  region  (Fig.  69). 

Psychic  Centers. — It  is  possible  that  the  frontal  lobes,  anterior  to 
the  precentral  fissure,  contain  the  psychic  centers.  Su^h  extensive 
compensation  probably  exists  that  no  ordinary  lesion  produces  mental 
aberration,  but  these  centers  are  probably  represented  by  the  whole 
cortex. 

The  function  of  the  cerebellum  is  that  of  coordination.  Fibers  pass 
from  its  cortex  to  that  of  the  cerebrum,  and  vice  versa.  The  impressions 
derived  from  the  cerebrum  are  believed  to  be  inhibitory. 

Peripheral  impressions  reach  the  cerebellum  through  the  direct  cere- 
bellar tracts  of  the  lateral  columns  of  the  cord,  and  also  from  fibers  de- 
rived from  cells  in  the  nuclei  of  the  columns  of  Goll  and  Burdach. 

Motor  impulses  run  from  the  cerebellar  cortex  to  the  motor  region 
of  the  cerebral  cortex  by  way  of  the  superior  or  middle  peduncle,  and  by 
way  of  the  inferior  peduncle  (restiform  body)  to  the  multipolar  ganglion- 
cells  of  the  anterior  horns. 

GENERAL   AND    TOPICAL   DIAGNOSIS. 

Nervous  diseases  are  usually  spoken  of  either  as  being  functional 
or  organic  ;  but,  as  our  methods  of  research  become  more  refined  and 
our  technic  more  perfect,  the  breach  between  these  two  groups  is  being 
gradually  but  steadily  lessened. 

Organic  nervous  diseases  may  be  produced  by  two  types  of  lesions : 

1.  Irritative.,  causing  an  increase  of  function,  continuous  or  inter- 
mittent. 2.  Destructive,  resulting  in  paralysis  of  motion  or  sensation, 
or  both. 

Irritative  lesions  are  prone  to  become  destructive  in  course  of  time. 
They  may  be  operative  in  the  upper  segment,  which  includes  the  brain 
and  fibers  leading  to  or  from  it  as  far  as  the  ganglion-cells  of  the  cord ; 
or  in  the  lower  segment,  including  the  multipolar  ganglion-cells  of  the 
anterior  horn,  together  with  the  peripheral  motor  nerve-fibers. 

When  a  complete  pathway  is  involved  a  systemic  disease  is  said  to  be 
produced.  When  two  or  more  paths  or  neuron  complexes  are  simultan- 
eously involved  combined  systemic  disease  results. 


GENERAL  ANT)   TOPICAL   nTAGNOSJS.  1075 

Brain-lesions  may  be  {a)  focal  or  (h)  (lifFuso.  Cord-lesions  are  either 
{a)  transverse,  (i6)  focal,  or  (c)  insular  (a  series  of  foci). 

Cord-lesions  result  in  ascending  or  descending  degeneration,  the  de- 
structive process  travelling,  as  a  rule,  in  the  direction  in  which  impulses 
are  normally  transmitted.  In  the  fillet  degeneration  may  extend  up  or 
down. 

The  theory  has  been  advanced  that  the  vulnerability  of  the  tracts  of 
the  spinal  axis  is  in  direct  proportion  to  the  degree  of  their  functional 
activity ;  hence  the  reflex  (sensory  and  pyramidal)  tracts  are  more  likely 
to  degenerate  under  nutritional  disturbances  or  toxic  processes  than 
other  parts. 

It  has  been  supposed  that  the  tardy  mvelination  of  the  pyra- 
midal tracts  predisposes  to  various  nervous  maladies,  and  particularly  to 
those  of  a  spastic  type.  The  following  may  be  accepted  as  a  general 
rule :  the  motor-nervous  system  is  the  last  to  develop,  the  first  to  lose, 
and  the  last  to  regain,  its  function ;  while  the  sensory  nervous  system  is 
the  first  to  develop,  the  last  to  lose,  and  the  first  to  regain,  its  function. 
In  making  a  diagnosis  it  is,  therefore,  of  the  utmost  importance  to  try  to 
determine  the  locality  and  extent  of  the  morbid  process,  and  to  ascertain 
whether  the  lesion  is  a  focal  or  systemic  one.  The  symptomatology  of 
systemic  diseases  is  pretty  constant,  and,  except  in  their  very  incipiency, 
they  are  usually  not  difiicult  of  diagnosis.  The  symptoms  of  focal  dis- 
eases, on  the  other  hand,  vary,  of  necessity,  according  to  the  location 
of  the  focus.  They  are  often  difficult  and  at  times  impossible  to  diag- 
nose. Especially  is  this  true  of  lesions  occurring  in  the  frontal  lobes 
of  the  cerebrum,  in  the  basal  ganglia,  and  in  the  cerebellum. 

Since  the  study  of  the  motor  centers  and  tracts  has  been  pursued 
with  so  much  more  success  than  that  of  the  sensory  system,  positive  or 
negative  motor  phenomena  occurring  in  the  course  of  nervous  diseases 
furnish  us  with  much  more  valuable .  information  than  do  sensory  mani- 
festations. 

Further,  motor  symptoms  are  objective,  and  consequently  appeal  to 
us  in  a  much  greater  degree  than  the  sensory  symptoms,  Avhich  are 
purely  subjective,  and  the  elicitation  of  which  depends  so  much  upon 
the  mental  capability  of  the  patient. 

Irritative  motor-lesions  produce,  according  to  the  degree  of  irritation, 
either  fibrillary  muscular  twitchings  or  mild  or  severe  convulsions,  tonic 
or  clonic  in  character. 

Destructive  motor-lesions,  according  to  their  extent,  produce  mere 
muscular  weakness,  paresis,  or  actual  paralysis  of  a  single  muscle, 
groups  of  muscles,  or  of  the  entire  musculature  of  one  or  more  limbs. 

Irritative  sensory  lesions  give  rise  to  neuralgia,  hyperesthesia,  or 
hyperalgesia. 

Destructive  sensory  lesions  cause  a  more  or  less  complete  absence  of 
sensation,  as  analgesia,  anesthesia,  or  loss  of  temperature-sense. 

Upper-segment  or  Upper-system  Diseases. — A  lesion  occurring  in  the 
motor  pathway  anywhere  between  the  cortex  and  the  multipolar  cells 
of  the  anterior  horns  (but  not  including  the  latter)  gives  rise  to  the 
following  symptom-complex :  Loss  of  motion,  both  automatic  and  vo- 
litional, and  chiefly  on  the  side  of  the  body  opposite  to  the  lesion.  The 
paralysis  is  usually  spastic  in  type.     The  muscles  resist  passive  move- 


1076 


DISEASES   OF  THE  yERVOUS  SYSTEM. 


nients,  showing  that  their  tone  is  increaseil.  This  is  rehitive,  and  is  due 
to  tlie  removal  ot"  cerebral  inhibition,  which  allows  the  lower  centers  free 
play.  They  also  tend  to  undergo  shortening,  and  contractures  result. 
Reflexes  below  the  seat  of  the  lesion  are  increased.  If  it  is  cerebral, 
this  is  cliiefly  on  the  side  opposite  the  lesion,  but  also  on  the  same  side, 
the  increase  b&ing  the  result  of  the  removal  of  cerebral  influences. 

Uwiiig  to  inactivity,  the  muscles  of  the  paralyzed  members  may  un- 
csg         csD  dergo  some  atrophy,  though  there 

are  no  degenerative  changes,  since 
the  peripheral  neuron  bodies  are 
intact.  Usually  there  is  very  little 
if  any,  excepting  when  the  disease 
has  been  acquired  in  childhood,  in 
which  case  there  is  found  to  be  a 
general  lack  of  growth,  bone  as 
well  as  muscle.  For  the  same  rea- 
son the  response  to  electric  stimu- 
lation is  not  interfered  with. 

An  irritative  lesion  of  this  upper 
system,  ])articularly  when  operative 
in  or  upon  the  cortical  region,  gives 
rise  to  tonic  or  clonic  convulsive 
movements.  When  the  lesion  is 
localized  to  a  single  center,  focal 
or  so-called  Jacksonian  epilepsy  re- 
sults. The  cortex  is  wonderfully 
tolerant,  when  the  lesion  is  of  grad- 
ual onset,  and  the  parts  accommo- 
date themselves  to  the  slowly  in- 
creasing pressure.  However,  a  local 
irritative  lesion  may  at  first  cause 
widespread  symptoms,  due.  as  Noth- 
nagel  pointed  out,  to  pressure,  vas- 
cular disturbances,  or  irritative  in- 
hibition. 

Lower-seep}} en  f  or  Loti'er-Hystem 
Diseases. — This  includes  the  pe- 
ripheral neuron  system.  Sjnce 
there  is  no  crossing  of  the  fibers, 
the  lesion  and  resulting  paralysis 
are  on  the  same  side  of  the  body. 
The  paralysis,  however,  is  of  the 
flaccid,  flail-like  variety,  hypotonus  being  present.  The  muscles  offer  no 
resistance  Avhatever  to  passive  movement,  contractures  do  not  occur,  ex- 
cepting when  there  occurs  the  unopposed  action  of  healthy  antagonistic 
muscles,  and  reflexes  are  lost.  Extreme  deforces  of  wasting  occur  in  this 
type  of  paralysis,  owing  partly  to  disuse,  but  chiefly  to  the  fact  that  the 
neuron  body,  the  neutritional  or  trophic  center  for  the  fiber,  is  injured. 
Pathologic  changes,  therefore,  take  place  in  the  muscles  themselves,  and 
form  a  true  degenerative  atrophy,  ^fhe  protoplasm  first  becomes  granu- 
lar and  then  fatty ;  it  then  breaks  down  and  is  absorbed.     Its  place  is 


Fig.  76.— Scheme  represenliiiK  cord-lesion  and 
effects  in  Brown-Scquard  paralysis  (after  Bris- 
saud) :  (JSG,  Left  sensitivetraet :"  CSD,  right  sen- 
sitive tract ;  A,  B,  C,  £>,  lesion  involving  the  left 
half  of  the  cord  ;  S,  S,  S,  sensory  roots  from  ri^ht 
side  of  body ;  Z,  Z,  Z,  sensory  roots  from  left  side 
of  body  ;  ZK  Z^,  and  S-  are  irritated  only  at  the 
points".!,  B,  ^',  and  their  peripheral  area  is  hy- 
peresthetic;  iT"  jg  divided  and  its  skin  area  is 
anesthetic  on  the  same  side  as  the  lesion.  Cor- 
responding to  .S'  and  all  the  roots  below  arising 
from  the  right  side  of  the  body,  there  is  anesthe- 
sia. 


NEURALGIA.  1077 

taken  by  the  connective  tissue,  which  is  hoth  relatively  and  ahsolutely 
increased,  so  that  in  the  course  of  time  fibrous  masses  alone  remain. 
Electric  changes  also  occur.  The  muscles  first  cease  to  respond  to  the 
faradic  current,  and  soon  respond  in  an  abnormal  manner  to  the  galvanic. 
Instead  of  short,  sharp  contractions,  they  react  in  a  slow,  wavy  manner, 
ACC  being  equal  to  or  stronger  than  KCC.  Irritative  lesions  of  this 
system  may  cause  fibrillary  muscular  contractions  and  peripheral  convul- 
sions, of  which  laryngismus  stridulus  is  a  type. 

Owing  to  the  arrangement  of  the  various  tracts  of  the  spinal  cord  a 
lesion  involving  its  lateral  half  causes  a  peculiar  combination  of  symp- 
toms, frequently  termed  Brown-S^quard's  paralysis. 

It  is  met  with  particularly  as  a  result  of  injuries  (knife-thrusts  and  the 
like),  though  it  may  also  be  due  to  tumor  or  caries  of  the  cord,  to  syphilis, 
or  to  any  process  causing  compression  of  one-half  of  the  cord.  Sucli 
lesions  intercept  the  motor  impulses  of  the  same  side;  the  fibers  having 
crossed  in  the  medulla,  the  sensory  fibers,  conducting  pain  and  tempera- 
ture impressions,  cross  in  the  cord  soon  after  entering,  and  hence  these 
forms  of  sensation  will  be  absent  on  the  side  opposite  to  the  lesion ; 
tactile  sensation  may  also  be  abolished,  but  in  some  cases  is  not  {vide 
Fig.  76).  A  lesion  in  the  cervical  cord  above  the  arm-nuclei  causes 
motor  paralysis  of  both  arm  and  leg  of  the  same  side  (spinal  hemiplegia) 
and  sensory  paralysis  on  the  opposite  side.  If  in  the  dorsal  or  lumbar 
cord,  the  leg  on  the  corresponding  side  is  paralyzed,  while  that  of  the 
other  is  anesthetic.  Lesions  are  seldom  strictly  confined  to  one  side  of  the 
cord,  but  overlap  a  trifle,  so  that  there  is  apt  to  be  some  loss  of  power  on 
the  anesthetic  side ;  this,  however,  may  be  due  to  the  redecussation  of  a 
few  motor-fibers  at  a  lower  level.  The  side  of  the  lesion  is  hyperes- 
thetic — a  fact  for  which  no  satisfactory  explanation  has  ever  been  ad- 
vanced. Muscular  sense  is  diminished  or  lost  on  the  same  side.  Above 
the  hyperesthetic  region  an  ,area  of  anesthesia  commonly  exists,  and 
above  this,  again,  an  area  of  hyperesthesia.  The  reflexes  are  increased 
on  the  side  of  the  lesion  (inhibition  being  removed),  and  the  temperature 
of  that  side  is  usually  higher.  On  the  anesthetic  side  the  motor  power, 
reflexes,  muscle  sense,  and  temperature  are  all  normal. 


I.  DISEASES  OF  THE  PERIPHERAL  NERVES. 
NEURALGIA. 

Definition. — Neuralgia  (nerve-pain)  is  a  term  used  to  denote  painful 
sensations  that  have  the  following  characteristics :  1st.  In  their  distribu- 
tion they  follow  the  course  of  the  nerve-trunks  or  their  branches.  2d. 
They  show  a  tendency  to  shift  from  place  to  place.  3d.  There  are  pain- 
ful points  (points  douloureux)  along  the  course  of  the  nerve-trunks.  4th. 
Intermission  and  remission  of  the  pain.  5th.  There  are  no  constant 
objective  signs  and  no  constant  morbid  changes  in  the  nerves.  True 
neuralgia  is,  therefore,  a  functional  condition,  and  a  symptom  produced 
by  a  number  of  diiferent  causes. 

Any  nerve  in  the  body  may  be  afiected.     Quite  often  one  can  find  no 


1078  DISEASES  OF  THE  XEEVOUS  SYSTEM. 

definite  cause  of  the  neuralgia.  A  number  of  cases  classified  as  such 
are  due  either  to  a  mild  j)erineuritis  or  to  disease  of  the  root  ganglion, 
as  in  herpes  zoster.  In  many  of  these  it  may  be  difficult  to  make  a 
diflereutial  diagnosis  if  the  process  is  not  severe  enough  to  interfere  with 
the  function  of  the  nerve,  and  such  cases  may  be  classified  with  the  neu- 
ralgias. 

Htiologfy. — Anemia  from  any  cause ;  toxemia,  which  may  be  of 
exogenous  origin,  as  from  lead,  arsenic,  mercury,  copper,  alcohol,  tobacco, 
tea,  coffee,  any  of  the  infectious  diseases,  or  endogenous,  as  diabetes  and 
nephritis  ;  the  deprivation  of  either  morphin  or  cocain  in  a  habitu^  ;  re- 
Ilex,  as  the  referred  pains  of  visceral  disease,  thus  a  sciatica  may  be  due 
to  prostatic  disease,  neuralgic  pain  in  the  distribution  of  the  sixth  dorsal 
nerve  may  be  due  to  heart  disease,  and  so  on  ;  ^  heredity,  neuropathic, 
gouty,  and  scrofulous  individuals  being  especially  liable  :  exposure  to 
cold  and  wet  ;  chronic  vascular  disease,  especially  arteriosclerosis.  The 
early  stages  of  involvement  of  nerve  trunks  from  pressure  of  tumors, 
especially  neuromata,  aneurism,  fractures,  exostoses,  displacements  of 
bones,  etc.  ;  irritation,  as  from  decayed  teeth,  etc. ;  general  impairment 
of  health,  as  in  neurasthenia. 

General  Symptomatology. — The  neuralgic  attack  may  be  of  sudden  or 
slow  onset,  Avith  or  without  prodromata.  When  the  latter  exist  they 
consist  of  a  sense  of  uneasiness,  perverted  sensations,  chilliness,  and 
stinging  or  slight  burning  pains.  The  pain  is  usually  of  a  paroxysmal, 
darting,  boring  character,  radiating  into  the  distribution  of  the  affected 
nerves.  In  the  intervals  there  may  be  either  dull  pain  or  freedom  from 
it.  In  the  case  of  the  reflex  neuralgias  the  area  supplied  by  the 
affected  nerve-roots  is  the  seat  of  the  pain.  It  is  apt  to  be  increased  by 
movements  of  the  affected  parts,  draughts,  or  excitement.  Tenderness 
ma}^  be  found  over  certain  points,  especially  where  the  nerve  emerges 
from  a  bony  canal  (points  of  Yalleix);  these  are  not  always  present.  The 
afliected  part  is  usually  hyperesthetic ;  occasionally,  however,  it  is  anes- 
thetic, and  may  continue  so  for  some  time  after  an  attack. 

Reflex  muscular  contraction  may  be  present  in  proportion  to  the  in- 
tensity of  sensory  irritation.  Vasomotor  symptoms  manifest  themselves 
in  the  flushing  or  blanching  of  the  affected  part  and  in  increased  secre- 
tions, as  sweating. 

Trophic  disturbances  may  result  in  temporary  or  permanent  changes. 
To  the  former  belong  the  herpetic  and  urticarial  eruptions,  while  the  latter 
groups  include  change  of  color  in,  loss  of,  or  overgrowth  of  the  hair, 
various  changes  in  the  skin  (as  pigmentation  and  morphea,  and  even 
ulceration,  though  in  the  latter  instance  there  is  probably  a  more  pro- 
found pathologic  change  than  that  which  we  regard  as  the  cause  of  neu- 
ralgia). Unless  the  attacks  are  severe  or  prolonged,  however,  the  general 
system  seMom  suffers. 

Diagnosis. — Neuralgia  must  be  distinguished  from  neuritis,  a  mild 
attack  of  which,  as  has  been  said,  it  may  resemble  very  closely.  So  much 
.so,  in  fact,  that  in  some  eases  the  distinction  cannot  be  made.  Whenever 
the  function  of  the  nerve  is  interfered  with,  as  shown  by  motor  weakness, 

1  These  relations  have  been  studied  and  classified  by  Henry  Head,  Brain,  1893,  p.  1 ; 
1894,  p.  23;  1896.  p.  153. 


TIC  DOULOUREUX.  1079 

constant  diminution  of  sensibility,  absent  or  diminished  reflexes,  tender- 
ness along  the  nerve-trunk,  and  wasting  of  the  niusch^s,  neuritis  is  present. 
Headache  is  distinguished  by  the  fact  that  the  pain  is  more  or  less  diffuse, 
and  is  not  paroxysmal  and  shooting  in  type.  It  must  be  remembered  that 
pain  of  a  neuralgic  type  may  occur  in  diseases  of  the  cranial  or  spinal 
bones,  tumor  of  the  cord  or  its  membranes,  tabes  dorsalis,  multiple 
sclerosis,  syringomyelia,  meningomyelitis,  basal  meningitis,  cervico- 
pachymeningitis,  tumor  of  the  cerebe]l<j-pontile  angle,  of  the  Gasserian 
ganglion,  and  inflammation  of  the  sensory  root  ganglia,  either  cranial 
or  spinal.  The  diagnostic  points  will  be  detailed  under  their  respective 
headings. 

Prognosis. — This  depends  upon  the  cause,  whether  removable  or 
not ;  some  forms,  especially  those  of  the  fifth  and  sciatic  nerves,  are  very 
intractable  (pp.  1079,  1082).  There  is  always  the  danger  in  chronic  cases 
of  a  drug  habit  being  formed. 

Certain  types  require  special  mention.     Treatment  is  given  on  p.  1083. 

TIC    DOULOUREUX. 

This  is  a  neuralgia  involving  one  or  more  of  the  branches  of  the  fifth 
nerve.  It  varies  greatly  in  character  and  intensity  in  different  cases, 
and  in  its  severest  forms  is  one  of  the  most  terrible  of  all  the  diseases 
of  the  nervous  system. 

The  pathology  is  doubtful.  In  those  cases  that  have  been  subjected 
to  surgical  operation,  excised  portions  of  the  nerves  sometimes  were 
normal  and  sometimes  contained  a  moderate  number  of  degenerated 
fibers.  In  other  cases  in  which  the  Gasserian  ganglion  has  been 
removed  and  examined,  considerable  sclerosis  of  the  blood-vessels  has 
been  detected,  alterations  in  the  axis-cylinders  of  the  nerves,  and  occa- 
sionally moderate  changes  in  the  ganglion  cells.  It  is  not  known  exactly 
how  these  lesions  produce  the  symptoms,  but  it  is  probable  that  vascular 
alterations  are  exceedingly  important. 

The  etiology  is  various.  Neuropathic  heredity  appears  to  play  an 
important  part.  It  is  more  frequently  a  disease  of  late  than  of  early 
life.  Peripheral  irritation  is  frequently  found,  and  when  removed  often 
results  in  complete  cure.  Among  the  structures  disease  of  which  is  a 
frequent  cause  of  tic  douloureux  are  the  nose  and  the  cavities  enter- 
ing into  it,  and  the  mouth.  Lesions  of  the  former  structures  com- 
prise chronic  irritations,  spurs,  occlusion  of  the  nasal  openings,  and 
suppuration.  In  the  latter,  abscesses  at  the  roots  of  the  teeth,  irritated 
pulp,  and  occasionally,  either  non-eruption  or  malpositions  of  the  teeth, 
are  among  the  exciting  factors.  It  is  possible  that  eye-strain  may  also 
be  an  exciting  cause. 

The  symptoms  may  be  variable  in  extent,  duration,  and  intensity. 
In  the  mild  form  there  is  only  an  occasional  paroxysm,  limited  to  one 
of  the  branches  of  the  nerve,  such  as  the  type  that  occurs  in  acute 
coryza.  In  the  more  severe  form  there  may  be  repeated  paroxysms,  the 
intervals  varying  from  a  few  minutes  to  several  days,  involving  the  ■whole 
side  of  the  face,  and  causing,  for  the  time  being,  complete  prostration  on 
the  part  of  the  patient.  The  pain  is  often  radiating,  or  of  a  rending  or 
boring  character,  and  sometimes  so  severe  as  to  cause  nausea.  It  is 
often  accompanied  by  certain  vasomotor  or  secretory  phenomena,  such 


1080  DISEASES  OF  THE  yERVOUS  SYSTEiM. 

as  flushing,  perspiration,  or  excessive  tear-pro<hiction,  and  even  in  some 
eases  more  or  less  persistent  edema  of  the  skin.  In  some  instances 
there  may  be  more  or  less  twitching  of  the  facial  muscles.  The  duration 
of  the  attacks  varies  greatly.  The  paroxysms  may  succeed  each  other 
frequently  for  long  periods  of  time,  or  until  the  patient  becomes  insane 
or  commits  suicide ;  in  other  cases,  after  a  few  paroxysms,  the  attack 
passes  off  and  may  not  return  for  months.  In  some  instances  the  jmin 
is  persistent,  and  although  in  these  cases  it  is  rarely  severe,  the  discom- 
fort of  the  patient  is  sometimes  greater.  The  painful  points  are :  for 
the  first  branch,  the  supraorbital  foramen  ;  for  the  second,  the  infra- 
orbital foramen ;  for  the  third,  the  mental  foramen.  Often  the  sur- 
rounding portions  of  the  skin,  particularly  those  where  the  periosteum 
is  near  the  surface,  are  tender.  If  the  disease  continues  for  some  time 
there  may  be  trophic  changes,  such  as  the  formation  of  ulcers,  drying  of 
the  skin,  and  the  appearance  of  gray  hairs. 

The  (hai/nosis  may  have  to  be  made  from  tumor  involving  the  Gas- 
serian  ganglion  or  one  in  the  cerebello-pontile  angle.  The  former  can  be 
distinguished  by  the  existence  of  anesthesia  in  the  fifth-nerve  distribu- 
tion. The  diagnostic  points  of  the  latter  are  given  on  p.  1188.  Bulbar 
tabes  (p.  1148)  may  also  cause  pain  in  the  course  of  the  fifth  nerve. 
Neuralgic  pain  in  front  of  the  auricle  and  within  the  meatus  may  be  due 
to  disease  of  the  geniculate  ganglion  or  intumescentia  gangliformis  (p. 
1103).     A  skiagram  Avill  show  the  existence  of  non-erupted  teeth. 

The  prognosis  depends  largely  upon  the  cause.  In  the  so-called 
idiopathic  cases  it  is  exceedingly  unfavorable. 

Tiie  treatment  consists  first  in  the  removal  of  the  cause,  if  it  can  be 
found.  The  eyes,  nose,  and  mouth  should  be  carefully  examined,  and 
any  source  of  irritation  thoroughly  removed.  For  the  treatment  of  the 
paroxysms,  if  they  are  mild,  the  coal-tar  analgesics  may  be  employed. 
If  severe,  the  only  drug  that  is  at  all  effective  is  morphin,  which  is  pref- 
erably given  hypodermically.  Of  course,  in  nearly  all  instances,  if  the 
disease  is  chronic,  the  patient  becomes  addicted  to  the  use  of  this  drug. 
Occasionally,  the  external  application  of  a  mixture  of  the  ointments  of 
opium  and  belladonna  has  proved  of  service.  Strychnin,  in  full  doses, 
combined  with  complete  rest  and  liquid  diet,  aconitin,  nitroglycerin  in 
old  people  in  full  doses,  have  sometimes  rendered  the  attacks  milder  and 
less  frequent.  They  should  be  given  hypodermically.  Salicylates  may 
also  prove  useful.  The  general  health  of  the  patient  should  be  improved 
if  possible,  and  the  disease  treated  expectantly  for  some  time.  The  gal- 
vanic current,  the  anode  being  placed  over  the  painful  areas  and  given 
without  interruption,  may  sometimes  prove  useful.  Formerly,  section  of 
the  painful  nerve  branch  was  employed,  and  even  resection  of  a  portion 
of  the  nerve,  but  the  results  were  either  so  trifling  or  so  transient  that  in 
recent  years  the  tendency  has  been  to  resort  more  frequently  to  the  ex- 
cision of  the  Gasserian  ganglion.  This  is  a  serious  operation,  and  the 
mortality  is  considerable ;  nevertheless,  it  is  often  Aviser  to  employ  it 
early  rather  than  to  delay  until  the  patient  is  exhausted  by  long  suffering. 
Spiller  has  suggested  the  section  of  the  sensory  root  of  the  ganglion,  and 
this  operation  gives  the  same  results  as  excision  of  the  ganglion.  The 
most  satisfactory  method  of  treatment,  if  medical  methods  fail,  is  the  in- 
jection of  alcohol  into  the  region  of  the  foi'amina  rotundum  or  ovale, 


NEURALGIA    OF  THE  EXTREMITIES.  1081 

according  to  the  branch  aifected.^     By  this  plan  relief  for  several  years 
at  least  is  obtained. 

NEURALGIA  OF  THE  NECK  AND  TRUNK. 

The  cervical  branches  of  the  dorsal  and  lumbar  nerves  are  involved  in 
this  group. 

1.  Cervico-occipital  neuralgia,  occurring  in  the  occipital  and  posterior 
parietal  region,  is  apt  to  be  quite  severe,  but  when  not  due  to  spondylitis 
(the  result  of  caries)  or  neoplasms  the  prognosis  is  fair.  It  is  sometimes 
the  result  of  direct  pressure,  as  in  carrying  heavy  loads  on  the  neck  and 
shoulders.  The  painful  spot  is  found  between  the  mastoid  process  and 
upper  cervical  vertebrae.  Falling  of  the  hair  may  also  occur.  This  is 
much  mox'e  apt  to  take  place,  however,  when  the  occipitalis  minor  is  in- 
volved, as  it  is  said  that  the  latter  is  generally  a  syphilitic  neuralgia. 

2.  Phrenic  neuralgia  has  been  described,  but  is  a  rare  condition. 
The  pain  is  in  the  lower  anterior  thoracic  region,  at  the  points  of  insertion 
of  the  diaphragm. 

3.  Intercostal  Neuralgia. — The  middle  intercostal  nerves  are  most 
liable  to  be  affected,  and  generally  on  the  left  side.  The  posterior  dorsal 
branches  are  seldom  involved.  When  specially  severe  and  persistent, 
intercostal  neuralgia  may  be  a  symptom  of  disease  of  the  cord  or  its  mem- 
branes, aneurysm  of  the  aorta,  neoplasms,  or  disease  of  the  vertebrae  or 
ribs.  Traumatism  and  cold  also  give  rise  to  it.  This  form  of  neuralgia 
is  most  common  in  women,  the  painful  spots  being  at  the  extremity  and 
at  the  middle  of  the  ribs.  The  pain  is  of  a  sharp,  lancinating  character 
and  radiates  along  the  nerve.  It  is  intensified  by  all  movements  of  the 
chest ;  hence  the  aifected  side  is  more  or  less  fixed.  Herpes  may  develop, 
but  in  such  cases  it  is  probable  that  an  inflammation  of  the  root  ganglion 
exists  (p.  1132). 

4.  Mastodynia  is  really  a  variety  of  intercostal  neuralgia,  and  occurs 
almost  solely  among  women.  It  is  very  painful  and  gives  rise  to  the 
development  of  tender  "lumps  "  in  the  breast,  simulating  malignant  dis- 
ease.    The  paroxysms  are  often  accompanied  by  vomiting. 

5.  Lumho-abdominal  neuralgia  is  not  a  common  form.  The  pain  is 
chiefly  in  the  lumbar  region,  though  the  hypogastrium,  genitals,  and 
buttocks  may  also  be  involved. 

NEURALGIA   OF   THE   EXTREMITIES. 

Cervico-hrachial  neuralgia  occurs  in  the  distribution  of  the  four  lower 
cervical  nerves.  When  the  condition  is  bilateral  we  should  look  for  dis- 
ease of  the  cord,  especially  tabes  or  membranes,  for  new  growths,  or  for 
disease  of  the  vertebrge.  When  unilateral,  any  of  the  causes  already 
enumerated  may  be  operative.  The  radial  and  ulnar  nerves  are  more 
frequently  affected  than  the  median.  The  pain  is  most  apt  to  be  dis- 
tributed along  the  Avhole  course  of  the  nerve,  but  painful  points  are  found 
in  the  following  situations :  in  the  axilla ;  over  the  brachial  plexus  ;  on 
the  shoulder,  where  the  cutaneous  branches  of  the  circumflex  nerve  emerge 
through  the  deltoid  muscle  ;  about  the  middle  of  the  outer  surface  of  the 
upper  arm  ;  over  the  ulnar  nerve ;  in  the  sulcus  between  the  olecranon 
'  Joxtr.  of  the  Amer.  Med.  Asfioc,  Jan.  20,  1912,  p.  155. 


1082  DISEASES  OF  THE  NERVOrS  SYSTEM. 

and  epitrochlea ;   also  near  the  wrist  and  at  the  bend  of  the  elbow  over 
the  musculo-spiral  nerve. 

Femoral  or  crural  neurah^ia  is  a  somewhat  rare  type  that  attacks  the 
anterior  surflice  of  the  thigh,  the  knee-joint,  and  the  inner  surface  of  the 
leg  and  foot. 

Obturator  neurahfia  is  distributed  along  the  inner  side  of  the  thigh 
down  to,  and  includintr,  the  knee-joint.  This  form  is  common  in  women 
subject  to  ovarian  diseases,  and  may  be  mistaken  for  the  pain  of  hip- 
joiut  tlisease. 

Sciatica  is  such  a  common  condition  that  a  more  extended  description 
is  necessary.      The  term  is  applied  to  pain  in  the  course  of  the  sciatic 
nerve,  whether  due  to  a  pure  neuralgia  or  a  neuritis.     It  is  probable  that 
the  majority  of  the  cases  are  due  to  a  perineuritis  in  which  the  presence 
of  the  exudation   is  not  sufficient  to  cause  marked  interference  with  the 
nerve  functions.      It   may  be   caused  by  any  of  the  causes  of  neuralgia 
(p.  1078),  but   most  cases  are   due  to  exposure,  especially  marked  and 
sudden  clianges  in  temperature.      Traumatism  and  prolonged  pressure  is 
also  a  frequent  cause  of  the  neuritic  form.      That  due  to  pressure  most 
frequently  occurs   after   childbirth.      It    occurs   most   commonly  in  men 
during  mid  He  life.      Some  cases  are  due  to  chronic   constipation.      The 
painful  points  are  in  the  gluteal  region  and  the  popliteal  space  or  malle- 
olar region,  though  tenderness  may  be  elicited  along  the  whole  course  of 
the  nerve.      The  pain  is  sharp  and  shooting,  or  more  often  of  a  tearing 
variety.      It  miy  be  localized  to  tiie  region  either  of  the  sciatic  notch  or 
calf.      Th3  anterior  crural  nerve  may  also  be  involved.      It  is  increased 
by  putting  the  nerve  on  the  stretch,  which  can  be  done  by  forcibly  flex- 
ing the  thigh  on  the  body  (Laseque's  sign),  and  by  motion  after  a  period 
of  rest.     Rarely  both  nerves  are  involved,  especially  if  due  to  toxemia. 
Pain  may  also  be  felt  in  the  lumbar  region.     Fine  or  coarse  tremors  or 
spasms  may  be  present.     Herpes  occasionally  develops  along  the  course 
of  the  nerve.     In  cases  due  to  neui'itis  of  any  severity  the  Achilles  jerk 
is  absent,  wasting  and  weakness  of  the  muscles  occur,  and  sensation  in 
the  foot  and  leg  may  be  diminished  or  absent. 

In  making  the  diagnosis,  it  must  be  borne  in  mind  that  tabetic  pains 
and  neuritis,  due  to  diabetes,  may  simulate  sciatica.  The  pain  of  hip- 
joint  disease  and  either  inflammation  or  relaxation  of  the  sacro-iliac 
synchondrosis  may  also  simulate  it.  A  careful  examination  will  reveal 
the  true  condition.  The  same  may  be  said  of  tumor  involving  the  cord 
and  its  membranes  (p.  1157).  Lesions  of  the  cauda  equina  also  cause 
sciatic  pain  Avhich  is  usually  bilateral,  and,  in  addition,  there  will  be 
atrophy  and  paralysis  and  involvement  of  the  sphincters  (p.  1159).  Intra- 
pelvic  growths  should  also  be  borne  in  mind.  The  pain  of  intermittent 
claudication  occurs  only  after  exercise,  is  not  limited  to  the  course  of  the 
nerves,  and  the  posterior  tibial  and  dorsalis  pedis  arteries  will  not  be 
palpable.  In  making  a  j^rognosis  it  must  be  borne  in  mind  that  it  is 
often  rebellious  to  treatment,  but  most  cases  ultimately  recover.  Relapses 
are  apt  to  occur. 

The  most  useful  plan  of  treatment  is  absolute  rest  in  bed,  with  the  limb 
kept  perfectly  still  by  means  of  sand-bags  or  a  long  splint,  with  the  applica- 
tion of  heat  along  the  course  of  the  nerve,  and  the  galvanic  current,  the 
anode  over  the  sciatic  notch  and  the  other  at  the  foot,  applied  daily  for  ten 


NEURALGIA   OF  THE  GENITALIA   AND  RECTUM.  1083 

minutes  without  interruption.  IIigh-frc(|uency  and  tlie  static-wave  cur- 
rent are  useful  in  many  cases.  Full  doses  of  the  salicylates  should  be  gi  ven 
internally.  Local  applications  of  one  of  the  salicylic  acid  preparations, 
as  a  25  per  cent,  ointment  of  mesotan,  may  also  be  of  service.  In  old 
people  with  arterosclerosis  full  doses  of  nitroglycerin  and  potassium  iodid 
may  give  relief.  In  severe  chronic  cases  electricity,  as  mentioned  above,  and 
counter-irritation,  preferably  by  means  of  a  succession  of  small  fly-blisters 
along  the  course  of  the  nerve,  is  of  great  value.  When  all  else  fails,  stretch- 
ing the  nerve  after  exposing  it  often  cures,  but  sometimes  aggravates,  the 
symptoms.  The  bowels  should  always  be  kept  free.  Deep  injections  of 
cocain,  eucain,  thein,  ether,  or  chloroform  are  sometimes  used,  and  even  dis- 
tilled water  may  give  relief  when  injected  into  the  nerve.  The  use  of 
guaiacol  (Uli-ij — 0.066-0.1332)  in  association  with  chloroform  (THx — 
0.666)  by  this  method  has  yielded  very  encouraging  results  in  my  hands.' 
Excellent  results  have  recently  been  reported  from  deep  perineural  injec- 
tions of  salt  solution." 

Neuralgia  of  the  Genitalia  and  Rectum. — These  varieties  are 
not  met  with  frequently.  The  former  is  sometimes  a  symptom  of  stone, 
prostatic  disease,  or  stricture,  and  in  women  ovarian  and  uterine  neu- 
ralgias are  generally  hysteric  manifestations.  Coccygodynia,  unless  of 
traumatic  origin,  is  almost  solely  found  in  women.  The  pain  in  the  region 
of  the  coccyx  is  excruciating  at  times,  and  may  even  call  for  operation. 

Visceral  Neuralgia. — As  implied  by  the  name,  these  foi-ms  are 
neuralgias  resident  in  the  various  viscera.  They  most  frequently  attack 
the  stomach  or  bowel,  and  are  recognized  as  colic.  Other  viscera  may 
also  be  involved  (liver,  kidney).  Such  pains  may  be  simulated  by  tabetic 
crises  (p.  1147}. 

Treatment  of  Neuralgia. — The  first  requisite  in  the  treatment 
of  neuralgia  is  to  ascertain  whether  it  is  due  to  local  or  general  causes. 
That  of  the  former  class  may  be  caused  by  a  cicatrix,  neuroma,  aneur- 
ysm, neoplasm,  or  by  caries  or  traumatism ;  and  the  treatment  must 
necessarily  be  directed  toward  the  removal  of  the  cause  when  possible. 
When  the  fault  is  a  general  one,  the  neuralgia  may  occur  either  as  the 
immediate  result  of  the  systemic  disease,  or  remotely,  as  the  result  of  the 
altered  blood-state  (anemia).  This  is  particularly  well  illustrated  by  an 
attack  of  malaria,  in  which  it  is  obvious  that  success  can  only  be  obtained 
by  attention  to  the  underlying  cause.  It  is  sometimes  necessary  to  use 
an  analgesic,  of  which  morphin  is  certainly  the  best.  Its  therapeutic 
value  is  most  decided  when  the  drug  is  given  hypodermically,  and  if  in- 
jected directly  over  the  track  of  the  painful  nerve  {e.  g.,  supraorbital 
branch  of  the  fifth),  it  not  only  affords  immediate  relief,  but  also  obviates  re- 
currences of  the  painful  paroxysms  in  many  instances.  It  is,  however, 
scarcely  necessary  to  urge  the  exercise  of  caution,  for  the  morphin-habit 
is  readily  formed  in  these  cases.  The  following  may  also  be  used :  anti- 
pyrin,  phenacetin,  codein,  veratrum  viride,  aconite,  also  counter-irritants 
and  vesicants,  including  the  galvanic  current,  which  is  applied  by  placing 
the  anode  over  the  tender  spots  if  they  exist,  otherwise  over  the  seat  of 
the  pain.  A  rapidly  interrupted  faradic  current  applied  over  this  area 
and  the  high-frequency  current  may  also  prove  valuable.      The  general 

^  "  The  External  and  Internal  Use  of  Guaiacol,"  Therapeutic  Gazette,  Mar.  15,  1895. 
^lyOrsay  Hecht,  Jour.  Amer.  Med.  Assoc,  Feb.  6,  1909,  p.  444. 


1084  DISEASES  OF  THE  yEBVOUS  SYSTEM. 

tone  of  the  system  must  be  attended  to,  bad  liabits  proliibited,  the  state 
of  the  bowels  regulated,  and  the  eyes  examined  and  corrected  for  errors 
of  refraction.  Rest  is  a  valuable  adjunct  to  any  form  of  treatment.  lu 
severe  neuralgia  of  either  the  brachial  or  lumbosacral  plexus  division  of 
the  posterior  roots  has  been  pi-actised  with  varied  success.* 


NEURITIS. 


Definition. — An  inflammation  of  a  nerve  or  of  its  fibrous  envelope. 

It  may  be  confined  to  a  single  nerve,  termed  local  neuritis,  or  a  num- 
ber of  nerves  may  be  affected,  when  it  is  termed  multiple  or  poly-neuritis. 

Pathology. — The  inflammation  may  be  chiefly  confined  to  the  sheath 
of  the  nerve  (perineural)  or  may,  in  addition,  involve  the  deeper  portions 
of  the  sheath  (endoneurium),  in  which  an  accumulation  of  lymphoid  ele- 
ments will  be  found  between  the  nerve-bundles.  This  form  is  known  as 
interstitial  neuritis,  and  is  the  condition  usually  found  in  the  localized 
form.  The  nerve  Avill  be  found  to  be  fjWoUen  and  red  in  color,  but  the 
nerve-fibers  do  not  appear  involved.  Eventually,  however,  changes  re- 
sembling those  found  in  Wallerian  degeneration  may  occur,  the  myelin 
becoming  fragmented,  the  nuclei  in  the  sheath  of  Schwann  increasing;  in 
number,  the  nuclei  of  the  internodal  cells  becoming  swollen,  and  the 
nerve-fibers  undergoing  granular  degeneration.  In  parencJii/inatous 
neuritis,  the  condition  found  in  multiple  neuritis,  the  nerve-fibers  are 
primarily  and  principally  affected.  Changes  like  those  met  with  in 
Wallerian  degeneration  described  above  are  met  with,  but  the  sheath 
shows  little  evidence  of  inflammation. 

etiology. — (a)  Local  neuritis  may  be  due  to — (1)  Exposure  or  cold 
(the  so-called  rheumatic  neuritis).  (2)  Extension  of  inflammation  from 
neighboring  parts.  (3)  Traumatism — wounds,  compression,  excessive 
stretching  resulting  from  fractures  or  dislocation,  electrical  shock.  (4) 
Microbic  and  autogenetic  poisons.  (5)  Arterio-sclerosis.  (6)  Stoop 
shoulders,  Avhich  cause  compression  of  the  axillary  structures  between  tlie 
humerus  and  ribs,  causing  either  brachial  or  ulnar  neuritis.^ 

(b)  Multiple  neuritis  may  be  due  to — (1)  Poisons  of  extrinsic  origin — 
carbon  monoxid,  alcohol,  carbon  bisulphid,  lead,  arsenic,  mercury,  ether. 
(2)  Poisons  resulting  from  the  infectious  fevers  (typhoid,  diphtheria,  vari- 
ola, typhus,  leprosy,  beri-beri,  measles,  syphilis,  tuberculosis,  septicemia, 
malaria,  influenza.  (3)  Poisons  produced  Avithin  the  body,  as  from  gout, 
rheumatism,  diabetes,  and  pregnancy.  (4)  Cachexias,  anemia,  carcinoma, 
arteriosclerosis.  (5)  Gases  arise  in  which  no  definite  cause  can  be  ascer- 
tained ;  these  are  the  so-called  idiopathic  or  spontaneous  cases. 

Symptoms. — {a)  Focal  Neuritis. — In  localized  neuritis  the  symptoms 
vary  according  to  the  function  of  the  nerve  involved.  In  the  case  of  a 
sensory  nerve  there  is  pain,  usually  of  a  boring  or  shooting  character, 
along  its  course  and  distribution.  There  is  also  tenderness  on  pressure 
along  the  nerve.      The  skin  is  generally  hyperalgesic  (though  tactile  sen- 

1  Neir  York  Medical  Jour.,  Aug.  3,  1907,  p.  192,  and  Jour.  Ncrv.  and  Meat.  Dis.,  Sei)t., 
1907,  p.  589. 

^  Goldthwait,  Jour.  Amer.  Med.  Aia^or.,  Sept.  11,  1909,  p.  852. 


NEURITIS.  1085 

sation  is  often  lowered),  may  be  reddened,  sometimes  edematous,  and 
local  sweatings  may  occur.  In  the  more  chronic  cases  trophic  symptoms 
eventually  arise,  as  glossiness  of  the  skin  and  an  impaired  growth  of  the 
nails.  When  a  motor  nerve  bears  the  brunt  of  the  attack  there  is  more 
or  less  impairment  of  motion,  even  amounting  to  paralysis;  and  ulti- 
mately wasting  of  the  muscles  and  even  reactions  of  degeneration  take 
place.  When  both  motor  and  sensory  nerves  are  simultaneously  involved 
the  symptoms  will  necessarily  partake  of  a  mixed  character.  Many  cases 
of  a  mild  type  occur  in  which  the  symptoms  consist  of  pain,  tenderness  on 
pressure  over  the  affected  nerves,  some  impairment  of  motion,  slight 
atrophy,  and  a  diminished  contractility  to  the  faradic  current.  The  con- 
stitutional symptoms  are,  as  a  rule,  of  little  moment.  The  symptoms  of 
neuritis  affecting  special  nerves  are  detailed  on  pp.  1090-1117. 

(6)  Multiple  neuritis  is  an  involvement  of  the  jieripheral  nerves  in 
various  parts  of  the  body,  affected  simultaneously  or  in  ({uick  succession, 
and  due  to  endogenous  or  exogenous  poisons. 

Among  cases  due  to  poisons  of  extrinsic  origin  is  alcoholic  neuritis. 
This  is  the  most  common  type  of  multiple  neuritis.  It  results  from 
spirit-drinking  in  moderate  amounts  and  continued  over  a  long  time. 
The  onset  is  generally  slow,  being  preceded  by  gastric  catarrh,  insomnia, 
and  particularly  numbness  and  tingling  of  the  extremities.  A  rapid, 
weak  heart  and  a  tendency  to  sweating  on  exertion  may  also  be  present. 
Weakness,  especially  of  the  extensor  muscles  of  the  wrists  and  dorsal 
flexors  of  the  feet ;  pain  and  muscular  tenderness,  the  latter  being  most 
prominent  in  the  muscles  of  the  calf,  where  it  is  usually  an  early  symp- 
tom, are  soon  noticed.  As  a  rule,  the  legs  are  first  affected,  and  in  mild 
cases  the  arms  may  escape.  As  a  rule,  however,  all  of  the  nerves  supply- 
ing the  extremities  ultimately  become  more  or  less  affected,  and,  in 
extreme  cases,  cranial  nerves  may  also  suffer.  The  reflexes  are  lost 
(rarely  the  knee-jerks  may  be  increased  in  the  early  stages),  muscular 
atrophy  becomes  marked,  and  pain  and  tenderness  very  severe.  Rarely 
loss  of  control  of  the  bladder  and  rectum  take  place.  Fever  is  seldom 
noticed.  More  or  less  impairment  of  pain,  tactile,  and  muscle  sense  may 
also  be  present.  The  early  loss  of  power  in  the  extensor  muscles  soon  causes 
double  wrist-  and  foot-drop,  and  the  gait,  owing  to  the  effort  to  make  the 
toes  clear  the  ground,  is  of  a  peculiar  high-stepping  variety,  known  as 
"steppage  gait." 

The  cutaneous  reflexes  are  preserved  unless  the  anesthesia  is  marked. 
In  less  severe  cases  a  certain  amount  of  incoordination  may  be  present. 
When  this  is  the  case,  the  absence  of  the  knee-jerk,  the  loss  of  muscular 
sense,  occurrence  of  ataxia,  and  the  pains  in  the  extremities  simulate  loco- 
motor ataxia,  and  the  term  pseudo-tabes  has  been  applied  to  the  condition. 
Vasomotor  and  trophic  symptoms  appear,  and  in  some  cases  the  special 
senses  are  involved  (impairment  of  vision,  amblyopia,  limitation  of  the  color- 
field).  The  mental  symptoms  are  important.  They  may  be  so  slight  as 
to  consist  merely  of  loss  of  memory,  irritability,  perhaps  an  hallucination 
or  illusion  (particularly  after  nightfall,  and  especially  if  the  patient  has 
had  insomnia),  or  they  may  be  very  severe,  consisting  of  marked  mental 
impairment,  hallucinations,  delusions,  disorientation,  etc..  a  symptom 
group  known  as  Korsakow's  psychosis.  The  duration  of  an  attack  varies 
from  a  few  weeks  to  a  year  or  more. 


108G  DISEASES   OF  THE  yERVorS  SYSTEM. 

Arsoiic  neuritis  difters  from  the  above  in  that  the  mental  symptoms 
are  generally  absent.  The  onset  may  be  much  more  abrupt  and  the 
course  is  usually  shorter. 

Carbon  bisnltiil  )uHritii<  occurs  chietly  in  workers  in  rubber  factories 
and  imitation  silks.  There  are  noted  intense  frontal  headache,  giddiness, 
marked  excitability,  muscular  cramps,  and  possibly  convulsions.  Satur- 
nine 7ieuritis  is  confined  to  motor  nerves,  and  especially  to  those  of  the  upper 
extremities,  the  posterior  interosseous  branch  of  the  musculospirals  being 
especially  liable  to  be  involved,  causing  doul)le  wrist-drop.  Any  or  all 
nerves  mav,  however,  become  affected.  Peculiar  features  are  the  usual 
absence  of  pain  and  tenderness,  and  the  escape  of  the  supinator  longus 
and  extensor  ossis  metacarpi  pollicis  muscles.  Lesions  of  the  anterior 
cornua  are  more  likely  to  occur  in  saturnine  multiple  neuritis  than  in  any 
of  the  other  varieties.  Delirium  (lead  encephalopathy),  optic  neuritis, 
and  convulsions  may  occur,  but  are  not  common  .symptoms. 

Cases  due  to  an  attack  of  some  infectious  disease  may  be  local  or 
multiple,  and  generally  present  the  same  symptoms  of  neuritis  due  to 
any  other  cause.  Jiecurri)u/  Multiple  Seuritis. — A  few  cases  have  been 
reported  in  which  attacks  of  more  or  less  widespread  paralysis,  due 
to  neuritis,  have  recurred.  Senile  neuritis  occurs  in  old  age,  and  is 
probably  a  degeneration  due  to  arteriosclerosis.  The  symptoms  de- 
velop gradually  and  consist  of  weakness  and  numbness  of  the  limbs, 
especially  the  lower:  absent  knee-jerks,  sometimes  slight  atrophy  and 
diminished  response  to  the  faradic  current.  Cranial  nerves  may  also  be 
affected. 

Spontaneous  or  the  so-called  idiopathic  neuritis  does  not  differ  from 
the  general  type  of  the  disease,  except  that  no  cause  can  be  discovered 
to  account  for  it. 

Beri-Beri. — This  is  a  form  of  multiple  neuritis,  occurring  endemically, 
chieflv  in  the  islands  of  the  Pacific  Ocean  and  in  Asia.  It  is  especially 
prevalent  in  Japan  and  the  Philippines.  Sporadic  cases  are  met  with  in 
increasing  frequency  in  Europe  and  America,  brought  on  ships  from  the 
Orient.  Its  exact  nature  is  not  known.  It  is  probably  an  infectious 
maladv,  which,  to  a  certain  extent,  may  be  communicated  either  by  direct 
contact  or  by  living  in  rooms  where  a  case  has  previously  been.^  It  is 
especially  apt  to  occur  where  many  are  crowded  into  a  limited  space,  as 
jails,  barracks,  ships,  etc.  Moisture  and  heat  favor  its  development. 
An  exclusive  rice  diet  may  act  as  a  predisposing  factor. 

The  essential  feature  of  the  pathology  is  the  changes  in  the  nerves ; 
these  are  inflammatory  and  degenerative.  Degeneration  in  the  muscles 
also  occurs,  and  not  infrecjuently  serous  effusion.  A  variety  of  clinical 
types  have  been  recognized.  Of  these  the  most  important  are  the 
wasting  and  the  wet  forms.  The  onset  may  be  rapid  or  more  gradual. 
In  the  first  type  there  is  loss  of  power  in  the  limbs,  wasting  of  the 
muscles,  and  more  or  less  emaciation.  Subjectively,  there  are  pain  and 
paresthesiae  in  the  limbs,  tenderness  in  the  muscles  and  over  the  nerve 
trunks.  The  patients  also  complain  of  weakness,  dyspnea,  and  palpita- 
tion. The  wet  form  is  characterized  by  the  earlier  or  later  occurrence 
of  general  anasarca,  with  effusion  into  the  serous  cavities.  The  .swelling 
may  be  enormous  and  obscure  the  muscular  wasting.     Sometimes  the 

1  Brain,  1903,  p.  488. 


NEURITIS.  1087 

dyspnea  and  palpitation  of  the  heart  predominate.  The  prognosis  is 
usually  favorable,  but  the  course  is  prolonged  and  recurrence  is  not 
unusual.      In  the  cardiac  form  death  may  occur  in  a  few  days. 

Diagnosis. — This  does  not  present  any  difficulty,  as  a  rule.  In  the 
early  stages,  a<?(i^e  anterior  'poliomyelitiH  and  acute  aacendinfj  paralynin 
may  be  mistaken.  In  the  former  constitutional  symptoms  usually  pre- 
cede by  several  days  the  development  of  the  paralysis,  which,  when  it 
occurs,  is  usually  more  or  less  general,  to  be  followed  by  a  rapid  im- 
provement in  most  of  the  affected  limbs.  The  paralysis  in  multiple  neu- 
ritis develops  progressively.  If  pain  and  tenderness  occur  in  poliomye- 
litis, they  consist  of  a  general  hyperesthesia,  and  are  not  confined  to  the 
affected  nerve-trunks,  as  in  neuritis. 

In  ascending  paralysis  there  are  no  sensory  symptoms,  there  is  neither 
muscular  atrophy  nor  electric  change,  and  the  order  in  which  the  paralyses 
supervene  differs  from  that  of  peripheral  neuritis. 

Cases  of  pseudo-tabes  are  sometimes  confounded  with  locomotor  ataxia. 
The  main  points  of  differentiation  are  included  in  the  following  table : 

Pseudo-tabes.  Locomotor  Ataxia. 

The  course  is  shorter,  and  often  results  The   course  is  progressive  from  bad  to 

in  recovery.  worse,  and  chronic  in  nature. 

Pain  is  never  of  the  fulgurant  type.  Fulgurant  pains  often  are  present.    Pain- 
crises  are  almost  diagnostic. 

There  is  tenderness  over  the  nerve-trunks.  There  is  no  tenderness  over  the  nerves. 

Sensory  disturbances   are  more  marked  Sensory  disturbances  are  less  marked. 

(tingling  and  numbness). 

Argyll-Robertson  pupil  is  absent.  Argyll-Robertson  pupil  is  present. 

There  is  a  "  foot-drop,"  with  the  typical  No  "  foot-drop."    The  toes  are  raised,  and 

"  steppage  "  gait.  the  foot  is  brought  down  flatly,  with 

the  heel  first. 

Paralysis  is  often  present.  There  is  no  actual  loss  of  power. 

The  distinguishing  symptoms  from  progressive  neural  atrophy  are 
given  on  p.  1088. 

Prognosis. — Peripheral  neuritis  may  terminate  in  one  of  the  fol- 
lowing ways,  according  to  Drs.  Gibson  and  Fleming  ^ :  1.  In  complete 
recovery ;  2,  With  damaged  peripheral  nerves ;  3.  With  injury  to  the 
central  nervous  system,  especially  of  the  cells  in  the  anterior  horns ;  4. 
In  death  from  failure  of  the  organic  centers,  especially  that  of  respiration. 
The  prognosis  is  generally  good,  though  in  the  acute  variety  (from  any 
cause)  it  should  be  guarded,  and  occasionally  is  grave.  Exposure  and 
chill,  alcohol,  diphtheria,  and  beri-beri  give  rise  to  the  most  serious 
types,  and  often  cause  death  by  failure  of  the  heart  or  respiration  or  by 
coagula  in  the  vessels.  Mild  cases  may  entirely  recover  in  a  few  weeks, 
while  severe  ones  often  require  a  year  or  two. 

Treatment. — First  ascertain  the  cause  and,  if  possible,  remove  it. 
It  may  be  unwise  in  alcoholic  cases  to  stop  the  alcohol  suddenly,  but 
each  case  must  be  judged  on  its  merits.  Rest  is  very  important,  and  all 
sources  of  worry  should  be  stopped.  Locally,  anodynes  may  be  em- 
ployed and  the  part  wrapped  in  cotton  wool.  Ointments  of  either 
ichthyol  and  belladonna,  or  some  of  the  salicylic  acid  preparations  for 
external  use,  as  mesotan,  are  often  of  service.  The  pain  can  often  be 
relieved  for  several  hours  by  the  application  of  the  galvanic  current, 
^  Edinburgh  Hospital  Reports,  vol.  iii. 


1088  DISEASES  OF  THE  yERVOUS  SYSTEM. 

applied  without  interruption  down  the  limb.  In  acute  cases,  especially 
in  the  earlier  stages,  the  salicylates  are  valuable.  The  general  liealth 
should  be  toned  up  by  strychnin  and  tonics,  and  by  nourishing  but  easily 
digestil)le  food.  Further  modiL-atiou  Avill  depend  ujion  the  etiology, 
(juinin  being  demanded  in  malarial,  iodids  and  other  measures  to  elimi- 
nate the  lead,  in  lead  cases.  As  soon  as  the  acute  cases  have  subsided, 
massage  and  passive  movements  should  be  begun,  galvanism  applied  to 
the  muscles,  and  warm-water  or  sulphur  baths  administered.  Care 
should  be  taken  to  prevent  deformity  due  to  the  unojiposed  action  of 
antagonistic  muscles,  as  when  foot-  or  wrist-droj)  is  present. 


PROGRESSIVE  NEURAL  MUSCULAR  ATROPHY. 

{H'oJf7nan). 

{Progressive  Neurotic  Muscular  Atrophy  ;  Charcot-Marie-Tooth-Type  of  Progressive  Muscular 
Atrophy;  Peroneal  Type,  Gowers.) 

Definition. — A  degenerative  process,  apparently  commencing  in  the 
nerves,  and  characterized  by  muscular  degeneration,  with  subsequent 
contractures,  sensory  disturbences,  and  a  loss  of  the  reflexes. 

Pathology. — Sclerosis  of  the  posterior  columns  of  the  cord,  slight 
degeneration  of  the  pyramidal  tracts,  alteration  of  the  columns  of  Clarke, 
atrophy  of  the  cells  in  the  anterior  horns  of  the  cord,  degeneration  of 
the  peripheral  nerve-fibers  and  of  the  intramuscular  branches,  atrophy 
of  the  muscle-fibers,  and  chronic  spinal  meningitis  have  been  found  by 
different  observers  in  cases  of  this  disease. 

Ktiology. — Heredity  seems  to  play  an  important  part  in  the  causa- 
tion of  the  disease,  which  may  either  occur  in  successive  generations  of 
a  family  or  affect  several  members  of  the  same  generation.  Sporadic 
cases  occasionally  occur  for  which  it  is  impossible  to  trace  any  ancestral 
influence,  though,  as  the  disease  has  been  known  to  skip  a  generation,  it  is 
not  impossible  that  such  cases  are  still  hereditary.  Males  are  much 
more  frequently  affected  than  females,  and  the  disease  almost  invariably 
commences  between  the  ages  of  ten  and  twenty  years. 

Symptoms. — As  the  name  implies,  muscular  wasting  usually  begins 
in  the  muscles  of  the  feet  or  hands,  either  the  peronei,  the  common  ex- 
tensors of  the  toes,  or  the  small  muscles  of  the  foot  itself,  or  else  in  the 
muscles  of  the  thenar  and  hypothenar  eminences  and  the  interossei. 
Usually  the  atrophy  is  symmetric.  In  the  feet  it  leads  to  an  early 
development  of  club-foot,  which  is  most  pronounced  when  the  extremity 
is  at  rest.  Very  early  the  atrophy  of  the  small  muscles  causes  the  toes 
to  assume  the  claw  position,  and  the  atrophy  of  the  peroneals  causes 
foot-drop,  so  that  in  walking  the  foot  is  dragged  along  the  ground.  In 
the  later  stages  the  foot  becomes  permanently  fixed  in  a  position  of 
equino-varus  or  valgus.  The  hands  have  the  characteristic  appearance 
given  by  a  flattening  of  the  ball  of  the  thumb  and  middle  finger.  The 
interosseal  groores  also  become  deeper  and  the  fingers  gradually  assume 
the  claw-like  position  ("  mam  en  gi'ijfc  )■  The  disease  extends  slowly 
upward,  involving  the  muscles  of  the  calf  and  forearm  ;  the  muscles  of 


NEUROMATA.  1089 

the  thighs,  upper  arms,  and  trunk  usually  escape.  The  affected  muscles 
usually  show  distinct  fibrillary  twitchings.  When  electrically  examined, 
the  muscles  either  show  a  marked  diminution  in  reaction  to  the  galvanic 
and  faradic  currents,  or  distinct  reaction  of  degeneration  can  be  elicited. 
Similar  electric  changes  arc  also  found  in  the  nerves.  Mechanic  excita- 
bility of  the  muscles  is  considerably  diminished,  these  changes  being 
found  also  in  the  muscles  that  are  apparently  healthy.  Tbe  tendon- 
reflexes  are  usually  absent,  although  in  the  early  stages,  when  the  mus- 
cles of  the  thigh  are  still  unaltered,  the  knee-jerk  may  be  merely  dimin- 
ished. Sensation  is  sometimes  unaltered,  but  ordinarily  there  is  some 
diminution  of  sensibility  in  the  peripheral  parts  of  the  limbs.  Often 
there  are  paresthesias  and,  occasionally,  pains  of  considerable  intensity. 
The  general  condition  of  the  patient,  however,  remains  excellent.  The 
vegetative  organs  are  unaffected  and  nutrition  is,  therefore,  intact. 

The  diagnosis  can  be  made  from  other  forms  of  progressive  mus- 
cular atrophy  (particularly  the  type  "  Aran-Duchenne,"  p.  1142)  by  the 
sensory  disturbances,  the  fact  that  the  proximal  muscles  escape,  and  the 
early  age  at  which  the  symptoms  appear ;  from  the  muscular  dystrophies 
by  the  presence  of  fibrillary  tremors,  sensory  symptoms,  and  changes  in 
the  electrical  reactions  and  the  escape  of  the  proximal  muscles ;  from 
multiple  neuritis  by  the  absence  of  tenderness  over  the  nerve-trunks ; 
from  acute  poliomyelitis  by  the  mode  of  development. 

The  prognosis  is  good  as  regards  life,  but  unfavorable  as  regards 
cure  or  even  improvement.     The  course  of  the  disease  is  extremely  slow. 

The  treatment  employed  in  the  other  forms  of  amyotrophy  may  be 
tried,  but  so  far  nothing  has  succeeded  in  staying  the  course  of  the 
disease. 

A  type  of  disease  closely  allied  to  the  preceding  has  been  described 
by  D^jerine  under  the  name  of  ^''infantile  hypertrophic  and  progressive 
interstitial  neuritis."  The  muscular  symptoms  were  the  same,  but 
there  were  in  addition  ataxia,  lancinating  pains  in  the  limbs,  consider- 
able sensory  disturbances,  Romberg's  sign,  myosis,  with  slow  or  absent 
pupillary  reflexes  and  nystagmus.  In  addition  to  these  a  peculiar  symp- 
tom in  his  case  was  the  enormous  hypertrophy  of  the  nerve-trunks, 
which  could  be  felt  under  the  skin  as  large,  firm  cords.  Pathologically 
the  muscles  showed  degenerative  changes  and  the  nerves  a  pseudo-hyper- 
trophy due  to  the  enormous  proliferation  of  the  connective  tissue  and 
degeneration  in  the  posterior  columns  of  the  spinal  cord.  The  dis- 
ease appears  also  to  be  due  to  old  hereditary  influence,  the  first  2  cases 
described  being  a  brother  and  sister. 


NEUROMATA. 


Neuromata,  or  tumors  of  nerves,  have  been  described  as  (a)  true  and 
(6)  false. 

(a)  True  neuromata  consist  of  medullated  or  non-medullated  nerve- 
fibers  (the  myelinic  and  amyelinic  varieties — Virchow),  and  rarely  of 
ganglion-cells  also. 

(6)  False  neuromata  contain  no  nerve-elements.  The  growth  is  situ- 
ated on  the  nerve-trunk  itself,  and  consists  of  either  fibrous,  myxoma- 
tous, gliomatous,  or  sarcomatous  tissue. 

69 


1090  DISEASES  OF  THE  yERVOUS  SYSTEM. 

Neuromata  have  also  been  classified  according  to  their  situation  as 
(1)  Stump  neuromata,  or  bulbous  nerves :  (2)  Subcutaneous  neuromata, 
or  tuhercula  dolorosa ;  (3)  Nerve-trunk  neuromata ;  (4)  Plexiform 
neuromata. 

(1)  Stump  neuromata  develop  on  stumps  or  on  the  ends  of  divided 
nerves  as  the  result  of  traumatism.  They  may  consist  of  fibrous  tissue, 
but  are  usually  myelinic. 

(2)  Subcutaneous  tumors,  or  tubercula  dolorosa,  are  painful,  as  the 
latter  word  implies,  and  are  apt  to  be  multiple.  In  individuals  so 
afilicted  nerve-trunk  neuromata  may  coexist. 

(3)  Nerve-trunk  neuromata  are  usually  multiple.  In  one  case  quoted 
by  Gowers  as  many  as  3020  were  found.  They  may  be  true  or  false. 
In  the  former  case  the  nerve-fibers  are  less  apt  to  be  interfered  with  than 
in  the  heterologous  growth. 

(4)  Plexiform  neuromata  consist  of  beaded  and  tortuous,  interlacing 
neural  cords.      They  are  usually  congenital. 

Htiology. — Neuromata  may  be  due  to  traumatism.  When  multiple, 
however,  they  are  usually  hereditary,  occurring  in  families  of  a  neurotic 
or  strumous  diathesis.      They  are  most  commonly  found  in  men. 

Symptoms. — There  may  be  none.  When  present  their  character 
necessarily  depends  on  the  nature  of  the  nerve  involved  and  whether  the 
lesion  is  an  irritative  or  destructive  one.  More  or  less  pain,  numbness 
or  tingling,  paresthesia,  and  palsy  are  among  the  most  common.  Various 
reflex  manifestations  have  been  described,  and  epileptiform  convulsions 
have  been  attributed  to  their  presence,  pi'obably  unjustly. 

Treatment. — Apart  from  anodynes,  operative  measures  are  alone 
of  value,  except  when  the  tumors  are  the  result  of  syphilis,  as  occasion- 
ally happens ;  in  such  cases  specific  treatment  must  be  employed. 

It  must  not  be  forgotten,  however,  that  stump  neuromata  may  occur 
in  those  hereditarily  predisposed,  in  which  case,  as  Bowlby  has  pointed 
out,  their  removal  will  almost  surely  be  followed  by  a  return. 


DISEASES  OF  THE  CRANIAL  NERVES. 

OLFACTORY   NERVE. 

The  following  morbid  conditions  have  been  described  in  connection 
with  the  sense  of  smell : 

(rt)  Hypen-osmia  or  Olfactory  Hyperesthesia. — The  sense  of  smell  is 
abnormally  acute,  so  that  objects,  and  even  persons,  can  be  recognized 
by  this  means.     It  occurs  in  hysteria  and  insanity. 

{h)  Parosmia  (perverted  sense  of  smell)  may  occur  for  one  or  for  many 
odors  and  is  often  associated  with  an  obtunding  of  the  normal  sense. 

(c)  Subjective  sensations  of  smell  are  due  to  the  same  causes  as  the 
above.  An  olfactory  aura  may  precede  an  attack  of  epilepsy.  Olfactory 
hallucinations  occur  occasionally  in  the  insane,  and  in  irritative  lesions 
of  the  uncinate  gyrus  (Fig.  69). 

(d)  Anosmia  or  olfactory  anesthesia  (loss  of  the  sense  of  smell)  may 
be  caused  by — (1)  injury  to  the  peripheral  filament  by  local  disease  of 
the  nasal  mucous  membrane.  (2)  Injury  to  the  nerve-trunk  or  bulb, 
by  blows  on  the  head,  basal  fractures  of  the  skull,   bone-disease,  and 


DISEASES  OF  THE  RETINA,    OPTIC  NERVE  AND    TRACT.     1001 

meningitis.  Anosmia  may  occur  during  locomotor  ataxia.  Pungent  nnd 
powerful  odors  have  been  said  to  cause  loss  of  the  sense  of  smell,  due  to 
excessive  stimulation.  There  may  be  a  congenital  absence  of  the  olfac- 
tory nerves.  (3)  Centric  lesions,  "as  tumors  in  the  region  of  the  uncinate 
gyrus  (Fig.  69).  Unilateral  anosmia  has  been  described  as  part  of  a 
hemianesthesia,  due  to  a  lesion  in  the  posterior  part  of  the  internal  cap- 
sule and  in  hysteria. 

In  testing  the  sense  of  smell  it  is  advisable  to  use  aromatic  oils,  as 
they  only  stimulate  the  olfactory  nerve,  Avhile  ammonia  and  such  strong 
substances  also  stimulate  the  fifth  nerve.  It  is  obviously  necessary  to 
make  a  rhinoscopic  examination. 

Treatment  is  generally  unsatisfactory,  though  the  cause  must  be 
removed  when  possible.  When  the  disturbance  is  due  to  some  general 
condition,  as  hysteria,  it  may  of  course  be  disregarded,  as  it  will  improve 
with  the  disease. 

DISEASES    OF   THE   RETINA,    OPTIC   NERVE     AND    TRACT. 

The  Retina. — Hemorrhage  into  the  retina  may  be  venous  or  arterial, 
single  or  multiple,  monocular  or  binocular.  It  may  be  part  of  a  general 
vascular  change  ;  occasionally  it  occurs  during  parturition,  but  more 
often  at  the  menopause  ;  it  may  be  an  indication  of  renal  trouble  or  of 
some  primary  or  symptomatic  anemia,  as  in  leukocythemia,  pernicious 
anemia,  or  malaria.  Hemorrhage  is  prone  to  occur  also  in  depraved 
nutritional  conditions,  in  purpura,  and  in  scurvy. 

More  or  less  complete  loss  of  vision  develops  in  these  cases,  either 
suddenly  or  gradually  ;  an  ophthalmoscopic  examination  is  necessary  to 
make  the  diagnosis.  If  the  hemorrhage  is  superficial,  the  eye-ground  is 
red  and  swollen ;  if  deeper,  the  blood  escapes  between  the  fibers  of  the 
retina,  spreads  them  out,  and  assumes  a  flame-shaped  appearance. 

Retinitis. — Three  forms  of  this  condition  are  commonly  described — 
(1)  albuminuric,  (2)  syphilitic,  and  (3)  pigmentary. 

(1)  Albuminuric  retinitis  is  probably  not  a  distinct  affection,  but  part 
of  a  general  fibro-vascular  change  associated  with  nephritis.  The  fail- 
ure of  vision  may  precede  the  advent  of  albuminuria,  but  more  often 
the  two  conditions  are  coincident.  It  occurs  in  chronic  nephritis,  espe- 
cially in  the  interstitial  variety. 

The  retinal  changes,  according  to  Gowers,  are  either  hemorrhagic  or 
degenerative.  In  the  former  the  arterial  blood  occupying  the  interstices 
between  the  fibers  assumes  a  striated  or  feathery  aspect,  while  in  the 
degenerative  form  white  patches  of  fatty  degeneration  or  deposits  of 
cholesterin  are  dotted  over  the  fundus  ;  they  may  also  be  grouped  about 
the  macula  lutea,  or  around  the  disk.  Occasionally  the  latter  appears 
swollen,  owing  to  the  elFnsion  of  serum  into  the  fiber-layer. 

(2)  Syphilitic  retinitis  generally  occurs  in  the  later  stages  of  ac- 
quired syphilis,  and  particularly  in  neglected  cases.  Failure  of  vision 
directs  attention  to  the  eye-ground,  which  is  found  to  have  either  scat- 
tered or  uniformly  distributed  whitish  or  slightly  opalescent  filmy  patches 
upon  it.  The  vitreous  may  be  turbid  also.  Retinitis  is  far  less  common 
than  choroiditis  or  chorio-retinitis. 

(3)  Pigmentary  retinitis  is  essentially  a  chronic  process,  usually  attack- 
ing young  adults,  and,  as  a  rule,  more  than  one  member  of  a  family. 
It  may  also  occur  in  inherited  syphilis  and  in  low  grades  of  vitality. 


1(192  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  affected  parts  receive  a  deposit  of  pigment  Avliich  specially  follo\vs 
the  course  of  the  main  arteries.  At  the  same  time  a  circumferential 
annulus  of  pigment  forms.  This  gradually  encroaches  more  and  more 
upon  the  disk,  until  finally  atrophy  ensues. 

Among  retinal  aftections  occur  also — 

((/)  Toxic  Amblyopia. — This  is  due,  as  a  rule,  to  tobacco  or  alcohol,  and 
more  rarely  to  certain  drugs  and  lead-poisoning.  Failure  of  vision 
is  gradual  and  progressive,  though  it  rarely  reaches  absolute  blindness. 
The  center  of  the  field  is  chiefly  aftected,  and  a  central  scotoma  for  red 
and  green  exists ;  this  is  said  to  be  caused  by  a  chronic  neuritis  begin- 
ning in  the  fibers  that  are  distributed  to  the  macula  lutea.  It  is  believed 
to  be  due  to  a  retrobulbar  neuritis. 

(h)  Hemeralopia,  or  dai/-hh'ndn('Si<,  may  either  be  functional  or  a 
symptom  of  .some  retinal  affection — e.  y.,  hyperesthesia  or  albinism,  or 
the  result  of  central  cataract.  Objects  can  either  not  be  seen  at  all  or 
only  indistinctly  during  the  day  or  in  a  strong  artificial  light ;  but  at 
nitrlit  vision  is  excellent. 

((•)  Nyctalopia,  or  nii/ht-blhuhtess.  In  this  condition  vision  may  be 
normal  during  the  day  or  in  a  strong  artificial  light,  but  after  nightfall 
or  in  a  darkened  room  objects  can  be  seen  only  -with  difficulty  or  not  at 
all.      It  is  usually  associated  with  syphilitic  retinitis. 

Optic  Nerve. — The  important  pathologic  conditions  of  the  optic  nerve, 
especially  with  reference  to  diseases  of  the  nervous  system,  are:  (1)  neuri- 
tis and  (2)  atn>j)h//.  (1)  Neuritis  is  met  -with  in  two  forms :  first,  where 
the  lesion  is  not  visible  at  tlie  intra-ocular  end  of  the  nerve  (orbital  optic 
neuritis  or  retrobulbar  neuritis,  see  Toxic  Amblyopia),  and,  second,  where 
the  lesions  are  visible  at  the  intra-ocular  nerve-ending.  The  latter  is  the 
more  important,  and  is  also  known  as  papillitis.  Optic  neuritis  may  be 
caused  by  the  acute  infectious  diseases,  syphilis,  lead,  alcohol,  uremia, 
anemia,  menstrual  disorders,  exposure  to  cold,  rheumatism,  injuries,  dis- 
ease of  the  orbital  region,  and  possibly  intranasal  lesions.  Rarely  it  is 
congenital,  and  mild  forms  may  be  caused  by  refractive  errors.  When 
the  nerve  head  projects  markedly  into  the  interior  of  the  eye,  it  is  known 
as  "choked  disk,''  or  from  the  condition  present,  papilledema.  This  is 
not  a  true  neuritis,  but  is  due  to  mechanical  causes.  The  early  injection 
with  stasis  of  the  retinal  vessels,  edema,  and  elevation  of  the  nerve-head, 
;ind  final  cellular  infiltration,  Avith  new  tissue  formation  leading  to  atrophy, 
are  due  to  distention  of  the  sheath  of  Sclnvalbe  by  obstructed  cerebro- 
spinal fluid. ^  Neuritis  at  times  may  be  associated.  Kidney  disease  may 
cause  a  similar  condition.  Intracranial  lesions  are  the  most  frequent 
causes.  Of  these,  brain  tumor  ranks  first.  Others  are  meningitis,  cere- 
bral abscess,  cerebral  and  meningeal  hemorrhage,  thrombosis  of  the  cav- 
ernous sinus,  chronic  hydrocephalus,  serous  meningitis,  and  aneurysm  of 
the  internal  carotid.  "\'ision  may  not  be  lost  for  some  time.  If  the  proc- 
ess is  not  arrested,  consecutive  atrophy  occurs. 

(2)  Optic  Atrophij. — This  may  be  immary^  when  it  is  usually  asso- 
ciated with  disease  of  the  spinal  cord  and  brain,  as  tabes  dorsalis.  paretic 
dementia,  and  multiple  sclerosis,  secondary,  when  it  results  from  pressure 
more  or  less  tlirectly  applied  to  the  optic  chiasm  or  tracts,  and  consecu- 
tive, when  it  follows  a  previous  neuritis  or  ''  choked  disk."'  There  is  also 
^  Bordley  and  dishing,  Jonr.  Amer.  Med.  Assoc,  1909,  111.,  p.  353. 


DISEASES  OF  THE  RET/NA,   OPTfC  NERVE  AND   TRACT.    1093 

an  hereditary  form  known  as  Leber's  disease,  and  that  vvliich  occurs  in 
amaurotic  family  idiocy  (p.  1248). 

In  any  case  there  is  alteration  of  the  field  of  vision,  color  perception 
is  abnormal,  and  there  is  more  or  less  dimness  of  sight.  In  the  heredi- 
tary form  the  disk  is  less  white  than  in  the  other,  and  the  vessels  are 
almost  normal  in  appearance. 

The  Optic  Tract. — The  lesions  of  tlie  optic  tract  arc  important  rather 
on  account  of  their  situation  than  their  nature.  They  may  exist  without 
corresponding  changes  in  the  retina,  although  when  they  have  lasted  for 
a  long  time  there  is  often  some  secondary  atrophy  resulting  from  a 
descending  degeneration  of  the  optic  nerves.  Lesions  of  the  chiasm 
usually  affect  the  decussating  fibers,  causing  blindness  of  the  nasal  halves 
of  the  retina,  and,  in  consequence,  temporal  hemianopsia.  This  condition 
occurs  in  basal  tumors  especially  of  the  hypophysis,  and  has  therefore 
been  observed  in  acromegaly,  in  tuberculous  basal  meningitis,  and  in  hy- 
drocephalus. Lesions  of  either  optic  tract,  if  complete,  causes  homony- 
mous bilateral  hemianopsia ;  if  incomplete,  there  is  irregular  disturbance 
of  the  visual  field,  sometimes  bilateral,  sometimes  unilateral.  It  may  be 
involved  in  hemorrhage,  tumors,  softening  or  basilar  meningitis ;  ordi- 
narily other  structures  are  also  involved,  giving  rise  to  symptoms  of  focal 
disease.  Lesions  anterior  to  the  anterior  corpora  quadrigemina  usually 
cause  more  or  less  destruction  of  some  of  the  other  cranial  nerves,  with 
the  production  of  ocular  palsies,  or  disturbances  of  the  other  special 
senses,  or  anesthesiae  or  neuralgias  of  the  face.  A  very  valuable  sign, 
that,  however,  cannot  always  be  elicited,  is  the  failure  of  the  pupil  to 
contract  when  light  is  thrown  upon  the  blind  half  of  the  retina.  This 
is  explained  by  supposing  that  the  pupillary  reflex  center  is  situated  in 
the  anterior  corpus  quadrigeminus,  lateral  geniculate  body,  and  pulvinar. 
If  the  lesions  affect  the  optic  thalamus  or  the  internal  capsule,  hemiplegia 
and  hemianesthesia  are  also  often  present  or  may  form  the  most  important 
symptoms.  Lesions  posterior  to  the  anterior  corpora  quadrigemina  pro- 
duce hemianopsia  without  disturbance  of  the  pupillary  reflex.  These 
lesions  are  divided  into  two  groups,  the  cortical  and  the  subcortical,  and 
they  may  be  of  two  varieties,  either  irritative  or  paralytic.  The  irritative 
lesions  give  rise  to  hallucinations  of  sight,  which  may  vary  from  the 
scotomata  of  migraine  to  most  complex  visions.  Paralytic  lesions  ordi- 
narily lead  to  hemianopsia.  Occasionally  curious  symptoms  are  pro- 
duced, the  visual  field  being  sometimes  irregular,  while  at  others  only 
certain  elements  of  sight  are  affected,  cases  having  been  reported  in  Avhich 
the  hemianopsia  only  involved  the  recognition  of  colors,  not  of  form. 
In  all  these  cases  the  pupillary  reflexes  are  not  affected.  Bilateral  lesions 
do  not  always  lead  to  total  blindness  ;  sometimes  the  macula  lutea  escapes 
and  the  patient  is  able  to  see  only  by  direct  fixation.  Occasionally  a 
single  lesion  Avill  produce  total  blindness  in  one  eye,  but  this  is  rare,  and 
no  satisfactory  explanation  has  been  found  to  account  for  it.  Cortical 
lesions  are  those  involving  the  occipital  lobe.  The  center  of  visual  per- 
ception appears  to  be  in  the  cuneus  and  calcarine  fissure ;  if  this  is  de- 
stroyed on  both  sides,  blindness  occurs.  If  on  one  side,  lateral  homonymous 
hemianopsia  (Fig.  77).  The  center  for  the  recognition  of  the  object  seen  is 
apparently  upon  the  convex  surface  of  the  occipital  lobe,  probably  in  the 
second  and  third  convolutions,  but  it  may  extend  also  into  the  temporal 


^ 


LQ 


IT 


i    LF 


^v: 


't^- 


^-~^k;^Rj 


Fig.  T7.— Diagram  of  the  visual  apparatus  (after  Vialet) :  I.O,  LO',  <ccipital  lobes;  C,  cuneus; 
Had.  opt.,  optic  radiation;  TQa.  anterior  corpus  quadrigeminus :  PU,  PL",  pulvinar;  CGe,  external 
geniculate  ganglion  ;  iiO,  optic  tract ;  r  7/,  optic  chiasm  ;  i\'0,  optic  nerve:  OA  right  eye  ;  OO',  left 
eye;  UN,  nasal  half  of  retina  (supiilicd  bv  the  opposite  hemisphere);  PT,  temporal  half  of  the 
retina  (supplied  by  the  homolateral  hemisphere) ;  M,  macula  lutea.  A  total  transverse  lesion  at 
1.  2,  or  3  would  cause  total  blindness  of  the  right  eve.  A  lesion  at  -1,  destroying  the  central  part 
of  the  chiasm,  would  cause  blindness  of  the  nasal  halves  of  the  retime,  and  therefore  bitemf>oral 
hemianopsia.  A  lesion  at  t  would  cause  blindness  of  the  right  halves  of  the  retime,  and  therefore 
left  homonvmous  hemianopsia.  The  pupillary  reflex  would  be  lost  in  the  affected  lialf  of  the  eye 
in  all  these' cases,  A  lesion  in  the  optic  radiation  would  cause  symptoms  similar  to  those  of  the 
corresponding  optic  tract,  excepting  that  the  pupillary  reflex  would  be  preserved.  Lesions  of  the 
cortex  cause  various  disturbances  of  vision  according  to  the  part  affected. 

1094 


DISEASES  OF  THE  MOTOR   NERVES   OF  THE  EYEBALL.    1095 

lobe.  When  this  is  destroyed  the  patient  can  see  either  objects, 
words,  letters,  or  symbols,  as  the  case  may  be,  with  which  he  was  once 
familiar,  but  fails  to  recognize  them  ;  this  is  called  raind-blindnesH  or 
visual  agnosia.  Hemianopsia  is  very  frequently  merely  a  temporary 
symptom,  and  as  such  it  may  occur  in  uremia,  apoplexy,  migraine, 
and  certain  intoxications,  especially  that  of  lead.  It  may  also  occur  in 
brain  tumor,  and  disappear  if  the  pressure  is  relieved,  as  by  trephining. 
It  is  a  permanent  symptom  only  when  the  visual  tract  has  been  involved 
by  some  destructive  lesion.  If  the  patient  is  perfectly  conscious  and 
intelligent,  it  is  not  difficult  to  recognize  it ;  nevertheless,  its  pres- 
ence can  often  be  detected  in  young  children  and  in  those  who  are  only 
partially  conscious  or  unable  to  speak.  This  can  be  accomplished  by 
taking  a  bright  object,  placing  it  behind  the  head,  and  then  bringing  it 
forward  slowly,  first  on  one  side  and  then  on  the  other.  It  will  then  be 
noted  that  the  patient  perceives  it  on  the  hemianopsic  side  only  when  it 
has  been  brought  to  the  middle  line,  whilst  when  moved  on  the  other 
side  the  eyes  will  turn  toward  it  when  it  is  still  a  considerable  distance 
from  this  point.  Another  method  is  to  bring  a  blunt  object  (a  wisp  of 
cotton)  very  nearly  in  cantact  with  the  cornea,  first  on  the  one  and  then  on 
the  other  side  of  the  median  line.  The  palpebral  reflex  will  occur  upon  the 
normal  side  whilst  the  object  is  still  some  distance  away ;  on  the  blind  side 
only  when  it  has  come  in  contact  with  the  conjunctiva  (see  Fig.  77). 

DISEASES  OP  THE  MOTOR  NERVES  OF  THE  EYEBALL  (THIRD,  FOURTH, 

AND  sixth). 

The  extrinsic  ocular  muscles  are  supplied  by  these  three  nerves,  while 
the  intrinsic  are  supplied  by  the  third  and  the  sympathetic. 

I.  The  motor  oculi,  or  third  nerve,  is  purely  motor,  and  sup- 
plies all  the  muscles  of  the  eye  except  the  superior  oblique  and  external 
rectus,  and  controls  in  part  also  the  ciliary  muscle  and  the  sphincter  of 
the  iris.  Its  apparent  origin  is  from  the  inner  side  of  the  crus  cerebri 
just  anterior  to  the  pons.  It  can  be  traced  through  the  crus,  how- 
ever, to  its  deep  origin  in  a  nucleus  beneath  the  corpora  quadrigemina, 
situated  in  the  floor  of  the  aqueduct  of  Sylvius.  Above  the  crus  it 
pierces  the  dura,  passes  between  the  two  clinoid  processes  of  the  sphe- 
noid bone,  along  the  outer  wall  of  the  cavernous  sinus,  where  it  receives 
some  filaments  from  the  cavernous  plexus  of  the  sympathetic ;  it  then 
divides  into  two  branches  that  enter  the  orbit  through  the  sphenoid 
fissure.  The  superior  and  smaller  division  supplies  the  superior  rectus 
and  levator  palpebrae  superioris,  while  the  inferior  and  larger  branch 
subdivides  into  three  portions,  one  going  to  the  internal  rectus,  another 
to  the  inferior  rectus,  and  the  third  to  the  inferior  oblique. 

Lesions  of  the  third  nerve  result  in  (1)  spasm  or  (2)  paralysis. 

Spasm  rarely  if  ever  occurs  in  all  the  muscles  simultaneously.  Any 
muscle  may  be  affected,  but  the  internal  rectus  and  levator  palpebrae  are 
specially  liable.  It  is  met  with  in  meningitis,  hypermetropia,  and  hys- 
teria ;  also  as  nystagmus,  in  which  the  spasm  is  clonic  and  bilateral ;  it  also 
occurs  in  albinism,  occasionally  in  coal-miners,  or  it  may  be  congenital. 

Irritation  of  the  center  or  nerve  may  cause  contraction  of  the  pupil 
(myosis),  as  occurs  in  locomotor  ataxia.  The  same  result  is  brought 
about  by  paralysis  of  the  sympathetic. 

Paralysis. — The  nerve  may  be  involved  in  any  part  of  its  course  by 


1090  DISEASES  UF  THE  yERVOHS  SYSTEM. 

inflammatory  deposits  or  tumors,  or  tlio  nucleus  may  be  diseased.  In  the 
latter  ease  there  is  usually  uplitlialmui)lcgia. 

Kelapsini:  and  recurring  palsy  are  two  varieties.  The  first  occurs 
chieHy  in  syj)hilitic  subjects.  C>ne  nerve  becomes  affected  and  jiartially 
recovers.;  the  other  one  then  becomes  j)aralyzed,  and  partially  recovers, 
relapses,  and  so  on.     The  internal  muscles  may  be  involved. 

Recurring  or  periodic  palsy,  the  migraine  opJithalmique  of  Charcot,  is 
a  rare  form  (p.  1209).  It  occurs  in  both  sexes,  but  women  are  especially 
susceptible.  It  may  begin  in  infancy  and  recur  at  intervals  for  years,  the 
attacks  being  periodic,  lasting  a  few  days  to  six  or  eight  weeks,  and  end- 
ing in  complete  recovery.  They  may  be  precipitated  by  some  emotional 
disturbance,  by  menstruation,  or  by  exhaustion.  Their  exact  nature  is 
not  understood,  but  they  resemble  migraine  in  that  there  is  severe  head- 
ache or  pain,  usually  over  one  eye,  and  in  their  association  with  vomiting. 

Generally  paralysis  of  the  extra-ocular  muscles  is  partial,  and  the 
symptoms  will  vary  according  to  the  muscles  affected.  When  they  are 
all  involved  there  are  ptosis,  divergent  strabismus,  diplopia,  and  dilated 
pupil,  with  loss  of  the  light-reflex  and  accommodation. 

Intra-ocular  Paralysis. — (a)  Cycloplegia,  or  ciliary  muscle-paralysis, 
gives  rise  to  a  loss  of  the  power  of  accommodation,  so  that  "  far-sight"  is 
good,  while  "near-sight"'  is  blurred  and  indistinct.  This  can  be  corrected 
by  a  convex  glass.  Bilateral  cycloplegia  is  usually  due  to  a  nuclear  lesion. 
It  occurs  most  frequently  as  a  symptom  of  neuritis  following  diphtheria. 

{h)  Iridoplegia. — The  pupil  may  be  dilated  {tnydriasis)  from  palsy  of 
the  sphincter  or  spasm  of  the  dilator,  or  it  may  be  contracted  [myosis) 
from  the  antithesis  of  the  above. 

The  iris  has  three  actions — two  reflex  and  one  associated :  First,  a 
reflex  contraction  of  the  sphincter  on  exposure  of  the  eye  to  the  light ; 
second,  a  reflex  dilatation  of  the  radiating  fibers  on  stimulation  of  some 
cutaneous  nerve  ;  and,  third,  a  contraction  on  accommodation,  usually, 
but  not  necessarily,  associated  with  convergence  (Gowers). 

First,  light-reflex  iridoplegia.  The  iris  reflex  is  lost  in  locomotor  ataxia, 
in  general  paresis,  and  occasionally  in  disease  of  the  peripheral  portion  of 
the  third  nerve,  and  sometimes  also  in  syphilis.  Accommodation  and  con- 
vergence are,  however,  usually  prefieryed  {Argyll-Mobertson  pupil).  When 
these  also  are  lost  the  condition  is  termed  opltthalmoplegia  interna. 

In  testing  this  reflex  care  must  be  taken  to  avoid  the  contraction  of 
accommodation.  The  patient  should  look  at  a  remote  part  of  the  room  ; 
then  a  light  is  brought  suddenly  in  front  of,  and  three  or  four  feet  dis- 
tant from,  the  eye.  One  eye  should  be  examined  at  a  time,  the  other 
being  covered,  but  not  closed. 

Second,  skin-reflex  iridoplegia.  Normally,  painful  stimulation  of  the 
skin  of  the  neck  causes  reflex  dilatation  of  the  pupil  (pupillary  skin- 
reflex),  the  afferent  impulse  being  carried  along  the  sympathetic.  In 
locomotor  ataxia  myosis  often  exists.  In  such  cases  Erb  showed  that  the 
skin-reflex  was  lost  [spinal  myotds). 

Third,  accommodation  iridoplegia,  in  which  the  power  of  accommoda- 
tion is  lost.  The  pupil  does  not  become  smaller  when  looking  at  near  ob- 
jects. Westphal  and  Piltz  have  recently  discovered  independently  that  in 
certain  pathological  conditions  the  pupil  contracts  strongly  upon  closure, 
or  attempted  closure  against  resistance,  of  the  eyelids.  This  reflex  occurs 
most  constantly  in  general  paresis.     Its  exact  significance  is  not  known. 


DISEASES  OF  THE  MOTOR  NERVES  OF  THE  EYEBALL.    1007 

II.  The  fourth  nerve,  or  patheticus,  the  smallest  cranial  nerve, 
supplies  the  superior  oblique  muscle.  Its  superficial  origin  is  to  the 
outer  side  of  the  crus  cerebri,  just  in  front  of  the  pons.  The  fibers  can 
be  traced  backward  to  the  valve  of  Vieusscns,  in  the  substance  of  which 
it  decussates  with  its  fellow.  Its  deep  origin  is  in  a  nucleus  in  the  floor 
of  the  aqueduct  of  Sylvius,  immediately  behind  and  in  close  connection 
with  the  third-nerve  nucleus.  After  piercing  the  dura  mater  the  nerve 
runs  along  the  outer  wall  of  the  cavernous  sinus  and  enters  the  orbit 
through  the  sphenoid  fissure.  Since  the  superior  oblique  muscle  directs 
the  eyeball  downward  and  rotates  it,  paralysis  causes  defective  down- 
ward and  inward  movements,  and  consequent  diplopia  with  inclination 
of  the  head  forward  and  to  the  sound  side.  When  occurring  alone  it  is 
probably  due  to  a  nuclear  lesion. 

III.  The  sixth  nerve,  or  abducens,  has  its  deep  origin  in  the 
floor  of  the  fourth  ventricle  in  close  proximity  to  the  seventh-nerve 
nucleus.  Its  superficial  origin  is  from  the  lower  part  of  the  pons,  in 
the  groove  between  it  and  the  medulla.  Emerging,  it  pierces  the  dura, 
runs  along  the  cavernous  sinus,  and  enters  the  orbit  through  the  sphe- 
noid fissure  to  supply  the  external  rectus.  Owing  to  its  long  course,  this 
nerve  is  specially  liable  to  injury,  usually  from  pressure  due  to  tumors 
or  from  syphilitic  or  other  forms  of  meningitis.  Paralysis  of  the  muscle 
causes  convergent  strabismus  and  consequent  diplopia,  owing  to  an  in- 
ability to  rotate  the  eye  outward.  In  nuclear  lesions  the  external  rectus 
of  the  same  side  and  the  internal  rectus  of  the  opposite  side  are  paralyzed, 
loss  of  associated  lateral  movements  of  the  eyes  toward  the  side  of  the 
lesion  resulting.  Conjugate  deviation,  the  eyes  being  directed  away  from 
the  side  of  the  lesion,  may  also  be  observed.  This  is  due  to  the  fact  that  the 
sixth  nerve  nucleus  and  that  part  of  the  third  nerve  nucleus  governing  the 
internal  rectus  are  connected  through  the  posterior  longitudinal  fasciculus. 

The  internal  rectus  is  not  wholly  controlled  by  the  sixth  nerve  nucleus, 
however,  for  Avhen  the  eye  with  the  paralyzed  external  rectus  is  covered, 
the  opposite  internal  rectus  will  act,  though  less  readily  than  normally. 
Independent  contraction  of  the  internal  rectus  is  controlled  alone  by  the 
third  nerve  nucleus.  Conjugate  deviation  also  occurs  in  supranuclear 
lesions,  as  in  apoplexy  (p.  1165) ;  if  irritative,  the  deviation  is  away  from 
the  side  of  the  lesion ;  if  paralytic,  toward  it. 

General  Symptomatology  of  Paralysis  of  the  Eye-muscles. 
— Loss  of  power  in  the  ocular  muscles  is  indicated  by  five  kinds  of  symp- 
toms (Gowers) :  (1)  Limitation  of  Movement. — The  amount  of  limitation 
in  the  movement  of  the  eyeball  is  in  direct  ratio  to  the  degree  of  palsy. 
In  complete  palsy  the  globe  is  ultimately  fixed,  owing  to  contraction  of 
the  unopposed  muscle.  In  partial  paralysis,  as  the  limit  of  movement 
is  approached  the  motion  is  often  jerky  {paralytic  nystagmus). 

(2)  Strabismus. — Owing  to  defective  movement  the  axes  of  the  eyes 
do  not  correspond.  "  The  deviation  of  the  axis  of  the  paralyzed  eye  from 
parallelism  with  that  of  the  sound  eye  is  termed  the  primary  deviation." 

(3)  Secondary  Deviation. — "  If  the  sound  eye  is  prevented  from  see- 
ing the  object,  and  the  patient  looks  at  this  (is  made  to  'fix'  it)  only 
Avith  the  affected  eye,  the  sound  eye  is  moved  still  farther  in  that  direc- 
tion, and  hence  the  deviation  of  the  visual  axes  is  increased.  This  is 
called  the  'secondary  deviation,'  and  depends  on  the  fact  that  two  mus- 
cles normally  acting  in  unison  are  equally  stimulated  (innervated)  for 


1098  DISEASES  OF  THE  yERVOUS  SYSTEM. 

any  given  movement.  When  one  is  ueak.  the  amount  of  nerve-force 
employed  to  move  the  sound  eye  acts  e([ually  on  the  imjiaired  eye.  and 
hence  the  overaetion.  In  paralytie  strabismus  fixation  Avith  the  sound  eye 
shows  the  primary  deviation,  while  fixation  with  the  aftected  eye  reveals 
secondary  deviation.  In  ordinary  strabismus  due  to  spasm  this  does  not 
hold  good  ;  it  matters  not  which  eye  is  used,  deviation  remains  the  same." 

(4)  Erroneous  Projection. — We  judge  of  our  relation  to  surrounding 
objects  by  the  position  of  the  eyeball  as  indicated  to  us  by  the  degree 
of  stimulation  necessarily  brought  to  bear  on  the  ocular  muscles.  When 
one  of  these  muscles  is  weak,  the  additional  stimulation  (innervation) 
necessary  to  move  it  in  fixing  an  object  impresses  us  with  the  idea  that 
it  is  really  farther  away  than  is  actually  the  case,  and  in  attempting  to 
touch  it  the  finger  goes  beyond.  This  erroneous  projection,  or  inter- 
ference of  visual  sense-impressions,  causes  a  disturbance  of  equilibrium 
and  gives  rise  to  vertigo,  which  has  been  named  "ocular  vertigo." 

(5)  Double  Vmon. — This  is  not  due  alone  to  a  difterence  in  the  axis 
of  vision,  causing  images  on  non-corresponding  portions  of  the  retina, 
but  also  to  the  erroneous  projection.  "  If  the  patient  looks  with  both 
eyes,  the  field  of  the  unaffected  eye,  being  normally  projected,  does  not 
correspond  with  the  field  of  the  affected  eye ;  the  images  formed  in  the 
two  eyes  are  mentally  referred  to  different  positions;  objects  are  seen 
double  "  (Gowers).  The  ''  true  image  "  is  that  one  formed  in  the  sound 
eye,  while  the  retina  of  the  affected  eye  receives  the  '*  false  image."  The 
symptom  is  known  as  diplopia. 

ITomonymous  or  simple  dij)lopia  is  that  in  which  the  fiilse  image  ap- 
pears on  the  '"same  side  of  the  other  as  the  eye  by  which  it  is  seen." 
This  is  due  to  paralysis  of  an  abductor  muscle — convergent  strabismus 
Grossed  diplopia  occurs  in  divergent  strabismus,  the  result  of  paralysis 
of  an  adductor.  The  false  image  appears  to  be  on  the  other  side  of  the 
real  object — /.  e.  toward  the  sound  eye. 

Gowers"  mnemonic  is,  "  When  the  visual  lines  (prolonged  ocular  axes) 
cross,  the  diplopia  is  not  crossed." 

Ophthalmoplegia,  a  paralytic  condition  of  the  eye-muscles,  may  be 
partial  or  complete.  Either  the  internal  or  the  external  muscles  may  be 
involved,  constituting  ophthalmoplegia  interna  or  cvterna,  and,  when  both 
are  affected,  total  ophthalmoplegia.  The  lesions  may  be  due  to  disease 
either  of  the  nerve  trunks  or  nuclei.  The  former  may  be  due  to  some 
infectious  disease,  as  diphtheria  ;  excessive  use  of  alcohol,  arteriosclerosis  ; 
traumatism,  causing  either  fracture  at  the  base  of  the  skull  or  hemorrhage 
into  the  region  of  the  nerves ;  pressure  of  an  aneurysm  of  a  cerebral 
blood-vessel,  basal  meningitis,  especially  if  syphilitic,  and  tumor.  The 
latter  may  also  be  due  to  infectious  diseases  and  excessive  use  of  alcohol. 
Chronic  lead-poisoning  may  also  cause  it,  and  it  may  be  an  early  manifes- 
tation of  either  tabes,  paresis,  disseminated  sclerosis,  or  cerebral  syphilis. 
Tumors,  inflammation  within  the  orbit,  or  fractures  involving  it,  and 
thrombosis  of  the  cavernous  sinus  may  also  be  causes  of  a  more  or  less 
developed  ophthalmoplegia.  If  acute,  the  condition  may  be  due  to  a 
hemorrhage  in  the  region  of  the  nuclei,  or  an  embolus  or  thrombosis  in  a 
branch  of  the  basilar  artery,  or  an  inflammation  of  the  nuclei,  due  either 
to  infection  or  intoxication,  as  mentioned  above  (polio-encephalitis  superior 
of  Wernicke).  Symptoms  of  bulbar  palsy  may  coexist  in  chronic  nuclear 
degenerations. 


DISEASES  OF  THE  FIFTH  NKR  VK.  1099 

The  symptoms  vary  necessarily  according  to  the  muscles  involvetl. 
The  eyes  fail  to  follow  objects  and  the  face  acquires  a  peculiar  expression 
("Hutchinson  face"). 

The  treatment  consists  in  the  removal  of  the  cause  when  possible. 
As  a  large  number  of  cases  are  due  to  some  of  the  manifestations  of 
syphilis,  iodids  and  mercury  should  be  used  in  all  cases  where  another 
cause  is  not  definitely  known.  In  inflammatory  cases  counterirritation 
is  employed  by  blisters  placed  on  the  temples,  behind  the  ears,  or  at  the 
occiput,  or  by  leeches.  Internally,  the  salicylates,  mercury,  iodids,  and 
general  tonics  are  useful.  Rarely  a  case  will  recover  spontaneously. 
Electricity  is  probably  of  little  value.  The  diplopia,  unless  it  can  be 
obviated  by  a  suitable  lens,  should  be  met  by  means  of  an  opaque  glass. 

DISEASES    OF   THE    FIFTH   NERVE. 

The  trigeminus  nerve  has  an  extensive  origin  from  the  floor  of  the 
fourth  ventricle.  It  supplies  with  sensation  the  whole  region  innervated 
by  all  the  other  cranial  nerves  except  the  first  and  second.  It  resem- 
bles a  spinal  nerve  in  -that  it  has  two  roots,  a  motor  and  sensory,  and  on 
the  latter  a  ganglion  (Grasserian).  From  the  latter  arise  three  sensory 
branches — viz.  the  ophthalmic,  superior  maxillary,  and  inferior  maxillary. 
A  motor  root  joins  the  last  named,  the  largest  branch  of  the  fifth  nerve. 

Morbid  conditions  of  the  fifth  nerve  cause  sensory,  motor,  or  gusta- 
tory symptoms.  The  lesion  may  be — (1)  Pontine  hemorrhage,  softening, 
sclerosis,  or  tumor.  (2)  Disease  or  injury  at  the  base  of  the  brain — 
e.  g.  meningitis,  gumma  or  other  tumor,  caries  of  bone.  (3)  Disease 
or  injury  of  the  branches,  as  neuritis,  pressure  due  to  aneurysm  of 
the  internal  carotid  or  to  a  tumor  in  the  cerebello-pontile  angle  or  spheno- 
maxillary region,  orbital  cellulitis,  and  punctured  wounds  of  the  mouth 
and  nose.  (4)  Rarely  fracture  of  the  skull.  (5)  Diseases  of  the  Gas- 
serian  ganglion. 

Symptoms. — Sensory  Portion, — In  the  irritative  stage  the  chief 
feature  is  pain ;  this  may  be  shooting,  boring,  or  burning  in  character. 
Tenderness  along  the  course  of  the  nerve  and  hyperesthesia  may  also 
exist.  Later,  anesthesia  develops  in  the  distribution  of  some  or  all  of 
the  branches  in  the  skin  of  the  face  and  in  the  mucous  membrane  of  the 
nose,  mouth,  lips,  tongue,  and,  in  some  cases,  of  the  hard  and  soft  palate 
also.  The  occurrence  of  such  anesthesia,  associated  with  pain,  indicates 
an  organic  lesion,  usually  of  the  ganglion,  as  distinguished  from  a  func^ 
tional  neuralgia  (p.  1077). 

The  secretions  are  often  increased,  though  at  first  they  are  lessened ; 
hence  the  anosmia,  due  to  dryness  of  the  nasal  mucosa.  Loss  of  sense 
of  taste  may  also  occur.  Other  trophic  changes  are — inflammation  and 
ulceration  of  the  gums,  looseness  of  the  teeth,  and  inflammation  of  the 
eye.  Corneal  opacities,  ulceration,  sometimes  perforation,  and  finally 
complete  destruction  of  the  eye — neuro-paralytic  ophthalmia — are  noted. 
This  is  especially  apt  to  occur  when  the  Gasserian  ganglion  is  involved. 
Painful  and  intractable  herpes  may  develop.  Hemifacial  atrophy  may 
result  from  disease  of  the  fifth  nerve  (Mendel). 

Motor  Portion. — Paralysis. — Partial  or  complete  inhibition  of  the 
movement  of  the  muscles  in  the  region  supplied — i.  e.,  those  of  the 
jaw,  the  masseter^  temporal,  pterygoid,  mylo-hyoid,  and  the  posterior 


1100  DISEASES  OF  THE  NERVOUS  SYSTEM. 

belly  of  the  digastric.  The  degree  of  palsy  can  be  ascertained  by 
placing  a  finger  on  each  nnisseter  or  temporal  muscle  while  the  patient 
alternately  opens  and  forcibly  closes  the  mouth.  In  external  pterygoid 
paralysis  movement  tOAvard  the  sound  side  is  impossible,  and  on  de- 
pression of  the  lower  jaw  it  deviates  toward  the  aftected  side.  I  Iti- 
mately   wasting  of  the  muscles,   with   deformity,   takes  place. 

Spasm  (the  so-called  ''masticatory  spasm"  of  Romberg)  may  be 
tonic  or  clonic.  In  tonic  spasm — trismus  or  lockjaw — the  jaw  is  firmly 
set  and  the  muscles  are  hard,  rigid,  and  sometimes  painful.  This  occurs 
in  tetanus,  in  certain  cases  of  tetany  and  hysteria,  in  caries  of  the  teeth, 
occasionally  after  exposure,  and  in  irritative  centric  or  peripheral 
lesions.  Clonic  spasm  is  more  or  less  continuous  or  intermittent.  The 
former  consists  of  short,  quick,  vertical  or  rarely  lateral  movements 
{e.  g.,  gnashing  of  the  teeth),  usually  associated  with  some  other  con- 
dition, as  paralysis  agitans,  general  convulsions,  and  the  like,  or  it  may 
exist  alone,  especially  in  women  late  in  life.  The  intermittent  form  rs 
rare  and  occasionally  occurs  in  chorea.  Contractions  are  single,  forci- 
ble, and  are  separated  by  some  little  time.  The  tongue  and  cheeks 
may  1)e  bitten  in  the  attack.     (See  Tic,  p.  1216.)  • 

Gustatory  Portion. — S[//mptoms  referable  to  this  portion  are  not  always 
present  in  disease  of  the  fifth  nerve.  ^Nlany  neurologists  do  not  believe 
that  gustatory  sensations  are  transmitted  by  it,  the  glossopharyngeal 
(p.  1110)  being  believed  by  them  to  be  the  nerve  of  taste.  If  the  fiftli 
does  take  part  in  this  function,  it  does  it  for  the  anterior  two-thirds  of  the 
tongue.  There  may  be  a  loss  of  taste  without  sensory  disturbance,  or  vice 
versd,  or  both  may  exist  contemporaneously.  Lesions  of  the  nerve-root 
or  middle-ear  disease  may  cause  it,  but  pontine  lesions,  as  a  rule,  do  not. 
It  occurs  in  paralysis  of  the  seventh  nerve,  if  the  lesion  is  in  the  Fallopion 
canal,  due  to  involvement  of  the  chorda  tympaui.  A  perverted  sense  of 
taste — parageusia — may  be  present  in  hysteria  and  insanity.  Increased 
sensitiveness — hgpergeusia — and  subjective  sensations  of  taste  may  result 
from  irritative  lesions,  and  the  latter  may  precede  an  attack  of  epilepsy 
(as  an  aura). 

The  diagnosis  is  not  difficult  as  a  rule.  Anesthesia  in  the  area 
supplied  by  the  nerve,  with  pain,  is  in  favor  of  organic  disease,  the 
nature  of  which  must  be  determined  by  the  accompanying  symptoms. 
Spasm  may  be  simulated  in  cases  of  rheumatism  or  rheumatoid  arthritis 
involving  the  temporo-maxillary  articulation. 

Treatment. — The  underlying  cause  should  be  attacked  when  pos- 
sible, and  mercury,  the  iodids,  and  the  salicylates  should  be  administered 
in  specific  cases  and  in  those  due  to  exposure.  Analgesics,  and  even 
opiates,  may  be  necessary.  Sometimes  vigorous  counter-irritation  is  of 
value.  Attention  must  be  paid  to  the  condition  of  the  general  system. 
The  battery  may  be  tried,  preferably  with  the  faradic  current,  or  by 
means  of  electricity  short  and  extremely  rapid  blows  may  be  made  over 
the  nerve. 

DISEASES    OF    THE    SEVENTH    OR   FACIAL   NERVE. 

The  nucleus  of  this  nerve  in  the  floor  of  the  fourth  ventricle  is  in  rela- 
tion Avith  those  of  the  sixth,  eighth,  and  twelfth  nerves.  Like  the  spinal 
nerves,  it  has  an  upper  and  a  lower  neuron  or  motor  segment,  the  former 


DISEASES  OF  THE  SEVENTH  OR   FACIAL   NERVE.  1101 

extending  from  the  cortical  center  in  the  lower  I'olandic  region  to  the 
nucleus,  while  the  latter  runs  from  the  nucleus  to  the  peripliery.  Lesions 
may  involve  any  part  of  the  tract,  producing  either  spasm  or  paralysis. 

Spasm. — This  may  be  cither  general  or  partial,  affecting  only  the  orbic- 
ularis palpebrarum  (blepharospasm).  It  is  sometimes  called  tic  facialis 
or  mimic  spasm  (p.  1217). 

Htiology. — The  commonest  causes  are  peripheral  irritations,  and 
particularly  those  that  involve  the  trigeminus,  as  carious  teeth,  conjunc- 
tivitis, or  some  nasal  irritation.  Less  frequently  irritation  in  some  other 
part  of  the  body,  as  intestinal  parasites  or  uterine  disease,  may  be  the 
exciting  cause.  Finally,  there  may  be  lesions  in  any  part  of  the  motor 
tract  supplying  the  face,  either  in  the  cortex  (meningeal  tumor,  exosto- 
ses, or  focal  softening),  when  it  becomes  one  of  the  manifestations  of  the 
Jacksonian  convulsion  ;  in  the  facial  nucleus  in  the  lower  part  of  the 
pons ;  along  the  course  of  the  facial  nerve  (aneurism  or  atheroma  of  the 
vertebral  artery) ;  and  as  a  sequela  of  peripheral  paralysis  of  the  nerve 
(Bell's  Palsy,  p.  1101).  Morbid  changes  in  the  nerve  itself  or  in  the 
muscles  have  not  been  observed. 

The  symptoms  of  the  disease  include,  first,  the  spasm :  this  is  usually 
a  sudden  clonic  convulsion  of  the  muscles  of  one  side  of  the  face,  with 
closure  of  the  eyelids  and  retraction  of  the  angle  of  the  mouth.  Rarely 
there  are  associated  movements  of  the  palate  and  eyeballs.  The  spasms 
may  be  single  or  they  may  occur  in  groups  frequently  repeated,  or  recur 
constantly  at  more  or  less  irregular  intervals.  Less  frequently  the  con- 
traction may  be  tonic  in  character,  lasting  several  seconds  or  even  minutes. 
These  forms  are  frequently  associated  with  clonic  spasms.  Ordinarily  the 
spasm  is  painless.  Sometimes  there  is  also  tinnitus  aui'ium.  Occasionally 
edema  of  the  face,  especially  in  the  orbital  region,  occurs.  The  immediate 
exciting  cause  of  an  attack  may  be  fatigue  or  excitement,  or  it  may  occur 
as  an  associated  movement,  as  in  a  case  that  I  observed,  in  which  spasm 
always  accompanied  the  beginning  of  speaking. 

The  diagnosis  must  be  made  from  tic  (p.  1216).  It  may  be  occa- 
sionally confounded  with  chorea^  especially  when  the  latter  is  chiefly 
localized  in  the  face,  or  with  athetosis  due  to  infantile  brain-lesions.  In 
the  former  the  movements  are  not  so  quick  nor  confined  exclusively  to 
the  anatomical  distribution  of  a  certain  nerve ;  in  the  latter  hemiplegia 
will  usually  coexist  (p.  1174).  In  fact,  athetosis  is  a  spasm.  Recognition 
of  the  cause  is  often  very  difficult,  and  a  careful  examination  of  the 
whole  body  should  be  made  for  any  possible  source  of  irritation. 

The  prognosis  is  extremely  unfavorable  for  cure,  since  only  in  cases 
of  recent  occurrence,  and  with  a  distinct  source  of  peripheral  irritation,  is 
permanent  recovery  likely. 

The  treatment  consists  in  the  removal  of  any  source  of  irritation 
and  the  application  of  electricity,  particularly  the  mild  galvanic  currents, 
with  the  anode  over  the  sensitive  points.  Patrick^  has  injected  alcohol 
into  the  region  of  the  nerve  at  the  stylomastoid  foramen  with  success. 
The  use  of  antispasmodics,  as  conium,  gelsemium,  raorphin,  and  the 
bromids,  may  give  temporary,  but  rarely  permanent,  relief. 

Paralysis  (Bell's  Palsy). — Depending  on  the  seat  of  the  lesion,  we 
have — (a)  supra-nuclear,  (h)  nuclear,  and  [c]  infra-nuclear  palsy.  The 
1  Jouv.  Nerv.  and  Ment.  Dis.,  Jan.,  1909. 


1102  DISEASES  OF  THE  yERVOUS  SYSTEM. 

following  table  presents  the  general  differences  between  upper  and  lower 
neuron  palsy  : 

Sl'PRA-NVCI.EAR    PaRALVSIS.  NuCLEAR  AM)  InFRA-MCLEAR  PaRALYSIS. 

The  upper  part  of  the   face  is  not  af-  All  parts  of  tlie  face  involved,  including 

fect^d,  the  muscles  of  the  ant;le  of  the  the    t>rl)icularis  and   froiitnlis.     Nuclear 

mouth  beini;  chiefly  concerned.  palsies  are  sometiuu-s  ineoniplete. 

Voluntary  movements  are  more  impaired  Voluntjiry    and     emotional     movements 

than  the  emotional.  equally  aflected. 

All  reflex  movements  are  normal.  All  reflex  movements  are  lost. 

Electric    reaction    is    normal,    or    only  Reactions  of  degeneration  are  present, 
slightly  impaired  to  both  galvanic  and 
farudic  currents. 

There  is  no  wasting.  Wasting  is  present. 

(a)  Supra-nuclear  paralysis  is  generally  associated  with  hemiplegia, 
the  palsy  of  face  and  limbs  being  on  the  same  side — i.  c.  opposite  the 
lesion,  which  may  consist  of  a  hemorrhage,  tumor,  abscess,  softening. 
It  may  be  the  result  of  injury,  and  may  be  situated  in  the  cortex,  corona 
radiata,  or  the  internal  capsule.  When  the  cortical  face-center  is  alone 
involved,  the  limbs  escape  (ynonoplegia  facialis).     This  form  is  rare. 

(h)  jSfucIear  paralysis  is  due  to  hemorrhage,  tumor,  or  softening  at  the 
site  of  the  nucleus  in  the  pons,  in  which  case  paralysis  of  the  arm  and  leg 
of  the  opposite  side  freijuently  coexists.  It  may  also  result  from  an  attack 
of  diphtheria,  and  very  rarely  occurs  in  cases  of  anteropoliomyelitis 
(polioencephalitis).  It  most  commonly  occurs  in  connection  with  the 
involvement  of  the  motor  nuclei  of  the  ninth  and  tenth  nerves  and  the 
nucleus  of  the  twelfth  in  the  disease  known  as  glosso-labiolaryngeal 
paralysis  or  chronic  bulbar  palsy.  As  already  noted,  the  symptoms  are 
similar  to  those  of  infranuclear  paralysis,  but  the  affection  is  usually 
bilateral  (p.  1129). 

(c)  Infranuclear  paralysis  is  caused  by  pressure  on  the  nerve  at  the 
base  of  the  brain  by  tumors,  meningitis,  aneurysm,  or  hemorrhage.  In 
the  Fallopian  canal  the  nerve  may  be  damaged  by  bone-disease  or  some 
form  of  otitis.  This  is  the  seat,  too,  of  the  so-called  "  rheumatic  neu- 
ritis." the  result  of  exposure  or  infection  (Bells  Palsy). 

Fracture  of  the  base  of  the  skull  or  injury  to  the  nerve  as  it  emerges 
from  the  stylo-mastoid  foramen  may  result  in  facial  palsy.  Diplegia 
facialis  is  rare,  but  may  be  caused  by  a  single  lesion  in  the  pons,  where 
the  facial  paths  cross,  or  by  two  lesions,  one  on  either  side.  The  causes 
enumerated  above,  Avhen  bilateral,  beget  double  facial  paralysis. 

Lesions  in  the  lower  part  of  the  pons  may  result  in  crossed  hemi- 
plegia, the  fibers  being  involved  in  their  course  between  the  nucleus 
and  the  point  of  emergence  of  the  nerve,  the  side  of  the  pons.  The  face 
will  be  paralyzed  on  the  same  side  as  the  lesion,  since  this  latter  is  below 
the  decussation  of  the  facial  tracts,  and  involves  the  outgoing  nerve,  to- 
gether with  opposite  hemijilogia.  In  alternate  or  crossed  hemiplegia 
the  facial  palsy  is  of  the  infra-nuclear  type,  while  in  ordinary  hemiplegia 
the  supra-nuclear  type  is  met  with.  Certain  symptoms  of  nerve-irrita- 
tion may  precede  the  actual  palsy  or  may  be  concomitant,  such  as  slight 
pain  and  tenderness,  some  swelling  in  front  of  the  ear,  muscular  twitch- 
ing, and  occasionally  vertigo. 

Symptoms. — The  affected  side  is  immobile  and  expressionless,  and  the 


DISEASES  OF  THE  SEVENTH  OR  FACIAL  NERVE.  110:i 

normal  lines  are  diminished  or  abolished.  This  is  seen  most  markedly 
in  those  above  middle  life.  The  eye  cannot  be  closed,  owing  to  weakness 
of  the  orbicularis  palpebrarum,  and,  as  the  tears  are  not  directed  into 
their  proper  channel,  tiie  eye  waters.  Voluntary  and  emotional  move- 
ments are  lost.  Whistling  and  smoking  are  performed  with  difficulty,  if 
at  all ;  if  the  cheeks  are  puffed  out,  air  escapes  upon  the  paralyzed  side  ; 
food  collects  between  the  teeth  and  cheek,  owing  to  paralysis  of  the  buc- 
cinator; in  drinking  the  patient  inclines  the  head  to  the  sound  side  to 
prevent  escape  of  the  liquid  from  the  corner  of  the  mouth.  The  dilator 
naris  is  paralyzed ;  hence  sniffing  is  interfered  with,  and  the  sense  of 
smell  is  diminished  on  that  side. 

When  the  tongue  is  protruded  it  seems  to  be  drawn  toward  the  pal- 
sied side.  This  is  not  the  case,  however,  the  effect  being  due  to  con- 
traction of  the  unopposed  muscles  on  the  sound  side  of  the  face.  All 
reflex  movements  are  lost.  The  palate  is  not  affected  and  sensation  is 
not  impaired.  When  the  nerve  is  involved  between  the  intumescentia 
gangliformis  and  the  origin  of  the  chorda  tympani — i.  e.,  within  the 
Fallopian  canal — taste  is  lost  in  the  anterior  part  of  the  tongue,  and 
there  is  some  diminution  in  the  secretion  of  saliva.  When  other  parts 
of  the  nerve  are  diseased,  taste  is  not  interfered  with.  Hearing  may  be 
increased,  owing  to  paralysis  of  the  stapedius,  with  consequent  unopposed 
action  of  the  tensor  tympani.  When  due  to  middle-ear  disease  and  in 
disease  of  the  base  of  the  brain,  involving  both  facial  and  auditory 
nerves,  hearing  is  lessened.  In  the  latter,  however,  bone  conduction  will 
be  either  diminished  or  lost.  Some  degree  of  wasting  takes  place  in  the 
affected  muscles,  and  both  quantitative  and  qualitative  electric  changes 
quickly  follow  the  palsy.  If  the  intumescentia  gangliformis  is  involved, 
we  may  have  herpes  of  the  auricle  and  neuralgic  pains  in  the  ear  in 
addition  to  paralysis.      This  may  also  occur  without  paralysis. 

The  duration  of  an  attack  varies  from  a  few  days  to  several  months 
or  a  year,  and  in  rare  cases  it  is  permanent.  The  onset  is  usually  acute, 
and  the  acme  of  the  attack  may  be  reached  in  from  a  few  hours  to  a 
couple  of  days. 

Diagnosis. — From  the  table  previously  given  it  will  be  easy  to  diff'er- 
entiate  supra-nuclear  from  infra-nuclear  palsy.  When  contractures  have 
taken  place,  owing  to  the  furrows  thus  produced  the  aff'ected  side  may  be 
taken  for  the  sound  side,  but  on  getting  the  patient  to  whistle  the  true 
state  of  affairs  will  manifest  itself. 

Prgonosis. — In  the  rheumatic  cases  and  those  due  to  middle-ear  dis- 
ease recovery  usually  occurs  in  from  six  weeks  to  three  months.  Perma- 
nent contractures  and  deformity,  sometimes  associated  with  clonic  spasm 
may  result. 

Treatment. — Search  for  the  cause.  If  ear-disease  is  present,  make 
provision  for  free  drainage ;  if  syphilis,  give  iodid  of  potash,  mercury, 
or  both.  In  cases  due  to  cold,  the  so-called  rheumatic  palsies,  counter- 
irritation  is  especially  called  for,  and  cantharidal  collodion,  fly-blisters, 
or  the  actual  cautery  behind  the  ear  or  over  the  occiput  are  very  useful. 
The  bowels  should  be  freely  opened,  and  diaphoretics  or  hot  baths,  alkaline 
diuretics,  and  salicylates  administered ;  in  the  inflammatory  stage  small  doses 
of  mercury  are  of  value,  and  later  mercuric  iodid  or  general  tonics.  After 
the  acute  symptoms  have  subsided  (in  about  ten  days\  galvanism  should 
be  employed  to  stimulate  the  nerves  and  to  help  in  maintaining  the  tone 


1104  DISEASES  OF  THE  XERVOUS  SYSTEM. 

of  the  muscles.  When  contractures  threaten  in  late  cases  the  use  of 
electricity  should  be  dispensed  with.  When  the  paralysis  has  become 
permanent  benefit  can  sometimes  be  rendered  by  transplanting  parts  of 
either  the  hypoglossal  or  spinal  accessory  motor  nerves  into  the  trunk  of 
the  facial  peripheral  to  the  lesion.  For  severe  and  chronic  pain  due  to 
disease  of  the  geniculate  ganglion  or  intumescentia  gangliformis  cure  has 
been  obtained  by  its  removal.' 

DISEASES    OF    THE    AUDITORY   NERVE. 

The  eighth  nerve  has  its  deep  origin  in  the  medulla.  It  consists  of 
two  parts  :  the  cochlear,  Avhich  has  to  do  with  hearing,  and  the  vestibular, 
which  has  to  do  with  maintaining  of  our  relation  to  space,  or,  in  other 
words,  our  eciuilibrium.  The  auditory  fibers  decussate  in  the  region  of 
the  nuclei,  passing  in  the  posterior  extremity  of  the  internal  capsule  to 
the  opposite  hemisphere.  The  cortical  center  is  in  the  temporosphenoidal 
lobe  (first  and  second  convolutions.  Fig.  68).  It  is  also  connected  with 
the  medial  geniculate  body  and  posterior  corpora  quadrigemina;  the 
vestibular  branch,  in  addition,  is  connected  with  the  cerebellum.  De- 
struction of  that  of  the  left  side  results  in  word-deafness  :  thus,  spoken 
words  may  be  heard,  but  are  not  recognized  as  such.  This  is  not  a  com- 
mon condition.  Rarely  the  auditory  tract  may  be  involved  between  the 
cortex  and  the  nucleus.  The  nerve  may  be  implicated  at  the  base  of  the 
brain  by  tumors  of  the  cerebello-pontile  angle,  aneurysms,  hemorrhage, 
meningitis,  and  traumatism.  Erb  has  desci'ibed  a  primary  nerve  degen- 
eration in  tabes  dorsalis.  Disease  may  attack  the  labyrinth,  either 
primarily  or  secondarily  to  middle-ear  disease,  which,  if  confined  to  the 
cochlear  division,  causes  deafness,  and,  if  to  the  vestibular  branch  in  the 
semicircular  canals,  vertigo.  If  both  branches  are  involved,  deafness  and 
vertigo  coexist.  Drugs — quinin,  apiol,  salicylates — may  cause  deafness  sim- 
ilar to  the  labyrinthine  variety.  In  anemia  and  in  other  conditions  in  which 
the  general  health  is  below  par,  also  in  hysteria,  hearing  may  be  affected. 
The  lesions  give  rise  either  to  an  increased  or  diminished  sense  of  hearing : 

(a)  Hyperacusis^  in  which  certain  or  all  sounds  are  intensified.  Paral- 
ysis of  the  stapedius  muscle  causes  low^  notes  to  be  heard  with  great  in- 
tensity. Auditory  hyperesthesia  may  also  occur  in  hysteria  or  during 
the  course  of  cerebral  or  general  disease. 

(6)  Dysacusis — difficult  hearing — may  be  due  to  middle-ear  disease, 
or  it  may  exist  as  a  "nervous  deafness,"  the  result  of  labyrinthine  or 
nerve-disease.  These  may  be  differentiated  by  means  of  the  tuning- 
fork.  Normally,  air-conduction  is  better  than  bone-conduction,  and  if 
in  a  deaf  person  a  tuning-fork  can  be  heard  vibrating  longer  when  held 
against  the  skull-vault  or  temporal  bone  than  in  front  of  the  ear,  there 
is  some  impairment  of  conduction  in  the  meatus  or  middle  ear.  When 
the  patient  is  deaf,  and  yet  the  normal  relation  is  maintained  between 
air-  and  bone-conduction,  the  labyrinth  or  the  nerve  is  at  fault. 

(c)  Tinnitus  aurium — irritation  of  the  auditory  nerve — a  condition 
in  which  subjective  sounds  occur,  such  as  whirring,  buzzing,  ticking,  or 
ringing  in  character.  In  certain  subjects  they  are  worse  at  night  than 
during  the  day,  and  at  times  they  are  paroxysmal ;  as  a  rule,  in  any 
case  they  are  intensified  when  the  general  system  is  below  par. 

Tinnitus  may  be  caused  by  anemic  or  depraved  nutritional  states, 
*  Jour.  Amer.  Med.  Assoc,  Dec.  25,  1909,  p.  2144. 


MJ^JNlfmE'S  DISEASE.  1105 

high  blood-pressure,  intracranial  aneurysm,  pressure  on  the  cervical 
sympathetic  by  enlarged  glands,  tumor,  or  aneurysm,  impacted  cerumen, 
otitis  media,  labyrinthine  disturbance,  blows  upon  the  head,  excessive 
auditory  stimulation,  loud  noises,  or  it  may  occur  during  an  attack  of 
migraine  or  as  an  epileptic  aura.  In  a  neurasthenic  individual  tlie  sub- 
jective noise,  no  matter  what  the  cause,  will  be  accentuated.  The  more 
complex  and  elaborate  the  sound,  the  greater  the  probability  of  its  being 
of  central  origin.     (See  Meniere's  Disease.) 

Treatment. — Careful  search  must  be  made  for  the  cause  of  any  of 
these  morbid  conditions  just  described,  and,  when  practicable,  they  should 
be  removed.  The  system  should  be  brought  into  as  good  a  condition  as 
possible.  In  hyperesthesia  bromids  occasionally  avail.  In  dysacusis 
little  can  be  done  when  the  cause  is  labyrinthine.  The  same  is  true  when 
the  nerve  or  its  centers  are  involved.  For  tinnitus,  counter-irritation  and 
electricity  may  be  tried  externally,  and  iodids  internally,  but  with  little 
hope  of  relief;  in  addition,  sedatives,  as  the  bromids,  are  generally  called 
for,  and  even  morphin  may  be  necessary  in  paroxysmal  attacks.  Occa- 
sionally a  single  large  dose  of  pilocarpin  (gr.  ^L)  may  give  relief  for  some 
time.     Operation  has  been  resorted  to  (p.  1106). 

MENIERE'S   DISEASE. 

Definition. — An  aural  or  labyrinthine  vertigo — originally  described 
by  Meniere  in  1861 ;  the  cardinal  symptoms  are  vertigo,  deafness, 
noises  in  the  ear,  and  sometimes  vomiting. 

Pathology. — There  may  be  an  inflammation  or  atrophy  of  the 
nerve-endings.  There  are  also  changes  in  the  labyrinthine  membrane 
from  any  cause  or  from  hemorrhage. 

Etiology. — Meniere's  disease  is  most  common  after  thirty,  and  is 
rarely  met  with  before  that  age.  It  is  twice  as  common  in  men  as  in 
women.  The  precise  lesion  is  labyrinthine,  and  is  the  result  of  exposure, 
gout,  syphilis,  senile  change,  congestion,  and,  more  rarely,  hemorrhage. 
Any  cerebral  disturbance  or  gastric  or  other  irritation  is  apt  to  induce 
an  attack. 

Symptoms. — Vertigo  is  present,  and  varies  from  an  extremely  slight 
transient  attack,  and  one  that  is  entirely  subjective,  to  one  of  almost 
explosive  violence.  The  patient  may  have  a  sensation  of  having  been 
struck,  and  then  of  falling  heavily  to  the  ground.  The  slight  form  may 
be  continuous  with  more  or  less  frequent  severe  attacks,  or  a  complete 
intermission  of  days,  weeks,  or  months  may  transpire.  The  attacks 
may  arise  without  apparent  cause,  or  as  a  result  of  a  blow  or  even  a 
sudden  movement,  and  occur  during  both  working  and  sleeping  hours. 
The  giddiness,  when  severe,  causes  nausea  and  vomiting,  and,  if  pro- 
longed, bile  is  vomited  as  in  ordinary  bilious  attacks.  When  the  attack 
is  very  acute  momentary  unconsciousness  supervenes.  Nystagmus  and 
diplopia  may  occur  during  an  attack.  Tinnitus  and  deafness  usually 
exist  together,  the  former  may  be  either  mild  or  very  severe.  It  is 
usually  constant,  and  possibly  worse  during  an  attack  ;  it  may  be  entirely 
absent  between  the  attacks.  The  latter  (nervous  deafness)  is  constant 
and  of  varying  severity  in  different  individuals. 

Diagnosis. — The  occurrence  of  vertigo  and  tinnitus  in  a  person 
with  more  or  less  nervous  deafness,  with  or  without  gastric  symptoms, 
70 


1106  DISEASES  OF  THE  NERVOUS  SYSTEM. 

establishes  the  diagnosis.  The  tinnitus  and  the  character  of  the  deaf- 
ness usually  suffice  to  distino;uish  this  from  other  forms  of  vertigro.  A'^er- 
tigo  and  deafness  may  also  be  caused  by  middle-ear  disease,  but  in  such 
a  case  examination  (p.  1104)  will  show  that  the  deafness  is  not  of  nerve 
origin.  Similar  symptoms  may  also  be  caused  either  by  a  growth  or 
patch  of  meningitis  situated  in  the  cerebellopontile  angle.  In  such  a 
case  other  symptoms  of  brain  tumor  or  meningitis  will  be  present,  and 
the  seventh  nerve  is  also  usually  aftected.  In  epilepsy  with  auditory 
aurre  the  period  of  unconsciousness  is  generally  much  longer,  and  on 
regnining  consciousness  the  patient  is  dull  and  drowsy  for  some  time.  It 
is  possible  also,  as  a  rule,  to  elicit  a  history  of  convulsions. 

Prognosis. — In  some  cases  the  condition  grows  progressively  worse 
until  deafness  supervenes,  when  it  ceases.  Often,  however,  arrest  or 
improvement,  or  even  complete  recovery,  may  be  secured.  In  heart- 
disease  the  shock  may  prove  fatal,  and  in  the  very  acute  but,  fortunately, 
rare  cases  the  prognosis  is  always  bad. 

Treatment. — Counter-irritation  over  the  mastoid  process  and  the 
internal  use  of  bromids  to  lessen  the  morbid  sensibility  will  prove  valu- 
able. The  emunctories  must  be  gotten  in  good  condition,  and  any  un- 
derlying disease,  as  syphilis  or  gout,  must  be  treated.  Charcot  suggested 
the  use  of  drugs  that  produce  tinnitus — quinin,  for  instance.  The  cases 
were  worse  at  the  time,  but  some  of  them  seemed  to  improve  subse- 
quently. Gowers  employs  sodium  salicylate  in  5-gr.  (0.324)  doses, 
thrice  daily,  believing  that  more  good  arises  when  such  drugs  are  given 
in  moderation.  Small  doses  of  pilocarpin  sometimes  do  good.  Apiol 
might  be  tried  in  this 'connection.  Nitroglycerin  and  the  nitrites  are 
sometimes  of  value  in  cases  associated  Avith  arteriosclerosis.  Division  of 
the  auditory  nerve  has  cured  some  cases. ^ 

DISEASES    OF    THE    GLOSSO-PHARYNGEAL   NERVE. 

The  ninth  cranial  nerve  has  its  origin  in  the  posterior  part  of  the  floor 
of  the  fourth  ventricle,  in  close  relation  with  the  pneumogastric  nerve. 
Our  knowledge  as  to  its  function  is  not  exact,  both  because  it  is  seldom  if 
ever  involved  alone,  and  also,  on  account  of  its  many  connections  (with  the 
trigeminus,  the  facial,  the  pneumogastric.  and  the  sympathetic  nerves),  it 
is  difficult  to  say  Avhether  the  terminal  fibers  involved  represent  the  func- 
tions of  its  roots  or  of  one  of  its  connections  (Gowers). 

Its  fibers  are  distributed  to  the  tonsils,  the  back  of  the  tongue,  the  soft 
palate,  the  pharynx,  the  Eustachian  tubes,  the  tympanitic  cavity.  It  sup- 
plies both  motor  and  sensory  fibers,  it  is  also  the  nerve  of  taste,  certainly 
for  the  posterior  portion  of  the  tongue,  and  possibly,  by  means  of  connec- 
tions with  the  fifth  nerve,  for  the  anterior  as  well.  This  nerve  is  involved 
in  the  nuclear  degenerations  that  are  spoken  of  as  bulbar  palsies.  It  may 
be  also  affected  by  meningitis  or  new  growths. 

DISEASES    OF   THE   PNEUMOGASTRIC    NERVE. 

As  already  stated,  the  origin  of  the  tenth  cranial  nerve  is  in  intimate 
relation  with  that  of  the  ninth.  It  is  also  continuous  below  with  that 
of  the  eleventh,  and  all  three  are  associated  with  the  center  for  the 
hypoglossal  nerve.  The  nerve  proper  arises  from  the  side  of  the  me- 
dulla, and  runs  on  either  side  of  the  neck  in  the  sheath  of  the  carotid 

1  Ballance,  The  Lancet,  1908,  vol.  ii. 


DISEASES  OF  THE  PNEUMOGASTRIC  NERVE.  1107 

artery,  lying  behind  that  vessel.  It  enters  the  thorax  in  front  of  the 
subclavian  artery  on  the  right  side,  and  between  the  subclavian  and  the 
carotid  on  the  left;  then  it  courses  beside  the  esophagus,  and  is  distrib- 
uted to  the  pharynx,  larynx,  lungs,  heart,  esophagus,  and  stomach,  and 
sends  fibers  to  the  intestines  and  spleen. 

The  esophageal  fibers  are  both  motor  and  sensory,  gastric  fibers  being 
chiefly  sensory.  The  vagus  is  in  part  the  motor  nerve  of  the  intes- 
tines. It  also  contains  both  accelerator  and  inhibitory  fibers  for  the 
respiratory  center,  is  the  cardiac  inhibitory  nerve  and  a  vasodilator, 
and  is  said  to  contain  trophic  fibers  for  the  heart  and  lungs. 

Ktiology. — The  nerve  may  be  involved  at  its  nucleus  either  by 
hemorrhage  or  softening.  The  nuclei  of  the  ninth,  eleventh,  and  twelfth 
nerves,  and  frequently  the  seventh,  are  simultaneously  attacked,  either 
wholly  or  in  part,  giving  rise  to  a  group  of  symptoms  known  as  bulbar 
palsy.  The  tenth  nerve  at  its  superficial  origin  may  be  compressed  by 
neoplasms,  aneurysms,  and  the  products  of  meningitis;  in  its  course 
down  the  neck  it  may  suffer  pressure,  or  may  either  be  tied  in  ligating 
the  carotid  artery  or  cut  in  the  removal  of  a  tumor  or  enlarged  glands. 
Very  rarely  it  may  be  injured  by  incised  or  punctured  wounds,  or  be  the 
seat  of  neuritis  due  to  exposure  or  to  some  toxemia.  The  morbid  condi- 
tions of  the  pneumogastric  are  best  studied  by  considering  the  branches 
of  distribution  separately. 

(a)  Pharyngeal  Branches. — The  muscles  and  mucous  membrane  of  the 
pharynx  are  supplied  by  branches  of  the  pneumogastric  and  glossopha- 
ryngeal nerves,  constituting  the  pharyngeal  plexus.  The  pharynx  may 
be  the  seat  of  spasm  or  paralysis  :  this  is  purely  a  "  functional  "  condition, 
and  usually  occurs  rnhj^ievic  {^c/lobulus  hystericus)  or  m  nervous  individuals. 

Paralysis  of  the  pharynx  causes  difficulty  in  swallowing,  so  that  food 
remains  in  the  mouth  instead  of  being  passed  into  the  esophagus.  Par- 
ticles often  enter  the  larynx  and  give  rise  to  paroxysms  of  coughing,  and 
at  times  cause  choking.  When  the  soft  palate  is  also  paralyzed,  the  food 
is  regurgitated  into  the  nose.  The  lesion  is  generally  nuclear.  The  root 
of  the  nerve  may  be  involved  as  it  leaves  the  side  of  the  medulla  by  men- 
ingitis or  by  pressure  from  a  neoplasm  or  an  aneurysm.  It  may  also  be 
caused  by  a  toxic  neuritis,  as  in  diphtheria. 

(5)  Laryngeal  Branches. — The  superior  laryngeal  nerve  furnishes 
sensory  fibers  to  the  mucous  membrane  of  the  larynx  above  the  vocal 
cords,  and  supplies  also  the  crico-thyroid  and  epiglottidean  muscles. 
The  inferior  or  recurrent  laryngeal  nerve,  which  takes  its  origin  in  the 
superior  thoracic  region,  winds  around  the  arch  of  the  aorta  on  the  left 
side  and  around  the  subclavian  artery  on  the  right,  reaching  the  larynx 
by  running  up  between  the  trachea  and  esophagus.  It  is  the  sensory 
nerve  of  the  larynx  below  the  vocal  cords,  also  of  the  entire  trachea, 
and  supplies  all  the  muscles  of  the  larynx  except  those  named  above. 
It  has  been  shown  that  the  motor  fibers  of  the  larynx  come  from  the 
glosso-pharyngeal  nucleus,  the  pneumogastric  fibers  being  sensory. 

Spasm  of  the  larynx  is  due  to  over-action  of  the  glottis-closers  (the 
adductors),  though  some  cases  described  in  this  category  are  probably 
instances  of  abductor  paralysis.  The  condition  is  rather  rare  in  adults, 
but  quite  common  in  children  (laryngismus  stridulus),  and  particularly 
in  rachitic  subjects.  An  attack  may  also  be  induced  in  those  predisposed 
by  any  form  of  nerve-irritation  or  catarrhal  condition  of  the  respiratory 


1108  DISEASES  OF  THE  SERVO  US  SYSTEM. 

tract.  It  may  be  part  of  a  general  neurosis :  it  is  sometimes  seen  in 
tabes  dorsalis  {lan/)ujeal  crisis) ;  and  Liveing  reports  that  he  has  seen  it 
take  the  phice  of  an  attack  of  migraine.  Spastic  aphoria  consists  of  a 
spasm  induced  whenever  an  attempt  to  speak  is  made.  Laryngeal 
spasms  occur  most  frequently  at  night.  Dyspnea  is  the  most  striking 
symptom,  and  is  so  intense  in  some  cases  that  suffocation  seems  immi- 
nent. The  ])atient  may  be  cyanotic.  Soon  the  retained  carbonic  acid 
gas  causes  relaxation,  but,  as  the  cords  open  slowly,  the  inspiration  is 
accompanied  by  a  crowing  sound,  and  the  expiratory  sound  is  harsher 
than  normal. 

Paralysis  of  the  larj/n.r  may  be  the  result  of  a  nuclear  degeneration 
(glosso-pharyngeal),  as  in  chronic  bulbar  ])aralysis  :  this  form  may  occur 
in  disseminated  sclerosis,  tabes  dorsalis,  general  paralysis  of  the  insane, 
and  in  certain  toxemias.  The  paralysis  is  generally  bilateral ;  rarely  it 
is  unilateral. 

A  cerebral  lesion  in  the  laryngeal  cortical  center  may  cause  pseudo- 
bulbar paralysis.  Since  the  two  centers  are  compensatory,  the  lesion 
must  be  bilateral.  This  may  also  be  caused  by  capsular  lesions  (p.  1106). 
•  The  nerve  may  bo  involved  at  its  root  or  in  any  part  of  the  trunk, 
and  such  lesions  are  usually  unilateral.  The  recurrent  laryngeal  nerve, 
especially  the  left,  is  more  apt  to  be  diseased  than  the  superior,  on 
account  of  its  position.  Thus,  the  arch  of  the  aorta  is  more  frequently 
the  seat  of  an  aneurysm  than  the  subclavian ;  enlarged  thoracic  glands, 
neoplasms,  and  an  enlarged  thyroid  can  also  damage  these  nerves.  The 
peripheral  filaments  may  be  attacked  as  part  of  a  multiple  neuritis. 

In  certain  cases  the  muscles  become  Aveakcned  without  being  para- 
lyzed, this  possibly  being  due  to  a  local  neuritis,  or  to  a  congestion  and 
inflammation  of  the  mucous  membrane  from  over-use  {clergymen  s  sore 
throat)^  or  as  the  result  of  exposure. 

The  following  are  the  chief  forms  of  paralysis : 

(1)  Complete  Paralysis. — By  this  is  generally  understood  paralysis 
of  all  except  the  crico-thyroid  and  epiglottidean  muscles,  though  occa- 
sionally these  may  also  be  involved.  Since  the  cords  are  paralyzed, 
phonation  is  impossible.  As  a  rule,  there  is  no  interference  with  respi- 
ration, though  the  pressure  of  the  in-going  air  may  bring  the  cords 
nearer  together,  and  thus  produce  a  certain  amount  of  inspiratory 
harshness. 

As  the  cords  cannot  be  closed,  coughing  is  impossible,  as  the  air 
escapes  through  the  glottis,  and  no  expulsive  force  can  be  given  to  it. 
When  the  paralysis  is  unilateral  these  symptoms  will  of  necessity  be 
modified,  and  some  degree  of  phonation  may  be  possible.  The  most 
common  cause  of  this  condition  is  an  involvement  of  the  recurrent 
laryngeal  nerve ;  the  lesion  may,  however,  be  nuclear  or  in  the  course 
of  the  nerve-trunk. 

(2)  Paralysis  of  the  Abductors. — The  only  special  abductor  muscles 
are  the  posterior  crico-arytenoids.  When  they  are  involved  the  glottis 
fails  to  open  in  inspiration,  and  the  unopposed  adductors  bring  the  vocal 
cords  together.  They  are  still  more  closely  approximated  during  inspi- 
ration by  the  column  of  air,  and  hence  the  prolonged,  stridulous  inspi- 
ratory sound.  Phonation  and  expiration  are  practically  unchanged.  It 
is  quite  likely  that  many  cases  supposed  to  be  instances  of  hysteric 
spasm  of  the  glottis  are  really  cases  of  abductor  paralysis. 


DISEASES  OF  THE  rNElJMOGASTRICj  NERVE. 


1109 


In  unilateral  paralysis  the  normal  movements  of  the  unaflVjcted  vocal 
cord  prevent  any  marked  degree  of  dyspnea  and  stiidor:  j)hoiiation  is 
usually  hoarse  and  of  a  low  pitch.  In  cases  of  long  duration  the  symp- 
toms become  more  marked  as  the  unopposed  adductors  undergo  second- 
ary contracture  and  still  further  narrow  the  glottis. 

This  condition  may  be  due  either  to  central  disease  or  to  some  local 
change.  The  abductor  muscles  may  be  degenerated,  while  all  the  other 
laryngeal  muscles  are  healthy,  or  one  or  both  recurrent  nerves  may  be 
affected.  These  nerves  innervate  both  the  abductors  and  adductors,  and 
it  is  not  clearly  understood  why  the  abductors  alone  should  suffer  when 
the  parent  nerve-trunk  is  involved.  At  any  time  it  might  be  a  very 
grave  condition,  for  should  any  swelling  of  the  cords  supervene  nothing 
but  a  prompt  laryngotomy  could  prevent  suffocation. 

(3)  Adductor  Paralysis. — The  cords  move  normally  during  respira- 
tion, and  hence  there  is  no  stridor ;  as  they  cannot  be  approximated, 
however,  phonation  is  impossible.  This  condition  is  met  Avith  in  hys- 
teria, producing  hysteric  aphonia,  in  public  speakers  who  overtax  their 
voices,  and  also  in  laryngitis. 

The  following  table,  from  Gowers'  text-book  on  Diseases  of  the  Ner- 
vous System,  enables  one  to  get  a  comprehensive  idea  of  the  subject: 


Symptoms. 

No  voice  ;  no  cough  ;  stri- 
dor only  on  deep  inspi- 
ration. 

Voice  low-pitched  and 
hoarse  ;  no  cough  ;  stri- 
dor absent  or  slight  on 
deep  breathing. 

Voice  little  changed ;  cough 
normal :  inspiration  diffi- 
cult and  long,  with  loud 
stridor. 

Symptoms  inconclusive ; 
little  affection  of  voice  or 
cough. 

No  voice  ;  perfect  cough  ; 
no  stridor  or  dyspnea. 


Signs. 

Both  cords  moderately  ab- 
ducted and  motionless. 

One  cord  moderately  ab- 
ducted and  motionless, 
the  other  moving  freely, 
and  even  beyond  the  mid- 
dle line  in  phonation. 

Both  cords  near  together, 
and,  during  inspiration, 
not  separated,  but  even 
drawn  nearer  together. 

One  cord  near  the  middle 
line,  not  moving  during 
inspiration ;  the  other 
normal. 

Cords  normal  in  position, 
and  moving  normally  in 
respiration,  but  not 
brought  together  on  an 
attempt  at  phonation. 


Lesions. 
Total  bilateral  palsy. 


Total  unilateral  palsy. 


Total  abductor  palsy. 


Unilateral  abductor  palsy. 


Adductor  palsy. 


Sensory  disturbances  of  the  larynx  are  rare,  and  especially  hyperes- 
thesia. Anesthesia  may  be  due  to  hysteria,  or  to  bulbar  paralysis,  or  to 
disease  of  the  superior  laryngeal  nerve.  It  is  dangerous,  as  food  may 
enter  the  windpipe. 

(c)  Cardiac  Branches. — These  with  branches  from  the  sympathetic 
form  the  cardiac  plexus.  The  vagus  contains  both  accelerator  and  in- 
hibitory fibers,  but  the  latter  predominate ;  therefore  irritation  of  the 
nerve,  either  centric  or  peripheral,  will  slow  the  heart's  action.  Czermak 
was  able  to  slow  the  action  of  his  heart  by  pressing  a  small  tumor  in 
his  neck  against  the  vagus  nerve.  When  the  function  of  the  nerve  is 
lowered,  inhibition  is  removed  and  the  heart's  action  becomes  rapid. 


1110  DISEASES  OF  THE  NERVOUS  SYSTEM. 

This  may  be  brought  about  by  a  toxemic  neuritis,  by  pressure,  accidental 
ligature,  or  by  incised  or  punctured  wounds.  Various  emotions  and 
nervous  states   may   briuir  about  the  same  result. 

((/)  Pulmonary  Branches. — Both  accelerator  and  inhibitory  fibers  ex- 
ist, but  in  this  case  the  accelerator  influence  predominates,  so  that  irri- 
tation results  in  increased  respiratory  movements  or  even  in  bronchial 
spasm,  since  the  bronchial  muscles  are  also  supplied  by  this  nerve.  It 
is  this  nerve  that  is  supposed  to  be  concerned  in  the  production  of  asth- 
matic paroxysms.  Therefore,  when  the  nerve-function  is  lowered  the 
respirations  become  mucli  slower.  The  nerve  is  supposed  to  contain 
trophic  fibers  for  the  luuijjs. 

(«')  Esophageal,  ( /')  Gastric,  and  (//)  Intestinal  Branches. — The  esoph- 
ageal branches  are  rarely  damaged,  and  irritation  (spasm)  occurs  more 
frequently  than  paralysis.  The  pneumogastric  gives  the  sensory,  and 
in  part  the  motor,  nerve-supply  to  the  stomach,  and  irritation  gives  rise 
to  increased  contractions  with  some  pain. 

The  sensation  of  hunger  is  supposed  to  be  associated  with  the  vagus 
nerve,  and  vomiting  may  result  from  direct  or  reflex  irritation.  Par- 
alysis causes  some  diminution  of  the  gastric  contractions.  Normally, 
the  vagi  accelerate  intestinal  peristalsis. 

Treatment. — It  is  almost  always  impossible  to  remove  the  cause  of 
the  above  conditions.  Syphilitic  lesions  are  probably  the  most  amen- 
able, and  in  the  various  laryngeal  palsies  electricity  may  be  employed, 
though  it  is  of  somewhat  doubtful  utility,  and  in  abductor  palsy  may 
possibly  exert  a  harmful  influence  by  stimulating  the  adductors.  Strych- 
nin and  general  tonics  should  be  administered.  Massage  of  the  larynx 
may  be  tried,  and  in  spasmodic  conditions  attention  should  be  directed 
to  the  general  physical  state.  All  sources  of  nerve-irritation  should  be 
removed  if  possible,  and  bromids,  or  even  chloral,  should  be  given. 

DISEASES    OF    THE    SPINAL   ACCESSORY   NERVE. 

This  nerve  consists  of  two  parts — an  external  or  spinal,  and  an  in- 
ternal or  acces.sory,  portion.  The  latter  has  already  been  described  in 
connection  with  the  pneumogastric  nerve.  It  forms  the  motor  portion 
of  that  nerve,  and  is  distributed  to  the  laryngeal  and  pharyngeal  mus- 
cles. The  spinal  element  arises  from  the  multipolar  ganglion-cells  in 
the  anterior  gray  horns  of  the  cervical  cord,  ascends  and  enters  the 
cranium  through  the  foramen  magnum,  and  leaves  it,  after  joining  with 
the  accessory  part,  through  the  jugular  foramen.  It  supplies  the  sterno- 
mastoid  muscle  and  in  part  the  trapezius. 

Injury  or  disease  of  the  nerve  may  result  in  spasm  or  paralysis. 
Only  the  spinal  part  is  considered  in  this  section. 

TORTICOLLIS. 

( Wri/-neck.) 

This  may  be  a  congenital  or  an  acipiired  condition. 

Congenital  torticollis,  or  "fixed  wry-neck,"  is  the  result  of  an 
atrophy  and  shortening  of  the  sterno-mastoid  muscle,  brought  about 
by  some  intra-uterine  condition  or,  possibly,  by  an  injury  at  birth.    The 


TORTICOLLIS.  J  J  ^ 

right  muscle  is  most  commonly  aflfoctcd.  The  head  turns  slightly  to- 
ward the  sound  side  ;  the  eye  may  deviate,  and  curvature  of  the  cervical 
spine  may  develop. 

Facial  asymmetry  is  a  usual  concomitant  of  this  condition.  The 
face  on  the  same  side  as  the  lesion  develops  less  rapidly  than  the  other 
side,  and  in  time  secondary  contracture  of  the  unopposed  muscles  takes 
place.  The  torticollis  can  be  cured  by  tenotomy,  but  the  facial  asym- 
metry persists.  Fixation  is  necessary  for  a  while  when  contracture 
exists. 

Spasmodic  wry-neck  may  be  tonic  or  clonic.  These  forms  may  co- 
exist, alternate,  or  occur  independently  in  different  individuals.  The 
condition  is  met  with  almost  exclusively  in  adults,  and  occurs  mcst  fre- 
quently in  middle-aged  men. 

Pathology. — Usually  no  macroscopic  or  microscopic  evidence  of  any 
lesion  has  been  discovered,  and  the  condition  is  probably  dependent  upon 
an  overactivity  of  the  neurons  in  the  various  centers  that  control  the 
muscles  of  the  aifected  part.     Some  cases  belong  to  the  Tics  (p.  1216). 

Ktiology. — The  influence  of  sex  and  age  has  been  mentioned ;  a 
neurotic  heredity  may  also  predispose.  Torticollis  may  follow  habit- 
spasm,  or  some  injury  to  the  head  or  neck,  or  exposure  to  cold,  the  latter 
constituting  the  ''  rheumatic  "  type.  It  may  be  due  to  an  irritative  lesion 
either  in  the  spinal  cord  above  the  fifth  cervical  segment,  or  to  tumor, 
hemorrhage,  meningitis,  or  bone  disease  in  the  upper  part  of  the  vertebral 
canal.  Most  cases  are  apparently  functional,  and  may  be  due  to  reflex 
irritation,  as  eye-strain,  or  occur  without  apparent  cause. 

Symptoms. — The  occiput  is  drawn  toward  the  shoulder  of  the 
affected  side,  the  chin  is  elevated,  and  the  face  rotated  more  or  less 
toward  the  sound  side.  The  sternomastoid  may  alone  be  afi"ected,  but 
the  upper  fibers  of  the  trapezius  are  usually  also  involved.  In  addition, 
the  superior  obliquus  and  complexus  of  the  same  side  and  the  splenius 
capitis  and  inferior  obliquus  of  the  opposite  may  be  involved.  Affection 
of  the  deep  muscles  causes  greater  retraction  of  the  head  than  when  the 
sternomastoid  and  trapezius  are  alone  the  seat  of  spasm.  Spinal  curva- 
ture may  ensue,  the  convexity  being  toward  the  sound  side.  This  only 
takes  place  in  cases  that  have  existed  for  some  time.  Clonic  spasm  is 
infinitely  more  distressing  and  more  apt  to  be  permanent. 

Some  pain  and  muscular  twitching  may  precede  the  onset  of  the 
attack,  though,  as  a  rule,  muscular  contractions  are  the  first  indication. 
These  are  mild  at  first,  and  rarely  abruptly,  more  commonly  slowly, 
they  increase  in  severity.  As  the  case  progresses  other  muscles,  and 
even  those  of  the  arm,  become  involved.  Cases  have  been  described  in 
which  certain  muscles  or  groups  of  muscles  in  the  hand  or  arm  have 
been  primarily  affected,  the  condition  gradually  spreading  from  them. 
The  spasm  usually  ceases  during  sleep.  An  attack  may  cause  pain,  but, 
as  a  rule,  it  induces  merely  a  feeling  of  fatigue  in  the  muscles  ;  it  is 
worse  if  the  patient  is  excited  or  emotional.  Bilateral  spasm  may  occur, 
the  muscles  of  both  sides  being  equally  affected  (retro-coUie  Sj)asm). 
Gowers  speaks  of  a  case  in  which  the  backward  displacement  of  the  head 
was  so  great  that  the  face  was  horizontal  and  looked  directly  upward. 

Diagnosis. — As  a  rule  this  is  not  difficult.  When  spasm  is  in- 
duced by  enlarged  and  painful  glands  beneath  the    sterno-mastoid  the 


1112  DISEASES  OF  THE  XERVOUS  SYSTEM. 

age  of  the  patient  will  be  of  value  in  determining  the  true  condition. 
This  usually  occurs  in  children  ;  true  wry-neck,  on  the  other  hand,  very 
rarely  commences  before  the  thirtieth  year.  Hysteric  spasm  may  also 
simulate  spasmodic  torticollis,  but  it  generally  occurs  in  young  women, 
and  usually  other  evidences  of  hysteria  are  also  present.  The  rlwiDnatic 
ti/pe  and  the  rigidity  induced  by  caries  of  the  spine  must  be  differentiated 
from  one  another  and  from  spasmodic  wry-neck.  If  the  rigidity  comes 
on  suddenly,  following  exposure  to  cold  or  wet,  and  the  pain  is  not  in- 
creased at  night  or  by  depressing  the  head  upon  the  spine,  and  is  re- 
lieved by  hot  applications,  the  condition  is  probably  rheumatic.  When 
the  rigidity  and  pain  are  of  slow  onset,  without  history  of  exposure, 
and  the  pain  is  both  worse  at  night  and  is  increased  by  depressing  the 
head  upon  the  spine,  but  is  relieved  by  elevating  the  head,  the  condition 
is  very  probably  one  of  caries  of  the  spine.  In  irritative  lesions  within 
the  spinal  canal,  either  intra-  or  extraniodullary,  the  spasm  is  usually 
bilateral  and  tonic,  and  other  symptoms  of  involvement  of  the  cord  are 
likely  to  be  found. 

Prognosis. — Very  rarely  the  torticollis  may  diminish  or  even  cease 
after  an  existence  of  months  or  years.  Usually,  however,  it  is  persistent, 
either  being  stationary  or  slowly  increasing  in  severity  and  widening  in 
range.  The  prognosis  must  always  be  guarded,  and  in  severe  cases  grave 
as  to  recovery,  though  the  disease  does  not  shorten  life. 

Treatment. — Generally  very  little  can  be  expected  from  medica- 
tion. Broniids,  morphin,  chloral,  hyoscyamus,  or  cannabis  indica  may 
be  tried,  as  may  the  various  forms  of  countcrirritation.  Atropin,  in  in- 
creasing doses,  administered  hypodermically  into  the  muscles,  has 
been  effectual  in  some  cases.  Massage  of  the  affected  muscles  and  rest 
in  bed  may  also  at  times  be  of  service.  Galvanism  should  be  tried, 
the  negative  pole  being  placed  over  the  occipital  region  and  the  positive 
over  the  affected  muscles.  Nerve-stretching  and  tenotomy  of  the  affected 
muscles  is  of  very  little  value.  The  only  surgical  procedure  that  has 
proved  of  any  distinct  value  is  neurectomy  of  the  spinal  accessory  and 
posterior  branches  of  the  upper  four  cervical  nerves,  with  excision  of  a 
part  of  the  nerves  to  prevent  reunion.  This  necessarily  causes  paralysis 
and  atrophy  of  the  muscles  supplied  :  but,  since  it  often  aljolishes  the 
spasm,  the  slight  loss  of  power  and  the  interference  with  the  movement 
of  the  head  are  comparatively  infinitesimal.  The  results,  however,  are 
not  uniform,  even  so  far  as  the  spasm  is  concerned. 

PARALYSIS    OF    THE    SPINAL    ACCESSORY    NERVE. 

The  accessory  portion  has  been  previously  considered  in  describing 
the  laryngeal  branches  of  the  pneumogastric. 

In  the  spinal  portion  the  nuclei  may  be  involved  in  degenerative 
lesions  of  the  motor  region  of  the  spinal  gray  matter.  The  nerve-trunk 
may  be  damaged  by  pressure  from  exudative  products  (meningitis), 
tumors,  or  caries,  with  resulting  paralysis  and  wasting  of  the  sterno- 
mastoid  and,  in  part,  of  the  trapezius.  This  latter  muscle  is  also  sup- 
plied by  the  cervical  nerves.  The  patient  has  difficulty  in  rotating  the 
head  to  the  side  opposite  that  on  which  the  paralysis  exists,  and  the 
affected  muscle  does  not  stand  out  in  movements  of  the  head.  Unless 
secondary  contraction  of  the  unopposed  muscle  sets  in,  no  deviation  oc- 


DISEASES  OF  THE  JIYrOGLOSSAL  NERVE.  ]n;J 

curs  when  the  head  is  at  rest.  The  only  portion  of  tlie  trapezius  that 
is  ihvolved  in  paralysis  of  the  external  part  of  the  eleventli  nerve 
stretches  from  the  occipital  bone  to  the  acromion.  The  normal  contour 
of  the  neck  is  lost  in  such  cases,  and  the  ability  to  raise  the  arm  is  in- 
terfered with  because  the  trapezius  cannot  fix  the  scapula,  the  fulcrum 
of  the  deltoid.  Bilateral  paralysis  may  occur  as  in  progressive  muscu- 
lar atrophy  ;  if  both  sterno-mastoids  are  involved,  the  head  falls  back- 
ward ;  if  both  trapezii,  it  falls  forward. 

The  treatment  is  that  of  the  underlying  cause.  If  the  lesion  is 
nuclear,  practically  nothing  can  be  done.  If  the  condition  is  due  to 
pressure,  in  some  cases  relief  may  be  obtained.  Electricity  and  mas- 
sage should  be  employed  during  the  recovery  of  the  nerve. 

DISEASES    OF   THE   HYPOGLOSSAL   NERVE. 

The  nucleus  of  the  twelfth  cranial  nerve  is  in  the  most  posterior  por- 
tion of  the  floor  of  the  fourth  ventricle.  It  is  said  by  some  observers 
that  the  nuclei  of  the  fibers  for  the  palate  and  vocal  cords  that  run  in 
the  spinal  accessory  nerve  may  be  in  the  lower  part  of  the  twelfth- 
nerve  nucleus. 

The  cortical  center  for  this  nerve  is  in  the  lower  part  of  the  ascend- 
ing frontal  convolution,  in  the  neighborhood  of  the  cortical  facial  cen- 
ter. This  propinquity  probably  explains  the  simultaneous  involvement 
of  the  facial  and  lingual  muscles  in  some  cases.  The  hypoglossal  is  the 
motor  nerve  for  the  tongue  and  for  most  of  the  muscles  attached  to  the 
hyoid  bone.      Spasm  or  paralysis  may  follow  disease  of  the  nerve. 

Spasm  may  be  either  unilateral  or  bilateral.  It  is  probably  met  with 
most  commonly  in  hysteria,  or  as  a  part  of  some  general  convulsive 
condition,  as  epilepsy  or  chorea.  It  may  also  be  associated  with  facial 
spasm,  as  mentioned  above.  Irritation  of  the  fifth  nerve  (dental 
caries,  ulceration  of  the  gums)  seems  to  be  responsible  for  some  cases. 
"Paroxysmal  clonic  spasm  "  is  a  form  in  which  the  tongue  is  rapidly 
thrust  in  and  out  (p.  1216).  Various  sensations  in  the  affected  region 
may  precede  the  attack.  A  rare  form — apJithongia — is  induced  when  an 
attempt  to  speak  is  made.  The  prognosis  in  this  condition  is  good,  and 
a  general  tonic  treatment  is  indicated. 

Paralysis  may  result  from  supra-nuclear,  nuclear,  or  infra-nuclear 
lesions. 

Supra-nuclear. — The  lesion  may  be  anywhere  between  the  cortex 
(lower  part  of  the  ascending  frontal  gyrus)  and  the  medulla,  and  causes 
paralysis  on  the  opposite  side.  In  this  condition  the  aff'ected  muscles  do 
not  atrophy  nor  do  they  show  any  electric  change. 

Nuclear. — The  lesion  is  usually  degenerative.  It  may  either  be  of 
sudden  onset  (vascular),  less  rapid,  but  still  acute  (inflammatory),  or  it 
may  be  chronic,  as  in  bulbar  palsy  or  tabes  dorsalis.  The  nuclei 
are  so  close  together  that  the  condition  is  almost  invariably  bilateral. 

Infra-nuclear. — The  fibers  may  be  injured  by  the  pressure  of  neo- 
plasms or  by  the  products  of  meningitis  or  of  syphilis.  Disease  of  the 
bone  may  also  involve  the  nerve  in  its  passage  through  the  foramen. 
More  rarely,  some  traumatism  or  disease  of  the  upper  cervical  vertebrae 
may  simultaneously  injure  the  eleventh  and  twelfth  nerves. 


1114  DISEASES  OF  THE  XERVOUS  SYSTEM. 

Symptoms. — Paralysis  and  atrophy  of  oue  or  both  sides  of  the 
tongue  and  fibrillary  twitchings  may  be  noted,  and  if  the  condition  be 
unilateral,  the  tongue  "when  protruded  deviates  toward  the  affected  side. 
Articulation,  mastication,  and  swallowing  are  but  verv  slightly  interfered 
with.  In  the  bilateral  form,  however,  these  are  very  much  impaired ; 
the  tongue  cannot  be  protruded  and  lies  motionless  on  the  Hoor  of  the 
mouth.  The  atrophy  is  muscular.  This  throws  the  mucous  membrane 
into  deep  folds.      Sensation  and  taste  are  unaltered. 

Diagnosis. — If  the  lesion  is  supranuclear,  there  is  usually  hemi- 
plegia ou  the  same  side  as  the  lingual  paralysis,  without  atrophy  of  the 
tongue  muscles.  When  nuclear  it  is,  as  has  been  said,  generally  bilateral 
and  forms  part  of  a  bulbar  paralysis.  There  is  also  wasting  of  the 
lingual  muscles.  When  the  fibers  are  involved  in  the  medulla  there  is 
paralysis  of  the  tongue  on  one  side,  of  the  limbs  on  the  other,  and  the 
tongue  deviates  from  the  paralyzed  side  of  the  body.  Outside  the 
medulla  the  condition  is,  as  a  rule,  unilateral,  and  the  spinal  accessory 
fibers  are  frequently  involved.  In  the  nuclear  and  intranuclear  varie- 
ties there  is  wasting  of  the  muscles. 

The  prognosis  is  usually  unfavorable,  and  the  treatment  consists 
of  a  course  of  general  tonics  and  of  mercury  and  the  iodids,  w  ith  counter- 
irritation. 


DISEASES  OF  THE  SPINAL  NERVES. 

DISEASES    OF   THE    CERVICAL   PLEXUS. 

Phrenic  Nerve. — This  nerve  is  usually  involved  as  a  result  of  some 
lesion  of  the  ganglion-cells  in  the  anterior  gray  horns  at  the  level  of  the 
third  or  fourth  cervical  segments.  The  trunk  may  be  damaged  by  pres- 
sure, as  by  aneurysm  or  neoplasms,  or  by  traumatism,  or  it  may  be  the 
seat  of  neuritis.  More  or  less  immobility  of  the  diaphragm  follows, 
amounting  in  some  cases  to  complete  paralysis.  This  is  not  readily 
seen  with  the  patient  at  rest,  and  in  women  it  is  specially  hard  to  ob- 
serve, as  their  breathing  is  chiefly  of  the  costal  type.  The  abdomen 
moves  in  during  inspiration,  and  out  during  expiration,  forming  the  re- 
verse of  the  normal  movements.  Exertion  readily  causes  dyspnea,  and 
pulmonary  diseases  are  apt  to  be  exaggerated  as  the  products  of  secretion 
accumulate.  If  the  lesion  is  bilateral,  death  occurs  in  a  very  short  time 
after  distressing  dyspnea.  Neuritis  of  one  phrenic  nerve  lias  been 
observed,  and  leads  to  high  position  of  the  diaphragm  on  the  affected 
side,  with  collapse  of  the  corresponding  lung.  The  a:-ray  may  assist  in 
the  diagnosis. 

DISEASES   OF    THE   BRACHIAL   PLEXUS. 

This  may  either  be  involved  in  toto,  or  any  of  its  branches  may  be 
affected  separately,  or  the  nerve-roots  that  unite  to  form  the  brachial 
plexus.  Isolated  disease  of  any  of  the  roots  may  be  produced  by  injury, 
caries  of  the  vertebrae,  or  meningeal  disease.  The  symptoms  will  be 
almost  exactly  the  same  as  those  produced  by  disease  of  the  correspond- 
ing segment  of  the  cord,  but  are  more  likely  to  be  unilateral,  and  to  be 
either  purely  motor  or  sensory,  unless  the  lesion  is  extensive. 


DISEASES  OF  THE  BRACHIAL  PLEXUS.  1115 

The  posterior  thoracic  supplies  the  serratus  magnus  muscle.  It 
may  be  injured  directly  by  pressure,  as  in  the  carryinj^  of  heavy  loads 
on  the  shoulder  or  by  a  fiill  or  other  traumatism.  Rarely,  it  follows 
exposure  to  cold.  Its  involvement  may  be  a  part  of  an  anterior 
polio-myelitis  or  of  a  progressive  muscular  atrophy.  When  the  muscle 
is  paralyzed  the  posterior  edge  of  the  scapula  stands  out  prominently, 
and  particularly  when  the  arm  is  moved  forward.  Neuralgic  pains  in 
the  neck  generally  precede  the  neuritis.  The  course  of  the  disease  is 
always  slow.  During  the  early  stage  counter-irritation,  the  iodids  and 
mercury  internally,  and  later  electric  stimulation  to  keep  up  the  tone  of 
the  muscles,  constitute  the  treatment. 

Combined  Paralysis. — Two  or  more  nerves,  or  even  the  entire  plexus, 
may  be  involved  at  one  time  by  new  growths  in  the  cervical  region, 
neuritis,  stretching  or  rupture  of  the  nerves  by  wounds,  fractures,  or 
dislocations,  particularly  by  subcoracoid  dislocation  and  stoop  shoulders, 
which  cause  compression  of  the  axillary  structures  between  the  humerus 
and  the  ribs/  Duchenne  has  described  a  form  of  palsy  produced  in  infants 
during  birth,  due  to  laceration  of  and  hemorrnage  about  the  nerve-fibers 
by  severe  traction  on  either  the  head  when  the  shoulders  are  obstructed  or 
on  the  shoulders  in  breech  presentations.  The  roots  involved  are  usually 
the  fifth  and  sixth,  frequently  j  ust  at  their  junction.  The  muscles  involved 
are  the  deltoid,  biceps,  brachialis  anticus,  supinator  longus,  infra-  and  supra- 
spinati.  Other  roots  and  muscles  may  also  be  afi"ected.  This  condition  is 
known  as  "  obstetric  paralysis."  Brachial  neuritis  may  follow  some  injury 
to  one  of  the  nerve  branches  (ascending  neuritis)  or  it  may  be  primary. 
The  latter  variety  is  rare  and  usually  occurs  after  middle  life,  especially 
in  cases  with  a  gouty  history.  Paroxysmal  or  continuous  pain,  increased 
by  any  movement  of  the  arm  and  tenderness  on  pressure  over  the 
affected  nerves,  is  the  chief  symptom.  If  on  the  left  side,  it  simulates 
angina  pectoris. 

Individual  Nerves  of  the  Arm. — These  may  be  damaged  by  pressure 
due  to  a  tumor,  an  aneurysm,  or  to  callus.  Sleep-palsy  and  crutch-palsy 
are  both  pressure-palsies.  The  nerves  may  also  be  contused  or  torn  in 
fractures  or  dislocations,  and  palsy  may  follow  a  fall  or  blow  upon  the 
shoulder ;  I  have  seen  it  occur  in  a  heavy  man  after  a  fall  upon  the 
hand.  Primary  or  secondary  neuritis  may  develop,  and,  very  rarely, 
neuromata  appear. 

The  supra-scapular  nerve  supplies  the  supra-  and  infra-spinati  mus- 
cles. Paralysis  causes  imperfect  outward  rotation  of  the  humerus  and 
rotation  of  the  scapula,  with  elevation  and  inversion  of  the  lower  angle. 
Various  movements  of  the  arm  are  thereby  interfered  with,  and  the  limb 
tires  very  readily.  More  work  is  thrown  on  the  deltoid,  and  in  time  it 
hypertrophies,  causing  it  to  stand  out  more  prominently  against  the 
infra-spinatus.     The  skin  over  the  scapula  is  usually  anesthetic. 

The  circumflex  nerve  supplies  the  deltoid  and  teres  minor  and  the 
skin  over  the  deltoid  and  the  shoulder-joint.  Paralysis  results  in 
inability  to  raise  the  arm  and  in  wasting  of  the  muscles,  with  or  with- 
out anesthesia.     Adhesions  may  form  in  the  joint  (p.  1263). 

The  mudculo-spiral  nerve  is  more  often  paralyzed  than  any  other 
nerve  of  the  arm,  its  position  rendering  it  particularly  liable  to  pressure. 
1  Goldthwaite,  Jour.  Amer.  Med.  Assoc,  Sept.  11,  1909,  p.  852. 


ni6  DISEASES  OF  THE  SERVOrS  SYSTEM. 

It  supplies  tho  triceps  and  supinator  muscles,  and  is  the  extensor  nerve 
of  the  arm.  It  also  supplies  the  skin  on  the  radial  side  of  the  forearm, 
dorsal  surface  of  the  thumb  and  hand,  corresponding  to  the  index  and 
middle  fingers.  A  lesion  higli  up  results  in  paralysis  of  the  extensors  of 
the  elboAV.  wrist  and  hand,  and  of  the  supinators.  Probalilv  the  point 
most  commonly  attacked  is  about  the  middle  of  the  humerus.  In  such 
cases  the  triceps  escapes.  The  characteristic  symptoms,  however,  are 
wrist-drop  and  finger-dro]\  consisting  of  an  inability  to  extend  the  hand 
on  tlie  forearm,  also  the  first  phalanges  of  the  fingers  and  thumb.  In 
pressure-palsies,  usually  due  to  sleeping  -with  tlie  head  upon  the  arm, 
particularly  after  the  excessive  use  of  alcohol,  the  power  of  supination  is 
usually  lost  also.  Sensory  symptoms  vary  and  are  seldom  pronounced. 
There  may  be  slight  impairment  or  tingling  or  burning  sensations. 

This  condition  can  usually  be  differentiated  from  lead-palsy  by  the 
rapidity  of  onset — by  the  fact  that  pressure-palsies  are  almost  invari- 
ably unilateral,  and  that  the  supinators  are  involved.  Lead-palsy  has 
a  slow  onset  and  is  bilateral,  generally  without  supinator  involvement. 
Loss  of  sensation  precedes  the  pressure-palsy.  The  history  too  will 
generally  throw  some  light  on  the  case.  I  have  seen  a  case  of  right- 
sided  unilateral  wrist-drop  in  a  man  who  worked  in  lead  with  his  right 
hand  only.  Bilateral  wrist-drop  may  occur  in  any  form  of  toxic  neur- 
itis, but  the  involvement  of  other  nerves,  the  manner  of  attack,  and 
the  history  of  the  case  will  serve  to  simplify  the  diagnosis. 

Recovery  follows  in  almost  all  cases  of  musculo-spiral  nerve-involve- 
ment, though  in  cases  in  which  qualitative  nerve-changes  have  taken 
place  it  is  necessarily  delayed. 

The  treatment  is  that  of  neuritis. 

The  median  nerve  supplies  the  pronators,  digital  flexors,  except  the 
ulnar  half  of  the  deep  flexor,  the  radial  flexor  of  the  Avrist,  the  abduc- 
tor and  flexor  muscles  of  the  thumb,  and  the  two  radial  lumbricales.  It 
furnishes  sensation  to  the  radial  side  of  the  palm  and  front  of  the  thumb, 
and  to  the  front  and  back  of  the  first  and  second  and  half  of  the  third 
fingers.  This  nerve  may  be  the  seat  of  an  injury  or  of  neuritis,  but  is 
seldom  involved  alone.  A  form  described  by  Hunt'  is  due  to  pressure 
upon  the  nerve  at  the  base  of  the  thenar  eminence,  the  principal  symp- 
toms being  atrophy  and  paralysis  of  the  muscles  forming  it.  Localiza- 
tion in  this  group  distinguishes  it  from  a  beginning  progressive  muscular 
atrophy  (p.  1142).  The  most  striking  symptoms  (median  nerve  palsy) 
are  wasting  of  the  thenar  eminence  and  an  inability  to  oppose  the  thumb 
to  the  tips  of  the  fingers.  Loss  of  pronation  of  tlie  fo rearm.  Ulnar  flexion 
of  the  wrist  alone  remains.  Flexion  of  the  second  plialanges  upon  the 
first  is  interfered  with.      Sensation  may  or  may  not  be  lost. 

The  ulnar  nerve  supplies  the  ulnar  flexor  of  the  wrist,  the  ulnar  half 
of  the  deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the 
adductor  and  inner  head  of  the  short  flexor  of  the  thumb,  the  inter- 
ossei,  and  some  of  the  lumbricales.  It  supplies  with  sensation  the  front 
of  one  and  a  half  and  the  back  of  tAvo  and  a  half  fingers  on  the  ulnar 
side.  Paralysis  causes  radial  deviation  of  the  hand  in  flexion  of  the  Avrist, 
loss  of  adduction  of  the  thumb,  and  inability  to  move  the  little  finger. 
The  hypothenar  prominence  disappears. 

The  first  phalanges  cannot  be  flexed,  and  the  second  and  third  can- 
^  Journal  NervoiLS  and  Mental  Diseases^,  January,  1910,  p.  46. 


DISEASES  OF  THE  LUMBAR  AND  SACRAL  PLEXUSES.      1117 

not  be  extended.  This  is  cxag^^erated  in  old  cases,  though  still  it  is  not 
so  marked  as  the  "claw  hand"  of  progressive  muscuhir  atrophy,  since 
the  first  two  lumbricales  escape,  being  supplied  by  the  median  nerve. 
Sensory  symptoms  vary.  If  the  deep  palmar  branch  is  alone  affected, 
as  it  may  be  by  pressure,  as  it  passes  between  the  tendinous  origins  of  the 
abductor  minimi  digiti  and  flexor  brevis  minimi  digiti,tlie  sensory  symp- 
toms are  absent.^  Care  must  be  taken  not  to  mistake  this  condition  for 
the  beginning  of  a  progressive  spinal  muscular  atrophy  (p.  1142). 

The  diagnosis  is  usually  easy.  It  is  well  to  remember  that,  since 
this  nerve  is  the  lowest  in  its  point  of  origin  of  any  considered  in  this 
group,  ascending  cord-diseases  will  involve  it  before  any  of  the  other 
brachial  nerves.  It  may  also  be  damaged  by  disease  limited  to  the  low- 
est part  of  the  cervical  enlargement  of  the  cord. 

DISEASES    OF   THE   LUMBAR   AND    SACRAL   PLEXUSES. 

The  lumbar  plexus  or  its  branches  may  be  involved  by  abdominal 
growths,  enlarged  glands,  psoas  abscess,  disease  of  the  vertebrae, 
neuritis,  and  rarely  by  wounds  or  dislocation  of  the  hip  or  during 
parturition. 

The  Obturator  Nerve. — When  the  power  of  adduction  of  the  thigh  is 
lost  and  the  affected  leg  cannot  be  crossed  over  the  other,  outward  ro- 
tation is  somewhat  impaired. 

Anterior  crural  nerve  paralysis  causes  loss  of  power  and  wasting  of 
the  extensors  of  the  knee,  loss  of  knee-jerk,  and  anesthesia  of  most  of 
the  thigh  and  the  inner  side  of  the  leg  and  foot. 

The  superior  gluteal  nerve  supplies  the  gluteus  minimus  and  medius 
muscles.  When  it  is  involved  adduction  and  circumduction  of  the  thigh 
are  lost. 

The  sacral  plexus  and  its  branches  may  be  damaged  by  pelvic  neo- 
plasms or  inflammation,  neuritis  (generally  secondary  to  sciatic  nerve- 
involvement),  pressure  during  labor,  wounds,  dislocations,  aneurysms, 
and  diseases  of  the  bone. 

The  small  sciatic  nerve  supplies  the  gluteus  maximus  muscle.  It  is 
seldom  involved  alone.  Lesions  cause  difficulty  in  rising  from  the  sit- 
ting posture  and  anesthesia  of  the  back  of  the  thigh  and  of  the  upper 
part  of  the  leg  posteriorly. 

The  great  sciatic  nerve  supplies  the  flexors  of  the  leg  and  the  mus- 
cles below  the  knee,  and  also  sensation  to  the  outer  half  of  the  leg,  the 
sole,  and  part  of  the  dorsum  of  the  foot.  Paralysis  causes  more  or  less 
interference  with  the  act  of  walking,  anesthesia  in  the  part  supplied,  and 
wasting  of  the  muscles.  More  or  less  weakness  of  them  may  sometimes 
be  discovered  in  sciatica.     (See  Sciatica,  p.  1082). 

The  external  popliteal  or  peroneal  nerve  supplies  the  tibialis  anticus, 
the  peronei,  the  long  extensor  of  the  toes,  and  the  extensor  brevis 
digitorum  ;  it  also  supplies  sensation  to  the  outer  half  of  the  front  of 
the  leg  and  to  the  dorsum  of  the  foot.  Paralysis  causes  foot-drop  and 
toe-drop,  rendering  it  necessary  to  lift  the  leg  high  in  walking,  so  that 
the  foot  will  clear  the  ground ;  this  constitutes  the  steppage  gait  referred 

^  Hunt,  "  Occupation  Neuritis  of  Deep  Palmar  Branch  of  Ulnar  Xerve,"  Jour.  Kerv. 
and  Ment.  Dis.,  Nov.,  1908,  p.  673. 


1118  DISEASES  OF  THE  yERVOUS  SYSTEM. 

to  in  the  section  on  Neuritis.  If  sensory  impairment  is  present  it  will  be 
found  on  the  outer  half  of  the  front  of  the  leg  and  the  dorsum  of  tlie  foot. 

The  internal  popliteal  nerve  supplies  the  popliteus,  tibialis  posticus, 
the  calf  muscles,  the  long  flexors  of  the  toes,  and  the  muscles  of  the  sole. 
When  paralyzed,  flexion  of  the  foot  and  toes  is  impossible,  and  sensa- 
tion is  lost  over  the  back  of  the  leg  in  its  lower  part  and  over  the  sole. 
In  old  cases  talipes  calcaneus  results.  The  plantar  nerves  are  rarely, 
if  ever,  involved  alone.  Disease  of  the  plexuses  outside  the  canal  must 
be  distinguished  from  lesions  inside  involving  the  cauda  equina  (p.  1159), 
most  comiiionly  these  are  either  a  fracture  dislocation  of  one  or  more 
lumbar  vertebriB  below  the  first :  hemorrhage,  or  tumor.  If  the  first,  the 
diagnosis  is  easy,  as  the  fractured  vertebme  can  be  easily  recognized  by 
inspection,  and  in  doubtful  cases,  the  skiagram.  A  history  of  traumatism 
is  important  in  both  fracture  and  hemorrhage,  and  the  symptoms  are 
usually  bilateral,  but  not  always  strictly  symmetrical ;  tlie  pain  is  severe. 
Tumor  wouhl  be  indicated  by  a  sIoav  but  progressive  development  of 
atrophic  paralysis,  absence  of  reflexes,  sensory  paralysis,  intense  sacral 
pain  of  a  radiating  character,  and  often  tenderness  in  the  same  region. 
There  is  also  usually  sphincter  paralysis. 

Solution  of  continuity  in  an  intercostal  nerve,  as  in  a  fracture  of  a  rib, 
rarely  gives  rise  to  any  symptom  except  a  small  area  of  anesthesia  at  the 
sternal  end  of  the  corresponding  interspace. 


II.  INFLAMMATION  OF  THE  MENINGES. 

Meningitis  is  very  rarely  a  primary  condition.  Both  the  dura  and 
pia  may  be  involved.  In  the  former  case  the  inflammation  is  usually  due 
to  some  morbid  condition  of  the  vertebrae,  while  in  the  latter  it  is  sec- 
ondary to  some  infection,  as  in  pyemia,  sepsis,  pneumonia,  typhoid,  or 
the  acute  exanthemata.  It  may  be  part  of  a  tuberculous  condition  {vide 
Tuberculosis,  p.  249)  or  of  epidemic  cerebrospinal  meningitis  (p.  95). 
Injuries  also  lead  to  inflammation  of  the  meninges  of  the  cord. 


INFLAMMATION  OF  THE  DURA  MATER. 

CEREBRAL   PACHYMENINGITIS. 

Inflatmnation. — This  may  be  met  with  on  the  outer  or  inner  sur- 
face (paeJii/mcninf/itis  externa  or  interna).  Of  the  external  variety  the 
chief  causes  are  (a)  traumatism,  (b)  disease  of  the  bone,  (c)  syphilis,  and 
id)  middle-ear  disease.  That  due  to  traumatism  is  often  seen,  and  in 
the  mildest  form  is  of  little  moment.  When  severe  and  accompanied  by 
fracture  with  or  without  displacement,  infection  of  the  membranes  may 
either  take  place  at  once  or  later  from  diseased  bone.  That  form  due  to 
caries  or  any  other  form  of  osteitis  is  always  dangerous,  owing  to  the 
possibility  of  infection  of  the  diploe.  The  brain-sinuses  Avill  then  become 
aff'ected,  "and  infected  emboli  may  pass  into  the  circulation,  with  the  de- 
velopment of  pyemia.  In  the  syphilitic  variety  the  inner  table  of  the 
skull  is  thickened  and  roughened,  and  more  or  less  pus  and  granular 


INFLAMMATION  OF  THE  DURA  MATER.  1119 

material  is  found  between  it  and  the  dura  (see  also  Syphilis  of  the  Ner- 
vous System).      Sinuses  may  communicate  with  the  exterior. 

The  symptoms  are  indefinite  in  mild  cases,  and  may  consist  only  of 
lieadache.  In  the  severe  forms  there  are  headache,  malaise,  chills,  fever, 
drowsiness,  and  later  stupor,  and  rarely  convulsions,  paralysis,  or  other 
symptoms  of  compression.  The  ophthalmoscope  will  reveal  more  or  less 
evidence  of  choked  disc.     Rigors  are  suggestive  of  the  onset  of  pyemia. 

The  treatment  varies  with  the  cause.  Antiphlogistic  measures  and 
counter-irritation  are  of  value,  and  in  the  severe  grades  operative  inter- 
ference may  be  necessary.  The  internal  variety  either  occurs  as  a  simple 
inflammation  or  may  be  so  acute  as  to  cause  extravasation  of  blood.  This 
may  organize,  and,  together  with  the  products  of  inflammation,  cause  a 
pseudo-membrane.     Rarely  is  pus  found. 

Internal  hemorrhagic  pachymeningitis,  or  hematoma  of  the 
dura  mater,  is  characterized  by  the  formation  of  a  fibrous  exudate  upon 
the  inner  surface  of  the  dura,  into  which  capillaries  extend  that  sub- 
sequently rupture.  It  is  found  most  commonly  among  alcoholics,  the 
insane,  and  epileptic.     It  is  rare  in  childhood. 

The  symptoms  are  variable.  The  entire  course  may  be  without  symp- 
toms, or  they  may  be  marked  by  the  existence  of  other  conditions. 
More  frequently  there  are  headache  and  convulsions,  followed  later  by 
paralyses,  coma,  and  death.  The  location  of  the  lesion  causes  consider- 
able modification  of  the  symptomatology.  In  the  milder  form  recovery 
frequently  occurs,  or  the  case  may  become  chronic.  If  the  onset  is  sud- 
den, the  symptoms  may  resemble  those  of  hemorrhage. 

The  diagnosis  is  always  difficult.  In  children  muscular  contractions 
and  convulsions  are  frequently  met  with  ;  in  adults  the  slow  onset  may 
be  the  only  difference  between  this  condition  and  an  attack  of  grand  mal. 
Of  course,  there  is  a  greater  periodicity  in  epilepsy ;  but  a  repetition  of 
the  attacks  occurs  in  hematoma,  and,  as  already  stated,  the  repeated 
hemorrhages  are  believed  by  some  to  be  the  cause  of  the  lamination  of 
the  false  membrane. 

The  prognosis  is  extremely  unfavorable  in  children,  but  is  much  less 
so  in  adults. 

The  treatment  calls  for  the  use  of  leeches  behind  the  ears  and  over 
the  temples,  the  ice-cap,  and  counter-irritation.  Free  movement  of  the 
bowels  should  be  promptly  secured,  and  later  the  iodids  or  mercurials 
should  be  administered. 

SPINAL   PACHYMENINGITIS. 

Definition. — Inflammation  of  the  dura  mater.  The  dura  may  be 
involved  on  its  outer  or  inner  surface  (pachymeningitis  externa  or  in- 
terna), or  the  loose  connective  tissue  between  the  dura  and  bony  canal 
may  be  the  seat  of  a  peripachymeningitis. 

Pachymeningitis  externa  is  always  secondary,  and  usually  results  from 
disease  of  the  vertebrae,  due  to  syphilis,  tuberculosis  (Pott's  disease),  or 
malignant  disease,  or  from  pressure  due  to  tumors  or  to  traumatism.  It 
may  either  be  acute  or  chronic.  Of  the  latter  type,  those  cases  due  to 
Pott's  disease  are  most  common.  The  membrane  is  involved  to  a  greater 
or  less  extent.  The  internal  surface  may  escape  entirely,  or  it  may  be 
slightly  roughened  and  adherent  to  the  arachnoid ;  externally,  however, 
the  dura  is  usually  thickened,  rough,  and  covered  with  a  cheesy  material. 


1120  1)I^KA6ES   OF  THE  yEEVOUS  SYSTEM. 

Pachymeningitis  interna  was  first  described  by  Charcot  in  1871.  and 
named  "  j)(ic/ii///h  /tin</itlt>  ccrriraliti  Iij/pertrophica."  It  is  of  obscure 
origin,  but  traumatism,  alcoholism,  and  syphilis  have  been  given  as 
causes.  The  dura  is  generally  much  thickened,  and  gives  the  impression 
of  being  made  up  of  a  number  of  concentric  layers.  Hemorrhages  may 
occur  within  the  dura  or  within  the  newly  formed  tissue.  The  pia  is  only 
involved  to  a  slight  degree,  as  a  rule,  but  becomes  adherent  to  the  dura. 
Areas  of  degeneration  may  occur  in  the  cord,  as  may  also  dilatation  of  its 
central  canal.  As  implied  by  the  name,  this  variety  of  pachymeningitis 
is  found  chiefly  in  the  cervical  region,  and  the  clinical  symptoms  result 
from  involvement  of  the  nerve-roots  and  compression  of  the  cord.  It  is 
a  chronic  process,  and  has  been  divided  into  three  periods,  as  follows : 
[a)  The  painful  period,  lasting,  as  a  rule,  two  or  three  months,  in  which 
severe  neuralgic  pains  exist,  their  location  being  determined  by  the  roots 
involved.  They  are  mostly  in  the  occiput  and  upper  extremities,  how- 
ever. Early  there  may  be  hyperesthesia,  numbness,  tingling,  and,  rarely, 
an  herpetic  eruption,  (h)  The  Paralytic  Period. — As  a  result  of  com- 
pression of  the  motor  roots  an  atrophic  paralysis  of  the  upper  extremities 
develops.  A  peculiar  selective  tendency  is  manifested,  the  distribution 
of  the  median  and  ulnar  nerves  being  principally  involved.  This  results 
in  a  modified  "claw-hand"  deformity  and  in  an  overextension  of  the 
wrists,  with  flexion  of  the  fingers.  Anesthesia  may  be  noted,  {c)  Spastic 
Paraplegia. — This  results  when  the  compression  has  produced  degenera- 
tion of  the  cord.  Generally,  there  are  paresis  of  the  lower  extremities 
and  increased  reflexes,  but  no  muscular  wasting,  since  the  trophic  centers 
are  intact.  Occasionally,  however,  anesthesia  and  paralysis  of  the  legs 
and  bladder  develop,  bed-sores  following,  and  finally  death  from  ex- 
haustion. 

The  prognosis  is  unfavorable,  practically  all  cases  terminate  in  death, 
but  the  duration  is  variable. 

The  diagnosis  must  be  made  from  amyotrophic  lateral  sclerosis,  verte- 
bral caries,  syringomyelia,  and  from  pressure  by  tumors.  Amyotrophic 
lateral  sclerosis  does  not  give  rise  to  sensory  disturbances;  bulbar  symp- 
toms are  often  jiresent,  the  lower  extremities  may  atrophy,  and  the  bladder 
functions  are  preserved.  In  vertebral  caries  tenderness  on  jarring  will 
be  present,  and  a  skiagram  will  probably  show  evidence  of  bone  disease. 
Syringomyelia  induces  characteristic  symptoms  of  loss  of  temperature^ 
and  pain  sense  with  the  preservation  of  tactile  sense  (dissociation  of  sen- 
sation), although  this  may  rarely  be  present  in  pachymeningitis,  but 
severe  neuralgic  or  radiating  pains  are  rare  in  syringomyelia.  From 
tumor  the  diagnosis  may  be  difticult,  the  symptoms  in  this,  however, 
usually  develop  more  gradually  and  at  first  are  unilateral. 

Treatment  is  not  of  much  avail.  Potassium  iodid  and  mercury  are 
the  chief  measures.  In  cases  otherwise  hopeless  an  exploratory  opera- 
tion is  sometimes  justifiable. 

Pachymeningitis  haemorrhagica  interna,  or  hematoma  of  the  dura  mater, 
may  occur  in  any  part  of  the  cord,  and  is  usually  associated  with  a  similar 
condition  in  the' cerebral  dura.  Cysts  may  Ijc  found  in  the  inner  surface 
of  the  dura,  containing  broken-down  blood-cells  and  hematoidin  crystals, 
and  in  their  neighborhood  an  increase  of  fibrous  tissue  may  be  noted. 
The  condition  occurs  most  frequently  in  alcoholic  or  general  para- 
lytics. 


CEREBRAL   LEPTOMENINaiTIS.  ■    1121 

LEPTOMENINGITIS. 

Definition. — Inflammation  of"  the  pia  mater.     This  may  be  either 
acute  or  chronic. 


CEREBRAL  LEPTOMENINGITIS. 

Cerebral  leptomeningitis  is  an  inflammatory  condition  of"  the  pia 
arachnoid;  it  occurs  in  various  forms,  that  may  be  classifled  either  accord- 
ing to  the  distribution  of  the  process,  into  meningitis  of  the  convexity, 
of  the  base,  or  cerebrospinal  meningitis,  or  according  to  tlie  cause. 

etiology. — As  it  is  infectious,  this  is  always  micro-organismal.  It 
is  customary  to  distinguish  between  the  forms  produced  by  the  pyogenic 
micro-organisms  and  by  the  tubercle  bacilli.  Among  the  former  the  most 
important  are  the  pneumococcus,  the  meningococcus,  the  staphylococcus, 
and  the  bacillus  of  influenza,  but  a  great  variety  of  other  bacteria  have 
been  found,  such  as  the  colon  bacillus,  the  typhoid  bacillus,  and  others  in 
rare  or  isolated  instances.  The  method  of  access  to  the  meninges  varies, 
either  along  the  blood  or  lymph  channels  from  some  focus  of  infection,  as 
the  lungs,  the  nasal  cavities,  or  in  the  course  of  an  infectious  process  that 
gives  rise  to  bacteremia,  as  pyemia ;  or  by  direct  extension,  as  in  middle- 
ear  disease,  or  disease  of  the  sinuses  of  the  face.  Meningitis,  particularly 
the  tuberculous  variety,  may  follow  injuries  to  the  head.  It  may  be  due 
to  syphilis.  Purulent  meningitis  may  occur  at  any  age.  Tuberculous 
meningitis  is  more  common  in  childhood. 

Patholog"y. — In  the  extent  and  degree  of  the  inflammation,  great 
variations  exist.  It  may  be  either  (1)  limited  to  the  convexity,  with  or 
without  involvement  of  the  sides ;  (2)  limited  to  the  base ;  or  (3)  general, 
involving  both  convexity  and  base.  In  the  early  stages  and  in  the  mild 
forms  there  may  be  no  more  than  an  injection  of  the  part.  Later,  inflam- 
matory products  are  met  with,  usually  following  the  course  of  the  menin- 
geal vessels,  but  sometimes  covering  considerable  areas.  This  form  of 
leptomeningitis,  unlike  the  tuberculous  variety,  is  prone  to  attack  the 
convexity  of  the  brain. 

Symptoms. — These  are  very  varied,  and  naturally  depend  on  the 
seat  and  extent  of  the  inflammation.  Those  cases  in  which  symptoms 
pointing  to  involvement  of  the  base  occur  need  not  be  discussed  here, 
since  they  are  considered  in  detail  under  the  tuberculous  variety.  In  any 
case  headache,  localized  or  general,  is  usually  present.  In  children  too 
young  to  talk  its  presence  is  often  indicated  by  crying  or  putting  the 
hand  to  the  head.  Delirium,  insomnia,  and  coma  are  also  met  with  in 
different  cases.  There  is  more  or  less  fever.  Constipation,  a  coated 
tongue,  vomiting,  a  rapid  pulse,  are  usual,  and  the  tdche  c^rehrale  may 
be  elicited.  Spasmodic  movements  may  occur,  or  even  general  convulsions. 
Of  course,  in  cases  of  inflammation  of  the  base,  the  cranial  nerves  become 
affected,  and  we  have  ptosis  or  strabismus,  facial  spasm  or  palsi/,  and.  if 
the  fifth  nerve  is  involved,  sensory  and  trophic  changes.  The  head  is 
usually  retracted  until  it  seems  to  bore  into  the  pillow ;  the  muscles  of 
the  back  of  the  neck  are  tense ;  the  spine  is  often  rigid ;  the  abdomen 
retracted,  and  the  limbs  flexed.  The  tendon  reflexes  are  exaggerated 
and  cutaneous  irritability  greatly  increased.     Kernig's  sign  consists  in 

71 


1122  DISEASED  OE  THE  yEJiVOUS  SYSTEM. 

the  inability  of  the  patient  to  straighten  the  leg,  -when  the  thigh  is 
Hexed  to  a  ])osition  of  90  degrees  to  the  axis  of  the  body.  It  is  nearly 
always  present  iu  acute  nou-tubereulous  meningitis,  but  often  absent  in 
the  tuberculous  form  ;  occasionally  it  may  be  found  in  focal  encephalitis, 
either  acute  or  chronic,  and  even  in  acute  infectious  disease — typhoid 
fever.  It  is,  tiicrefore,  valuable  as  a  suggestive  sign  of  meningitis,  but 
can  no  longer  be  considered  pathognomonic.  A  type  frequently  found 
in  young  children,  and  thought  by  many  to  be  a  form  of  s])oradic  cerebro- 
spinal meningitis  (p.  J'-')),  consists  of  an  inflammation  confined  to  the 
meninges  of  the  posterior  part  of  the  base  of  the  brain  from  the  optic 
commissure  to  the  medulla.  From  its  location  livdrocephalus  frequently 
develops  ;  blindness,  due  to  pressure  on  the  optic  chiasm,  also  is  common. 
The  intense  retraction  of  the  head  is  a  characteristic  symptom.  It  is 
known  as  posterior  basic  meningitis. 

Diagnosis. — Where  no  etiologic  hint  can  be  obtained  the  diagnosis 
is  generally  in  doubt  for  two  or  three  days.  There  may  be  nothing  more 
than  a  reilex  irritation  (dental  or  gastro-intestinal),  or  possibly  one  of 
the  infectious  fevers.  The  symptoms  should  be  studied  in  their  entirety ; 
one  or  two  supposedly  pathognomonic  signs  should  not  be  allowed  to 
cloud  our  vision.  In  some  cases  it  may  be  necessary  to  distinguish 
meningitis  from  the  so-called  serous  meningitis  (p.  1123).  Meningitic 
symptoms,  associated  with  marked  deliiium,  may  occur  in  the  course  of 
acute  articular  rheumatism.  In  this  condition  the  cerebrospinal  fluid 
will  be  clear  (p.  1123).  The  condition  is  known  as  cerebral  rheumatism. 
It  must  also  be  borne  in  mind  that  meningeal  symptoms  are  simulated  by 
the  infectious  diseases  (p.  1128).  Having  made  the  diagnosis  of  meningitis, 
it  becomes  important  to  diflFerentiate  the  tulereulous  from  the  non-tubercu- 
lous variety.  The  family  history  is  of  importance.  In  fubereuhnis  meningi- 
tis the  focal  symptoms  usually  appear  early,  and  are  due  to  involvement  of 
the  cranial  nerves  at  the  base  of  the  brain,  chiefly  those  controlling  the 
eye.  The  eye-grounds  often  show  a  slight  perineuritis  without  choked 
discs,  and  perhaps  one  or  more  miliary  tubercles.  There  is  sometimes  a 
mild  form  of  confusional  delirium,  often  preceding  the  appearance  of 
focal  symptoms.  The  leukocytes  are  slightly,  if  at  all,  increased.  There 
is  rarelv  rigidity  of  the  neck.  In  other  forms  of  meningitis  this  appears 
early ;  the  optic  nerve  shows  intense  inflammation  and  there  is  usually 
pronounced  leukocytosis.  Examination  of  the  fluid  withdrawn  by  lumbar 
puncture  (p.  1124)  is  important.  A  differential  count  of  the  leukocytes 
in  the  spinal  fluid  should  always  be  made  (Cytodiagnosis,  see  p.  1124). 

Prognosis. — This  is  always  grave.  A  percentage  of  cases  of  epi- 
demic cerebrospinal  meningitis,  varying  with  the  severity  of  the  epidemic, 
may  recover.  In  all  other  forms  any  termination,  except  in  death,  is 
exceedingly  exceptional.  Remissions  frequently  occur  in  the  symptoms, 
and  the  course  may  be  very  prolonged. 

Treatment. — We  have  no  specific,  and  all  that  can  be  done  is  to 
meet  the  symptomatic  indications.  Absolute  quiet  in  a  darkened  room, 
an  ice-cap  to  the  head,  and  the  internal  use  of  full  doses  of  hexamethyl- 
enamin  (urotropin)  may  be  of  service.  Opium  may  have  to  be  given 
for  pain.  If  of  syphilitic  origin,  either  mercury  should  be  used  by  in- 
unction or  injection  or  salvarsan  (006)  employed.  In  certain  cases — e.  g., 
those  secondary  to  middle-ear  disease — either  opening  the  skull  above 


SEROUS  MENINdlTIS.  1123 

and  below  the  tentorium  and  draining/  or  the  operation  of  Ilaynes,^  vvliich 
consists  in  draining  the  cisterna  magna  in  the  posterior  fossa,  may  seem 
justifiable.  When  in  doubt  the  physician  should  not  delay  action  until 
too  late,  but  should  call  in  a  surgeon  while  there  is  still  hope  for  some 
benefit. 

The  treatment  of  the  epidemic  and  tubercular  forms  is  detailed  on 
pages  95  and  249. 

SEROUS  MENINGITIS. 

[Meningiiis  Serosa ;    Wet  Brain. ) 

This  condition,  first  described  by  Quincke,  which  in  the  acute  form 
may  arise  spontaneously  or  follow  various  infective  processes.  Chronic 
alcoholism  is  a  frequent  cause.  The  symptoms  resemble  those  of  acute 
cerebral  meningitis,  and  lumbar  puncture  may  be  necessary  to  establish 
the  diagnosis,  in  serous  meningitis  the  fluid  being  clear,  not  containing 
organisms,  and  escaping  under  great  pressure.  The  more  chronic  type 
closely  simulates  tumor  of  the  brain,  especially  a  subtentorial  growth,  as 
paralysis  of  cranial  nerves,  choked  disc,  convulsions,  and  ataxia  may  all 
be  symptoms  of  this  condition. 

The  symptoms  are  apt  to  fluctuate,  and  if  they  develop  acutely  after 
an  infection  of  some  sort  it  would  be  in  favor  of  serous  meningitis.  In 
some  cases  an  inflammation  of  the  ependyma  exists,  and  internal  hydro- 
cephalus (p.  1190)  may  follow. 

The  prognosis  is  doubtful,  but  recovery  takes  place  in  a  fair  proportion 
of  cases.  In  the  alcoholic  type  the  greater  the  rigidity  and  retraction  of 
the  head  the  worse  the  outlook. 

Quincke  advises  mercurial  inunctions  in  all  cases.  Counter-irritation 
to  the  back  of  the  neck  and  cold  to  the  head  may  also  be  used.  Lumbar 
puncture  is  of  great  service.  The  bowels  should  be  kept  free  and  the 
diet  liquid,  but  liberal  in  quantity  (hot  milk,  eggs,  broths).  In  the 
alcoholic  cases  the  inunctions  should  be  omitted  and  strychnin  in  full 
doses  (gr.  -^^  every  three  hours)  given. 

ACUTE    SPINAL    LEPTOMENINGITIS. 

{Acute  Spinal  Meningitis.) 

Htiology. — This  is  always  microorganismal,  and  a  great  variety  of 
bacteria  have  been  discovered.  The  most  common  is  the  pneumococcus, 
in  which  case  the  disease  may  or  may  not  be  associated  with  pneumonia ; 
next  in  frequency  is  the  meningococcus  ;  and  then  the  various  pyogenic 
cocci,  the  influenza  bacillus,  the  typhoid  bacillus,  etc.  It  may  be  due  to 
syphilis ;  rarely  it  may  be  tubercular. 

Pathology. — The  vessels  are  injected,  the  membrane  becomes 
cloudy,  a  sero-fibrinous  or  purulent  exudate  either  surrounds  the  cord 
or  may  only  exist  in  patches,  and  in  the  more  severe  cases  the  cord  itself 
is  involved  {meningomyelitis).  The  spinal  meninges  alone  may  be  in- 
volved to  a  greater  or  less  extent,  but,  as  a  rule,  the  cerebral  meninges 

^  Day,  Annals  Otology,  Rhinology,  and  Laryngology,  June,  1911. 

2  Trans.  Amer.  Laryngol.,  Rhinolog.,  and  Otolog.  Society,  1912,  and  Progressive  Medicine. 
Mai-.,  1913,  p.  43. 


1124  DISEASES  OF  THE  XERVOUS  SYSTEM. 

are  similarly  involved.  Tubercles  ^vili  be  found  in  tbe  tubercular  form. 
It  should  be  remembered  iliat  many  cases  presenting  clinically  the  pic- 
ture of  meninsiitis  show  absolutely  no  gross  jwstmortem  lesions  of  the 
cerebral  or  spinal  membranes.  This  may  occur  from  any  toxemia,  but 
especially  in  pneumonia,  typhoid  fever,  influenza,  and  rheumatism  no 
lesions,  not  even  microscopic,  are  found.  These  are  spoken  of  as  men- 
itu/isniUK. 

Symptoms.  — The^e  are  chiefly  pain  in  the  back,  often  excruciating, 
with  hxatiou,  retraction  of  the  head,  tenderness  on  pressure  along  the 
spine,  tremors  or  spasm  of  the  muscles,  and  various  sensory  disturbances. 
Reflexes  are  early  increased,  and  later  diminished  or  absent.  Should 
the  cord  be  involved,  paralysis,  incontinence  of  urine  and  feces,  and  even 
bed-sores,  may  develop  (p.  1135).  The  syni])t()ms  are  more  fully  dis- 
cussed in  speaking  of  the  tuberculous  and  epidemic  varieties. 

Diagnosis. — It  is  often  very  difficult  to  differentiate  the  several 
varieties  of  spinal  meningitis,  and  equally  so  to  decide  Avhether  the  case 
is  actually  meningeal  when  some  other  disease  is  present.  The  tubercu- 
lous form  is  readily  diagnosticated,  especially  if  any  collateral  evidence 
of  tuberculosis  exists.  It  is  a  point  of  some  value  in  the  diagnosis  to 
note  the  absence  of  marked  leukocytosis  in  the  cerebrospinal  fluid  ob- 
tained by  lumbar  puncture  in  tuberculous  and  its  presence  in  purulent 
meningitis.  The  presence  of  Kernig's  sign  is  in  favor  of  cerebrospinal 
meningitis. 

Spinal  paracentesis  or  lumbar  'puncture,  first  introduced  by  Quincke 
of  Kiel  in  1891,  is  a  most  valuable  diagnostic  measure  and  simple  of  ap- 
plication. It  is  performed  as  follows :  The  patient  either  sits  up  or  lies 
preferably  upon  the  left  side,  with  the  back  arched  and  the  knees  flexed 
against  the  abdomen.  The  spine  of  the  fourth  lumbar  vertebra  should 
be  located  (a  line  drawn  from  one  posterior  superior  spine  of  the  ilium  to 
the  other  passes  across  it),  and  the  puncture  made  half  an  inch  to  one 
side,  at  the  level  of  its  lower  end.  The  needle  should  be  inclined  at  an 
angle  of  about  45  degrees  to  the  surface  of  the  skin,  and  should  be  thrust 
in  a  distance  of  from  2|  to  3  inches.  The  most  scrupulous  asepsis  must 
be  observed.  The  spinal  fluid  flows  readily,  either  in  a  stream  when  the 
pressure  is  high,  or  drop  by  drop  if  it  is  normal.  In  purulent  meningitis 
it  is  cloudy,  contains  pus-cells,  and  does  not  reduce  Fehling's  solution  : 
in  tuberculous  meningitis  it  is  usually  clear  and  does  reduce  Fehling"s 
solution ;  in  cerebral  hemorrhage  it  may  be  bloody,  but  as  admixed  blood 
mav  be  due  to  the  injury  of  a  vessel  by  the  needle,  this  sign  should  be 
used  with  caution.  The  quantity  obtained  varies  from  2  or  3  to  80  or 
90  c.cm.  After  centrifugation  a  diff'erential  count  of  white  cells  should 
be  made.  An  excess  of  lymphocytes  indicates  a  tubercular  infection  ;  an 
excess  of  polymorphonuclear  cells,  a  pyogenic  infection.  Cultures  should 
be  made  and  the  sediment  or  coagulum  stained  for  bacteria.  In  menin- 
gismus  the  ffuid  is  practically  normal.  Often  there  is  great  relief  from 
the  puncture,  and  occasionally,  in  serous  meningitis,  the  patient  appears 
to  be  permanently  benefited. 

The  prognosis  is  unfavorable  as  a  rule.  ))articularly  in  the  tuber- 
culous fonii. 

The  treatment  is  the  same  as  that  of  cerebro-spinal  meningitis  {vide 
p.  103). 


DISEASED  OF  THE  SPINAL   CORD.  1125 

C IIRON IC    LE  I'TO  M  KN I  N(;  FT  IS. 

This  disease  may  follow  the  acute  form  or  be  due  to  chronic  alcohol- 
ism, syphilis,  trauma,  or  disease  of  the  cord. 

Pathology. — The  pia  is  cloudy  and  swollen,  and  often  adherent  to  the 
arachnoid,  or  all  three  membranes  may  bo  glued  together.  'They  are 
usually  injected.  Usually  there  is  considerable  prolifomtion  of  fibrous 
tissue.  The  periphery  of  the  cord  is  also  occasionally  affected.  A  con- 
dition known  as  circumscribed  serous  spinal  mcnin/jifis  may  be  here  Mian- 
tioned.  It  may  follow  either  traumatism  or  infectious  diseases.  When 
the  dura  is  slit,  its  opening  is  filled  by  a  more  or  less  opaque  pia  that 
bulges  forth  under  tension  of  the  contained  fluid  which  is  clear.' 

Symptoms. — These  are  not  well  marked.  Unless  the  nerve-roots  are 
involved  the  symptoms  are  slight  or  none  at  all  exist;  however,  pains  of  a 
radiating  character,  stiff"ness,  tremors,  hyperesthesia,  herpes,  and  even  par- 
alyses, may  occur.  The  course  is  slow,  and  may  extend  over  many  years. 
Idiopathic  circumscribed  spinal  serous  meningitis  is  described  in  connec- 
tion with  spinal  tumors,  as  the  symptoms  of  the  two  are  practically  the 
same  (p.  1157). 

The  prognosis  is  unfavorable  ultimately. 

The  treatment  consists  in  the  use  of  iodids  and  mercury  internally, 
and  the  application  of  baths,  and  counter-irritation  along  the  spine. 


III.  DISEASES   OF  SPINAL  CORD. 
HEMORRHAGE  INTO  THE  SPINAL  MENINGES. 

(Meningeal  Apoplexy ;  HematorracMs.) 

(a)  Extrameningeal  hemorrhage  occurs  when  the  blood  is  between  the 
dura  and  spinal  canal. 

(b)  Intrameningeal  hemorrhage  is  that  in  which  the  bleeding  takes 
place  beneath  the  dura. 

Large  hemorrhages  are  more  common  in  the  extrameningeal  form ; 
they  result  from  trauma  or  rupture  of  an  aneurysm.  The  peridural 
space  will  accommodate  a  large  amount  of  blood  without  giving  rise  to 
pressure-symptoms.  Caries  of  the  vertebrae  or  carcinoma  may  cause 
hemorrhage  by  erosion  and  rupture  of  a  blood-vessel.  The  intra-menin- 
geal  form  is  common,  and  may  result  from  meningitis,  from  trauma, 
or  may  occur  as  a  complication  of  any  of  the  infectious  or  hemorrhagic 
diseases.  In  such  cases  the  hemorrhages  are  small  and  scattered.  It 
may  also  occur  in  convulsive  disorders  or  in  strychnin-poisoning.  Rupt- 
ure of  an  aneurysm  at  the  base  of  the  brain  may  give  rise  to  extensive 
hemorrhage ;  blood  may  also  pass  into  the  spinal  cerebrospinal  fluid  from 
either  a  ventricular  or  subdural  cerebral  hemorrhage. 

Sj^Hiptotns. — When  the  hemorrhage  is  large  enough  to  cause  pressure 
the  symptoms  are  very  acute,  apoplectiform  indeed,  but  consciousness  is 
preserved.  Generally,  however,  they  are  quite  indefinite.  In  any  case 
they  depend  upon  the  degree  and  location  of  the  compression.  At  first 
they  are  irritative — viz.,  hyperesthesia,  paresthesia,  neuralgic  pains  that 
^  Weisenburg,  Amer.  Jour.  Med.  Sci.,  Nov.,  1910,  p.  719. 


1  r2(i  DISEASES  OF  THE  yERVOUS  SYSTEM. 

are  radiating  in  character,  muscular  irritability,  tremors,  or  contractions. 
If  subdural,  the  Huid  obtained  by  lumbar  puncture  will  probably  contain 
blood.  Later,  jxiralytic  symptoms  may  develop,  as  anesthesia  and  l)laddor- 
and  bowel-symptoms,  girdle  j>ains.  or,  when  the  lesion  is  high  up,  inter- 
ference with  ros))iration  and  pupillary  changes. 

The  diagiiosis  is  often  difficult,  unless  the  onset  is  sudden  and 
explosive. 

The  prognosis  depends  on  the  cause  and  extent  of  the  hemorrhage. 
If  small  in  amount,  absorption  is  usually  prompt,  with  little  or  no  dis- 
turbance of  function  remaining. 

The  treatment  consists  of  rest,  ice  to  the  spine,  and  morphin  to 
relieve  pain  ;  later  mercury  and  the  iodids  may  be  given  to  hasten  absorp- 
tion. Local  measures,  such  as  leeches,  cupping,  etc..  or  general  styptics, 
such  as  ergot  and  calcium  chlorid,  are  of  very  doubtful  value ;  although 
the  latter  may  be  used  if  the  hemorrhagic  diathesis  is  present.  In  cer- 
tain cases  operative  procedures,  with  a  view  to  removing  the  clot,  may 
be  justifiable. 

HYPEREMIA  AND  ANEMIA  OF  THE  CORD. 

These  may  be  due  to  qualitative  and  quantitative  changes  in  the 
blood,  and  morbid  conditions  of  the  vessel-w^alls.  They  give  rise  to  no 
characteristic  symptoms,  unless  softening  or  degeneration  occurs. 

The  blood-vessels  may  be  the  seat  of  peri-  or  endarteritis,  and  rarely 
miliary  aneurysms  may  develop.  Embolism  and  thrombosis  also  occur, 
the  former  much  less  frequently  than  the  latter,  which  is  prone  to  follow 
sclerotic  changes  in  the  vessels,  giving  rise  to  ischemia  and  ultimately  to 
softening  (p.  1188).  Degenerative  changes  in  the  cord  may  be  caused 
by  anemia  (p.  1157). 


HEMORRHAGE  INTO  THE  SPINAL  CORD. 

(Heniatomyelia  ;  Spinal  Apoplexy.) 

This  is  of  very  much  less  frequent  occurrence  than  cerebral  hemor- 
rhage. It  is  usually  due  to  traumatism,  but  may  possibly  follow  some 
severe  strain  or  overexertion,  probably  only  when  the  vessels  are  ather- 
omatous. Hemorrhage  may  occur  in  cases  of  myelitis,  epidemic  cerebro- 
spinal meningitis,  syringomyelia,  tumors  of  the  cord,  convulsive  disor- 
ders, and  infectious  diseases ;  it  is,  however,  usually  small.  If  the 
hemorrhage  is  extensive,  disruption  of  more  or  less  cord-substance 
necessarily  follows.  An  area  may  exist  large  enough  to  cause  distention 
of  the  cord  without  rupture,  and  from  this  extravasations  may  take  place 
in  the  cord-substance  above  and  below.  Unilateral  hemorrhage  may 
occur,  the  gray  matter  being  chiefly  involved.  If  of  recent  origin,  fre.^h 
blood  will  be  found  postmortem ;  but  if  of  long  standing,  a  brown  or 
brownish-yellow  area  will  be  noted,  consisting  of  disintegrated  blood- 
corpuscles,   cell-detritus,  and  hematoidin  crystals. 

The  symptoms  necessarily  vary  according  to  the  region  involved,  the 
gray  matter  of  the  cervical  region  being  tliat  most  frequently  aifected. 
The  onset  is  always  sudden,  the  symptoms  rarely  requiring  as  long  as 
a  half-hour  to  develop.      They  consist  of  a  flaccid  paralysis  of  the  limbs 


CAISSON  DISEASE.  1127 

below  the  seat  of  the  lesion,  loss  of  reflexes,  and  probably  of  sensibility. 
The  urine  and  feces  will  also  be  retained.  Consciousness  is  not  lost. 
If  in  the  cervical  region,  contraction  of  the  pupils  and  narrowing  of  the 
palpebral  tissues  will  be  observed,  owing  to  involvement  of  the  oculo- 
pupillary  fibers  at  the  eighth  cervical  and  first  dorsal  segments  (cervical 
sympathetic  nerve).  If  death  does  not  occur,  the  symptoms  gradually 
more  or  less  subside,  and  ultimately  resemble  those  of  acute  myelitis  (p. 
1135).  As  the  hemorrhage  is  most  often  in  the  gray  matter,  dissociation 
of  sensation  (preservation  of  tactile  and  loss  of  pain  and  temperature 
sense)  will  result ;  atrophy  of  the  muscles  supplied  by  the  affected  seg- 
ments (p.  1071)  will  also  result ;  below  the  seat  of  the  lesion  the  paraly- 
sis becomes  spastic  with  increased  tendon  reflexes.  If  one  side  of  the 
cord  is  principally  involved,  the  Brown-Sequard  syndrome  (p.  1077) 
results. 

The  diagnosis  must  be  made  in  acute  cases  from  meningeal  hemor- 
rhage and,  if  traumatic,  fracture  of  the  vertebra.  The  presence  of  severe 
lancinating  pain,  muscular  twitchings,  and  a  less  degree  of  paralysis  dis- 
tinguishes the  former.  The  latter  can  usually  be  determined  by  the  char- 
acteristic deformity,  as  determined  by  inspection  and  the  skiagram — 
hemorrhage,  of  course,  can  coexist  with  fracture.  The  residual  symp- 
toms, if  the  patient  survive,  may  be  mistaken  for  syringomyelia  and  mye- 
litis ;  the  history  of  traumatism  and  sudden  onset  will  distinguish  it  from 
the  former.  In  the  latter  it  may  be  difficult,  as  hemorrhage  frequently 
precedes  the  development  of  myelitis  in  traumatic  cases.  A  history  of 
apoplectiform  onset  is  evidence  that  the  primaiy  condition  at  least  was 
hemorrhagic. 

The  prognosis  during  the  acute  stage  is  doubtful,  death  may  occur 
from  exhaustion  or  septic  infection  due  to  bed-sores  or  cystitis.  If  this 
stage  is  survived,  a  considerable  degree  of  power  may  return  and  the 
patient  get  about  with  a  more  or  less  spastic  paraplegia,  and  if  in  the 
cervical  region,  atrophic  paralysis  of  the  arms  and  hands. 

Treatment. — Rest,  ice  locally,  attention  to  bladder  and  bowels,  and 
the  internal  use  of  calcium  salts  and  opium  make  up  the  treatment  of 
the  acute  staee ;  afterward  the  treatment  is  similar  to  that  of  myelitis 
(p.  1137). 


CAISSON  DISEASE. 

{Diver's  Paralysis.) 


Definition. — A  paralytic  condition  caused  by  sudden  transference 
from  an  abnormally  great  atmospheric  pressure  to  one  of  normal  intensity. 

The  etiology  of  the  disease  is  very  clear,  and  certain  predisposing 
factors  are  worthy  of  note.  Divers  are  more  apt  to  suffer  if  they  have 
been  working  at  extreme  depths,  particularly  if  the  period  of  exposure 
to  great  pressure  has  been  prolonged  ;  every  moderate  pressure  will  some- 
times produce  symptoms  if  continued  for  a  sufficient  length  of  time,  and 
short  periods  of  rest  do  not  prevent  the  development  of  the  disease.  Ordi- 
narily, it  can  be  said  that  unless  the  pressure  exceeds  two  and  one-half  or 
three  atmospheres  no  danger  may  be  apprehended.  Alcoholism  is  a  pre- 
disposing cause. 


1128  DISEASES  OF  THE  XERVOUS  SYSTEM. 

Patholog^y. — Two  theories  have  been  advanced  to  account  tor  the 
condition.  One  is  that  under  the  high  pressure  the  blood  becomes  over- 
cliarged  witli  nitrogen  gas  ;  when  the  pressure  is  relieved  this  is  liberated, 
causing  emboli,  which  block  up  the  spinal  vessels.  The  other  is  that  the 
blood  is  driven  from  the  surface,  causing  distention  of  the  vessels  with 
paralysis  of  their  walls;  when  the  air  pressure  diminishes  they  are  unable 
to  accommodate  themselves  to  the  changed  condition,  and  stasis  with 
congestion  and  hemorrhages  result.  Both  factors  are  probably  account- 
able. Small  hemorrhages  and  laceration  of  nerve-fibers  have  been  found 
in  the  cord. 

The  symptoms  vary  greatly  in  intensity.  In  the  mildest  form  they 
consist  of  neuralgic  pains  in  the  joints,  sometimes  Avith  slight  articular 
swelling,  headache,  giddiness,  and  a  little  tintiitus.  These  pains  may  be- 
come more  violent,  particularly  in  the  loins,  and  be  followed  by  a  gradual 
loss  of  power  and  by  anesthesia  in  the  limbs;  these  symptoms  may  disap- 
pear in  a  few  hours  or  become  more  severe,  with  the  development  of  com- 
plete  paralysis  and  interference  with  the  action  of  the  sphincters.  This 
paralysis  usually  assumes  the  form  of  paraplegia  ;  monopkyia  and  hemi- 
plegia also  occur,  and  sometimes  there  are  complete  paralysis  and  anesthesia 
of  all  four  extremities  and  of  the  trunk.  In  the  most  severe  cases  cere- 
bral symptoms  are  also  present,  consisting  of  sudden  loss  of  consciousness, 
profound  coma,  irregular  respiratory  action,  and  finally,  after  a  short  time, 
death  from  cardiac  failure. 

The  diagnosis  is  very  easy.  It  is  possible,  however,  that  an  attack 
of  apoplexy  should  occur  in  a  man  who  has  been  under  water,  and  the 
patient  should  always  be  examined  for  the  presence  of  this  or  some  other 
organic  lesion. 

The  prognosis  varies  with  the  intensity  of  the  symptoms.  The  lighter 
forms  consist  merely  of  joint-pains  and  slight  dizziness  that  usually  pass 
away  in  the  course  of  a  few  hours.  Paraplegias  or  hemiplegias,  develop- 
ing slowly  and  not  assuming  a  severe  form,  are  also  transient  in  character. 
A  more  severe  paraplegia  is  usually  permanent,  although  some  improve- 
ment may  be  expected.  The  apoplectic  forms  are  almost  invariably  fatal 
in  the  course  of  a  few  hours. 

The  treatment  consists,  firstly,  of  prophylactic  measures.  In  all  places 
where  caisson-work  is  carried  on  one  or  more  locks  should  be  provided  in 
■which  the  pressure  can  be  gradually  reduced  until  it  is  approximately  that 
of  the  atmosphere.  Divers  should  be  instructed  to  come  slowly  to  the 
surface.  If  the  pressure  exceeds  three  atmospheres,  the  nuiximum  length 
of  the  working-period  should  not  be  more  than  one  hour,  and  several 
hours  should  be  permitted  between  the  descents.  A  chamber  should 
also  be  provided  in  which  a  man  avIio  exhibits  symptoms  of  the  disease 
can  be  once  more  subjected  to  a  pressure  greater  than  that  of  the  at- 
mosphere, as  this  usually  causes  an  arrest  of  the  process.  When,  how- 
ever, the  condition  resembles  that  of  acute  myelitis,  the  treatment  is 
purely  symptomatic.  It  consists  of  rest,  careful  hygiene,  and  a  stimu- 
lating diet.  Stimulating  liniments  and  the  rapidly  interrupted  faradic 
current  may  be  used  for  the  pain.  If  the  heart  is  not  Aveak,  phenacetin 
and  similar  drugs  may  be  used.  If  it  is,  strychnin  and  caffein  may 
prove  useful.  In  the  comatose  cases  enemas  of  hot  coffee  should  be  used 
and  artificial  respiration  and  inhalation  of  oxygen  may  be  necessary.  For 
the  resulting  paralysis  the  treatment  is  that  employed  for  chronic  myelitis. 


BULBAR  PARALYSTH.  1129 

BULBAR  PARALYSIS. 

( GlofiHO-labio-laryngcfd  Paralyai.^. ) 

Definition. — Bulbar  paralysis  is  usually  termed  a  disease  of  tlie 
brain,  but  as  the  pons  and  medulla  are  anatomically  and  physiologically 
parts  of  the  cord,  it  seems  more  logical  to  discuss  it  here.  It  is  an  acute 
or  chronic  disease,  due  to  involvement  of  the  motor  nuclei  of  the  medulla 
oblongata,  and  is  characterized  chiefly  by  a  difficulty  of  speech  or  of 
deglutition.      Three  varieties  have  been  described  : 

1.  Sudden  or  apoplectiform,  this  being  due  to  hemorrhage,  embolism, 
or  thrombosis  either  of  a  bi-anch  of  the  basilar  or  inferior  posterior  cere- 
bellar arteries.  In  the  latter  case  anesthesia  of  the  ffice,  ataxia,  and 
other  symptoms  also  occur  (p.  1172).  The  onset  is  always  sudden, 
often  with  vertigo,  and  without  loss  of  consciousness.  The  power  to 
articulate  is  impaired  or  lost.  The  lips  and  tongue  are  involved,  and 
hence  the  pendulous  lower  lip,  the  dribbling  of  saliva,  and  the  atrophy 
of  the  lingual  muscles.  There  are  dysphagia  and  generally  frequent 
attacks  of  choking. 

The  symptoms  are  less  characteristic  than  those  of  the  degenerative 
form.  They  are  less  regular  in  type,  and  usually  are  widespread  at 
first ;  later,  some  improvement  takes  place.  In  other  cases,  after  more 
or  less  of  a  respite,  degeneration  sets  in  and  they  grow  progressively 
worse.      Death,  however,  usually  occurs  speedily. 

The  diagnosis  of  this  type  is  not  usually  difficult.  "  Pseudo-bulbar 
paralysis  "  must  be  borne  in  mind,  however,  and  is  a  condition  due  to  a 
bilateral  lesion  of  the  motor  cerebral  cortex  in  the  lower  frontal  parietal 
region  or  of  the  motor  fibers  in  the  course.  There  is  great  danger  to 
life  for  some  little  while  in  these  sudden  cases.  Later  the  prognosis  is 
rather  more  favorable  than  in  the  other  forms. 

2.  Acute  Inflammatory. — Here  the  onset  is  less  abrupt,  requiring  a 
few  days  to  a  week  to  develop,  and  follows  either  one  of  the  infectious 
diseases,  the  excessive  use  of  alcohol,  or  lead-poisoning  (polio-encephalitis 
inferior).  But  for  this  fact  the  symptoms  are  much  the  same  as  in  the 
preceding  form.  It  may  be  associated  with  acute  anterior  poliomyelitis 
(p.  1130). 

3.  Chronic  Bulbar  Paralysis. — This  condition  occurs  chiefly  m  males 
beyond  middle  life.  The  cause  can  seldom  be  discovered,  though  certain 
cases  seem  to  be  of  toxic  origin.  It  may  develop  in  the  course  of  progres- 
sive muscular  atrophy,  amyotrophic  lateral  sclerosis,  and  insular  sclerosis. 

The  symptoms  are  bilateral,  the  tongue  being  usually  the  first  to 
suffer.  The  patient  may  notice  that  he  cannot  speak  for  any  length  of 
time  without  fatigue,  and  that  he  will  then  articulate  indistinctly.  Soon 
he  observes  that  there  is  a  marked  and  progressive  impairment  of  speech. 
The  muscles  of  the  lips  and  other  muscles  of  the  lower  part  of  the  face 
atrophy.  He  can  no  longer  whistle.  Speech  is  rendered  still  more  defec- 
tive, owing  to  paralysis  of  the  lips.  The  lower  lip  drops,  and  the  saliva 
constantly  dribbles  from  the  mouth  and  may  be  greatly  increased  in 
amount.  Difficulty  in  swallowing  is  always  present  to  a  greater  or 
less  degree.  Owing  to  the  lingual  paralysis,  the  tongue  can  neither  be 
protruded  nor  can  it  be  used  to  manipulate  the  food  and  make  a  bolus. 
It  is  atrophied  and  the  mucous  membrane  is  wrinkled.  Fibrillar  trem- 
ors are  present  and  reactions  of  degeneration  may  occur.     The  larynx  is 


1130  DISEASES   OF  THE  yERVOUS  SYSTEM. 

involved,  so  that  phonation  is  iuipertect,  but  it  is  not  so  marked  as  the 
implication  of  other  parts.  Particles  that  enter  the  larynx  cannot  be 
ejected,  owing  to  motor  paralysis.  There  are  no  sensory  symptoms,  and 
tiie  power  of  taste  is  normal.  The  mind  generally  remains  clear,  though 
the  patient  is  often  emotional,  and  cries  or  laughs  without  apparent  cause. 
This  tyi)e  of  bulbar  palsy  is  particularly  liable  to  develop  in  the  course 
of  either  progressive  muscular  atrophy  or  myotrophic  lateral  sclerosis, 
or  may  precede  them.  The  course  of  the  disease  is  slow,  and  death  is 
usually  <lue  either  to  inspiration-pneumonia  or  to  interference  with  respi- 
ration or  circulation. 

The  diagnosis  is  not  difficult,  as  a  rule,  the  bilateral  character  of 
the  symptoms  rendering  them  distinctive.  In  the  pxcudd-Jadbar  form 
the  limbs  are  often  paralyzed  also  (double  hemiplegia).  The  tongue  is 
not  atrophied,  the  muscles  of  the  fiice  do  not  show  changes  in  their  elec- 
trical reaction,  and  there  is  usually  a  history  of  successive  apo))lectic 
attacks  (p.  1166).  Tumors  rarely,  if  ever,  give  rise  to  such  regular  bi- 
lateral symptoms.  It  may  also  have  to  be  distinguished  from  myasthenia 
gravis  (see  p.  1167). 

Treatment. — The  disease  is  incurable.  Hypodermics  of  strychnin, 
or  of  strychnin,  morphin,  and  atropin,  are  of  value  in  controlling  the 
salivary  floAv.  Electricity  is  of  no  value.  Semisolid  food  is  probably 
the  most  readily  taken,  and  it  is  often  necessary  either  to  use  an  esopha- 
geal tube  or  to  employ  rectal  alimentation. 


ACUTE  ANTERIOR  POLIOMYELITIS. 

ESSENTIAL   PARALYSIS    OF   CHILDREN. 
(Atrophic  Spinal  Paralysis;  Infantile  Paralysis.) 

Definition. — An  infectious  febrile  disease  of  more  or  less  rapid  on- 
set, a.-sociated  with  muscular  paralysis  and  atrophy,  occurring  chiefly  in 
children,  and  most  frequently  in  those  under  three  years  of  age. 

Etiology. — The  precise  cause  is  not  known,  but  it  is  evidently  due 
to  a  specific  infection  of  unknown  nature.  The  disease  has  been  pro- 
duced in  monkeys  by  intracerebral  inoculation  with  an  emulsion  of  an 
affected  spinal  cord.'  Monkeys  have  also  been  inoculated  with  the  se- 
cretions from  the  nasopharynx  of  those  suffering  from  the  disease.  The 
virus  will  live  jn  the  intestines  and  pass  from  the  body  in  the  feces.^ 
While  probably  the  disease  is  communicable  to  some  extent  by  direct 
contact,  the  stable  fly  ^  (Stomoxys  Calcitrans)  plays  a  large  part  in  its 
transmission.  The  disease  may  occur  at  any  age,  but  by  far  the  greatest 
number  of  cases  occur  before  the  third  year  of  life;  they  are  about  equally 
distributed  between  the  two  sexes.  Later  in  life  the  condition  is  more 
common  in  males,  chiefly  between  the  ages  often  and  twenty-five.  It  is 
rare  after  this  period.  Epidemics  have  been  described,  and,  notably,  one 
occurring. during  the  summer  of  1804.     Dr.  Caverly,  of  Rutland,  Vt., 

1  Flexner  and  I^wis,  Jour.  Amer.  Med.  Assoc,  Jan.  1,  1910,  p.  45. 

^  Flexner,  (Jlark,  and  Docliez,  Jour.  Amer.  Med.  Assoc,  July  27,  1912,  p.  273. 

■'  Jour.  Amer.  Med.  Assoe.,  Nov.  2,  1912,  p.  1627. 


ACUTE  ANTKRrOR   POLfOMVELfTfS.  1131 

then  reported  126  cases  occurring  in  Otter  Creek  Valley,  a  limestone 
region  of  Vermont.  Similar  epidemics  have  been  ol^served  in  Norway 
and  Sweden,  and  in  various  parts  of  Europe  and  tlie  United  States.  It 
is  especially  apt  to  occur  in  warm  weather.  Traumatism  may  be  a  pre- 
disposing factor.  The  acute  infectious  diseases  may  cause  a  symptom 
group  resembling  the  specific  disease. 

Pathology. — The  parenchyma  of  the  heart,  liver,  and  kidneys  are 
the  seat  of  cloudy  swelling,  and  the  lymph-nodes  and  spleen  show  hyper- 
plasia and  proliferated  endothelial  cells. 

Macroscopically  the  cord  is  congested  and  softened  with  hemorrhages 
into  the  anterior  horns. 

Microscopically  the  perivascular  lymph-spaces  are  found  filled  with 
cells,  first  polymorphonuclear  leukocytes,  later  endothelial  cells  and 
lymphocytes.  The  vessels  are  congested,  their  walls  degenerated,  with 
rupture  of  and  hemorrhage  from  the  capillaries.  Degeneration  and  de- 
struction of  the  ganglion  cells  and  of  the  nerve-fibers  in  the  anterior 
roots.  A  round-cell  infiltration  of  the  pia-arachnoid.  These  changes 
are  most  pronounced  in  the  anterior  gray  matter  of  the  lumbar  and  cer- 
vical enlargements,  but  the  white  matter  may  also  be  affected.  The  pons 
and  medulla  may  also  show  similar  changes. 

Symptoms. — The  onset  is  generally  acute,  and  may  be  sudden. 
Constitutional  symptoms  are  present  as  a  rule.  Generally,  the  sequence 
is  as  follows  :  Fever  (usually  slight),  malaise,  possibly  vomiting  (especially 
in  children),  diarrhea,  headache,  and  restlessness.  In  a  few  hours  or 
after  one  or  two  days  paralysis  supervenes  and  quickly  spreads,  involv- 
ing a  greater  or  less  area  ;  it  then  remains  stationary  for  from  two  to  four 
days  to  from  five  to  eight  weeks,  when  improvement  takes  place,  begin- 
ning in  the  part  last  affected.  In  some  cases,  after  a  most  trifling  indis- 
position over  night,  paresis  is  met  with  in  the  morning.  In  a  few  weeks 
only  that  portion  remains  paralyzed  that  is  to  be  permanently  damaged. 
Wasting  of  the  muscles  will  be  noticed  a  week  or  two  after  the  onset  of 
paralysis ;  these  become  flaccid  and  give  the  reactions  of  degeneration. 
Sensory  symptoms  are  very  rarely  present.  There  may,  however,  be 
general  hyperesthesia  during  the  early  stages,  and  evidences  of  meningeal 
irritation,  as  rigidity,  retraction  of  the  head,  etc.  The  reflexes  are  lost, 
both  superficial  and  deep,  and  later  contractures,  due  to  the  overaction  of 
unopposed  muscles,  may  develop  and  result  in  various  deformities.  The 
growth  of  bone  is  seriously  impaired  in  some  cases. 

Diagnosis. — Usually  this  is  not  difficult,  except,  possibly,  for  the 
first  few  days  in  some  cases.  Before  the  occurrence  of  paralysis  in  sus- 
pected cases  examination  of  the  cerebrospinal  fluid,  obtained  by  lumbar 
puncture,  is  of  service.  In  this  stage  it  may  be  slightly  turbid,  but  is 
usually  clear,  contains  an  increase  of  lymphocytes  and  globulin  and 
sugar,  as  shown  by  testing  with  Fehling's  solution.  This  latter  re- 
action does  not  occur  in  the  fluid  from  any  form  of  meningitis  except 
the  tubercular.  Bacteria  are  absent,  and  when  paralysis  ensues  all  of 
these  changes  disappear.^  Close  scrutiny  Avill  enable  one  to  difler- 
entiate  between  this  disease  and  a  pseudo-palsy,  the  result  of  pain  on 
active  or  passive  motion,  as  seen  in  rickets,  scurvy,  and  in  hip-joint  dis- 
ease. From  multiple  neuritis  it  is  distinguished  by  the  absence  of  ten- 
derness over  the  nerve-trunks  and  the  fact  that  in  neuritis  the  symptoms 
^  Flexner  and  Clark,  Jow.  Amer.  Medical  Assoc,  Feb.  25,  1911,  p.  586. 


1132  DISEASES  OF  THE  yERVOUS  SYSTEM. 

are  progressive  and  not  retrogressive,  as  they  are  in  poliomyelitis.  The 
symptoms  of  the  cerebral  palsies  of  chihlliood  are  giver,  on  p.  1174,  and 
of  transverse  myelitis  on  p.  113-"). 

Prognosis. — Some  impairment  of  motion  and  more  or  less  wasting 
of  the  miisck'S  almost  invariably  remain.  Danger  to  life  is  usually  not 
great,  althougli  death  may  occur  from  either  involvement  of  the  bulbar 
nuclei  or  violence  of  the  toxemia.  Marked  improvement  in  power  may 
•result  several  years  after  the  oncoming  of  the  disease  if  proper  treatment 
is  persisted  in. 

Treatment. — Owing  to  the  possibility  of  the  disease  being  com- 
municable (luring  the  acute  stage,  the  patient  should  be  isolated  and  the 
discharges  disinfected,  as  in  other  similar  diseases.  The  mouth  esjiecially 
should  be  kept  as  clean  as  possible  with  washes  containing  formalin.  If 
fever  is  excessive,  cool  sponging  or  an  ice-bag  to  the  head  may  be  em- 
ployed. If  pain  and  lioadaehe  are  severe,  lumbar  puncture  may  relieve. 
If  the  respiratory  muscles  are  affected,  oxygen  inhalations  are  of  service. 
During  the  acute  stage  a  brisk  calomel  ])urge,  followed  by  a  saline,  is  of 
benefit;  and  it  is  necessary  to  support  the  general  condition.  For  this 
reason  absolute  rest  should  be  enjoined;  the  diet  should  be  liquid  and 
nourishing,  and  stimulants  should  be  given  freely  if  necessary.  Hexa- 
methylenamin  probably  exerts  an  influence  in  destroying  the  disease 
germ.  After  the  first  few  weeks  the  affected  parts  must  be  kept  warm  by 
means  of  cotton  wool  or  extra  clothing  or  artificial  heat.  As  soon  as 
possible  the  child  is  to  be  taken  into  the  fresh  air.  It  is  of  vital  im- 
portance to  keep  up  the  general  systemic  tone,  and  hence  the  necessity 
for  fresh  air,  change  of  scene,  and  for  nourishing  but  easily  digestible 
food.  During  this  period  massage  and  electricity  should  be  employed, 
together  with  the  administration  of  strychnin.  In  the  later  stages,  when 
contractures  have  set  in,  mechanical  appliances  may  be  necessary  to 
correct  deformity  and  to  give  support.  In  suitable  cases  either  nerve 
anastomoses  or  the  transplantation  of  tendons  have  given  good  results. 

CHBONIC   POLIOMYELITIS    IN   ADULTS. 

That  chronic  poliomyelitis  exists  has  been  proved  by  Oppenheim  and 
other  observers.  The  symptoms  resemble  very  much  those  of  progressive 
spinal  muscular  atrophy  (p.  1142).  In  this  affection,  however,  the  in- 
trinsic muscles  of  the  hands  are  usually  first  affected,  while  in  chronic 
poliomyelitis  any  group  may  be  the  first  to  suffer. 

Treatment. — Mercury  or  the  iodids  may  be  tried,  especially  if  there 
is  a  history  of  syphilis.  Electricity  and  massage  are  of  the  greatest 
value. 


ACUTE  POSTERIOR  POLIOMYELITIS. 

{Hei-^pes  Zoster. ) 

The  posterior  root  ganglia  of  the  spinal  nerves,  and  those  found  in 
connection  with  the  sensory  cranial  nerves,  are  also  subject  to  inflam- 
mation due  to  some  infective  agent.  The  symptoms  are  neuralgic  pain 
in  the  course  of  the  affected  nerves,  possibly  anesthesia  in  their  distribu- 
tion, and  herpetic  eruptions.  Constitutional  symptoms  may  also  be 
present.     Herpes  zoster  is  a  type  of  this  disease.      See  also  p.  1103. 


A  CUTE  ASCENDTNG   PA  RA  7>  YSm.  1 1 33 

While  most  cases  recover,  it  may  be  a  sei-ious  condition.  Siglit  may 
be  lost  if  the  vesicles  involve  the  eye,  and  unsightly  scarring  is  not 
unusual. 

The  treatment  consists  in  protecting  the  vesicles  from  rupture  and  in- 
fection by  anodyne  powders  or  salves,  covered  with  a  dressing.  Ano- 
dynes internally,  if  the  pain  is  severe.  Drugs  seem  to  have  no  effect  in 
shortening  the  disease,  but  the  salicylates,  quinin,  and  general  tonics 
may  be  tried. 


ACUTE  ASCENDING  PARALYSIS. 

{Landry'' s  Paralysis. ) 

Definition. — An  acute  paralysis,  beginning  in  the  legs  and  ascend- 
ing by  way  of  the  trunk  and  upper  extremities,  and  ultimately  involving 
the  medullary  centers.  It  usually  runs  a  short  course,  and,  as  a  rule, 
terminates  in  death. 

Pathology. — Although  in  many  cases  neither  gross  nor  microscopic 
lesions  have  been  found,  either  in  the  cells,  peripheral  fibers,  or  muscles, 
a  number  of  different  anatomical  changes  have  been  found  in  cases 
believed  to  have  this  disease,  viz.,  multiple  neuritis,  acute  diffuse  mye- 
litis, and  poliomyelitis.  A  fluid  exudation  in  the  central  canal  of  the 
cord  and  hyaline  change  in  the  central  arteries  have  also  been  found. 
The  symptoms  are  evidently  due  to  a  severe  type  of  infection,  involving 
the  peripheral  motor  neuron,  which  when  very  malignant,  causes  death 
before  visible  changes  occur,  while  in  less  acute  cases  the  characteristic 
evidences  of  neuritis,  myelitis,  or  both,  can  be  discovered. 

l^tiology. — No  definite  cause  is  knoAvn.  It  has  followed  cold  and 
exposure,  traumatism,  and  the  infectious  fevers,  including  influenza. 
It  occurs  in  males  chiefly  between  twenty  and  forty  years. 

Symptoms. — In  the  most  acute  cases  there  are  practically  no  pro- 
dromal symptoms  other  than  malaise  and  possibly  chilly  sensations. 
Weakness,  followed  in  a  few  hours  or  a  day  or  two  by  paralysis,  develops 
in  the  lower  extremities.  One  may  be  involved  a  few  hours  earlier  than 
the  other.  It  spreads  toward,  and  soon  involves,  the  trunk  also,  and  in 
quick  succession  the  arms.  The  third  and  usually  fatal  stage  is  reached 
when  bulbar  symptoms  develop.  Very  rarely  the  upper  extremities  may 
be  first  attacked.  Death  may  occur  in  forty-eight  hours.  The  paralysis 
is  a  flaccid  one ;  the  muscles  can  be  passively  moved  without  offering  any 
resistance.  Wasting  rarely  occurs  and  there  are  no  electrical  changes. 
In  less  acute  cases  a  decided  febrile  stage  precedes  the  onset  of  paralysis, 
chills,  fever,  malaise,  and  possibly  formication  or  even  sharp  pain.  In 
any  case  the  later  symptoms  are  preeminently  or  solely  motor.  Sensory 
symptoms  when  present  are  very  slight.  The  deep  reflexes  are  absent. 
The  bladder  and  rectum  are  not  implicated  nor  do  bed-sores  develop. 
As  stated,  when  the  bulb  is  attacked  death  generally  follows,  due  to 
cardiac  or  respiratory  failure  or  to  interference  with  deglutition.  There 
are  no  cerebral  symptoms. 

Course. — Death  may  occur  in  from  forty-eight  hours  to  a  few  weeks. 
A  few  cases  of  recovery  have  been  reported  (Sinkler),  in  some  of  which 
paralysis  had  been  widespread,  even  reaching  the  bulb,  judging  from  the 


1134  DISEASES   OF  THE  NEEVOUS  SYSTEM. 

labored  respiration.  When  improvement  takes  place,  it  does  so  in  the 
reverse  order  to  the  onset,  so  that  the  last  part  affected  is  the  first  to 
recover.      It  is  much  slower  than  the  invasion. 

Diagnosis. — Tlie  rapid  onset  of  a  paralysis  that  usually  ascends, 
the  relaxation  of  the  muscles,  slight  wasting,  if  any,  and  the  absence  of 
electric  changes  and  of  sensory  symptoms,  with  or  without  fever,  serve 
to  make  the  diagnosis  and  to  distinguish  Landry's  disease  from  polio- 
myelitis, neuritis,  and  spinal  hornorrhage.  For  the  differential  diagnosis 
between  Landry's  paralysis  and  acute  myelitis,  see  page  118(J. 

Prognosis. — Always  grave,  particularly  if  bulbar  symptoms  occur, 
and  especially  if  they  appear  early. 

The  treatment  is  essentially  the  same  as  that  for  any  acute  disease 
of  the  cord  or  nerves — /.  e.,  rest,  freedom  from  all  excitement  or  worry, 
warm  baths  and  ]iacks,  moderate  purgation,  and  diaphoresis;  hexamethyl- 
enamin,  ergot,  belladonna,  salicylates,  and  iodids  internally.  Should 
the  patient  survive,  electricity  and  massage  should  be  employed. 


ACUTE  MYELITIS. 

{Myelitis;  Acute  Diffuse  Myelitis ;  Transverse  Myelitis ;  Myelomalacia.) 

Definition  and  Varieties. — An  inflammation,  with  softening  of 
the  cord,  giving  rise  to  various  groups  of  s^'mptoms  depending  upon  the 
region  or  regions  involved,  and  not,  therefore,  as  constant  in  its  symptom- 
atology as  the  systemic  nervous  diseases  (tabes  dorsalis,  lateral  sclerosis). 
It  may  be  acute,  subacute,  or  chronic.  If  the  gray  matter  only  is  inn 
volved,  it  is  termed  poUomyelitis  (p.  1130) ;  if  a  small  vertical  extent 
(several  segments)  of  both  Avhite  and  gray  matter,  transverse  myelitis ; 
if  an  extensive  area  of  both  white  and  gray  matter,  diffuse  myelitis  ;  if 
a  large  area  of  gray  matter,  central  myelitis ;  if  in  scattered  areas,  dis- 
seminated mjielitis.  If  it  follows  a  previous  hemorrhage,  Jieviorrhagio 
myelitis,  and  if  it  is  caused  by  pressure,  as  a  tumor  or  bone  disease,  com- 
pression myelitis. 

Ktiology. — Myelitis  may  follow  exposure  (especially  in  alcoholics), 
the  infectious  fevers,  and  it  may  be  due  to  traumatism  or  disease  of  the 
vertebriB  (caries,  malignant  disease).  Syphilis  precedes  it  in  nearly  one- 
half  of  all  cases.  It  has  also  been  described  as  following  peripheral 
neuritis,  ascending  neuritis,  and  we  meet  with  sowe  cases  in  which  preg- 
nancy seems  to  act  as  the  predisposing  cause.  In  many  of  the  cases 
occurring  in  those  who  have  arterial  disease  the  cause  is  thrombosis  in  a 
spinal  artery,  causing  softening.  This  is  known  as  myelomalacia.  It 
may  be  difficult  clinically  to  distinguish  it  from  true  myelitis.  It  is  most 
common  in  males,  generally  from  fifteen  to  thirty  years  of  age. 

Pathology. — The  cord  may  present  little  or  no  change  to  the  naked 
eye,  or  in  the  most  acute  cases  it  may  be  diffluent.  Between  these  ex- 
tremes many  grades  exist  in  which  the  pia  will  be  found  congested  and 
adherent,  the  cord  being  more  or  less  ingested  and  areas  of  softening, 
and  even  cavities,  being  found.  Three  forms  of  softening  are  spoken  of 
by  some  writers — the  red,  yellow,  and  gray — depending  upon  the  pre- 
dominance of  blood,  fat,  or  connective  tissue  respectively.    The  postmor- 


ACUTE  MYELITIS.  11,35 

tern  finding  depends  upon  the  duration  of  tlie  disease ;  the  more  chronic 
the  course,  the  greater  the  amount  of  nervous  connective  tissue  (neurog- 
lia), and  in  consequence  sclerosis  will  be  the  predominant  feature.  The 
nerve-cells  and  fibers  are  found  in  various  stages  of  disintegration,  tlie 
former  being  swollen,  vacuolated,  granular,  and  their  processes  broken  and 
in  many  cases  missing;  while  the  latter  swell,  the  myelin  brcfiks  up,  un- 
dergoes fatty  change,  and  is  removed,  and  the  axis-cylinders  finally 
break  up  and  disappear.  A  single  area  of  degeneration  may  exist  cen- 
trally, in  one  half  of  the  cord,  transversely,  or  many  localized  or  widely- 
disseminated  areas  may  be  found  ;  but  above  and  below  all  of  them  will 
be  found  degenerated  fibers — ascending  and  descending  degeneration — 
due  to  a  solution  of  continuity  between  the  cell-body  and  its  axis-cylinder 
process.  Transverse  myelitis,  or  when  the  extent  of  several  segments  of 
the  cord  is  affected,  is  the  most  common. 

Symptoms. — These  will  vary  according  to  the  seat  and  extent  of 
the  lesion.  In  the  most  acute  form  the  course  of  the  disease  is  quite 
rapid,  reminding  one  of  hemorrhage  into  the  cord  or  membranes ;  the 
onset,  however,  is  not  so  explosive,  and,  though  rapid,  it  is  not  sudden. 
It  is  most  apt  to  follow  cold  or  exposure.  There  may  be  chills  and  fever, 
malaise,  backache,  pains  in  the  limbs ;  quite  often,  however,  there  is  no 
warning.  Motor  weakness  develops,  and  is  rapidly  followed  by  paralysis. 
Some  irritative  sensory  symptoms  appear,  as  hyperesthesia  and  pares- 
thesia, and  then  more  or  less  complete  anesthesia  supervenes.  The 
reflexes  are  generall}'^  lost;  there  is  incontinence  of  urine  and  feces, 
and  bed-sores  and  cystitis  develop  with  frightful  rapidity.  The  tem- 
perature now  rises  to  105°  F.  (40.5°  C.)  or  even  higher,  and  typhoid 
symptoms,  exhaustion,  and  death  close  the  scene.  I  have  seen  a  case 
that  developed  in  a  woman  a  few  days  after  delivery  and  proved  fatal  in 
six  days.  In  the  majority  of  instances  constitutional  symptoms  are  not 
so  marked,  in  fact  they  are  often  absent,  and  the  paralysis  develops  more 
slowly. 

Acute  transverse  myelitis  is  the  type  most  frequently  met  with,  the 
lesion  being  generally  situated  in  the  dorsal  cord.  The  motor  symptoms 
generally  appear  before  the  sensory  symptoms,  though  they  may  be  con- 
temporaneous. In  any  event,  they  are  apt  at  first  to  be  irritative.  The 
limbs  will  feel  tired  and  heavy  and  drag  in  walking,  and  tremors  or  twitch- 
ing occur,  even  cramps,  and  later  paralysis,  partial  or  complete,  in  the  region 
involved.  The  lower  limbs  may  alone  be  involved,  or  when  the  lesion  is  in 
the  cervical  region  paralysis  and  atrophy  of  the  upper  with  a  spastic  condi- 
tion of  the  lower  extremities  may  develop.  The  breathing  is  generally 
diaphragmatic  in  cases  in  which  the  intercostal  muscles  are  involved.  If 
the  lesion  is  still  nigher  up,  death  will  quickly  take  place  from  failure  of 
respiration.  Such  cases,  however,  are  more  apt  to  occur  in  the  type 
known  as  disseminated  myelitis,  in  which  bulbar  symptoms  are  prone 
to  appear.  The  sensory  symptoms  at  first  are  those  of  a  tingling  or 
burning  character,  or  formication.  Later,  certain  or  all  forms  of  sen- 
sation may  be  lost,  and,  roughly  speaking,  the  upper  level  of  anesthesia 
corresponds  to  the  level  of  the  cord  involved.  This  "  boundary  re- 
gion"  is  apt  to  be  hyperesthetic,  and  in  it  the  "girdle-feeling"  is  ex- 
perienced. The  reflexes  are  usually  lost  at  first ;  they  may  remain  perma- 
nently absent  or  they  may  return,  and  become  exaggerated  below  the 


1136  DISEASES  OF  THE  yERVOUS  SYSTEM. 

lesion.  The  condition  of  the  tendon-reliexes  may  enable  one  to  locate 
the  position  of  the  cord-lesion,  thov  being  lost  in  parts  supplied  by  the 
aft'ected  soiiments,  but  increased  below  the  seat  of  the  lesion.  Whether 
or  not  there  is  wasting  of  the  muscles  depends  on  the  location  of  tlie 
lesion ;  if  in  the  dorsal  cord,  as  is  usually  the  case,  none  will  be  found. 
When  the  cervical  region  is  involved,  the  muscles  su)>plicd  by  the  seg- 
ments involved  will  atrophy  and  the  reaction  of  degeneration  will  de- 
velop. The  same  thing  occurs  if  in  the  lumbar  cord  (p.  1071).  Below 
the  seat  of  the  lesion  there  is  ])aralysis,  but  not  atrophy.  Loss  of  control 
of  the  bowel  and  bladder  may  be  among  the  earliest  symptoms,  though 
this  is  not  the  rule.  While  superficial  ulceration  may  occur  in  any 
neglected  case,  the  most  marked  trophic  changes  take  place  in  those  in 
which  the  lumbar  cord  is  involved,  either  directly  or  by  extension.  In 
such  cases,  despite  the  most  assiduous  attention,  extensive  bed-sores 
develop.  The  course  of  the  disease  depends  on  the  cause  and  extent  of 
the  lesions.  Death  may  occur  in  a  few  weeks  from  exhaustion,  heart  or 
respiratory  failure,  or  from  kidney  diseases  secondary  to  cystitis.  Re- 
covery is  the  rule,  though  with  more  or  less  permanent  damage  due  to 
degeneration  of  some  of  the  paths  of  conduction. 

Diagnosis. — The  distinction  from  hemorrhage  into  the  cord  or 
membranes  has  already  been  mentioned.  From  Landry's  paralysis  it 
can  be  separated  by  a  reference  to  the  subjoined  table : 

Acute  Myelitis.  Landry's  Disease. 

Paralysis  is  sudden  and  generally  be-  Paralysis  begins  in  the  feet  and  rapidly 

comes  complete.  spreads  to  the  muscles  of  respiration 

and  depjlutition. 

Wasting  and  bed-sores  are  marked.  Trophic  disturbances  are  absent. 

If  atrophy  occurs,  reaction  of  degen-  No  reactions  of  degeneration, 
eration  is  present. 

Early  involvement  of  the  sphincters.  Bladder  and  rectum  are  not  involved. 

Girdle-pains  sometimes  mark  the  height  Girdle-pains  are  absent, 
of  the  lesion. 

Sensory  paralysis.  No  loss  of  sensation. 

Anterior  poliomyelitiB  is  not  accompanied  by  sensory  paralysis.  Bed- 
sores and  disturbances  of  the  sphincters  do  not  occur.  In  periphevdl 
neuritis  pain  of  a  shooting  character  and  tenderness  over  tlie  affected 
nerves  are  present,  and  is  almost  invariably  the  first  symptom  to  appear. 
Motor  symptoms  may  not  appear  for  some  days.  This  is  not  the  case  in 
myelitis.  In  compression  of  the  cord  sufficient  collateral  evidence,  as 
evidence  of  bone  disease,  can  usually  be  obtained  to  differentiate  it  from 
myelitis.  Hysteric  paraplegia  is  occasionally  misleading.  The  character 
of  the  patient  and  the  previous  history  should  be  thoroughly  considered ; 
moreover,  in  this  form  there  are  no  trophic  changes,  and,  as  a  rule,  no 
bladder-symptoms ;  at  any  rate,  there  is  no  cystitis.  Retention  of  urine 
may  occur,  but  not  incontinence,  and  the  Babinski  reflex  is  absent. 
The  diagnosis  of  myelitis  can  usually  be  made  without  great  difficulty 
from  the  motor  and  sensory  symptoms,  the  vesical,  rectal,  and  trophic 
symptoms,  and  often  from  the'  presence  of  the  girdle-sensation  in  addi- 
tion. Myelomalacia  can  usually  not  be  distinguished  clinically  from 
myelitis.  The  symptoms  occurring  in  an  old  person,  without  any  of  the 
causes  of  the  latter  having  been  operative  and  the  existence  of  a  previous 
history  of  syphilis,  is  rather  in  favor  of  the  former. 


CI  I  RON W  MYELITIS.  1137 

ProgtlOSis. — The  most  acute  cases  are  fatal  in  from  three  flays  to  a 
week.  Less  acute  cases  generally  recover  with  more  or  less  loss  of  motor 
power.     Improvement  may  continue  for  several  years. 

Treatment. — Very  little  can  be  done  to  arrest  the  process  in  acute 
myelitis.  Absolute  rest  should  be  enjoined,  and  the  patient  given  a 
nutritious  liquid  diet  with  free  stimulation.  The  patient  should  be 
placed  on  an  air-  or  water-bed.  Trophic  changes  should  be  looked  for 
daily,  and  at  the  first  sign  of  their  appearance  alcohol  or  some  stimu- 
lating liniment  should  be  employed.  If  the  skin  is  broken,  absolute 
cleanliness  must  be  observed,  and  the  wounds  dressed  antiseptically.  It 
is  well,  also,  to  change  the  patient's  position  from  time  to  time  to  avoid 
too  long-continued  pressure  in  any  one  spot.  Either  the  salicylates  or 
hexamethylenamin  should  be  given  in  infectious  cases,  and  in  specific 
cases,  mercury  and  potassium  iodid  in  full  doses.  A  general  tonic  and 
supportive  treatment  is  indicated,  and  later  massage,  electricity,  and 
baths. 


CHRONIC  MYELITIS. 


That  there  are  both  a  subacute  and  a  chronic  form  of  myelitis  is  gen- 
erally conceded,  though  these  types  are  not  sharply  circumscribed.  As 
has  been  previously  mentioned,  it  is  quite  likely  that  many  cases  exist 
in  which  the  clinical  symptoms  do  not  seem  to  warrant  the  diagnosis  of 
myelitis,  and  yet  extensive  areas  of  degeneration  may  be  found  post- 
mortem. 

Htiologfy. — This  is  not  clearly  known;  an  acute  attack  may  termin- 
ate and  the  tissue  of  the  cord  become  sclerosed  with  persistence  of  the 
symptoms ;  or  the  disease  may  commence  insidiously  as  the  result  of  the 
existence  of  some  chronic  infectious  process,  such  as  syphilis,  it  may  be 
the  sequel  of  an  acute  infection,  such  as  typhoid  fever,  or  follow  a  fall  or 
blow  upon  the  back. 

Pathology. — Histologically,  the  chief  differences  from  the  acute 
variety  consist  in  the  greater  amount  of  sclerosis,  the  thickened  blood- 
vessels with  contracted  lumen,  and  an  entire  absence  of  recent  hemor- 
rhage. In  some  cases  also  the  pia  is  much  thickened  in  patches  and 
firmly  adherent.  The  nerve-cells  are  either  seen  to  be  in  advanced  stages 
of  degeneration  or  they  have  actually  disappeared.  Secondary  degener- 
ationSy  above  and  below,  proceed  from  the  primary  foci. 

Symptoms. — Any  symptom  occurring  in  the  acute  may  be  dupli- 
cated in  the  chronic  form,  though  the  onset  of  the  latter  is  gradual. 
The  symptoms  are  more  or  less  obtrusive,  according  to- the  region  of  the 
cord  that  is  affected,  and  it  may  be  several  years  before  they  are  fully 
developed.  In  those  cases  which  do  not  follow  the  acute,  the  first  symp- 
toms complained  of  are  usually  numbness  of  the  legs  and  a  feeling  of 
weakness,  which  gradually  progresses  until  in  some  cases  the  legs  may 
become  useless.  If  the  meninges  are  involved,  as  they  frequently  are 
(meningomyelitis),  shooting  pains  in  the  extremities  and  a  girdle  sensation 
are  complained  of.  The  symptoms  differ  some^vhat,  according  to  the 
nature  of  the  lesion.  This  is  usually  of  the  transverse  variety,  which, 
if  in  the  dorsal  region,  as  it  usually  is,  causes  a  spastic  paraplegia,  with 
increased  deep  reflexes,  Babinski  reflex,  some  sphincter  disturbance,  and 
72 


1138  DISEASES  OF  THE  NERVOUS  SYSTEM. 

more  or  less  complete  loss  of  sensation  to  the  level  of  the  aft'ected  seg- 
ments. If  in  the  cervical  enlargement,  which  is  rare,  more  or  less  atro- 
phic })aralysis  of  the  arms,  owing  to  the  involvement  of  the  gray  matter, 
with  a  spastic  paralysis  of  the  legs  and  loss  of  sensation  to  the  affected 
segments,  will  be  present.  If  in  the  lumbar  region,  the  symptoms  will 
differ  somewhat,  according  to  the  segments  involved.  There  will,  how- 
ever, be  atrophy  in  certain  muscles  and  spasticity  and  absence  of  atrophy 
in  others  (p.  1135).  Owing  to  involving  of  the  posterior  columns  there 
may  be  more  or  less  ataxia,  so  that  the  gait  is  a  mixture  of  a  spastic  and 
ataxic  type  (ataxic  paraplegia).  The  disseminated  type  resembles  mul- 
tiple sclerosis. 

Diagnosis. — The  gradual,  and  in  many  cases  the  irregular,  onset 
characterize  this  disease.  In  its  various  phases  it  may  simulate  almost 
any  spinal-cord  disease,  and  it  is  most  apt  to  be  confounded  with  tumor- 
pressure  (carious  or  malignant),  primary  lateral  sclerosis,  amyotrophic 
lateral  sclerosis,  and  syringomyelia.  Pressure,  Avhether  due  to  a  tumor, 
to  caries,  or  to  malignant  disease,  is  apt  to  cause  pain  radiating  in  char- 
acter, and  the  last  two  usually  present  collateral  evidences  in  the  deformity 
and  cachexia  (p.  1139).  The  symptoms,  too,  in  the  case  of  tumor  may, 
at  first,  be  unilateral  and  confined  principally  to  the  muscles  and  skin 
areas  supplied  by  the  aft'ected  segments  (p.  11.58).  Amyotrophic  lateral 
sclerosis  is  distinguished  by  the  fibrillary  tremors  in  the  atrophied  mus-. 
cles,  absence  of  sphincter  involvement,  and  sensory  symptoms.  Syringo- 
myelia is  characterized  by  the  loss  of  pain  and  temperature  sense  with 
preservation  of  tactile  sense  in  certain  areas. 

The  prognosis  is  necessarily  grave.  Recovery  may  be  possible,  but 
it  is  extremely  rare.  The  process,  however,  may  be  arrested  and  the 
patient  live  for  years  more  or  less  helpless. 

Treatment. — More  can  be  expected  from  general  hygienic  measures 
than  from  the  use  of  drugs.  In  the  early  stages  rest  is  indicated,  but 
it  is  well  also  to  employ  passive  exercise  to  prevent,  if  possible,  a  too 
great  contraction  of  the  muscles.  As  soon  as  expedient — each  case  being 
judged  on  its  merits — the  patient  should  be  taken  out  of  doors.  Change 
of  air  and  of  scene  is  advisable,  as  are  also  baths  and  massage.  Mild 
counter-irritation  may  be  applied  to  the  spine,  but  care  should  be  taken 
to  avoid  the  areas  of  anesthesia.  General  tonics — iron,  quinin,  arsenic, 
and  strychnin — should  be  given,  also  mercury  and  the  iodids.  The  greatest 
possible  care  of  the  bladder  should  be  taken  in  order  to  avoid  cystitis. 
Good  results  have  been  obtained  by  Bailey  and  Elsberg  ^  from  the  perform- 
ance of  what  they  term  "  spinal  decompression."  This  consists  in  opening 
the  spinal  dura  over  the  seat  of  the  lesion  and  then  closing  the  wound  in 
the  usual  manner. 


COMPRESSION  OF  THE  SPINAL  CORD. 

(  Compression  Myelitis. ) 

It  is  of  importance  to  be  able  to  recognize  this  condition.     To  be 
sure,  it  is  not  always  possible  to  diagnose  it  with  certainty,  but  when 
there  is  a  reasonable  surety  the  question  of  operation  may  arise.     Since 
'  Jour.  Amer.  Med.  Assoc,  Mar.  9,  1912,  p.  675. 


COMPRESSION  OF  THE  SPINAL   COIW.  1139 

it  has  so  many  features  in  common  witli  myelitis,  the  necessity  for  reserve 
and  caution  in  arriving];  at  a  conclusion  is  manifest,  because  the  latter 
condition  would  not  be  benefited  by  any  operative  procedure. 

Ktiology. — We  may  classify  the  causes  of  compression  under  three 
headings — {a)  traumatism  (fracture),  (h)  inflammatory  disease  (caries  of 
the  spine,  due  to  tuberculosis  or  syphilis),  and  (c)  neoplasms  (including 
various  tumors,  gummata,  and  aneurism);  but  these  will  receive  separate 
consideration  [infra). 

Pathology. — The  postmortem  findings  will  depend  upon  the  degree 
and  duration  of  the  pressure.  More  or  less  meningitis  is  often  associated, 
especially  in  the  cases  due  to  vertebral  caries.  The  cord  will  be  more  or 
less  flattened  and  distorted  at  the  seat  of  pressure,  and  in  the  early  stages 
hyperemic  and  possibly  softened.  Later  it  is  hard,  sclerosed,  and  of  a 
grayish  color,  and  above  and  below  the  compressed  region  degenerated 
areas  will  be  seen  on  sectioning  the  cord.  Microscopic  examination  re- 
veals various  stages  of  degeneration  of  the  nerve  elements  at  the  point 
of  pressure  and  secondary  degeneration  of  the  various  tracts.  The  nerve- 
roots  will  be  more  or  less  damaged  by  compression. 

Symptoms. — These  will  vary  according  to  the  site  of  the  lesion 
and  the  extent  of  involvement — ^'.  e.,  the  vertical  extent,  the  degree  of 
pressure  exerted,  and  the  amount  of  inflammation  present.  Two  groups 
of  symptoms  are  present  in  typical  cases — first,  those  due  to  involvement 
of  the  nerve-roots,  and,  second,  those  dependent  upon  involvement 
of  the  cord  itself — ascending  and  descending  degeneration.  Pressure 
upon  the  posterior  roots  gives  rise  to  pain,  neuralgic  in  character  and 
radiating  along  the  course  of  the  nerves.  The  parts  supplied  are  usually 
tender,  and  there  may  be  paresthesia  and  formication.  These  irritative 
symptoms  are  followed  sooner  or  later  by  destructive  changes,  and  hence 
the  anesthesia.  There  may  be  spontaneous  pain  in  the  anesthetic  areas 
{ancBSthesia  dolorosa),  which  areas  are  of  the  segmental  type  and  depend 
in  location  upon  the  cord  segment  and  corresponding  nerve-roots  in- 
volved (Fig.  75).  Pressure  upon  the  anterior  roots  also  causes  irritative 
and  paralytic  symptoms,  and  hence  the  early  twitching,  or  even  spastic 
condition,  and  later  the  loss  of  power  or  paralysis.  The  muscles  supplied 
by  nerves  from  the  affected  segments  waste,  and  qualitative  and  quanti- 
tative electric  changes  can  be  elicited. 

The  second  group  of  symptoms,  due  to  secondary  degenerations,  then 
develops,  and  may  set  in  either  rapidly  or  slowly.  If  myelitis  promptly 
supervenes  and  is  extensive,  cord-symptoms  of  a  pronounced  type  develop 
quickly.  The  parts  below  the  lesion  will  become  weak,  there  will  be 
girdle  pains,  and  a  sense  of  constriction  or  pain  in  the  legs.  Sensory 
paralysis  is  usually  not  so  marked  in  this  region  as  the  motor,  as  the 
sensory  tracts  are  less  vulnerable  to  pressure  than  the  motor,  but 
hyperesthesia  and  hyperalgesia  are  present  in  most  cases.  They  may,  how- 
ever, be  absent.  The  reflexes  are  usually  increased.  If  the  cause  of 
compression  ceases  to  act  for  some  time,  some  improvement  takes  place, 
due  possibly  to  the  subsidence  of  the  myelitis.  If  the  pressure  is  of 
slow  onset,  great  tolerance  is  manifested.  Usually  sensation  is  recovered 
before  motion.  In  certain  cases,  however,  motor  power  is  regained,  while 
the  muscular  and  tactile  senses  do  not  return.  In  such  instances,  in 
which  the  posterior  columns  bear  the  brunt  of  the  trouble,  incoordination 
results  and  there  is  secondary  ataxia. 


1140  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — If  the  com  bine  J  symptoms  of  peripheral  and  central 
oriiriii  develoj)  slowly  in  tlio  order  named,  eompression  is  likely.  It  has 
been  asserted'  that  when  tlie  paralysis  is  due  to  pressure,  actual  degen- 
erative changes  not  yet  having  taken  place,  that  the  tendon  reflexes 
are  not  increased  but  the  skin  reflexes  (plantar)  are  very  much  so. 
Mi/eUtis  gives  rise  first  to  cord-,  and  only  later  to  peripheral  symptoms; 
hence  the  difficulty  in  cases  in  which  myelitis  develops  quickly.  Exten- 
sive root-symptoms  are  suggestive  of  meninyval  Involvement.  In  any 
event,  too  much  stress  should  not  be  placed  on  the  nervous  symptoms 
alone.  The  spine  should  be  carefully  examined  and  palpated  for  points 
of  tenderness.  Careful  note  should  also  be  taken  as  to  whether  there  is 
any  limitation  of  movement  or  deformity  (kyphosis).  The  family  history 
may  suggest  tuberculosis  (caries  of  the  spine).  A  skiagraph  of  the  spine 
is  often  valuable,  as  it  must  be  home  in  mind  Potts  disease  may  occur 
without  s[)inal  deformity.  Tumor  is  discussed  on  p.  1156.  The  history 
will  indicate  if  due  to  vertebral  fracture. 

The  prognosis  depends  entirely  upon  the  cause.  Having  ascer- 
tained this,  it  then  depends  upon  the  possibility  of  its  removal. 

Treatment. — In  general  the  treatment  is  that  of  myelitis.  When 
due  to  tubercular  disease  of  the  vertebra,  the  treatment  indicated  is  for 
that  condition,  and  a  surgeon  should  be  consulted,  though  operative  cases 
are  the  exception  rather  than  the  rule.  It  is  well  to  impress  upon  the 
patient  and  relatives  the  chronicity  of  the  condition,  but  faithful  and  per- 
sistent efforts  will  yield  good  results.  Rest  is  of  vital  importance,  par- 
ticularly when  the  disease  is  active.  The  patient  should  be  kept  in  bed 
in  a  recumbent  position  until  consolidation  has  taken  place.  Extension 
mav  be  necessarv.  Good  and  easily  assimilable  food  and  cod-liver  oil 
and  alteratives  should  be  given.  The  nutrition  of  the  muscles  may  be 
improved  by  general  friction  (massage).  As  soon  as  possible  a  plaster 
jacket  should  be  put  on  the  patient,  and  he  should  be  taken  into  the 
open  air  and  sunlight.  If  a  history  of  syphilis  is  obtained,  that  condition 
should  be  vigorously  treated.  In  vertebral  fracture  the  question  of 
operation  to  remove  the  fragments  of  bone  pressing  on  the  cord  may 
arise.      When  due  to  tumor,  see  page  11.59. 


PRIMARY  LATERAL   SCLEROSIS. 

By  this  is  meant  a  primary  degeneration  of  the  central  motor  neurones. 
It  is  a  rare  condition,  most  cases  so  called  being  due  to  a  secondary  de- 
generation caused  bv  a  lesion  cuttinj]:  the  tracts  somewhere.  A  few  cases 
have  been  reported  in  which  no  such  lesion  could  be  found.  The  heredi- 
tary  tijjye^  \^  probably  the  most  common.  The  only  pathologic  change 
observed  is  in  the  pyramidal  tracts  of  the  anterior  and  lateral  regions. 

Htiology. — It  is  most  apt  to  occur  when  there  is  a  neuropathic 
family  tcndenry.  Age,  generally  between  twenty-five  and  forty,  exerts 
an  etiologic  influence.     J'Jxjwsure,  acute  disease,  and  traumatism  are  all 

'  Jour.  Amer.  Med.  Assoc,  Jan.  2o,  1913,  p.  269. 
2  Spiller,  Phila.  Med.  Jour.,  June  21,  1902, 


PRIMARY  LATERAL  SCLEROSIS.  1141 

predisposing  causes.  Nypliilis  has  been  said  to  predispose  to  the  condition, 
but  if  so,  it  is  rather  rare.  Most  cases  presenting  this  syrnptoni-coniplex 
are  due  to  a  secondary  degeneration  of  tlie  pyramidal  tracts,  caused  by 
some  lesion,  as  a  mild  myelitis  higher  up.  Vertebral  disease  may  also 
cause  similar  symptoms.  A  number  of  cases  have  been  reported  occur- 
ring in  a  number  of  genei'ations  of  a  family  (lipreditary  spastic  npinal 
paralygis).      In  these  cases  the  symptoms  may  appear  in  childhood. 

Sjntnptoins. — In  typical  cases  the  onset  is  slow.  The  patient  com- 
plains of  feeling  tired,  and  is  less  capable  of  exertion  than  formerly. 
Weakness  of  the  legs  develops,  and  with  it  increasing  difficulty  in  walk- 
ing. Even  at  an  early  stage  some  rigidity  of  the  muscles  will  be  present 
when  the  limb  is  extended  ;  later  this  becomes  a  prominent  symptom. 
The  spasm  is  at  first  of  little  moment.  It  may  only  be  noticed  in  the 
morning.  When  the  disease  has  advanced,  however,  it  becomes  pro- 
nounced, so  that  it  may  not  be  possible  to  flex  the  limb,  or,  if  flexed  and 
an  eifort  is  made  to  extend  it,  it  will  often  spring  forward  like  a  knife- 
blade  in  clasp-like  rapidity.  This  spasticity  is  often  so  marked  that  in 
walking,  so  long  as  the  ball  of  the  foot  touches  the  ground,  clonic  con- 
tractions occur  ;  these  also  appear  when  the  individual  is  in  a  sitting 
posture  unless  his  legs  are  extended.  The  gait  is  characteristic  ;  the  legs 
are  stiff",  and  move  with  an  evident  eff"ort,  while  the  toes  scrape  the 
ground.  In  some  cases  the  adductor  spasm  is  so  great  that  the  legs 
not  only  cannot  be  separated,  but  are  actually  overlapped  in  walking 
{cross-leg  progression).  In  course  of  time  the  power  of  walking  may 
be  lost.  The  flexor  muscles  are  usually  weakened.  The  knee-jerk  is 
very  much  exaggerated,  a  mere  tap  causing  a  sharp,  quick  response. 
Ankle-clonus  can  always  be  elicited.  The  Babinski  reflex  is  present 
(extension  of  the  toes  when  the  sole  of  the  foot  is  irritated).  Pains  and 
other  sensory  manifestations  are  often  absent,  though  dull  and  fleeting 
pains  in  the  back  and  limbs  may  be  complained  of.  The  arms  are  fre- 
quently unafl"ected.  The  sphincters  are  rarely  involved,  and  ocular 
symptoms  do  not  occur.  Seguin  states  that  the  ability  to  retain  the  urine 
is  lessened  and  precipitate  micturition  results. 

The  diagnosis  is  not  difficult.  Certain  hysteric  cases  may  occa- 
sionally simulate  it  very  closely,  but  these  do  not  present  the  chara<cter- 
istic  spasticity  of  the  true  form,  nor  is  the  knee-jerk  increased  quite  as 
much,  ankle-clonus  is  either  slight  or  absent,  and  the  Babinski  reflex  is 
not  present.  Then,  too,  in  hysteria  spots  of  anesthesia  are  commonly 
met  with.  In  myelitis  there  is  usually  more  or  less  sensory  paralysis 
and  involvement  of  the  sphincters ;  if,  however,  it  is  very  mild  in  type, 
the  diagnosis  is  most  difficult.  The  possibility  of  caries  of  the  vertebrae 
must  be  borne  in  mind  Avhen  the  symptoms  are  developing  (p.  1138). 
The  congenital  type,  due  to  cerebral  lesions,  is  described  on  p.  1163. 
Hydrocephalus  may  also  be  mistaken  (p.  1190). 

Treatr)ient  consists  of  maintaining  the  general  health,  warm  baths  for 
the  spasticity  and  antisyphilitic  medication  if  there  is  a  history  of  that 
disease.  In  the  hereditary  form  benefit  has  been  obtained  by  tenot- 
omies, followed  by  electricity.  Cutting  the  posterior  nerve-roots  may  also 
be  considered,  if  spasticity  and  not  weakness  is  the  dominant  condition.^ 

^  Univerfiity  of  Penna.  Med.  Bull.,  Jan.,  1910,  314;  New  York  Medical  Journal,  Jan. 
29,  1910,  215. 


1142  DISEASES   OF  THE  MiRVOUS  SYSTEM. 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY. 

{Amyotrophia  Spinalis  Progressiva ;  Type  of  Ihtchen7U'-Aran. ) 

Definition. — A  disease  of  the  peripheral  motor  neurons  and  the 
muscles  ilit'v  supply,   usually  l)e_2:inning  in  the  cervical  region. 

Pathology. — There  is  atropiiy  of  the  anterior  cornua  of  the  cord, 
affecting  (.lueily  the  ganglion-cells,  degeneration  of  the  nerve-fihcrs  and 
of  the  muscles.  Occasionally  there  are  small  areas  of  sclerosis  that 
may  involve  the  pyramidal   columns  for  a  short  distance. 

Htiology. — The  disease  appears  to  be  hereditary  in  a  few  cases,  and 
in  these  may  develop  in  childhood.  A  commonly  accepted  predisposing 
cause  is  prolonged  severe  muscular  exertion.  Syphilis  may  also  be  a 
factor.  It  is  most  common  in  males,  and  most  fre([ueiitly  appears  during 
the  third  decade^  of  life. 

Symptomatology. — The  first  changes  usually  appear  in  the  thenar 
and  InipotJieuar  eminences  of  the  hands,  but  may  begin  in  other  muscles. 
These  become  flat  and  soft ;  there  are  loss  of  power,  some  stiffness,  and 
inability  to  perform  delicate  coordinated  movements ;  the  thumb  assumes 
'a  position  parallel  to  the  other  fingers  (^ape-hand);  the  interossei  muscles 
■waste  and  grooves  appear  between  the  metacarpal  bones.  The  degener- 
ative changes  do  not  ascend  by  continuity,  the  deltoid  usually  being 
affected  immediately  after  the  muscles  of  the  hand.  If  the  two  hands 
have  not  been  affected  simultaneously,  the  other  noAv  begins  to  show  char- 
acteristic changes.  In  the  lower  limbs  the  quadriceps  femoris  is  usually 
the  first  muscle  attacked.  The  disease  gradually  involves  one  group  of 
muscles  after  another  until  a  large  part  of  the  muscular  system  is  affected. 
All  the  affected  muscles  exhibit  the  fibrillary  twitchings  and  the  wasting. 
Hypertrophy  never  occurs  and  the  jjoralysis  is  ahvays  flaccid.  The 
fibrillary  twitchings  are  characteristic,  but  not  pathognomonic.  They 
are  not  always  constant,  but  may  be  developed  by  slightly  irritating 
the  muscle.  At  first  there  is  usually  (quantitative  diminution  of  the 
response  to  the  faradic  and  galvanic  currents,  but  as  the  disease 
progresses  the  reaction  of  degeneration  becomes  completely  developed. 
The  reflexes  diminish  in  proportion  to  the  atrophy  of  the  muscles,  and 
ultimately  disappear  completely;  the  patients  gradually  become  almost 
incapable  of  voluntary  motion ;  but  for  a  time  they  learn  to  overcome 
their  disabilities  by  the  compensatory  use  of  other  groups  of  muscles. 
In  the  late  stage  the  diaphragm  becomes  paralyzed  and  bulbar  symptoms 
appear  (p.  1129);  usually  the  patients  die  from  inspiration-pneumonia. 
Rare  and  probably  accidental  symptoms  are  disturbances  of  the  pupillary 
reflexes  and  increase  in  the  secretion  of  sweat. 

Differential  Diagnosis. — In  chronic  anteropoliomyelitis  groups 
of  nmscles  are  affected  without  any  particular  order,  certain  groups  of 
muscles  becoming  paralyzed  suddenly,  followed  by  the  gradual  involve- 
ment of  other  muscles ;  in  amyotrophic  lateral  sclerosis  the  spastic 
symptoms  are  present ;  in  syringonijjelia  and  pachymeningitis  cervicalis 
hypertrophica  disturlnince  of  sensation,  pain,  and  trophic  lesions  occur; 
in  Pott's  disease  affecting  the  lower  cervical  region  there  are  tenderness 
over  the  spine  and  sensory  disturbances  ;  in  peripheral  neuritis  pain  and 
tenderness  over  the  nerve-trunks  are  present;  in  arthritic  atrophy  ^o'nit- 
symptoms   are  present ;   and  in  the  peculiar  muscle-atrophies  following 


AMYOTROPHIC  LATERAL  SCLEROSIS.  1143 

excessive  use  of  certain  groups  of  muscles,  rapid  improvement  occurs 
when  the  cause  is  removed  and  the  symptoms  are  confined  to  tiie  muscles 
originally  affected  (either  median  or  ulnar  distribution)  (pp.  1116  and 
1117).     The  muscular  dystrophies  are  described  on  page  1260. 

Prognosis. — This  is  unfavorable  as  to  cure.  The  course  is  ex- 
ceedingly slow,  and  the  patients  often  live  for  a  number  of  years 
after  the  first  symptoms  have  appeared.  They  are,  however,  exceed- 
ingly liable  to  pulmonary  complications,  particularly  a  fatal  form  of 
bronchitis. 

Treatment. — Prophylactic  measures,  such  as  the  avoidance  of  pro- 
longed excessive  work,  are  rarely  possible.  Retardation  may  possibly 
be  obtained  by  the  systematic  use  of  electricity,  massage,  and  gymnastics. 
Gowers  advocates  the  hypodermic  injection  of  strychnin  nitrate  in  ascend- 
ing doses,  commencing  with  y^-g-  gr.  and  rapidly  increasing  to  ^V  5  '^i^^ 
injection  should  be  given  daily.  The  general  nutrition  should  be  kept  at 
the  highest  possible  point. 


AMYOTROPHIC   LATERAL   SCLEROSIS. 

[Charcot's  Disease.) 

Definition. — A  disease  of  both  central  and  peripheral  motor  neurons, 
effecting,  therefore,  the  entire  motor  tract  from  the  cerebral  cortex  to  the 
muscles,  characterized  by  loss  of  power,  spastic  symptoms,  and  muscular 
atrophy.  The  first  clear  and  thorough  description  of  the  clinical  symp- 
toms and  pathological  anatomy  was  given  by  Charcot  in  1872. 

Ktiology. — The  disease  is  more  frequent  in  males  and  usually  begins 
in  early  adult  life.  Exposure  has  sometimes  been  noted  in  the  previous 
history,  but  neuropathic  heredity  does  not  appear  to  have  any  influence. 
Syphilis  may  be  a  cause. 

Pathology. — The  pyramidal  tracts  are  degenerated,  the  process 
commencing  either  in  the  cortex,  crura,  or  medulla,  and  extending  to 
the  termination  of  the  neurons  in  the  cord.  The  ganglion-cells  of  the 
anterior  cornua  are  atrophic,  there  is  degeneration  of  the  anterior  roots 
and  of  the  muscle-fibers,  the  blood-vessels  in  the  affected  parts  are  di- 
lated, and  in  the  early  stages  granular  cells  are  present. 

SjmiptoniS. — Three  stages  are  generally  recognized:  (1)  The  in- 
volvement of  the  upper  extremities.  (2)  The  participation  of  the  lower 
extremities.  (3)  The  appearance  of  bulbar  symptoms.  At  first  there 
are  weakness  of  the  upper  arms,  atrophy  of  the  muscles,  and  moderate 
exaggeration  of  the  reflexes ;  in  the  course  of  a  few  months  the  symptoms 
of  spastic  paraplegia  develop,  all  the  reflexes  are  greatly  increased,  and 
there  are  chin-  and  ankle-clonus,  the  Babinski  reflex,  and  dragging  of  the 
feet.  The  wasted  muscles  show  fibrillary  twitchings  and  give  the  reactions 
of  degeneration.  Contractures  then  occur,  the  forearms  are  flexed  on  the 
arms,  the  hands  are  held  in  pronation,  and  the  proximal  phalanges  of  the 
fingers  bent  backward,  giving  rise  to  the  so-called  claw-hand.  From  time 
to  time  there  are  tonic  spasms  in  the  muscles,  particularly  in  the  calves. 
Sensation  is  not  disturbed,  excepting  for  the  occurrence  of  occasional 
slight  paresthesia,  and  the  sphincters  continue  to  functionate  normally. 


1144  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Finally,  the  bulbar  symjjtoins  ajipear,  iiid  there  is  paralysis  of  the  lower 
part  of  the  face,  which  becomes  rinid  and  expressionless,  with  the  mouth 
jiartly  open  and  saliva  dribbling  fnmi  the  anj^les.  De^rlutition  and  artic- 
ulation become  difficult  or  impossible,  and  death  finally  occurs  from  ex- 
haustion or  inspiration-pneumonia.  During  the  course  of  the  disease  the 
intellect  is  slightly  involved.  Memory  is  impaired,  the  conduct  becomes 
childish,  and  there  is  a  tendency  to  weep  or  laugh  without  cause.  Atyp- 
ical cases  occur,  in  which  either  the  lower  extremities  are  first  involved 
or  the  paralytic  symptoms  are  more  prominent  than  the  spastic  symptoms, 
or  the  bulbar  symptoms  appear  very  early.  The  symptoms  at  first  may 
be  unilateral  (p.  1144).  The  course  is  steadily  progressive,  and  death 
usually   occurs   within   two  years. 

The  diflferential  diagJiOSis  is  to  be  made  from  multiple  sclerosis  by 
the  absence  of  nystagmus,  of  the  intention-tremor,  and  of  sensory  dis- 
turbances, and  by  the  degenerative  changes  in  the  muscles;  from  trans- 
verse )7o/elitis  by  the  absence  of  sphincter  disturbance,  sensory  paralysis, 
and  of  pain,  from  progressive  spinal  muscular  atropJii/  by  the  presence 
of  spastic  symptoms ;  from  syringomyelia  by  the  absence  of  sensory  dis- 
turbances, trophic  lesions  of  the  skin  and  joints,  and  the  greater  regu- 
larity of  the  course  ;  from  pressure  upon  the  spinal  cord  by  the  absence 
of  pain,  sensory  paralysis,  and  sphincter  disturbance.  It  niust  be  re- 
membered that  amyotrophic  lateral  sclerosis  may  be  associated  with 
multiple  sclerosis  or  infantile  spinal  paralysis. 

Prognosis. — It  will  be  understood  from  the  foregoing  description 
that  death  is  the  invariable  termination.  The  course  is  progressive,  al- 
though sometimes  very  deliberate,  and  even  temporary  amelioration 
rarely  occurs. 

Treatment. — The  patient  should  be  rendered  as  comfortable  as  pos- 
sible, excessive  physical  exercise  avoided,  and  the  general  nutrition  in- 
creased.    Arsenic  and  mercury  are  useless. 


UNILATERAL  ASCENDING  AND  UNILATERAL  DESCEND- 
ING PARALYSIS. 

Unilateral  ascending  paralysis,  first  described  as  an  entity  by  Mills,  is 
a  form  of  possibly  various  pathology  which  is  characterized  by  paresis 
commencing  in  one  leg  and  extending  to  the  arm  on  the  same  side.  The 
paresis  may  be  flaccid  (Patrick),  with  loss  of  the  reflexes,  or  spastic 
(Mills,  Potts,  etc.),  with  increased  knee-jerks,  ankle-clonus,  and  the 
Babinski  phenomenon.  In  time  complete  paralysis  may  develop.  Degen- 
eration of  the  motor  tract  has  been  found.  According  to  Mills  ^  it  may 
be  produced:  (1)  By  primary  degeneration  of  the  pyramidal  tracts,  to 
which  may  be  added  other  degenerative  lesions ;  (2)  as  the  early  stage 
of  multiple  sclerosis ;  (3)  as  the  form  assumed  by  unilateral  amyotrophic 
lateral  sclerosis ;  (4)  as  the  order  of  progression  in  unilateral  paralysis 
agitans;  (5)  as  the  expression  of  a  focal  lesion  either  cerebral  or  spinal ; 
(6)  as  a  clinical  type  in  cerebrospinal  syphilis  ;  (7)  as  a  peripheral  or 
hysterical  affection.     There  is  no  treatment. 

I  Journal  Nervous  and  Mental  DiseoHes,  April,   1900,  and    Proceedings  Neurological 
Section  oi  Amer.  Med.  J.s.soc.,  1906,  p.  166. 


TABES  DORS  ALTS.  '    1145 

INTERMITTENT   PARAPLEGIA. 

{Intermittent  Claudication.) 

Three  forms  of  this  affection  have  been  described,  i.  e.,  (1)  Those  due 
to  an  arteritis  of  the  vessels  supplying  the  peripheral  nerves ;  (2)  those 
caused  by  a  spasm  of  these  arteries;  (3)  those  due  to  similar  phenomena 
occurring  in  spinal  arteries.  The  symptoms  consist  of  muscular  cramps 
and  weakness,  usually  but  not  always  in  one  or  both  legs,  occurring  after 
moderate  exertion.  In  the  first  type  there  is  often  loss  of  pulsation  in 
the  posterior  tibial  and  dorsalis  pedis  arteries,  in  the  third  the  sphincters 
are  affected  and  cramps  do  not  occur  (p.  11 63).  The  treatment  is  that 
of  arteriosclerosis. 


TABES  DORSALIS. 

{Locomotor  Ataxia ;  Posterior  Sclerosis. ) 

Definition. — A  disease,  primarily  of  the  posterior  nerve-roots,  with 
consequent  secondary  degeneration  of  the  posterior  columns,  also  degen- 
eration of  peripheral  nerves  and  those  of  special  sense,  particularly  the 
optic.  It  is  characterized  by  more  or  less  incoordination  of  movement, 
various  sensory  and  trophic  disturbances,  and  impairment  of  the  special 
senses. 

Htiology. — Syphilis  precedes  such  a  large  proportion  of  all  the 
cases  (60  to  90  per  cent.)  that  it  is  reasonable  to  assume  that  it  is  the 
commonest  and  perhaps  the  exclusive  cause.  Whether  the  tabes  occurs 
because  the  individual  is  predisposed  or  because  the  syphilitic  virus  in 
these  cases  has  some  peculiar  predilection  for  the  central  nervous  system 
is  not  determined.  Some  interesting  evidence  has  been  collected  in 
favor  of  the  latter  view.  There  is  often  a  history  of  injury,  severe  pro- 
longed muscular  exertion,  dissipation,  or  sexual  excess.  Race  appears 
to  be  of  some  importance,  but  an  increasing  proportion  of  cases  is  found 
among  negroes  and  Jews,  who  were  formerly  considered  partially  immune. 
Males  are  more  liable  to  the  disease  than  females  in  the  proportion  of 
10  to  1.  About  75  per  cent,  of  all  cases  commence  between  the  ages  of 
thirty  and  fifty. 

Pathology. — Macroscopically,  it  may  be  observed — 1.  That  the 
posterior  roots  are  more  or  less  atrophied  and  grayish  in  color. 

2.  There  is  a  thickening  and  adhesion  of  the  spinal  membranes,  with 
some  degree  of  congestion,  particularly  noticeable  in  the  posterior  region 
(not  a  constant  change). 

3.  There  is  a  slight  change  in  the  shape  of  the  cord,  and  the  affected 
regions  assume  a  grayish  tint.  Change  of  color  is  well  seen  after  the 
cord  is  hardened.  Microscopically,  the  first  changes  are  found  in  the 
posterior  root,  usually  the  lumbar,  followed  by  sclerosis  in  the  column 
of  Burdach  and  zone  of  Lissauer,  also  most  marked  in  the  lumbar  region 
and  localized  at  the  point  of  entrance  of  the  root-fibers.  Higher  up  the 
columns  of  Goll  will  be  found  involved.  The  fibers  coming  from  the 
posterior  roots  to  join  the  column  of  Clark  are  also  sclerosed,  but  as  the 


1146 


DISEASES  OF  THE  yERVOUS  SYSTEM. 


cells,  as  a  rule,  are  not  destroyed,  the  direct  cerebellar  tract  is  rarely 
involved.  In  advanced  cases  sclerosis  of  Gower's  tract  may  also  be  ob- 
served. While  the  disease  usually  first  aft'ects  the  lumbar  nerve-roots, 
either  the  sacral,  upper  thoracic,  cervical,  or  bulbar  nerve-roots  may  be 
first  involved,  in  which  event  the  cord  changes  above  noted  will  be 
found  more  marked  in  one  of  these  respective  areas.  In  addition  to  the 
cord  chant^jes  degeneration  of  peripheral  spinal  nerves  and  of  cranial 
nerves  and  their  nuclei,  especially  the  ocular,  may  be  found.  Less  marked 
changes  may  also  be  found  in  the  anterior  nerve-roots. 

Nageotte's  views  as  to  the  pathogenesis  of  the  disease  are  now  those 
most  generally  accepted.  In  brief,  he  believes  that  tabes  is  the  result 
of  a  local  affection  of  the  spinal  roots  at  the  height  of  the  ''nerfs  radic- 
ulaires  " — i.  e.,  that  i^art  of  the  root  from   its  entrance  into  the  dura 


Fig.  78.— Diaernim  of  primary  degeneration-areas  and  secondary  defeneration  of  the  fibers  in 
the  beprinning  stage  of  tabes  (Leube):  psb,  pyramidal  tract;  ksb,  cerebellar  tract;  hwf,  posterior 
root-libers;  Iff,  lateral  entrance  of  delicate  root-fibers;  k,  area  of  earliest  degeneration;  r,  marginal 
zone;  sg,  substantia  gelatinosu:  cv,  Clark's  columns;  i.  anterior  zones  (remaining free) ;  sc,  sensory 
collateral  fibers  ;  hrc,  collateral  reflex  of  posterior  column ;  src,  collateral  reflex  of  the  lateral 
column;  ,  healthy  fibers ; ,  degenerated  fibers. 


mater  to  the  spinal  ganglion.  It  consists  of  an  endo-  and  perineuritis 
with  interstitial  and  parenchymatous  changes,  due  to  a  mild  but  chronic 
syphilitic  meningitis.  The  "  nerf  radiculaire,"  being  a  channel  for  the 
lymph  circulation  in  the  central  nervous  system,  is  believed  to  be  a  spot 
more  vulnerable  to  toxic  and  irritating  material  circulating  in  the  cerebro- 
spinal fluid.  This  is  further  intensified  by  the  fact  that  the  nerve-fibers 
lose  their  neurilemma  sheaths  as  they  pass  through  the  pia,  and,  hence, 
when  damaged  by  the  meningeal  exudation,  have  no  power  of  regenera- 
tion. The  degeneration  found  in  the  cord  is,  hence,  secondary,  the  nerve- 
fibers  being  separated  from  their  trophic  centers,  the  posterior  ganglion. 

In  addition  to  changes  in  the  nervous  system,  certain  cases  present 
some  morbid  condition  of  the  osseous  system,  consisting  of  erosion  of  the 
intra-articular  cartilages  and  atrophy  and  absorption  of  the  bony  articu- 
lating surfaces. 

Sytnptoms. — These  may  be  grouped  into  various  stages :  the  pro- 
dromal, prcataxic.  ataxic,  and  paralytic.  The  prodromal  stage  may  extend 
over  a  number  of  years,  the  symptoms  are  slight,  and  often  make  very 


TABES  DORSALIS.  1147 

little  impression  upon  the  patient.  They  consist  of  occasional  pains,  usu- 
ally in  the  legs,  of  transient  disturbances  of  the  ocular  muscles  leading 
to  ptosis,  diplopia,  etc.,  occasionally  of  slight  diminution  of  vision,  most 
noticeable  at  night,  of  more  or  less  pronounced  impairment,  very  rarely  ex-, 
altation,  of  sexual  power,  and  neurasthenic  symptoms.  The  symptoms  be-, 
come  characteristic  only  in  the  preataxic  stage.  I'he  pains  in  the  legs  be- 
come more  frequent  and  assume  the  typical  fulgurant  or  hmcinating  type  ; 
that  is,  a  stabbing  or  boring  sensation,  shooting  along  the  limbs  and  lasting 
for  a  brief  interval  of  time.  There  is  often  numbness  or  anesthesia  of  the 
extremities  and  the  patient  feels  as  if  walking  on  cotton.  The  pupils 
give  the  Argyll-Robertson  phenomenon  (failure  to  contract  to  light,  but 
do  to  convergence),  there  is  permanent  myosis,  nyctalopia,  and  the  pare- 
sis of  the  eye-muscles  may  be  still  present  or  may  have  disappeared  ; 
primary  atrophy  of  the  optic  nerve  Avill  also  frequently  be  found.  There 
is  usually  some  disturbance  of  motion,  chiefly  manifested  at  night,  and 
ataxia  may  be  revealed  by  the  finer  tests  (having  the  patient  hop  back- 
ward on  one  leg).  The  patella  and  Achilles  jerks  are  diminished  or 
absent.  There  is  now  distinct  impairment  of  sexual  power  and  difficulty 
in  urination.  Martin  has  described  a  peculiar  loss  of  tone  and  muscle 
sense  of  the  rectal  sphincters.  The  sensory  symptoms  belong  to  this  and 
the  following  stage. 

The  dominant  symptom  of  the  ataxic  stage  is  the  inco5rdination  of 
movement.  This  gives  rise  to  the  ataxic  gait.  The  legs  are  kept  far 
apart  and  are  lifted  higher  than  is  necessary  from  the  ground,  they  are 
brought  down  violently,  and  the  gait  is  of  a  peculiar  stamping,  irregular, 
slightly  staggering  character.  Walking  without  the  aid  of  a  cane  soon 
becomes  impossible,  and  the  feet  are  carefully  watched.  Ataxia  of  the 
arms  occurs  later  and  is  manifested  by  difficulty  in  grasping  objects  or  in 
accomplishing  finer  co5rdinated  movements.  Ataxia  of  the  lower  ex- 
tremities may  be  tested  by  directing  the  patient  to  touch  with  his  toe  an 
object  held  above  it,  or,  when  lying  down,  to  place  the  heel  of  one  foot 
upon  the  knee  of  the  other  ;  of  the  upper  limbs  by  directing  him  to  touch 
rapidly  the  tip  of  the  nose  with  the  forefinger,  or  to  spread  the  arms  apart 
and  bring  the  forefingers  rapidly  together.  Loss  of  station,  or  Romberg^ s 
iymptom,  is  tested  by  dii'ecting  him  to  stand  with  the  feet  close  together 
and  to  close  the  eyes.  The  swaying  of  the  body  will  vary  from  several 
inches  in  either  direction  to  falling  over.  The  reflexes  are  now  com- 
pletely abolished,  and  there  may  be  some  wasting  of  the  muscles,  and 
marked  muscular  hypotonia,  causing  relaxation  of  the  joints,  will  fre- 
quently be  found.  The  sphincters  are  involved,  there  is  often  difficulty 
in  voiding  the  urine,  associated  with  incontinence,  and,  as  a  result  of 
careless  catheterization,  cystitis  is  often  acquired.  The  facial  expression 
is  peculiar,  the  pallor,  drooping  lids,  small  pupils,  and  deep  lines  give  an 
impression  of  weariness,  dulness,  and  apathy  that  is  quite  characteristic. 

The  sensory  symptoms  are  various  :  in  addition  to  the  fulgurant  pains, 
there  m.iy  be  visceral  crises,  characterized  by  sudden  severe  pain  and 
disturbance  of  function.  The  most  common  seat  is  the  stomach,  and  the 
crises  are  associated  with  vomiting  of  acid  material.  Crises  may  also 
involve  the  larynx,  liver,  kidneys,  clitoris,  and  bladder.  Diminished 
sensation  afl'ects  the  organs,  nerves,  and  areas  of  the  skin.  There  is  loss 
of  sensation  in  the  testicles  or  breasts,  and  severe  blows  in  the  pit  of  the 


1148  DISEASES  OF  THE  NERVOUS  SYSTEM. 

stomach  cause  no  distress.  Bicrnacki's  fn^mptoni,  loss  of  sensation  in  the 
uhiar  nerve  when  pressed  upon  at  the  elbow  is  present.  The  same 
ijheuDUK'non  can  be  observed  in  the  peroneal  nerve,  where  it  winds 
around  the  head  of  the  fibula.  These  are  early  syniptoms.  Areas  of 
anesthesia  or  hyperesthesia,  usually  segmental  in  type,  can  be  detected 
upon  the  trunk  or  less  frequently  upon  the  extremities.  Astereognosis, 
or  the  loss  of  tiie  ability  to  recognize  objects,  may  be  present  on  one  or 
both  sides,  or  the  stereognostic  sense  may  not  be  impaired.  The  ;/h\Ue 
pain  is  a  feeling  of  constriction  about  some  part  of  the  trunk  that  may 
be  very  uncomfortable.  Tro/'/iic  chdni/cs  are  of  various  kinds,  paink^ss 
loosening  of  the  teeth  ;  ((rthrupathics,  characteiized  by  enlargement  and 
erosion  of  the  joints,  which  are  painless  ;  fragility  of  the  bones  leading 
to  spontaneous  fracture ;  herpes  and  perforating  ulcer  of  the  foot.  The 
parali/tic  sta(/e  inaugurates  the  termination  of  the  disease.  Locomotion 
becomes  impossible,  or  can  only  be  accomplished  with  the  aid  of  two 
canes,  loss  of  control  over  the  bladder  is  complete,  the  patient  is  (perulent 
or  even  demented,  and  muscular  wasting  and  bed-sores  may  appear.  In 
either  this  or  the  ataxic  stage  the  optic  nerve  may  atrophy,  and  this  is 
often  associated  with  a  remarkable  improvement  in  the  ataxia  that  is  at 
present  inexplicable.  Death  usually  occurs  as  a  result  of  infection,  either 
through  the  bladder  or  lungs,  more  rarely  as  the  result,  apparently, 
of  exhaustion. 

Atypical  cases  are  not  rare.  In  cervical  tabes  the  ataxia  may  appear 
first  in  the  upper  extremities  and  may  be  more  severe  in  them,  and  the 
fulgurant  pains  may  be  limited  to  them.  Laryngeal  crises  are  more  com- 
mon in  this  form,  and  neuralgic  pain  in  the  course  of  the  fifth  nerve  may 
be  present.  Certain  classical  symptoms  may  not  appear  in  the  entire 
course  of  the  disease.  In  sacral  tabes  the  knee-jerks  may  be  present, 
while  the  Achilles  jerks  are  lost. 

Course. — The  earliest  symptoms  are  usually  observed  from  5  to  20 
years  after  the  syphilitic  infection.  Rarely  the  disease  runs  a  very  rapid 
course.  The  preataxic  symptoms — pain,  loss  of  knee-jerk.  Argyll-Rob- 
ertson pupil,  with  or  without  ptosis  and  diplopia — may  only  exist  a  few- 
weeks  before  incoordination  develops.  The  latter  will  then  reach  its 
acme  in  twenty  to  thirty  days.  This  is  very  unusual,  however.  As  a 
rule,  the  first  or  preataxic  stage  extends  over  a  period  varying  from 
months  to  even  as  long  as  twenty-five  years.  Dr.  Wm.  Egbert  Robert- 
son has  related  to  me  the  case  of  a  man  aged  fifty-eight  Avho  for  fifteen 
years  has  had  fulgurant  pains  and  an  absence  of  the  knee-jerk,  but  neither 
ocular  nor  any  other  symptoms.  In  some  cases  the  first  stage  may  be  unnp- 
ticed.  The  second  or  ataxic  stage — that  of  incoordination — is  generally 
slowly  progressive,  finally  reaching  a  point  at  which  it  remains ;  rarely, 
more  or  less  improvement  may  follow.  When  optic  atrophy  develops, 
ataxia  either  does  not  appear,  or,  having  done  so,  fails  to  advance. 
The  final  stage  in  a  few  cases  is  only  reached  when  the  patient  has  be- 
come paralyzed  and  bedridden. 

Diagnosis. — This  is  readily  made  when  Ave  have  a  combination  of 
the  absent  knee-jerk,  fulgurant  pains,  and  the  Argyll-Robertson  pupil. 

Differential  Diagnosis. — Peripheral  KeuritiH. — The  symmetric  dis- 
tribution of  symptoms,  tenderness  in  the  muscles  and  over  the  nerve 
trunks,  more  weakness  and  wasting,  pain  (not  fulgurant  in  type),  absence 


TABES  DORS  ALTS.  1149 

of  the  Argyll-liobcrtson  pupil,  and  tlie  liistoi-y  of  the  case  are  sufficient. 
Alcoholic  and,  more  rarely,  arsenical  neuritis  give  rise  to  a  condition 
closely  resembling  true  tabes,  in  that  there  is  the  loss  of  knee-jerk,  often 
sharp  pain,  and  incoordination,  though  the  latter  symptom  is  never  as 
marked  as  in  advanced  tabes.  The  gait,  however,  is  totally  different, 
and  consists  of  the  high  "steppage  "  gait  described  in  the  discussion  of 
Peripheral  Neuritis. 

G-eneral  'paralysis  of  the  insane  {^.  1198)  may  present  much  difficulty. 
Spinal  symptoms  may  occur  in  general  paresis,  and  conversely  in  certain 
cases  of  tabes  symptoms  of  general  paresis  develop.  Such  cases  are 
really  combinations. 

Ataxic  Paraplegia. — Apart  from  the  absence  of  pain  and  anesthesia, 
incoordination  is  followed  by  a  spastic  condition.  The  knee-jerk  is  much 
exaggerated  and  ankle-clonus  develops. 

Cerebellar  Disease. — The  incoordination  does  not  resemble  that  of 
ataxia ;  optic  neuritis  is  present ;  also  headache  and  vomiting  appear  in 
well-marked  cases.     The  knee-jerk  is  usually  present. 

Ataxia  may  be  present  in  combined  sclerosis,  due  to  anemia  and  in- 
fections (p.  1153),  as  lesions  of  the  posterior  columns  are  present.  In 
this  disease  the  Argyll-Robertson  pupil  is  absent.  While  paresthesia  is 
pronounced,  the  characteristic  pains  of  tabes  are  not  complained  of. 
The  Babinski  reflex  will  also  usually  be  found.  The  history  of  the  onset 
and  course  of  the  disease  also  diff'ers. 

The  crises  may  be  mistaken  for  disease  of  the  various  organs  involved. 
Repeated  attacks  of  acute  pain,  tabetic  in  character,  and  particularly  in 
adult  males,  should,  however,  excite  suspicion,  a,nd  an  absence  of  the  knee- 
jerk  and  other  characteristic  evidences  will  always  be  present  in  ataxia. 

When  the  chief  lesion  is  in  the  dorsal  region  the  pain  may  be  mistaken 
for  that  of  spinal  caries  or  even  neuralgia  or  rheumatism.  From  caries 
it  may  be  diiferentiated  by  the  fact  that  in  vertebral  disease  the  pain  is 
more  or  less  localized,  and  that  it  is  much  increased  by  movements.  More- 
over, the  other  symptoms  of  ataxia  are  wanting — e.  g.  ocular  troubles, 
incoordination,  and  absence  of  the  knee-jerk.  The  latter  point  also  holds 
good  in  cases  of  rheumatism  and  intercostal  neuralgia.  For  the  diagnosis 
from  hereditary  ataxia,  vide  p.  1152.  Help  may  be  afforded  in  doubt- 
ful cases  by  an  examination  of  the  fluid  obtained  by  lumbar  puncture 
(p.  1124) ;  in  tabes  an  increased  number  of  lymphocytes  being  found. 
It  is  proper  to  state  that  these  may  also  be  found  in  paresis  and  other 
syphilitic  affections  of  the  cord=  The  Wassermann  test  may  also  help  in 
doubtful  cases,  although  this  may  be  negative  in  some  cases  of  genuine 
tabes. 

Prognosis. — The  outlook  is  not  particularly  bright.  While,  as 
already  stated,  the  disease  does  not  cause  death,  recovery  does  not 
directly  occur.  Even  improvement,  excepting  of  the  most  temporary 
nature,  is  rare,  but  the  disease  sometimes  seems  to  be  arrested  for  com- 
paratively long  periods.  The  possibility  of  arresting  the  progress  of  the 
disease  is  greater  when  proper  treatment  is  begun  early. 

Treatment. — Rest  (first  suggested  by  Weir  Mitchell)  is  imperative 
when  the  patient  commences  treatment,  and  especially  when  pain  is  an 
early  symptom,  massage  and  electricity  being   employed  meanwhile   to 


1150  DISEASES  OF  THE  NERVOUS  SYSTEM. 

keep  up  the  tone  of  the  muscles.  In  my  opinion  the  rest  treatment 
retards  the  progress  of  ataxia  more  eftectively  than  any  other  measure, 
but  it  cannot  be  used  with  tlie  expectation  of  producing  a  cure.  The 
bowels  should  be  moved  daily,  and  the  urinary  functions  osj)ecialiy  looked 
to.  In  certain  cases  catheterization  is  necessary.  The  ])atient  should 
then  be  taught, .first,  what  surgical  cleanliness  means;  and  secondly,  how 
to  use  the  instrument.  I'rotropin  in  doses  of  gr.  v — 0.3,  three  or  four 
times  daily,  is  a  valuable  prophylactic  against  cystitis.  Counter-irrita- 
tion along  the  spine  and  suspension  are  useless.  The  diet  should  not  be 
heavy,  and  if  gastric  crises  occur  special  care  should  be  taken  in  this 
direction.  As  some  cases  of  sy])hilitic  leptomeningitis  may  simulate  tabes 
so  closely  that  the  dift'erential  diagnosis  is  difficult  or  impossible,  some 
prescribe  antisyphilitic  medication  as  a  routine  treatment.  In  old  cases 
of  tabes  this  is  apt  to  be  harmful.  In  those,  however,  in  which  the  cel- 
lular content  of  the  cerebrospinal  fluid  is  great  and  a  Wassermann  reac- 
tion present  it  should  be  tried.  Mott  has  stated  that  in  true  tabes  the 
cells  do  not  diminish  with  such  treatment,  but  in  syj)hilitic  pseudo-tabes 
they  will.  In  such  cases,  therefore,  if  not  otherwise  contra-indicated, 
salvarsan,  mercury,  and  the  iodids  should  be  given  a  trial  with  reason  to 
hope  for  improvement.  Salvarsan  has  been  found  to  relieve  the  pains 
even  when  no  other  benefit  resulted.  It  should  be  remembered  in  using 
this  agent  that  meningo-encephalitis  and  myelitis,  sometimes  fatal,  may 
be  caused  by  large  or  fre(iuent  doses. ^  Arsenic,  chlorid  of  gold  and 
soda,  and  nitrate  of  silver  seem  to  have  some  influence  upon  the  course 
of  the  disease. 

The  fulgurant  pains,  or  those  of  the  various  crises,  are  occasionally  so 
severe  as  to  require  codein,  or  even  morphin,  though  the  use  of  the  latter 
agent  is  always  to  be  postponed  until  other  means  are  exhausted.  Anti- 
pyrin  or  salol  and  phenacetin  raay  also  be  tried.  Heroin  is  often  almost 
a  specific.  In  some  cases  the  crises  are  so  severe  that  even  morphin  fails 
to  give  relief.  The  cutting  of  the  posterior  roots  (seventh  to  tenth)  of 
the  dorsal  nerves  (rhizotomy)  has  been  efficacious  in  the  relief  of  intract- 
able gastric  crises.^  In  any  case  the  patient  should  live  a  simple,  regular 
life,  avoiding  excesses  of  all  kinds,  and  particularly  sexual  and  alcoholic 
indulgences. 

Electricity  is  of  service  in  relieving  paresthesia  and  pain.  For  this 
purpose  either  a  rapidly  interrupted  faradic,  static  spark  or  high-frequency 
current  applied  to  the  extremities  may  be  tried.  Hydrotherapy  is  a  ser- 
viceable measure  if  judiciously  employed.  Neither  cold  nor  hot  baths 
are  free  from  deleterious  eff'ects,  but  tepid  baths  (80°-90°  F.— 26.6°- 
32.2°  C),  combined  with  gentle  friction  of  the  body-surface,  are  signally 
useful. 

Recently  it  has  been  discovered  (Frenkel)  that  the  ataxia  can  be 
greatly  improved  by  systematic  exercises  designed  to  train  the  muscles 
in  coordinated  movements.  The  important  points  are  to  avoid  fatigue 
and  irritation,  and  to  increase  gradually  the  complexity  of  the  tasks. 

'  Newrnark,  Amer.  Jo-nr.  Med.  Sci.,  Dec,  1912,  p.  848. 
^  Frazier,  Amer.  Jour.  Med.  Sci.,  Jan.,  1913,  116. 


HEREDITARY  ATAXIA.  1151 

HEREDITARY  ATAXIA. 

This  may  be  divided  into  two  types,  viz.,  the  spinal  type  or  Friedreich '3 
disease  and  the  cerebellar. 

FRIEDREICH'S   IDISEASE. 

(Friedreich's  Ataxia.) 

Definition. — An  hereditary  disease,  first  described  in  18G1  by  Fried- 
reich. The  symptoms  are  primarily  manifested  in  early  life,  and  the  dis- 
ease is  characterized  by  ataxia,  defective  speech,  nystagmus,  absence  of 
the  knee-jerk,  and  more  or  less  secondary  deformity,  as  spinal  curvature 
or  talipes. 

il^tiology. — 1.  Family  tendency  (heredity)  has  a  strong  influence. 
A  single  case,  however,  may  develop  in  a  family.  It  is  due  to  an  in- 
herited and  inherent  lack  of  vitality  in  certain  parts  of  the  nervous 
system  (abiotrophy). 

Age. — Most  commonly  the  disease  appears  between  the  third  and 
twelfth  years,  though  it  may  appear  earlier  or  later. 

Infectious  fevers  (in  particular)  and  other  acute  diseases  frequently 
precede  the  evolution  of  this  complaint.  Trauma  and  many  other  con- 
ditions have  been  described  as  exciting  causes. 

Pathology. — The  cord  frequently  is  smaller  than  normal,  and  at 
times  there  is  some  thickening  of  the  membranes  over  the  posterior  aspect. 
Microscopically  are  found  degeneration  of  the  posterior  columns,  more 
marked  in  the  column  of  Goll,  of  the  crossed  and  direct  pyramidal  tracts, 
the  direct  cerebellar  tract,  and  that  of  Gowers.  In  the  columns  of  Clarke 
are  found  atrophy  of  the  cells  with  loss  of  fibers.  In  some  cases  the  pos- 
terior roots  may  also  be  found  degenerated,  also  the  cells  in  the  anterior 
horns  and  the  peripheral  nerves.  The  cerebellum  is  frequently  smaller 
than  normal,  and  degeneration  of  the  cells  composing  the  dentate  nucleus 
occurs.  The  cells  of  Purkinjie  are  also  atrophied  in  some  cases.  Changes 
have  also  been  found  in  the  cerebrum  consisting  of  atrophy  of  the 
gyri,  and  changes  in  the  cerebral  cortical  cells.  Atrophy  and  disappear- 
ance of  the  cells  of  the  posterior  root  ganglia  have  also  at  times  been 
observed.  Changes  in  the  muscles  similar  to  those  found  in  the  dys- 
trophies (p.  1260)  may  occur.  The  degeneration  in  the  posterior  columns 
is  more  marked  usually  than  in  other  parts,  the  pyramidal  tracts  being 
next  in  severity. 

Symptoms. — The  earliest  evidence  of  the  disease  is  impaired  coordi- 
nation, first  in  the  legs,  and,  later,  in  the  arms ;  it  is  most  marked  when 
the  eyes  are  closed.  Attention  is  often  called  to  this  symptom  by  the 
fact  that  the  child  stumbles,  ambles,  and  staggers,  and  cannot  walk  prop- 
erly. The  gait,  however,  lacks  the  pronounced  stamp  of  true  ataxia. 
Rutimeyer  has  pointed  out  that  in  many  cases  the  great  toes  are  turned 
upward.  Some  affected  children  never  learn  to  walk.  Romberg's  symp- 
tom is  generally  present.  Movements  of  the  arms,  when  these  are  ataxic, 
are  irregular  and  jerky,  and  jerky  movements  of  the  head  may  also  be 
observed.  Bilateral  nystagmus  develops  and  the  speech  becomes  affected. 
At  first  there  is  a  mere  impediment  (a  stuttei'ing),  but  later  syllables  or 
even  whole  words  are  omitted  and  an  unintelligible  jargon  results.  The 
knee-jerks  are  almost  always  absent.  There  is  no  optic  atrophy,^  nor  are 
1  See  Hereditary  Cerebellar  Ataxia,  p.  1152. 


1152  DISEASES  OF  THE  NERVOUS  SYSTEM. 

any  sensory  symptoms  present  as  a  rule.  The  sphincters  are  not  involved. 
There  are  no  trophic  changes  in  the  skin  or  the  joints,  and  no  visceral 
crises.  A^'asomotor  symptoms — flushing,  sweating — are  sometimes  ob- 
served.     There  is  usually  no  mental  change. 

Talipes  and  spinal  curvature  are  generally  met  with  after  the  dis- 
ease has  existed  for  some  time.  In  old  eases  muscular  weakness  and 
wasting  are  present,  but  the  muscles  do  not  give  the  reactions  of  degen- 
eration. 

The  course  is  always  slow.  It  may  last  for  many  years,  thirty  or 
even  more. 

Diagnosis. — Usually  this  is  not  difficult,  and  especially  when  more 
than  one  case  exists  in  a  famil3^  The  age,  incoordination,  shambling 
gait,  nystagmus,  scanning  speech,  and  deformity  are  strikingly  charac- 
teristic. 

Differential  Diagnosis. —  Tabes  dorsalis  appears  later  in  life,  and  the 
preataxic  stage  (pain,  absent  knee-jerk,  and  ocular  symptoms)  is  generally 
well  marked.  It  is  absent  in  hereditary  ataxia,  nor  does  the  latter  pre- 
sent the  sensory  and  visceral  symptoms  met  with  in  the  former.  The 
gait  is  very  different  and  the  Argyll-Robertson  pupillary  changes  are 
never  present. 

Ataxic  paraplegia  shovfs  an  exaggerated  knee-jerk,  the  presence  of 
ankle-clonus,  and  an  absence  of  the  ocular  symptoms,  nystagmus,  and 
the  scanning  speech. 

Disseminated  Sclerosis. — In  this  disease  the  tendon  jerks  are  usually 
increased,  optic  atrophy,  indicated  by  a  pallor  of  the  temporal  halves  of 
the  discs,  is  present ;  the  speech  is  more  likely  to  be  sing-song  instead 
of  thick  and  indistinct,  and  epileptiform  and  apoplectiform  attacks  are 
liable  to  occur,  and  the  disease  usually  comes  on  later  in  life  (twenty  to 
thirty  years). 

The  prognosis  is  necessarily  bad.  The  disease  is  progressive,  though 
it  does  not  kill  directly.      It  may  last  thirty  years  or  more. 

Treatment. — Little  or  nothing  can  be  accomplished.  The  same 
general  treatment  should  be  pursued  as  for  locomotor  ataxia. 

HEREDITARY    CEREBELLAR   ATAXIA. 
(Marie  and  Notine.) 

In  this  type  the  most  pronounced  ])athological  change  in  most  cases  is 
an  atrophy  of  the  cerebellum,  in  others  defective  development  of  the 
tracts  in  the  cord  leading  to  the  cerebellum  has  been  found.  The  etiology 
and  symptoms  are  similar  to  those  of  Friedreich's  disease,  except  that  it 
usually  develops  somewhat  later  in  life,  the  knee-jerks  are  present  or  in- 
creased, and  optic  nerve  atrophy,  diplopia,  and  Argyll-Robertson  pupil 
may  be  found. 


ATAXIC   PARAPLEGIA. 

( Posterolateral  Scleronus. ) 

This  name  was  given  by  Gowers  to  a  condition  in  which  spastic  para- 
plegia and  ataxia  coexist,  owing  to  simultaneous  involvement  of  the  lat- 
eral and  posterior  columns.      A  similar  condition  nuiy  follow  an  acute 


COMBINED  SYSTEM  SCLEROSIS.  1153 

myelitis,  representing  the  chronic  type  of  that  disease  (p.  1137).  Dis- 
seminated sclerosis  may  possibly  present  the  same  symptoms.  'J'he  type 
Gowers  describes  occurs  chiefly  in  males  of  middle  age.  Traumatism 
and  exposure  seem  to  pi-edispose  to  the  disease,  as  does  syj)hilis  very 
rarely. 

Symptoms. — These  develop  insidiously.  The  patient  tires  rapidly, 
and  some  impairment  of  the  power  of  walking  is  observed.  In  turning 
quickly  he  stumbles,  and  there  is  difficulty  in  walking  in  the  dark,  or 
even  in  standing  when  the  feet  are  close  together.  The  reflexes  are  in- 
creased at  an  early  date,  and  spasticity  supervenes  and  is  progressive, 
thousrh  it  never  becomes  as  marked  as  in  uncombined  lateral  sclerosis. 
The  gait  is  somewhat  similar  to  that  met  with  in  locomotor  ataxia,  but  it 
lacks  the  forcible  stamp  present  in  that  disease.  When  the  arms  are  in- 
volved the  same  ataxia,  with  weakness,  spasticity,  and  increased  reflexes, 
is  met  with.  Sensory  symptoms  are  generally  absent  and  fulgurant 
pains  are  never  present.  When  pain  occurs  at  all,  it  is  of  a  dull  charac- 
ter and  often  in  the  sacral  region.  Optic  atrophy  does  not  occur.  Nys- 
tagmus is  often  seen,  though  other  eye-symptoms  very  rarely  appear. 
Sexual  power  is  lost.  The  sphincters  are  not  usually  involved,  though 
retention  of  urine  may  occur.  Ultimately,  the  case  generally  partakes 
more  of  the  nature  of  a  lateral  sclerosis,  but  the  features  of  a  posterior 
sclerosis  may  rarely  predominate.  Mental  symptoms  often  develop  in 
the  late  stages.  The  so-called  Erb's  type  of  syphilis  of  the  cord  pro- 
duces a  very  similar  group  of  symptoms.  In  this,  however,  there  is 
incontinence  of  urine  and  sometimes  of  feces. 

The  diagnosis  is  easy  in  typical  cases.  The  ataxia,  with  myotatic 
irritability  and  spasticity  in  the  absence  of  sensory  and  ocular  symptoms, 
is  characteristic. 

The  treatment  consists  in  maintaining  the  general  health  by  proper 
hygiene,  food,  etc.  If  due  to  syphilis,  a  vigorous  antisyphilitic  treat- 
ment is  necessary. 


COMBINED  SYSTEM  SCLEROSIS. 

(Subacute  Combined  Sclerosis  of  the  Spinal  Cord;  Diffuse  Degeneration  of  Spinal  Cord.) 

This  affection,  while  described  by  many  as  a  true  combined  sclerosis 
or  system  disease,  is  more  correctly  classified  as  a  diffuse  process,  as  has 
been  done  by  Putnam  and  Taylor.^  It  was  first  described  by  Lichtheim 
in  1887,  in  cases  due  to  pernicious  anemia.  Putnam,  in  1891,  described 
cases  due  to  other  causes,  viz.,  influenza,  chronic  diarrhea,  lead-poisoning, 
and  malaria.  It  occurs  most  frequently  between  thirty  and  sixty,  and 
always  follows  some  chronic  wasting  disease  or  toxic  condition.  It  has 
been  described  in  pellagra.^ 

The  posterior  columns  are  usually  first  and  most  involved.  The 
lateral  columns,  especially  the  crossed  pyramidal  tracts,  are  also  soon 
affected.     Other  tracts  may  become  affected  later,  as  do  also  the  cells 

^  Journal  Nervous  and  Mental  Diseases,  Jan.,  1901,  p.  1. 
^  Amer.  Jour.  Med.  Sci.,  Jan.,  1911,  p.  94. 
73 


1154  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  the  anterior  horns  and.  in  some  cases,  the  anterior  nerve-roots.  The 
blood-vessels  in  the  aft'ectcd  areas  are  eiigor<:;ed,  their  -walls  thickened. 

The  initial  symptom  is  usually  a  persistent  paresthesia,  usually  of  the 
feet ;  with  this  some  weakness,  rigidity,  and  possibly  ataxia  will  be  found. 
Later  the  arms  become  similarly  affected.  At  this  time  the  tendon  jerks 
will  usually  be  found  increased.  There  may  also  be  pain  in  the  back  and 
limbs.  Later  the  muscles  become  flaccid  and  the  deep  reilexes  lost. 
Late  in  the  course  of  the  disease  loss  of  sensation  and  muscular  atrophy 
may  also  occur. 

The  diagnosis  is  based  upon  the  presence  of  the  above  symptoms 
occurring  in  one  suffering  from  any  of  the  causes  mentioned. 

The  prognosis  is  bad,  death  usually  occurring  in  from  six  months  to 
three  years. 

The  treatment  consists  of  general  measures  to  combat  the  cause  if 
known  and  improve  the  general  health.  If  anemia  exists,  iron  and 
arsenic  should   be  given   in  full  doses. 


SYRINGOMYELIA. 


Definition. — A  neurogliar  overgrowth  of  more  or  less  vertical  ex- 
tent, and  situated  in  the  gray  matter  of  the  cord  in  the  neighborhood  of 
the  central  canal.  Its  symptomatology  is  not  constant,  but  the  following 
have  come  to  be  looked  upon  as  typical  of  most  cases,  viz.,  progressive 
muscular  atrophy  and  dissociation  of  sensation  (i.  e:,  impairment  or  loss 
of  temperature — and  pain-sense,  with  retention  of  the  tactile  and  mus- 
cular sense  and  trophic  and  vasomotor  disturbances). 

Ktiology. — The  symptoms  usually  develop  during  the  second  or 
third  decades.  The  exciting  cause  is  uncertain.  Traumatism  by  pro- 
ducing hemorrhage  into  the  gray  matter  possibly  may  cause  some  cases. 
Many  sufferers  from  this  disease  have  congenital  anomalies  of  various 
sorts,  as  abnormal  smallness,  disproportionately  large  hands  and  feet, 
varieties  of  club-feet,  etc.  Syphilis  plays  no  direct  part,  but  may  have 
some  influence  by  its  causation  of  diseased  blood-vessels. 

Pathology. — The  usual  seat  of  the  process  is  in  the  cervico-dorsal 
region,  but  it  may  be  in  other  regions  or  extend  throughout  the  length 
of  the  cord,  even  into  the  medulla.  It  consists  of  an  overgrowth  of  neu- 
rogliar tissue  (gliomatosis)  in  the  region  of  the  central  canal  of  the  cord. 
This  breaks  down  and  forms  a  cavity,  which  usually  extends  irregularly 
in  a  transverse  direction  backward  into  the  posterior  horns,  or  may  ex- 
tend into  the  anterior.  The  cavity  is  lined  with  a  varying  thickness  of 
gliomatous  tissue.  Secondary  degenerations  occur  in  the  white  matter, 
either  ascending  or  descending,  according  to  the  tracts  cut  off.  In  most 
cases  the  condition  results  from  a  congenital  anomaly  of  the  central 
embryonal  tissue,  resulting  during  the  early  years  of  adult  life  in  a 
slow-growing  hyperplasia,  having  some  of  the  characteristics  of  a  benign 
neoplasm  anfl  a  marked  tendency  toward  the  formation  of  cavities. 

Symptoms. — (^)wing  to  the  fact  that  different  levels  of  the  cord  are 
involved,  and  that  the  extent  claimed  by  the  process  varies  in  different 


SYRTNC  OMYELTA .  1  1  55 

cases,  it  will  readily  be  understood  that  no  account,  however  concise, 
will  fit  every  case.  The  disease  is  of  dow  onset.  The  commonest  situa- 
tion of  the  cavity  is  the  lowei*  cervical  region;  when  this  is  the  case  the 
earliest  symptoms  appear  in  the  hands,  there  is  a  numbness,  loss  of  the 
pain  and  temperature  senses,  usually  in  an  area  bounded  by  a  horizontal 
line  surrounding  the  limb  (glove  anesthesia),  and  preservation  of  the 
touch  sense.  This  constitutes  the  dissociation  of  sensation,  perhaps  the 
most  characteristic  symptom  of  the  disease.  The  first  symptom  usually 
noticed  is  weakness  and  atrophy  of  the  muscles  of  the  hands,  which  show 
changes  in  the  electrical  reactions  and  fibrillary  tremors,  as  in  progressive 
spinal  muscular  atrophy.  The  atrophy  may  begin  in  other  groups,  accord- 
ing to  the  location  of  the  lesion.  Vasomotor  and  usually  trophic  changes 
occur  in  the  ends  of  the  fingers,  especially  multiple  painless  whitlows. 
Neuralgic  pains  and  often  exaggeration  of  the  tendon  reflexes  are  present 
in  the  arms.  At  the  same  time  the  syndrome  of  the  transverse  lesion  of 
the  spinal  cord  develops  there  is  spastic  paresis  of  the  legs  and  disturb- 
ance of  the  functions  of  the  bladder  and  rectum.  As  the  disease  prog- 
resses the  symptoms  become  more  general.  The  pain  and  temperature  sen- 
sations are  lost  over  large  areas,  the  tactile  and  muscular  sensations 
are  preserved ;  there  may,  however,  be  areas  in  which  all  forms  of  sensa- 
tion are  lost.  The  trophic  lesions  are  various;  Charcot's  joint  or  a  dry 
arthritis  may  occur,  there  may  be  extensive  bed-sores,  or  slight  injuries 
may  lead  to  chronic  sores.  Vasomotor  disturbances  are  common,  especially 
in  the  secretion  of  sweat.  As  a  result  of  unequal  involvement  of  the 
muscles  of  the  back,  lateral  curvature  of  the  spine  occurs.  Not  infre- 
quently, as  a  result  of  the  involvement  of  the  posterior  columns,  inco- 
ordination, with  loss  of  knee-jerks,  similar  to  that  observed  in  tabes 
dorsalis,  may  develop. 

As  the  morbid  process  extends  upward,  the  centers  in  the  medulla 
become  involved,  giving  rise  to  bulbar  symptoms,  such  as  paralyses  of 
the  "cranial  nerves  and  disturbances  of  the  urinary  secretion.  These  are 
usually  terminal  signs.  The  symptoms,  of  course,  vary  with  the  position 
of  the  lesion  in  the  cord,  and  in  rare  cases  they  may  commence  in  the 
legs  or  indicate  primary  involvement  of  the  medulla. 

The  disease  originally  described  by  Morvan  of  Brittany  in  1883 
should  be  included  here.  He  had  observed  many  cases  prior  to  that  time, 
but  his  attention  was  specially  called  to  the  matter  by  a  case  of  whitlow 
which  he  incised,  but  to  his  surprise  no  pain  whatever  was  experienced. 
He  described  the  disease  as  affecting  the  upper  extremities,  with  neu- 
ralgia, progressive  paresis  and  wasting,  dissociated  anesth.-sia,  and,  later, 
painless  whitlows  and  necrosis  of  the  phalanges.  Joffroy  and  Achard 
have  made  three  autopsies  upon  cases  dying  of  this  disease,  and  in 
each  syringomyelia  was  found.  In  Gombault's  case  neuritis  was 
present.  The  current  view  is  that  3Iorvans  disease  is  a  variety  of 
syringomyelia. 

Dia^^nosiS. — The  loss  of  pain  and  thermic  sense,  with  preservation 
of  the  muscular  and  tactile  senses,  in  association  with  the  muscular 
wasting,  which  is  most  marked  in  the  upper  extremities ;  and  with  the 
spasticity  of  the  lower  extremities,  and  the  trophic  changes,  especially 
in  the  fingers,  constitute  a  group  of  symptoms  that  has  come  to  be  re- 
garded as  typical. 


1156  DISEASES  OF  THE  yEEVOUS  SYSTEM. 

DifiFerential  Diagnosis. — ITiipertrophic  cervical  pachjjniemngitis  may 
be  mistaken  tor  tliis  disease,  and  vice  vcrad.  In  this  case,  hoAvever,  the 
pain  is  usually  greater,  the  tactile  sense  is  apt  to  be  lost,  and  possibly 
the  other  senses  also ;  but  there  is  not  the  dissociation  met  with  in 
syringomyelia.  Amyotrophic  lateral  sclerosis  presents  neither  sensory 
nor  trophic  symptoms,  other  than  the  muscular  wasting.  DisHcminated 
sclerosis,  apart  iVom  the  tremor  that  is  usually  present,  ])resents  less 
trophic  disturbance.  Hemorrhage  into  the  gray  matter  of  the  cord  may 
cause  a  similar  symptoni-c'om])lex  :  in  this,  however,  the  onset  is  acute, 
and  usually  follows  traumatism.  The  neural  form  of  Icprosi/  may  present 
a  clinical  picture  that  cannot  be  difierentiated.  There  are  dissociation 
of  sensation,  trophic  changes  in  the  fingers,  and  muscular  degeneration. 
Even  s[)asticity  of  the  lower  limbs  may  occur,  although  this  is  rare. 

The  prognosis  is  always  unfavorable,  though  the  disease  runs  a  very 
chronic  course,  lasting  even  fifteen  or  twenty  years. 

Treatment. — Nothing  can  be  done,  except  by  attention  to  hygienic 
and  dietetic  details. 


TUMORS   OF  THE   SPINAL  CORD  AND  ITS 
MEMBRANES. 

Under  this  heading  are  included  the  granulomata,  parasitic  cysts,  and 
those  due  to  other  causes,  as  circumscribed  spinal  serous  meningitis  as 
well  as  neoplasms  proper.  The  classification  of  Bruns  is  a  convenient 
one : 

I.  Tumors  which,  arising  in  its  envelopes,  secondarily  affect  the  spinal 
cord. 

(a)  Vertebral  tumors  arising  from  the  spinal  column  or  the  soft  tissues 
immediately  surrounding  it. 

(b)  Intravertebral  tumors,  which  may  be  divided  into  two  classes,  in 
accordance  with  their  relation  to  the  dura  mater. 

1.  Extradural  tumors  originating  in  the  periosteum  of  the  vertebra, 
the  outer  layer  of  the  dura  mater,  or  the  fatty  areolar  tissue  of  the  epi- 
dural space. 

2.  Intradural  tumors  originating  from  the  inner  layers  of  the  dura,  the 
arachnoid, the  ligamentum  denticulatum,  the  spinal  roots,  or  the  pia  mater. 

II.  Intramedullary  tumors  of  intrinsic  spinal  origin.  Those  arising 
from  the  vertebra  are  fref{uently  malignant,  either  carcinoma  or  sarcoma, 
and  are  usually  metastatic.  Myelomata  also  occur.  Benign  growths,  as 
osteomata,  exostoses,  chondromata,  etc.,  are  rare. 

Extradural  groicths  comprise  sarcomata,  lipomata,  fibromata,  myxo- 
mata,  and  chondromata.     The  first  two  are  the  most  common. 

Intradural  tumors  may  be  either  diffuse  or  localized.  Sarcomata, 
which  may  or  may  not  be  metastatic  ;  endotheliomata,  cylindromata,  fibro- 
mata, and  lymphangiomata.  Fibromyxomata  and  fibrosarcomata  are 
frequently  found  in  connection  with  the  nerve-roots.  Cysts  are  also 
found  within  the  dura.  Intradural  growths  are  usually  found  in  the 
lateral  or  posterolateral  surfaces  of  the  cord,  a  fact  which  facilitates  their 
removal. 


TUMORS  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANES.     1157 

Intramedullary  neoplasms  comprise  gliomata,  sarcomata,  angiosarco- 
mata,  gummata,  and  tubercles.  Gliomata  usually  give  rise  to  the 
symptom-complex  known  as  syringomyelia  (p.  1154),  but  may  be  cir- 
cumscribed. 

etiology. — As  has  been  said,  malignant  and  tubercular  growths  are 
often  secondary  to  similar  conditions  elsewhere.  IVnuina  seems  to  be  a 
cause  in  some  cases,  especially  non-parasitic  cysts.  ^J'hey  most  frequently 
occur  after  middle  life  (forty  to  sixty).  Extramedullary  growths  are  more 
common  than  intramedullary.  The  former  occur  most  frequently  in  the 
dorsal  region  ;  the  latter  in  either  the  cervical  or  lumbar  enlargement. 

Symptoms. — The  symptoms  of  extramedullary  growths  are  due  to 
irritation  of  nerve-roots,  especially  the  posterior  and  compression  of  the 
cord  (p.  1138).  These  are,  therefore,  pain  in  course  of  the  roots  arising 
from  the  affected  region  and  a  gradually  developing  paraplegia.  If  the 
anterior  roots  of  either  enlargement  are  affected,  clonic  spasms  may 
occur.  The  pain  is  usually  shooting  in  character,  but  in  between  the 
paroxysms  it  may  be  constant.  Hyperesthesia  may  also  be  present  in 
the  skin  area  supplied  by  the  affected  nerves.  According  to  Starr,  the 
order  in  which  the  symptoms  arise  is  commonly  :  (1)  Peculiar  pains  of 
limited  distribution ;  (2)  Increase  of  reflexes  below  the  lesion  ;  (3)  Para- 
plegia; (4)  Loss  of  sensibility;  (5)  Loss  of  all  subjacent  reflexes.  The 
pain,  as  well  as  evidences  of  compression,  may  at  first  be  unilateral  and 
the  Brown-S^quard  syndrome  (p.  1077)  may  be  present.  As  the  growth 
enlarges  they  become  bilateral.  In  some  cases  ataxic  symptoms  with 
increased  reflexes  may  be  more  prominent  than  paralysis.^  Segmental 
areas  of  anesthesia  usually  soon  develop. 

The  symptoms  of  intramedullary  tumors  depend  on  their  location  ;  if 
within  the  gray  matter,  the  symptoms  are  those  of  syringomyelia  (p. 
1154),  otherwise  they  resemble  those  of  a  slowly  developing  myelitis, 
motion  being  lost  before  sensation.  Pain  is  not  apt  to  be  a  prominent 
symptom  until  the  periphery  is  reached.  The  BroAvn-Sequard  syndrome 
frequently  occurs.  The  functions  of  the  different  segments. of  the  cord 
are  given  on  page  1071.  Interference  with  these  functions  points  to  the 
particular  part  of  the  cord  involved. 

Circumscribed  spinal  serous  meningitis'^  causes  symptoms  so  much 
resembling  tumor  that  it  may  be  mentioned  here.  The  dura  is  usually 
found  very  tense  and  bluish  in  color,  but  no  macroscopic  lesion  is  found. 
When  opened  the  fluid  escapes  under  marked  pressure.  The  symptoms 
are  usually  sensory,  especially  intense  pain  of  a  segmental  distribution 
first  appearing  before  other  symptoms  develop,  which  are  those  of  press- 
ure, as  in  tumor.  A  peculiarity  is  that  the  symptoms  are  apt  to  vary 
from  time  to  time,  according  as  the  pressure  of  the  fluid  increases  or 
diminishes. 

Course. — Tumors  usually  grow  slowly,  and  therefore  the  symptoms 
are  gradual  in  their  development.  Ordinarily  there  are  periods  of  arrest 
or  even  improvement  that  are  followed  subsequently  by  further  advance. 
The  duration  of  spinal  tumors  is  variable.  Those  of  malignant  nature 
or  rapid  growth  may  pi-oduce  death  in  a  short  time ;  those  that  simply 
exert  pressure  and  enlarge  very  slowly  may  not  produce  total  disability 

'  Potts,  Journal  Nenious  and  Mental  Dixease^,  Oct.,  1910,  p.  621. 
"  Amer.  Jour.  Med.  Sci.,  Nov.,  1910,  p.  719. 


1158  DISEASES  OF  THE  yERVOUS  SYSTEM. 

for  several  years.  In  general  it  may  be  said  that  from  five  to  ten  years 
i.s  the  ordinary  limit  after  the  first  appearance  of  motor  disturbance. 
Some  tumors,  however,  particularly  lipomata,  produce  only  slight  dis- 
turbances throughout  life,  or  else  no  symptoms  at  all,  remaining  entirely 
latent. 

The  diagnosis  involves  three  points :  first,  the  recognition  of  the 
presence  nf  the  tumor;  second,  of  its  site;  and  third,  of  its  nature. 
The  prodromal  symptoms  of  spinal  tumor  are  often  confounded  with 
ni'itrdi /ia  or  lumbago.  It  is  sometimes  possible  to  make  a  differential 
diagnosis  by  means  of  the  presence,  in  neuralgic  conditions,  especially  of 
intercostal  nature,  of  the  sensitive  points  along  the  course  of  the  ribs, 
and  of  the  existence,  in  the  case  of  tumor,  of  exaggerated  knee-jerks 
and  sensitiveness  over  certain  portions  of  the  vertebral  column.  In  the 
paraplegic  condition  it  may  be  confi)unded  with  a  neuritu^  but  in  this 
there  is  tenderness  over  the  nerve-trunks,  absence  of  reflexes  in  the 
paralyzed  parts.  Sensory  paralysis,  if  it  exists,  is  not  confined  to  the 
distribution  of  individual  nerves,  but  is  of  the  segmental  type  (Fig.  75), 
and  the  sphincters  are  not  disturbed.  Lesions  of  the  Cauda  e(juina  may 
be  difficult  to  diftcreutiate  (p.  115'.'). 

The  intrmsie  diseitscs  of  the  spinal  canal  give  rise  to  much  greater 
diflSculty,  especially  myelitis  and  pa cJiji meningitis  cervicalis.  From  the 
former  the  correct  diagnosis  may  sometimes  be  suspected,  because  in 
tumor  there  are  severe  radiating  pains  and  the  symptoms  are  more  pro- 
nounced on  one  side  than  on  the  other,  and  are  apt  to  be  more  gradual 
in  their  development.  Moreover,  the  symptoms  of  segmentary  involve- 
mL>nt  are  sharper  and  the  root-symptoms  more  characteristic.  From 
pachymeningitis  cervicalis  a  tumor  in  the  cervical  region  can  be  usually 
distinguished  by  the  fact  that  the  radiating  pains  are  less  severe  and  the 
symptoms  not  so  distinctly  bilateral.  It  may  be  impossi})le  to  distinguish 
a  central  tumor  from  Hyringomyelia  unless  the  symptoms  of  root-pressure 
are  quite  ilistinct.  Pott's  disease,  in  its  early  stage,  may  also  give  rise 
to  some  difficulty.  However,  the  rapid  development  of  the  kyphosis, 
and  particularly  the  pain  that  is  elicited  by  sudden  pressure  upon  the 
head,  renders  it  possible,  after  a  reasonable  period  of  observation,  to 
recognize  the  true  nature  of  the  case  (p.  1188). 

The  diagnosis  of  the  position  of  the  tumor  has  been  largely  discussed 
in  the  Symptomatology.  In  general,  this  is  determined  by  determining 
the  existence  of  symptoms  dependent  upon  interference  with  the  functions 
of  certain  segments  of  the  cord  (p.  1071,  Fig.  75)  plus  disturbance  of 
the  functions  of  tracts  of  the  cord,  causing  symptoms  in  parts  innovated 
by  the  segments  below  those  affected  [vide  Compression  of  Spinal  Cord, 
p.  1138).  The  symptom-complex  may,  however,  be  considerably  dis- 
turbed by  the  presence  of  multiple  tumors.  In  these  cases  the  majority 
ordinarily  remain  latent.  It  may  also  be  said  that  the  presence  of  root- 
pains  suggests  a  meningeal  seat,  while  pronounced  paraplegia,  dissociation 
of  sensation,  or  the  Brown-S^quard  symptom-complex,  points  to  the 
presence  of  a  tumor  in  the  substance  of  the  cord  itself.  (See  table  on 
p.  1071.) 

Finally,  the  recognition  of  the  nature  of  the  groirth  can  often  be  made 
from  the  history  of  the  existence  of  the  tumor  or  an  infectious  process  in 
other  parts  of  the  body  ;  the  rapidity  of  the  growth ;  the  age  of  the 


LESIONS  OF  CON  US  MKDULLARIS,  EPKJONUS,   CAUDA  EQUINA.    1159 

patient;  and  occasionally  from  the  results  of  an  exploratory  operation. 
It  must  be  remembered,  however,  that  it  does  not  always  follow  that  a 
tumor  in  the  spinal  canal  is  similar  to  that  found  elsewh<;re. 

The  prognosis  depends  upon  the  sevei-ity  of  the  symjjtoms,  the 
rapidity  of  their  development,  and  the  nature  of  the  growth,  if  this 
should  be  known.  Complete  subsidence  of  all  the  symptoms  may  occur, 
even  after  a  spastic  paraplegia  has  existed-  Of  course  this  is  only  likely 
in  those  cases  in  which  the  tumor  can  be  removed  by  operation  or  ab- 
sorbed through  the  action  of  drugs. 

The  treatment  depends  wholly  upon  the  recognition  of  the  nature 
of  the  tumor;  if  this  be  syphilitic,  mercury  and  potassium  iodid  should 
be  given  in  full  doses.  If,  on  the  other  hand,  it  is  not  specific,  and 
especially  if  extradural,  operation  would  seem  to  offer  a  possibility  of 
cure.  This  has  been  done  successfully  a  number  of  times.  Early  opera- 
tion in  cases  of  circumscribed  spinal  serous  meningitis  has  given  most 
excellent  results.  As  the  prognosis  is,  in  general,  unfavorable  as  to  cure 
and  often  gloomy  as  to  life,  the  clinician  should  not  hesitate  to  recom- 
mend surgical  interference. 


LESIONS  OF  THE  CONUS  MEDULLARIS,  EPICONUS, 
AND  THE  CAUDA  EQUINA. 

As  symptoms  produced  by  lesions  of  these  regions  frequently  resemble 
each  other,  they  are  described  together. 

The  conus  medullaris  comprises  that  portion  of  the  cord  extending 
from  the  filum  terminale  to  and  including  the  third  sacral  segment. 
Lesions  in  this  region  are  characterized  by  the  absence  of  paralysis  of  the 
limbs  and  by  paralysis  of  the  sphincters  of  the  bladder  and  rectum  with 
loss  of  sexual  power.  There  is  also  a  saddle-shaped  area  of  anesthesia 
involving  the  skin  about  the  anus,  perineum,  scrotum,  penis,  and  the 
mucous  membrane  of  the  urethra  and  anus.  The  testicle  is  sensitive,  its 
nerve-supply  originating  higher  up  (Fig.  75,  p.  1071). 

That  part  of  the  cord  comprised  between  the  fourth  and  fifth  lumbar 
as  the  upper  and  the  second  and  third  sacral  segments  as  the  lower  limit, 
is  knoAvn  as  the  epiconus.  A  lesion  hei'e  causes  loss  of  Achilles  jerks, 
preservation  of  knee-jerks,  intact  sphincters,  motor  paralysis,  most 
marked  in  the  peroneal  muscles,  with  atrophy  and  reactions  of  degenera- 
tion and  a  steppage-gait.  Sensory  pai'alysis  will  be  found  in  the  distri- 
bution of  the  affected  segments  (Fig.  75). 

As  the  spinal  cord  terminates  at  the  second  lumbar  vertebra,  tumors  or 
injuries  below  this  point  produce  symptoms  only  in  so  far  as  they  compress 
or  destroy  the  lumbar  and  sacral  roots  (cauda  equina).  This  destruction  may 
be  partial  or  complete.  If  partial,  there  are  paralyses  of  various  groups 
of  muscles  and  circumscribed  areas  of  anesthesia,  with  radiating  pain  in 
the  course  of  the-affected  roots.  This,  especially  in  the  sciatic  nerves,  may 
precede  by  a  considerable  period  the  development  of  other  symptoms. 
There  may  or  may  not  be  a  disturbance  of  the  functions  of  the  bladder  and 
sphincters.     If  all  of  the  nerve-roots  are  involved,  there  are  complete 


1160  DISEASES  OF  THE  NERVOUS  SYSTEM. 

anesthesia,  complete  paraplegia,  flaccid  in  character,  ■Rith  reactions  of 
degeneration  in  the  muscles,  loss  of  the  knee-jerk  and  Achilles  jerk,  ab- 
sence of  the  Babinski  jerk,  and  rectal  and  vesical  incontinence.  In 
some  cases  there  may  be  isolated  paralysis  of  the  bladder  and  rectum. 
These  lesions  may  consist  of  tumors,  such  as  are  found  in  the  membranes 
of  the  cord  or  on  the  nerve-roots,  and  it  should  be  noted  that,  probably 
on  account  of  greater  space  for  their  development,  tumors  in  this  situation 
are  apt  to  be  larger  than  those  in  other  parts  of  the  spinal  canal.  They 
may  also  consist  of  fractures  or  lesions  occurring  as  a  result  of  congenital 
anomalies,  such  as  spina  bifida.  If  tumor  is  suspected,  the  treatment  is 
similar  to  that  of  spinal  tumors  (p.  1159).  In  conus  lesions  the  inconti- 
nence of  urine  may  be  relieved  by  anastomosing  the  first  lumbar  and 
third  and  fourth  sacral  roots. ^ 


IV.    DISEASES  OF  THE  BRAIN. 

DISTURBANCES  OF  CIRCULATION  OF  THE  BRAIN 
AND  MENINGES. 

Meningeal  Hemorrhage. — Hemorrhage  may  be  (1)  extradural — 

(a)  traumatic  and  [h)  due  to  rupture  of  a  vessel  by  erosion,  the  result  of 
caries;  or  (2)  intradural — into  the  so-called  arachnoid  sac — (a)  traumatic  ; 

(b)  due  to  injuries  at  birth  (p.  1173) ;  (c)  due  to  pachymeningitis  interna ; 
(d)  met  with  in  general  paral3^sis  of  the  insane ;  {c)  occurring  in  the 
course  of  anemia,  scurvy,  or  some  other  profoundly  altered  blood  condi- 
tion ;  (/)  in  cardiac,  renal,  or  pulmonary  disease;  (g)  the  result  of  strain 
— e.  f/.,  -whooping-cough. 

The  symptoms  will  depend  upon  the  circumstances,  whether  the 
amount  of  blood  is  small  or  large,  whether  the  onset  is  (jradual  or 
abrupt ;  they  may  be  further  obscured  by  the  primary  disease  or  by 
shock,  if  the  cause  is  some  trauma.  In  the  slight  forms  absolutely 
nothing  characteristic  exists.  In  others  there  are  headache,  vertigo, 
vomiting,  and  possibly  mental  confusion,  convulsions,  or  coma  ;  in  fact, 
the  ordinary  symptoms  of  apoplexy.  The  blood-pressure  is  increased. 
Cases  due  to  traumatism  are  of  most  importance,  both  from  a  diagnostic 
and  therapeutic  point  of  view.  If  extradural,  the  hemorrhage  is  usually 
from  a  branch  of  the  middle  meningeal.  When  such  is  the  case  the 
symptoms  are  characteristic.  They  consist  of  a  varj^ing  period,  in 
extreme  cases  a  day  or  more,  in  which,  with  the  exception  of  a  brief 
period  of  evidences  of  concussion,  there  are  no  symptoms,  the  patient 
possibly  going  about  his  business.  Then  he  gradually  becomes  more  and 
more  stupid,  muscular  twitching,  and  some  degree  of  paralysis  upon  the 
side  opposite  the  seat  of  hemorrhage,  and  if  the  posterior  branch  is  the 
one  affected,  sensory  symptoms  appear.  A  choked  disk  and  Babinski 
reflex  may  also  be  foun<l  on  this  side  and  a  dilated  pupil^lpon  the  side  of 
the  hemorrhage  (Hutchinson's  pupil).    When  the  hemorrhage  is  subdural, 

^  Frazier  and  Mills,  Jour.  Amer.  Med.  Assoc,  Dec.  21,  liil2,  p.  2202. 


DISTURBANCES  OF  CIRCULATION  OF  BRAIN  AND  MENINGES.    1161 

the  symptoms  usually  appear  more  fjuickly  and  the  paralysis  is  more 
profound.  In  these  cases  blood  will  be  found  in  the  cerebrospinal  fluid. 
The  treatment  is  that  of  cerebral  hemorrhage,  except  in  those  due 
to  traumatism,  when  opening  the  skull  over  the  seat  of  hemorrhage  should 
at  once  be  done.  Gushing  has  recently  done  this  in  infantile  cases  with 
success. 

HYPEREMIA. 

Definition. — An  abnormal  increase  in  the  amount  of  blood  in  the 
cerebral  capillaries.  The  condition  is  not  in  any  way  associated  with 
the  primary  phenomena  of  inflammation. 

What  has  already  been  mentioned  in  the  case  of  hyperemia  of  the 
cord  is  equally  true  in  this  case — viz.,  thatv^hile  congestion  undoubtedly 
may  take  place,  there  is  nothing  symptomatically  pathognomonic  in  the 
fact,  and  hence  we  do  not  recognize  it  as  a  definite  clinical  entity. 
The  transient  apoplectiform  seizures,  which  may  occur  during  the  course 
of  paresis,  brain  tumors,  and  multiple  sclerosis,  have  been  ascribed  to  a 
sudden  congestion  ;  in  other  words,  a  localized  active  hyperemia.  They 
should  be  treated  by  slight  elevation  of  and  cold  applications  to  the  head, 
mild  purgation,  and  bromids  internally. 

Passive  congestion  is  met  with  in  cases  of  obstruction  of  the  cerebral 
sinuses  and  veins,  and  is  due  to  pressure  on  the  superior  cava  or  the 
innominate  or  jugular  veins  by  tumors  or  aneurysms;  also  in  suffocation 
and  strangling,  in  cases  of  excessive  strain,  and  in  tricuspid  insufficiency. 

In  passive  congestion  the  veins  and  sinuses  are  engorged  and  more  or 
less  edema  may  be  present.  It  may  be  suspected  if  in  cases  of  mitral 
and  tricuspid  valvular  disease  of  the  heart  chronic  headache  and 
hebetude  occurs. 

The  treatment  in  such  cases  will  consist  in  endeavoring  to  restore 
the  circulation  to  as  near  the  normal  condition  as  possible  (p.  666). 

ANEMIA. 

Definition. — A  condition  in  which  an  insufficient  amount  of  blood 
circulates  in  the  cerebral  capillaries. 

It  is  due  to  exhausting  discharges  (diarrhea),  an  abnormally  slow 
pulse  or  weak  heart,  to  hemorrhage,  obstructive  endarteritis  of  the  ves- 
sels supplying  the  brain,  to  syncopal  attacks  and  dilatation  of  the  intes- 
tinal vessels,  owing  to  the  too  rapid  withdrawal  of  ascitic  fluid. 

Disease  of  the  blood  itself  may  also  cause  the  symptoms  attributed 
to  anemia  of  the  brain. 

Symptoms. — The  most  exaggerated  type  is  met  with  after  a  pro- 
fuse hemorrhage.  There  are  pallor,  iveakness,  vertigo,  headache,  flashes 
of  light,  subjective  Aloises,  rapid  respiration,  cool  skin,  possibly  profuse 
sweating,  and  in  extreme  cases  coma,  convulsions,  and  death.  AVe  are 
more  familiar  with  the  ordinary  fainting  attack.  When  cerebral  ane- 
mia is  brought  about  more  slowly,  "irritable  weakness"  results.  The 
patient  is  either  somnolent,  dull,  and  apethetic  ;  or  he  may  be  a  victim 
of  insomnia.  Headache,  vertigo,  tinnitus  aurium,  muscce  volitantes,  and 
lowered  muscular  power  are  present.  The  patient  becomes  irritable  on 
the  slightest  provocation.  Marshall  Hall  has  described  a  group  of  symp- 
toms as  "  hydrocephaloid,"  from  their  resemblance  to  hydrocephalus; 
they  occur  especially  in  young  children  after  diarrhea.     There  are  pal- 


1162  DISEASES  OF  THE  NERVOUS  SYSTEM. 

loi\  hebetude,  contracted  pupils,  and  depressed  fontanels.  The  somno- 
lence may  deepen  into  a  coma  that  often  becomes  more  profound,  until 
death  results. 

The  transient  attacks  of  paralysis  and  loss  of  consciousness  which 
occur  in  those  suft'ering  from  arterial  sclerosis  are  due  ])robably  to  a 
localized  anemia  caused  by  spasm  of  the  vessels  supplying  the  particular 
part  of  the  brain  affected. 

The  treatment  varies  witli  the  cause.  The  recumbent  posture  is 
always  indicatcil.  and  in  some  cases  it  is  necessary  to  depress  the  head, 
administer  stimulants,  and  even  transfuse  or  inject  a  normal  saline  solution. 
Ordinarily  it  consists  of  improving  the  tone  of  the  circulation  and  (quality 
of  the  blood.  In  the  transient  apoplexies  caused  by  arteriosclerosis, 
nitroglycerin  in  full  doses  is  of  service.  A  light  and  easily  assimilable 
diet  should  be  given  during  convalescence. 

EDEMA   OF    THE   BRAIN. 

Definition. — An  infiltration  of  serum  into  the  subarachnoid  space 
and  a  greater  or  less  increase  of  ventricular  fluid,  with  or  without  infiltra- 
tion  into  the  brain-substance. 

Pathology. — The  fluid  is  chiefly  in  the  meshes  and  beneath  the 
membrane.  The  ventricular  fluid  is  increased  in  amount;  the  brain- 
substance  is  pale,  and  in  some  cases  infiltrated  and  softened.  Micro- 
scopically, lacun?e  may  be  seen  in  the  cerebral  tissue,  the  perivascular 
spaces  are  dilated,  and  some  slight  degree  of  nerve-cell  degeneration  is 
often  present. 

Ktiologfy. — Edema  is  met  with  in  Bright's  disease,  in  senile  cerebral 
atrophy,  and  as  a  tesult  of  passive  hyperemia. 

Symptoms. — In  general  the  symptoms  are  those  of  anemia,  though 
nothing  definite  is  known  of  them.  Since  the  condition  is  always  sec- 
ondary, it  may  be  that  symptoms  directly  referable  to  the  edema  are 
masked  by  the  primary  condition.  Cases  of  apoplexy  are  seen  occasion- 
ally, in  which  the  only  postmortem  finding  is  an  effusion  of  fluid  into 
the  pia  and  ventricles.  This  has  been  termed  "serous  apoplexy."  (See 
also  Serous  Meningitis,  p.  1123.) 

The  treatment  is  that  of  the  primary  condition.  Lumbar  puncture 
may  be  employed. 


VASCULAR    DEGENERATION. 

Arterial. — The  cerebral  arteries  undergo  a  more  or  less  decided  de- 
generative change  in  the  majority  of  people  past  middle  life  (Bichat 
said  seven-tenths).  It  is  met  with  much  earlier,  however,  as  a  result  of 
disease.  Bright's  disease,  rheumatism,  gout,  alcoholism — in  fact,  any 
irritation  of  the  vessel-wall,  whether  autogenous,  the  result  of  faulty 
metabolism,  or  whether  introduced  from  without,  as  alcohol — is  capable 
of  bringing  about  a  change  of  the  inner  seat  of  the  vessel,  to  which 
Virchow  gave  the  name  "  endarteritis  deformans."  The  circle  of  Willis 
and  its  branches  are  the  most  frequent  seats.  Various  stages  may  be 
met  with  in  different  vessels  or  even  in  the  same  vessel — viz.  hyaline 
degeneration,  fatty  degeneration,  liquefaction-necrosis,  atheromatous 
ulcers,  and   calcification. 


CEREBRAL  HEMORRHAGE.  1103 

Syphilitic  arteritis  is  not  a  true  degenerative  process.  It  is  rather  a 
proliferative  process  in  which  both  intiraa  and  adventitia  are  involved. 
Arterial  degeneration  is  the  cause  of  many  diseases  of  the  nervous  sys- 
tem;  for  instance,  cerebral  apoplexy,  myelomalacia  (p.  1134),  neuritis  (p. 
1084).  A  condition  resembling  multiple  sclerosis,  due  to  disseminated 
areas  of  softening,  may  also  occur.  A  symptom-group,  characteristic  of 
arteriosclerosis  of  the  cerebrospinal  vessels,  consists  of  headache,  vertigo, 
inability  to  stand  well  with  the  eyes  closed,  a  gait  consisting  of  short, 
shuffling  steps,  laughing  and  crying  without  cause,  increased  knee-jerks, 
and  mental  failure.  Senile  dementia  is  also  so  caused  (p.  1194).  Degen- 
eration of  the  vessels  of  the  limbs  and  cord  may  cause  pseudoparalysis, 
as  intermittent  claudication  (p.  1145).  Spasms  of  degenerated  vessels 
are  liable  to  occur  in  the  brain,  also  causing  transient  apoplectic  attacks 
(p.  1161),  Also  such  symptomatic  conditions  as  headache,  neuralgias, 
vertigo,  tremor,  and  epileptiform  convulsions. 

Venous. — The  veins  are  less  liable  to  disease  than  the  arteries,  pos- 
sibly because  they  are  more  yielding,  yet  the  same  pathologic  changes 
may  be  met  with  in  them.  They  are  more  commonly  damaged  by  exten- 
sion of  inflammation  from  neighboring  tissues  or  by  pressure. 

Aneurysm. — Dilatation  of  a  vessel  results  from  any  of  the  causes 
above  mentioned.  The  aneurysms  may  be  very  small — miliary — or 
often  as  large  as  a  filbert-nut,  and  rarely  as  large  as  a  hen's  egg.  They 
occur  more  commonly  in  males  than  in  females.  The  middle  cerebrals 
and  basilar  are  most  frequently  attacked,  and  next  come  the  internal 
carotid,  the  vertebral,  and  the  anterior  and  posterior  cerebrals.  Miliary 
aneurysms  are  frequently  found  in  enormous  numbers  upon  the  basilar 
branches  of  the  cerebral  arteries. 

Symptoms  of  Aneurysm. — There  may  be  none  ;  but  in  any  case  they 
are  due  "to  pressure  exerted  by  the  mass,  and  are  therefore  comparable  to 
tumors  of  the  brain.  In  many  cases  the  first  evidence  of  any  trouble  is 
an  apoplectic  attach,  and  it  is  scarcely  necessary  to  add  that  this  is  usually 
fatal.  In  other  cases  headache,  vertigo,  and  optic  neuritis  are  present, 
and  more  rarely  a  subjective  murmur.  Still  more  rarely  an  objective 
murmur  may  exist. 


APOPLEXY. 

Definition. — As  defined  by  Dana,  "  apoplexy  is  a  clinical  term  used 
to  indicate  a  condition  characterized  by  sudden  paralysis,  usually  attended 
with  loss  of  consciousness,  and  due  either  to  the  breaking  or  blocking  up 
of  a  blood-vessel  in  the  brain."  Thus  we  have  hemorrhagic  apoplexy, 
due  to  the  rupture  of  a  blood-vessel  (intracranial  hemorrhage),  and  embolic 
or  thrombotic  apoplexy,  due  to  either  an  embolus  lodging  in  or  a  throm- 
bus forming  in  a  cerebral  vessel  (acute  cerebral  softening). 

CEREBRAL  HEMORRHAGE. 

Definition. — Hemorrhage  into  the  brain-substance:  bleeding  into 
the  meninges  is  generally  embraced  in  the  definition  (p.  1160). 

Pathologry  and  l^tiology.— At  the  time  of  birth  and  during  child- 
hood there  is  some  tendency  to  cerebral  hemorrhage  (seep.  1173).  From 
this  period  to  the  age  of  forty  the  liability  is  small;  after  this,  it  pro- 
gressively increases.     The  predisposing  causes  are  alcoholism,   syphilis, 


1164  DISEASES  OF  THE  SERVOUS  SYSTEM. 

and  gout.  Iloreditarv  intlucnci'  inav  also  be  a  factor,  as  may  also  the 
infectious  fevers.  Rarely  it  eomplicates  scurvy  and  purpura  litemor- 
rhagica.  The  exciting  causes  are  lifting  heavy  weiglits.  straining  at 
stool,  coitus,  and  mental  excitement ;  but  hemorrhages  occur  in  which  no 
exciting  cause  can  be  determined.  These  causes  are  usually  only  opera- 
tive in  those  predisposed.  Transient  ajioplectiform  attacks,  due  to  sudden 
congestion,  mav  occur  in  multiple  sclerosis,  brain  tumor,  and  paresis.  In 
intracerebral  hemorrhage  the  blood  Avill  be  found  to  have  infiltrated  the 
brain-substance,  and.  if  extensive,  it  may  have  penetrated  into  the  ven- 
tricle. In  such  cases  the  white  matter  is  torn  asunder,  leaving  a  ragged 
space  that  is  more  or  less  filled  with  recent  clot  and  fragmentary  gray 
matter ;  if  the  ventricles  have  been  entered,  blood  may  escape  from  the 
lowest  into  the  subarachnoid  space.  In  less  severe  cases  the  territory 
involved  is  less  extensive,  and  the  blood  may  occupy  a  single  s})ace  or 
several  small  spaces,  forming  mere  separations  of  the  nerve-fibers.  Other 
changes  take  place  according  to  the  duration  of  the  case.  The  blood 
changes  color  and  gradually  grows  lighter,  while  reactive  inflammation 
about  the  lesion  results  in  the  formation  of  a  wall.  The  cyst — for  such 
it  has  become  through  fatty  degeneration  of  its  contents — may  remain  as 
such  or,  when  the  lesion  is  a  small  one,  connective  tissue  may  form  within 
and  a  scar  result.  The  larger  arteries  are  generally  atheromatous,  and 
an  aneurysm  is  occasionally  met  with.  The  actual  cause  of  the  hemor- 
rhage in  most  cases  is  the  rupture  of  a  miliary  aneurism,  which  is  a  tiny 
dilatation  upon  a  small  vessel.  Many  of  these  can  usually  be  seen  on  the 
degenerated  vessels  of  a  brain  in  which  such  rupture  has  occurred.  The 
vessels  otlierwise  present  the  changes  of  arteriosclerosis.  A  vessel  may, 
however,  rupture  when  miliary  aneurisms  are  not  present.  Hyaline  de- 
generation may  in  some  cases  be  the  condition  present.  Rupture  may 
also  occur  in  an  area  of  softening  due  to  extension  to  the  vessel-wall  of 
some  neighboring  form  of  inflammation.  Such  cases  appear  often  to  be 
due  to  injury  to  the  head,  the  hemorrhage  occurring  some  little  time 
after  the  reception  of  the  injury  (delayed  apoplexy).^  It  is  very  seldom  that 
the  actual  source  of  the  hemorrhage  can  be  discovered. 

Secondary  degeneration  follows  a  lesion  occurring  in  the  motor  region 
(the  cortex  or  internal  capsule),  so  that  sclerotic  changes  can  be  traced 
from  the  cortex  through  the  corona  radiata,  internal  capsule,  crura,  pons, 
and  medulla,  to  the  termination  of  the  fibers  in  the  cord. 

Andral  states  that  varicose  veins  occur  in  the  pia,  and  that  they  occa- 
sionally rupture.  Capillary  hemorrhage  may  follow  the  plugging  of  a 
large  vein,  and  of  the  larger  vessels  any  one  or  more  may  be  involved, 
but  it  has  been  observed  that  hemorrhage  tends  to  take  place  at  par- 
ticular places.  In  more  than  one-half  of  all  cases  the  lenticulo-striate 
artery  (Charcot's  artery  of  cerebral  hemorrhage)  gives  way,  and  damages 
the  lenticular  nucleus  and  internal  capsule.  Other  regions  in  the  order 
in  which  hemorrhage  occurs  are  as  follows :  centrum  ovale,  cortex,  pons, 
peduncle,  cerebellum,  optic  thalamus,  and  the  posterior  and  anterior 
parts  of  the  hemispheres.  Hemorrhage  into  the  cerebrum  occurs  twenty 
times  more  often  than  hemorrhage  into  the  cerebellum  ;  it  may  take 
place  into  the  brain-substance,  into  the  ventricles,  or  into  the  meninges, 
the  latter  form  having  already  been  considered.  Ventricular  hemorrhage 
in  a  great  number  of  cases  is  caused  by  a  more  or  less  extensive  lacera- 
*  Allen,  Journal  Nen^ons  find  Mental  Diseasex,  October,  190S,  703. 


CEREBRA L   IIEMORRIIA  (IE.  1105 

tion  of  brain-matter,  thus  pennitting  the  blood  to  escape  into  tlie  ven- 
tricles. Not  only  the  lateral  ventricles,  but  the  tbird  and  fourth  also, 
may  contain  ])lood. 

Symptoms. — As  in  the  great  majority  of  cases  the  motor  tract  is 
damai^ed,  the  following  description  is  of  a  hemorrhage  in  that  region.  Tt 
must  he  rcmenibcred  that  other  parts  of  the  brain  may  be  the  seat  of  the 
lesion  (p.  1166).  Generally,  the  patient  is  seized  without  any  warning, 
but  in  other  cases  headache,  depression,  and  more  or  less  ]/aresf.he.ria 
precede  an  attack.  The  loss  of  consciousness  is  usually  the  first  man- 
ifestation, though  for  a  few  moments  before,  motor  weakness,  with  or 
without  spasmodic  movements,^  may  exist.  In  very  slight  attacks  con- 
sciousness may  be  preserved  throughout  or  there  may  be  a  feeling  of  ver- 
tigo or  mental  confusion.  The  symptoms  are  in  direct  proportion  to  the 
extent  and  position  of  the  hemorrhage.  The  patient  falls,  the  face  is 
usually  congested,  one  side  often  expressionless,  and  the  cheek  flaps  dur- 
ing respiration.  Breathing  is  stertorous  and,  in  grave  cases,  of  the 
Cheyne-Stokes  type ;  the  pulse  is  generally  feeble  for  a  few  moments, 
but  soon  becomes  full  and  bounding  in  character.  The  blood-pressure  in 
most  cases  is  high,  and  a  choked  disk  may  be  present  on  the  side  of  the 
hemorrhage.  The  pupils  vary,  but  are  usually  contracted.  There  is 
frequently  a  relaxation  of  the  sphincters,  and  on  raising  the  limbs  it  will 
be  found  that  those  of  one  side  offer  absolutely  no  resistance.  The  tem- 
perature, especially  on  the  paralyzed  side,  is  slightly  lowered  at  first,  but 
after  a  few  hours  rises  to,  or  just  above,  normal.  In  grave  cases  it  will 
either  remain  low  or  will  mount  up  to  106°  F.  (41.1°  C)  or  even  higher. 
Such  cases  are  usually  fatal.  Coiijugate  deviation  of  the  head  and  eyes 
takes  place  in  marked  cases ;  the  deviation  during  the  early  stages  may 
be  toward  the  paralyzed  side,  as  irritation  causes  a  spasm  of  the  muscles : 
for  the  -same  reason  there  may  be  early  rigidity  of  all  the  muscles  of 
the  paralyzed  side,  but  after  the  irritation  subsides  (a  few  hours  to 
a  day  or  two),  the  deviation  is  toward  the  lesion  and  away  from  the 
paralyzed  side ;  in  pontine  hemorrhage  the  opposite  to  this  occurs,  as  it 
is  here  due  to  involvement  of  the  sixth  nucleus,  after  decussation  has 
occurred  (p.  1097).  As  a  rule,  the  symptoms  that  we  group  under  the 
term  apoplexy — viz.,  loss  of  consciousness,  motor  power,  and  sensation, 
with  or  without  relaxation  of  the  sphincters — pass  olf  in  twelve  to  twenty- 
four  hours.  In  fatal  cases  the  coma  deepens,  but  death  rarely  ensues 
under  twelve  hours.  In  hemorrhage  into  the  medulla  or  ventricles  it 
may  be  more  rapid. 

During  the  first  few  days  (stage  of  irritation)  after  the  onset  febrile 
reaction  sets  in,  with  irritative  symptoms  due  to  the  inflammatory  changes 
occurring  about  the  original  lesion.  There  are  fever,  sometimes  delirium, 
twitchings  or  spasmodic  movements  of  a  more  pronounced  type,  and 
sometimes  rigidity  in  the  afi"ected  limbs.  The  temperature  of  the  para- 
lyzed side  is  often  from  one-half  to  two  degrees  higher  than  the  tempera- 
ture on  the  sound  side.  At  first  all  reflexes  may  be  lost,  but  the  tendon 
reflexes  usually  soon  return,  and  the  Babinski  phenomenon  (extension  of 
the  toes  when  the  sole  of  the  foot  is  irritated)  very  soon  appears.  The  cor- 
neal and  abdominal  reflexes  may  remain  permanently  absent.  Difficulty  in 
swallowing  and  thickness  and  indistinctness  of  speech,  due  to  muscular 

^  Convulsions  at  the  onset  of  hemorrhage  are  rare  except  in  children.  When  thev  do 
occur,  they  indicate  that  it  is  probably  cortical. 


1166  DISEASES   OF   THE  yERVOl'S  SYSTE2f. 

paralysis,  is  usually  present  at  iirst.  but,  as  a  rule,  disappears.  This  must 
be  distinguishod  from  aphasia  (p.  1175),  which  may  result  if  the  lesion 
is  in  the  left  side  of  the  brain.  Death  may  take  place  durinij  this  stage. 
Cases  are  generally  I'atal  also  in  which  a  second  '"  stroke  '"  follows  closely 
upon  the  iirst.  indicating  a  fresh  heint)rrhage.  After  the  reactionary 
period  a  stati'^nary  period  follows  ;  sooner  or  later  control  of  the  damaged 
members  is  then  gradually,  but  not  perfectly,  regained.  The  degree  of 
recovery  is  dependent  upon  the  resumption  of  function  of  slightly  damaged 
tissue  or  upon  the  compensatory  activity  of  the  other  side  of  the  brain. 
In  certain  cases  the  structural  damage  has  been  too  great,  and  permanent 
paralysis  remains,  Avith  rigidity,  slight  wasting,  secondary  contractures, 
and   increased  deep  reile.xes. 

Ingravescent  Apoplexy. — In  certain  cases  the  onset  is  slow,  conscious- 
ness being  lost  gradually.  Coma  deepens,  and  the  case,  as  a  rule,  termi- 
nates fatally. 

Ventricular  Hemorrhage. — This  may  be  primary  or  secondary.  The 
symptoms  are  very  severe  and  death  soon  occurs.  Blood  may  be  found 
in  the  cerebrospinal  tiuid  obtained  by  lumbar  puncture. 

Hemiplegia. — When  this  is  complete,  one  side  of  the  face  and  the  arm 
and  leg  of  one  side,  generally  the  same,  are  all  involved  (see  Pontine  Hemor- 
rhage). The  facial  palsy  is  not  complete,  the  frontalis  and  orbicularis  oculi 
escaping.  The  tongue  when  ]n-otruded  deviates  toward  the  paralyzed  side. 
As  a  rule,  the  arm  is  aifected  to  a  greater  extent  than  the  leg.  The  trunk 
muscles  and  muscles  of  swallowing  and  speech  nearly  always  escape,  possi- 
bly owing,  as  Broadbent  suggested,  to  the  functional  unison  of  the  spinal 
nuclei  of  the  Uvo  sides  that  preside  over  them,  and,  since  they  habitually 
act  together,  he  supposed  that  they  might  be  stimulated  from  either 
hemisphere.  If,  however,  the  patient  has  a  second  attack  affecting  the 
other  side  of  the  brain,  these  functions  are  interfered  with  and  symptoms 
simulating  bulbar  palsy  result  (]).  l]2:i)  This  is  known  as  2)seuiJo-Iml- 
har  pahy,  and  may  be  distinguished  from  the  true  form  by  the  absence 
of  atrophy  of  the  tongue.  The  paralysis  is  usually  spastic,  and,  there- 
fore, the  tendon  reflexes  on  the  paralyzed  side  are  increased,  there  is 
patellar  and  ankle  clonus,  and  the  Babinski  phenomenon.  The  tricipital 
and  bicipital  reflexes  and  the  scapulo-humeral  reflex  are  easily  elicited. 
The  reflexes  upon  the  unaffected  side  are  also  exaggerated,  but  the  path- 
ologic forms  are  rarely  present.  The  abdominal,  cremasteric,  and  other 
skin  reflexes  are  lost  on  the  affected  side.  This  is  important  as  a  dis- 
tinction from  hysterical  hemiplegia. 

Sensation  is,  of  course,  absent  during  the  period  of  unconsciousness. 
Subsecjuent  sensory  disturbances  are  not  constant  for  all  cases.  In  some 
cases  permanent  anesthesia  for  all  forms  of  sensation  upon  the  affected 
side  persists,  with  loss  of  the  skin  reflexes.  This  indicates  a  lesion  in 
the  posterior  part  of  posterior  limb  of  the  capsule,  and  lateral  homonymous 
hemianopsia  is  usually  associated.  Occasionally  only  dissociation  of  sen- 
sation is  present,  tactile  sensation  being  preserved,  whilst  muscular  and 
thermal  sensation  are  lost  or  diminished.  The  stereognostic  sense  is  often 
seriously  disturbed  in  these  cases. 

The  special  senses  may  be  temporarily  perverted  or  their  functions  in 
abeyance,  but  rarely  do  permanent  disturbances  occur. 

Pontine  Hemorrhage. — This  is  indicated  by  marked  contraction  of  the 
pupils,  high  tem))erature,  and  paralysis  of  cranial  nerves  upon  the  side 


CERKBRA  L   IIKMORRIIA  OK  1107 

of  the'hemorrhago  and  of  the  arm  and  leg  upon  tlie  otlicr  (crossed  pai'- 
alysis).      Bulbar  symptoms  may  remain  permanently. 

Crossed  Hemiplegia. — When  a  lesion  occurs  in  the  lower-  part  of  the 
pons,  the  fibers  of  the  facial  nerve  that  are  involved  have  already  decus- 
sated; hence  facial  palsy  occurs  on  the  same  side  as  the  lesion.  ^J'he 
fibers  coming  from  the  cortex  are  implicated  before  their  decussation,  so 
that  paralysis  of  the  limbs  occurs  on  the  side  opposite  to  the  lesion. 
Lesion  of  the  crus  may  lead  to  oculomotor  palsy  of  the  same  side,  and 
palsy  of  the  face,  arm,  and  leg  of  the  opposite  side. 

Cerebellar  Hemorrhage. — This  is  difficult  to  recognize.  Paralysis  of 
the  limbs  is  usually  absent,  but  of  cranial  nerves  is  common.  Bulbar 
symptoms  are  marked,  and  death  usually  occurs. 

Serous  Apoplexy. — The  cases  present  clinical  evidences  of  apoplexy, 
but  the  only  postmortem  finding  is  an  excess  of  serum,  and  this  is  in  no 
way  responsible  for  the  apoplexy.  These  cases  probably  belong  in  the 
same  category  as  those  just  mentioned,  but  occur  in  old  persons  whose 
brains  have  atrophied. 

Course  and  Terminations. — As  previously  intimated,  the  course 
depends  on  the  position  and  extent  of  the  lesion.  In  the  most  extensive 
cases  death  rarely  takes  place  under  several  hours.  Hemorrhage  into 
the  medulla  may  prove  fatal  more  quickly.  In  the  milder  cases,  perfect 
recovery  may  take  place  in  a  few  days  or  weeks.  Generally,  however, 
when  little  or  no  improvement  occurs  in  two  or  three  months,  permanent 
changes  result.  The  facial  muscles  soon  recover,  and  next  the  leg.  At 
first  the  patient  is  able  merely  to  move  the  toes.  Daily  improvement 
then  follows  until  he  can  support  his  weight ;  dragging  of  the  feet  rarely 
disappears  absolutely.  In  the  meantime  a  less  pronounced  change  for 
the  better  has  been  taking  place  in  the  arm.  This  member  very  rarely 
recovers  to  the  same  extent  as  the  leg,  and  secondary  contractures  develop 
in  time,  the  hand  and  arm  becoming  flexed,  while  the  leg  is  extended. 
The  hand  is  usually  bluish  and  cold,  and  swells  if  kept  in  a  dependent 
position.  Some  ataxia  may  be  noticed  if  motion  is  possible.  Pain  in  the 
afiected  limbs  sometimes  occurs,  in  the  majority  of  such  cases  a  lesion 
has  been  found  in  or  near  the  optic  thalamus.  Other  later  manifestations 
that  are  only  occasionally  met  with  are  athetosis,  posthemiplegic  chorea 
(p.  1174),  and  tremors.  Varying  degrees  of  mental  deterioi'ation  may 
develop  and  epileptiform  convulsions  occur. 

There  is  no  degeneration  of  the  affected  muscles  as  a  rule ;  nor  are 
there  electric  changes,  except  during  the  irritative  period,  when  the 
response  to  stimulation  is  heightened.  Occasionally  marked  atrophy 
occurs,  and  is  due  in  some  cases,  as  Charcot  has  shown,  to  changes  in 
the  cells  of  the  anterior  horns.  In  others  no  such  change  is  found,  and 
we  are  forced  to  regard  the  wasting  as  cerebral. 

Diflferential  Diagnosis. — Apoplexy  is  to  be  distinguished  from 
other  conditions  causing  unconsciousness,  such  as  traumatism  to  the  head, 
cardiac  syncope,  epilepsy,  alcohol-  or  opium-poisoning,  insolation,  and 
uremia.  If  some  previous  histoi'y  can  be  obtained,  the  difiiculty  of  the 
diagnosis  is  lessened,  though  it  may  still  be  great.  If  there  is  evidence 
of  a  blow  upon  the  head,  the  possibility  of  meningeal  hemorrhage  must  be 
considered  (p.  1160).  In  simple  concussion  there  are  evidences  of  shock 
without  any  paralysis;  in  syncopal  attacks  the  pulse  is  very  feeble  and 
the  face  is  pale,  respiration  being  shallow  and  often   suspended.     The 


1168  DISEASES  OF  THE  XEEVOUS  SYSTEM. 

sphincters  are  hardly  ever  relaxed ;  the  reflexes  are  usually-  preserved 
and  the  skin  is  often  moist.  In  epiJepsii  scarring  of  the  tongue  may  be 
present,  and  there  is  a  history  of  previous  attacks,  or.  failing  to  obtain 
this,  one  can  usually  learn  that  a  convulsion  has  immediately  preceded 
the  coma.  With  (ilcoholiatn  the  case  is  more  difficult.  The  odor  of 
alcohol  on  the  breath  is  of  no  value,  as  spirits  may  have  been  given  by  a 
bystander ;  moreover,  hemorrhage  is  common  in  alcoholics  [vide  table 
of  differential  diagnosis.  In  i>i>iHm-pohonin<i  the  coma  comes  on  grad- 
ually, and  when  not  too  profound  the  patient  can  be  aroused  -svlicn 
shaken  or  shouted  at.  The  respirations,  -which  are  very  slow  and  deep 
at  other  times,  become  somewhat  (piicker  and  shallower  when  he  is 
aroused.  In  insolation  the  temperature  suffices,  as  a  rule,  though,  as 
stated,  high  temperature  may  occur  in  apoplexy.  The  presence  of  albu- 
min is  not  conclusive  evidence  of  uremic  poisoning  unless  the  centrifuge 
and  the  microscope  reveal  the  presence  of  casts  or  other  indications  of 
renal  change;  even  then  the  case  may  be  one  of  apoplexy  in  a  subject 
of  nephritis.  It  is  important  to  remember  also  that  uremia  may  cause 
a  hemiplegia,  which,  as  a  rule,  is  not  persistent.  In  the  case  of  dia- 
betic coma  the  presence  of  sugar  in  the  urine  serves  to  make  the  diag- 
nosis. When  we  meet  Avith  a  comatose  case  in  which  there  is  abso- 
lutely no  resistance  when  the  liudjs  of  one  side  are  raised,  while  those  of 
the  other  still  exhibit  some  tonicity,  particularly  if  the  dee])  reflexes  are 
exaggerated  on  the  flaccid  side,  and  a  Bal)inski  reflex  and  conjugate 
deviation  of  the  head  and  eyes  present,  the  probability  is  that  it  is  an 
apoplectic  attack.  It  is  of  great  importance  to  tell  whether  the  condition 
is  due  to  hemorrhao;e,  embolism,  or  thrombosis,  althouo-h  at  times  this 
may  be  impossible.  The  tabulated  points  of  distinction  given  below  may 
aff'ord  aid  : 

Embolism.  Hemorrhage. 

Early  adult  life.  Late  adult  life  ;  in  early  life  rare. 

Previousdevelopment  of  cardiac  disease  fol-  Cardiac  hypertrophy,  arteriosclerosis,  in- 
lowing  acute  rheumatism,  sepsis,  chronic  creased  arterial  tension.  In  children, 
valvular  disease,  aneurism,  pregnancy.  previous  infections  diseiuse. 

History  that   the   patient  up  to  the  time 
of  attack  was  well ;  also  the  finding  of 
casts   in    urine    and  other  symptoms  of 
chronic  nephritis. 
During  the  attack  there  is  an  absence  of       During  the  attack  there  are  noted  flushes 
congestion    of    the   face ;    the   pulse    is  ( reddish )  of  the  face,  pulsating  carotids, 

normal ;  in   cardiac  affections   it   is    ac-  and  slow  pulse, 

celerated  and  irregular. 
Temperature  normal    or  but  slightly  dis-       Temperature    during   the    attack    is    sub- 
turbed.  normal,  followed  by  a  rise,  especially  on 

paralyzed  side. 
The  attack,  as  a  rule,  is  short ;  if  there  is      The  duration  is,  as  a  rule,  longer.     Coma 
a    protracted     embolic    infarction,    the  of  long  duration  (about  two  days)  gives 

duration    is  long  ;    usually  the    circula-  a  very  unfavorable  prognosis, 

tion  adjusts  itself  promptly. 
Hemiplegia  is  right-sided  usually.     Paral-      Kemote  effects  quite  frequent;    alteration 
ysis  may  occur  first,  followed  by  convul-  in  the  urine — albuminuria,  polyuria, 

sions  and  coma. 

Ophthalmoscopic  Examination. 

At  times  the  ophthalmoscope  reveals  The  retinal  arteries  may  show  various 
either  a  recent  or  an  old  embolus  in  the  stagesofarterio-sclerosis;  as  a  result  there 

arteria  centralis  retinae.  may  be  a  hemorrhagic  retinitis  or  there 

may  be  a  thrombus  of  the  central  vein  of 
the  retina?.  A  mild  degree  of  choked 
disk  may  be  present. 


CEREBRAL  HEMORRITAfJE.  1169 

TpIROMBOSIS.  1 1  KMfiJUtJI AGE. 

Prodromes,  as  transient  attacks  of    weak-       Prodromes  not  very  frequent. 

ness,  numbness,  vertigo   and   headache, 

frequent. 
Consciousness  frequently  preserved.  Usually  lost. 

Age  of  patient  greater  (after  50),  except  in       More  apt  to  occur  between  40  and  -50. 

syphilitic   cases,  when    it  may  occur  in 

early  adult  life. 
Paralysis  may  develop  slowly,  sometimes       Develops  at  once. 

taking  several  hours  to  become  complete. 
Temperature  changes  not  so  marked  (initial       Temperature  changes  marked. 

fall  followed  by  rise). 
Attack    occurs   while    patient    is    at   i-est       Attack  occurs  during  physical  exertion. 

(during  sleep). 
Pulse   weak,   breathing   quiet.     Face    not      Pulse    slow   and   full,    blood-pressure   in- 
flushed.     Vessels  atheromatous.  creased,     breathing     stertorous,     face 

flushed. 
Pupillary  disturbances  not  marked.  Pupils  unequal  or  contracted. 

It  is  not  an  uncommon  occurrence  to  have  patients  brought  to  a  hos- 
pital dazed  and  smelling  of  liquor.  These  should  always  be  carefully 
watched,  for  mistakes  readily  occur,  and  many  such  cases  have  been 
condemned  to  a  prison-cell  when  they  were  really  suffering  from  cerebral 
hemorrhage. 

Prognosis. — This  is  serious,  and  even  if  death  does  not  occur,  more 
or  less  disability  is  sure  to  result.  Even  if  the  brain  injury  does  not 
cause  death,  severe  bed-sores  are  likely  to  develop  upon  the  affected  side, 
and  the  patient  succumbs  either  to  infection  or  exhaustion.  If,  after  the 
primary  attack,  the  blood-pressure  remains  high,  other  hemorrhages  are 
likely  to  occur,  and  the  prognosis  is,  therefore,  graver.  Coma  persisting 
longer  than  two  days  and  high  temperature  are  also  bad  prognostic  signs. 

Treatment. — If  a  diagnosis  of  hemorrhage  cannot  be  positively  made, 
care  must  be  taken  not  to  do  harm ;  therefore  the  treatment  should  be  ex- 
pectant. The  patient  should  be  kept  as  quiet  as  possible  and  in  the 
recumbent  position,  with  the  head  somewhat  elevated,  and  preferably  on 
the  side,  to  prevent  the  paralyzed  tongue  from  falling  back  into  the 
throat.  The  clothing  about  the  neck  should  be  loosened  to  prevent  con- 
striction. An  ice-bag  may  be  put  to  the  head  and  hot  bricks  or  a  hot- 
water  bottle  to  the  feet,  while  sinapisms  may  be  placed  on  the  back  of 
the  neck  or  on  other  parts  of  the  body.  The  bowels  should  be  made  to 
move  freely ;  a  cathartic  may  be  exhibited  by  the  mouth  (croton  oil,  gtt. 
j  or  ij),  and  at  the  same  time  an  enema  may  be  given.  If  the  patient 
can  swallow,  calcium  salts  may  be  given  to  increase  the  coagulability  of 
the  blood.  Nitroglycerin  or  veratrum  viride  may  be  given  to  reduce  the 
blood-pressure.  When  the  pulse  is  very  slow  and  the  blood-pressure 
either  very  high  (280  mm.  or  over)  or  progressively  increasing.  Gushing  ^ 
has  advised  making  an  osteoplastic  flap  on  the  side  of  the  hemorrhage. 
In  this  connection  it  is  well  to  remember  that  a  moderate  increase  of 
blood-pressure  is  beneficial,  as  it  is  due  to  the  increased  effort  of  nature 
to  get  blood  to  the  vital  centers  in  the  medulla  which  otherwise  becomes 
anemic,  due  to  its  compression  against  the  foramen  magnum  by  the  in- 
creased intracranial  pressure.  When  consciousness  returns  the  patient 
should  be  kept  absolutely  quiet  for  several  days  and  only  liquid  food 
permitted.  Later  an  endeavor  should  be  made  to  keep  up  the  tone  of  the 
affected  muscles  by  massage  and  electricity.  The  general  arterial  disease 
should  also  be  treated  by  appropriate  hygiene,  the  use  of  the  iodids.  etc. 

^  Amer.  Jour.  Med.  Sci.,  June,,  1903. 
74 


1170  DISEASES  OF  THE  NERVOUS  SYSTEM. 

EMBOLISM    AND    THROMBOSIS. 
(Acute  CerehraJ  Softening.  ) 

Hmbolism. — Definition  and  Etiology. — The  obstruction  of  arteries 
or  capillaries  by  material  brought  to  the  spot  from  some  other  part  by 
the  blood-current.  The  material,  generally  fibrin,  usually  conu>s  from 
the  heart,  and  is  either  a  vegetation  of  a  recent  endocarditis  or,  more 
commonly,  of  chronic  valvular  disease;  it  may  possibly  be  a  fragment 
of  the  valve  plus  the  fibrin  in  ulcerative  endocarditis.  In  the  latter 
case  the  plug  is  generally  se))tic.  giving  rise  to  suppurative  processes. 
An  embolus  mav  be  washed  from  the  auricular  recesses,  from  an  aneur- 
ysm of  the  aorta  or  carotid,  or  from  atheromatous  patches :  rarely  from 
the  pulmonary  veins. 

In  puerperal  women,  and  in  certain  febrile  processes  (diphtheria  and 
pneumonia)  the  coagulability  of  the  blood  is  increased.  Heart-clots 
form,  and  fragments  may  be  washed  into  the  cerebral  vessels.  Owing 
to  the  direction  of  the  vessels  the  embolus  most  frequently  enters  the 
left  carotid,  whence  it  usually  passes  to  the  left  middle  cerebral.  Al- 
most any  cerebral  artery  may  be  obstructed,  but  the  cerebellar  very 
rarely.  Embolism  occurs  most  frequently  between  the  tenth  and  forti- 
eth years  of  life.  The  middle  cerebrals  are  most  frequently  involved, 
and  next  in  order  the  internal  carotid  and  anterior  cerebrals. 

Pathology. — The  region  of  the  brain  that  is  cut  off  from  its  blood- 
supply  by  the  embolus  undergoes  softening.  The  cortical  changes  are 
less  marked  than  those  of  the  central  ganglia,  since  in  the  former  case 
more  or  less  anastomosis  exists,  and  none  in  the  latter.  When  the  em- 
bolus is  septic  one  or  more  metastatic  abscesses  result.  The  degree  of 
softening  varies  in  different  cases  within  wide  limits.  There  may  be 
nothing  more  than  a  slight  diminution  in  the  consistence,  the  affected  area 
being  somewhat  paler  than  normal,  or  absolute  dissolution  may  occur, 
the  myelin  breaking  up  into  granules,  Avhile  the  tissue  becomes  infil- 
trated with  serum,  and  the  vessels  undergo  hyaline  or  more  often  fatty 
change.  The  color  of  the  part  varies  with  the  amount  of  blood.  In 
recent  cases  it  is  red.  As  the  hemoglobin  is  absorbed  a  yellow  color 
appears,  and  soon  predominates.  Red  and  yellow  softening  are  found 
chiefly  in  the  cortex.  The  so-called  white  softening  is  met  with  particu- 
larly in  the  white  matter.  A  variety  of  red  softening  in  which  numer- 
ous small  hemorrhages  exist  has  been  termed  capillary  apoplexy,  while 
plaques  jaunes  is  the  term  given  by  the  French  to  a  form  of  yellow  soft- 
ening often  seen  in  the  cortex  of  old  people.  The  ultimate  changes  de- 
pend in  a  great  measure  upon  the  extent  of  the  lesion.  If  this  is  small, 
the  granular  d(^bris  is  absoi'bed,  and  the  proliferation  of  connective  tis- 
sue results  in  the  formation  of  a  scar.  On  the  other  hand,  if  large  the 
solid  elements  are  removed,  and  the  cavity  that  remains  contains  more 
or  less  fluid  (a  cyst).  In  many  instances  fibers,  trabeculae,  and  even 
vessels  that  have  escaped  destruction,   pass  through  the  cyst. 

Thrombosis. — Definition. — Obstruction  of  a  vessel  due  to  clotting 
in  situ.  This  may  occur  (a)  in  the  arteries  or  (6)  in  the  veins  and 
sinuses. 

In  the  Arteries. — Etiology. — Thrombosis  results  from  disease  of 
the  vessel-wall,  atheroma,  endarteritis,  or  syphilitic  arteritis,  extension 


EMBOLISM  AND   TIIROMIiOSTS.  1171 

from  surrounding  diseased  areas,  trauTnatism,  in  aneurysms,  in  depraved 
blood-states,  and  at  the  seat  of  lodg(!nient  of  an  embolus.  'J'lironibosis 
of  a  cerebral  vessel  may  rarely  follow  ligation  of  the  carotid.  Jn  gen- 
eral we  may  say  thrombosis  results  from  (1)  changes  in  the  vessel-wall, 
(2)  retardation  of  the  blood-current,  and  (-J)  hypercoagulability  of  the 
blood.  It  occurs  most  frequently  in  the  middle  cerebral,  basilar,  internal 
carotid,  and  vertebral  arteries. 

Pathology. — The  changes  in  the  brain-tissne  are  precisely  those  de- 
scribed under  Embolism.  Within  the  vessel  a  clot  is  found  adherent 
to  the  vessel-wall,  and  extending  from  the  nearest  large  branch  on  the 
proximal  side  to  the  contracted  branches  on  the  distal  side.  If  of 
recent  and  rapid  formation,  it  is  always  of  a  red  color.  The  slower  the 
formation  the  paler  the  color.  Such  clots  are  often  laminated.  The 
ultimate  changes  are  contraction  and  atrophy,  or,  more  rarely,  calcifica- 
tion, or  even  softening  and  removal,  the  vessel  again  becoming  patulous. 

In  the  Veins  and  Sinuses. — Etiology. — Thrombosis  may  be  (1) 
primary,  due  to  general  causes,  or  (2)  the  result  of  local  changes. 

Primary  thrombosis  is  less  common  than  the  secondary  variety. 
It  is  met  with  in  marasmic  children  (one  of  the  causes  of  infantile 
hemiplegia — Gowers),  in  which  the  clot  is  called  marantic  throm- 
bosis, cachexia,  phthisis,  carcinoma,  and  in  blood-dyscrasise  (anemia, 
chlorosis). 

Secondary  thrombosis  usually  results  from  an  extension  of  neigh- 
boring forms  of  inflammation,  caries  of  the  bone,  middle-ear  disease,  or 
meningitis.  It  may  also  be  due  to  fracture  of  the  skull  or  compression 
of  a  sinus  by  a  tumor. 

Pathology. — In  primary  thrombosis  the  most  common  seat  is  the  su- 
perior longitudinal  sinus.  From  this  it  spreads  into  the  veins  of  both 
sides,  and  frequently  also  into  the  lateral  sinuses  of  one  or  both  sides. 
In  secondary  thrombosis  the  sinus  nearest  the  local  disease  suffers. 
The  veins  emptying  into  the  sinus  involved  become  distended,  often 
rupture,  and  in  consequence  the  brain-tissue  and  pia  become  infiltrated. 
When  the  veins  of  Galen  are  blocked  serum  escapes  into  the  ventricles. 
Red,  yellow,  and  white  softening  is  met  with  as  a  final  result  of  the  ex- 
travasation. Secondary  thrombi  are  usually  septic,  and  give  rise  to 
abscess  formation. 

Symptoms. — Following  Embolism  or  Thrombosis  of  Arteries. — The 
symptoms  necessarily  depend  upon  the  position  and  extent  of  the  lesion. 
Often  it  is  discovered  postmortem,  not  having  been  suspected  during 
life.  We  meet  with  many  such  cases  occurring  in  late  adult  life.  Then, 
too,  extensive  lesions  may  occur  in  those  portions  of  the  brain  that 
never  yield  any  localizing  symptoms — the  frontal  region,  for  instance. 
Apart  from  the  etiologic  differences,  the  clinical  pictures  of  embolism 
and  thrombosis  differ  as  follows  :  In  the  former  the  onset  is  sudden, 
without  premonitory  signs,  and  is  in  many  cases  accompanied  by  loss 
of  consciousness.  In  addition  to  symptoms  arising  directly  through 
implication  of  the  particular  part  involved,  there  are  those  of  shock. 
In  the  less  severe  cases  consciousness  soon  returns  and  the  apoplectic 
symptoms  pass  off.  When  more  severe,  coma  supervenes  and  may  prove 
fatal.  When  hyperemia  occurs  in  or  about  the  motor  region  the  irrita- 
tion may«give  rise  to  convulsions.     In  other  cases  delirium  is  a  promi- 


1172  DISEASES  OF  THE  yEEVOUS  SYSTEM. 

nent  feature ;  hence  three  varieties  of  softening  are  described  by  some 
writers — the  apoplectic,  coyiritlsivc.  and  dcl/n'ous,  from  the  prevailing 
feature.  Thrombosis  may  coniuK'nce  abruptly,  but,  as  a  rule,  the  onset 
is  slow,  the  patient  meanwliile  complaining  of  vague  pains,  numbness, 
tiniriiny;,  headache,  and  vertijro.  It  is  observed  that  a  graduallv  in- 
creasing  impairment  of  the  mind  is  going  on,  and  that  motor  weakness, 
slight  at  first,  increases  until  the  function  is  lost.  The  special  symp- 
toms are,  as  stated,  dependent  upon  the  location  of  the  obstruction.  If 
this  is  in  the  middle  cerebral  artery,  tlie  most  common  seat,  there  will  be 
heviiphgia.  The  trunk  may  be  s]>ared  and  one  of  its  brandies  stopped. 
The  latter  run  to  the  third  frontal,  ascending  parietal,  supramarginal, 
angular,  and  temporal  gyri.  Thus,  then,  we  can  account  for  tlie  aphasia 
so  often  met  with  in  these  cases  by  the  plugging  of  the  branch  that  sup- 
plies the  third  frontal  convolution  of  the  left  side.  If  both  middle  cere- 
brals are  ])lugged,  symptoms  develop  that  are  indistinguishable  from 
hemorrhage  into  the  ventricles.  This  condition  is  generally  fatal. 
Thrombotic  obstruction  of  the  anterior  and  posterior  cerebral  arteries 
rarely  causes  symptoms,  owing  to  compensatory  circulation.  "  Hebetude 
and  dulness  of  intellect  may  occur  "  (Osier),  with  obstruction  of  the 
anterior  cerebral.  Hemianopsia  may  arise  from  a  lesion  of  the  posterior 
cerebral,  since  it  supplies  the  cuneus.  Plugging  of  a  vertebral  artery 
causes  symptoms  of  acute  bulbar  palsy,  as  does  also  that  of  the  posterior 
inferior  cerebellar  artery,  which  is  a  branch  of  the  vertebral,^  in  this  the 
symptoms  develop  Avithout  loss  of  consciousness.  There  may  or  may  not 
be  slight  weakness  of  the  limbs  of  the  side  opposite  the  lesion  which,  if 
present,  soon  disappears.  Pain  and  temperature  sensations  are  diminished 
in  these  limbs  and  the  opposite  side  of  the  face,  and  there  may  also  be 
pain  and  paresthesia  in  this  area.  Ataxia  may  be  present  in  the  limbs 
on  the  side  of  the  lesion.  The  muscles  of  deglutition,  larynx,  and  soft 
palate  are  paralvzed  on  this  side  (p.  1129). 

Cerebellar  softening  is  rare.  There  may  be  no  symptoms  if  only  one 
hemisphere  is  involved ;  otherwise  they  are  similar  to  those  of  cerebellar 
disease  due  to  other  lesions. 

Thrombosis  in  veins  and  sinuses  cause  variable  symptoms.  Those 
directly  due  to  tlie  vascular  disturbance  are  severe  headache,  optic  neur- 
itis, delirium  or  convulsions,  and,  later,  great  depression.  Hemiplegia 
may  result.  When  the  superior  longitudinal  sinus  is  affected,  epistaxis 
is  common,  while  in  lateral-sinus  involvement  post-auricular  edema 
occurs.  If  the  cavernous  sinus  is  aff"ected,  there  are  exophtlialmus  and 
ophthalmoplegia  on  the  aff"ected  side,  with  edema  of  the  orbital  and 
frontal  regions.  In  secondary  cases,  moreover,  we  have  to  reckon  with 
the  cause.    Since  this  is  so  often  septic,  septicemic  symptoms  are  the  rule. 

Diagnosis. — 'J'his  must  be  made,  if  possible,  from  hemorrhage ;  the 
points  are  given  on  p.  1169.  If  it  cannot  be  made  with  certainty,  treat- 
ment should  be  very  guarded,  as  treatment  for  hemorrhage  would  do 
harm   in   thrombosis,   and  vice  versd. 

Prognosis. — This  is  somewhat  better  than  in  hemorrhage,  death 
not  being  so  liable  to  occur  and  the  resultant  disability  less. 

Treatment. — Of  EmhoUsm    and    Thrombosis    of  Arteries. — Very 
little   can  be  done  in  brain-softening.     In   the   early  stages,   however, 
1  Spiller,  Jonr.  New.  and  Ment.  Di.i.,  June,  1908. 


CKIIKIUIAL    PALSIES  OF  aUILDREN.  1173 

while  it  is  absolutely  impossible  to  repair  the  tissue  already  damaged, 
an  effort  should  be  made  to  prevent  the  spread  of  the  process.  Rest  in 
bed  with  the  head  low  should  be  insisted  on.  When  shoek  is  present,  it 
must  be  met  by  gentle  stimulation,  ammonium  carbonate,  and  even  by 
alcohol  and  digitalis  in  some  cases ;  hot-water  bottles  may  be  applied  to 
the  body.  Citric  acid,  in  the  form  of  lemon-juice,  may  be  given  to 
prevent  further  coagulation.  Venesection  is  contraindicated.  The  bowels 
should  be  made  to  move  gently  and  purgation  should  be  avoi<led.  Nitro- 
glycerin and  small  doses  of  the  iodids  are  useful  in  thrombosis.  Later, 
as  stated,  symptoms  of  irritation  often  appear.  In  such  cases  the  bro- 
mids  should  be  given,  and  also  a  diaphoretic  mixture,  or  ice  should  be 
placed  to  the  head.  In  any  case  in  which  syphilis,  rheumatism,  gout, 
chorea,  or  other  malady  capable  of  causing  or  adding  to  the  trouble  ex- 
ists, the  original  disease  should  be  treated  promptly  and  thoroughly.  In 
the  meantime  efforts  should  be  made  to  improve  the  patient's  general 
tone  by  the  strict  observance  of  hygienic  and  dietetic  rules. 

Of  Thrombosis  of  Veins  and  Sinuses. — Treatment  in  these  cases 
depends  largely  on  the  cause.  In  the  primary  form  it  is  that  of  the  sys- 
temic disease.  Good,  wholesome,  and  easily  assimilable  food  should  be 
given,  together  with  a  tonic  treatment.  In  secondary  thrombosis  care- 
ful search  should  be  made  for  pent-up  inflammatory  products,  which 
should  be  liberated  at  the  earliest  possible  moment.  The  brilliant  results 
of  operative  interference  in  some  apparently  hopeless  cases  should  suggest 
its  employment  Avhenever  there  is  good  reason  for  suspecting  septic  sinus- 
thrombosis.  The  emunctories  must  act  freely.  Counter-irritation  ap- 
plied to  the  neck  is  of  questionable  value,  but  internally  quinin,  iron, 
and  strychnin,  and,  if  stimulation  is  necessary,  ammonia  and  alcchol, 
will  all  be  useful. 


CEREBRAL  PALSIES  OF  CHILDREN. 

The  paralysis  may  involve  all  four  extremities  (diplegia),  or  be  para- 
plegic or  hemiplegic  in  its  distribution. 

Htiology. — They  may  be  congenital  or  develop  during  the  first  few 
years  of  life,  usually  within  the  first  two.  The  former,  in  the  great 
majority  of  instances,  are  due  to  meningeal  hemorrhage,  sometimes 
venous,  occurring  during  birth.  In  such  cases  there  is  often  a  history 
of  difficult  or  forceps  delivery ;  it  may  occur,  however,  during  easy  labors. 
When  due  to  this  cause,  the  symptoms  are  frequently  diplegic,  but  may 
be  either  hemiplegic  or  paraplegic.  Some  are  possibly  due  to  a  fetal 
meningo-encephalitis  ;  another  cause  may  be  lack  of  development  of  the 
motor  tracts,  and  in  such  cases  a  history  of  premature  labor  may  be  ob- 
tained. Either  neurotic  taints,  alcoholism,  or  syphilis  in  the  parents 
may  have  some  influence  in  the  causation.  The  congenital  cases  have 
been  known  as  Little  s  disease  and  birth  palsy. 

The  hemiplegic  form  is  most  frequent  in  the  latter  group.  These 
cases  usually  follow  the  infectious  diseases,  and  are  due  in  some  instances 
to  either  hemorrhage,  thrombosis,  or  embolism  in  a  branch  of  the  sylvian 
artery;  others  may  be  due  to  a  cortical  polio-encephalitis  (Striimpell)  (p. 
1183). 

Pathology. — If  the  patient  live  for  a  number  of  years,  the  following 
lesions  may  be  found :  atro.phj  and  sclerosis,  either  of  a  group  of  convo- 


1174  DISEASES   OF  THE  ^'ERVOUS  SYSTEM. 

lutions.  an  entire  lobe  or  the  hemisphere  is  most  fre(jiient.  The  afteoted 
parts  are  firm  and  liard.  and  the  convohitions  smaller  than  the  normal. 
The  selerosis  may  be  diftuse.  and  there  may  be  novliilar  projections 
(hypertrophic  sclerosis). 

Next  most  freciuently  is  found  porencepJialus,  by  which  is  meant  loss 
of  substance,  fomiini;  cavities  and  cysts  on  the  surface  of  the  brain  which 
may  extend  into  the  ventricle.  Porencephaliis  may  be  due  either  to 
hemorrhage  oocurrinii;  at  l)irth.  lack  of  develo})nu'nt.  or  the  lesions  of 
apoplexy  (embolism,  thrombosis,  hemorrhage),  which  may  occur  after 
birth.  The  j)rimary  lesion  in  the  cases  of  atrophy  and  sclerosis  is  doubt- 
ful.     Stviimpell  attributed  them  to  a  cortical  polio-encephalitis. 

Symptoms. — It  is  important  if  possible  to  recognize  the  occurrence 
of  meningeal  hemorrhage  during  birth,  as  treatment  then  may  be  of 
service.  These  are  convulsions,  asphyxia,  tense  and  non-pulsating  fon- 
tanelles,  slowing  of  the  pulse,  ine(}uality  of  the  pujjils.  an  intense  choked 
disc,  and  blood  in  the  cerebrospinal  fluid.  Usually  the  symptoms  are 
not  noticed  until  the  child  is  several  months  old,  when  it  will  be  observed 
that  he  is  unable  to  sit  up,  and  that  the  head  rolls  about,  owing  to  weak- 
ness of  the  neck  nmscles.  When  it  is  time  for  him  to  walk,  he  does  not 
attempt  to  do  .so,  and  examination  will  shoAV  more  or  less  rigidity  of  the 
limbs.  Later,  when  the  child  does  walk,  the  gait  Avill  be  more  or  less 
spastic,  sometimes  so  much  so  that  the  knees  rub  against  each  other,  and 
in  extreme  cases  one  leg  may  be  crossed  over  the  other  (cross-legged  pro- 
gression). The  deep  reflexes  are  increased,  unless  the  spasticity  is  so 
great  as  to  prevent  contraction  of  the  muscles,  and  the  Babinski  phenom- 
enon is  present.  The  arms  are  also  -rigid,  but  usually  do  not  suff'er  so 
much  as  the  legs.  The  face  is  rarely  afi'ected.  In  the  hemi))legic  cases 
the  afi'ected  side  does  not  develop  as  well  as  the  normal  one,  and  the 
limbs  are  often  shorter  and  the  muscles  smaller.  They  are  firm,  how- 
ever, and  the  presence  of  the  reflexes  and  normal  electric  reactions  will 
distinguish  the  condition  from  a  true  atrophy,  due  to  peripheral  neuron 
disease. 

When  hemiplegia  follows  an  infectious  disease,  there  are  usually  con- 
vulsions, with  or  without  loss  of  consciousness,  foUoweil  by  paralysis  of  a 
similar  type  to  that  above  described 

Many  of  these  cases  show  mental  impairment,  and  suffer  from  epilep- 
tiform convulsions.  They  are  specially  prone  to  develop  spasmodic  con- 
ditions, such  slS  posthemiplegic  chorea  and  athetosis.  The  former  consists 
of  choreiform  movements  developing  in  the  paralyzed  limbs.  There  is 
also  a  condition  consisting  of  intermittent  tonic  spasms  aff'ecting  groups 
of  muscles  called  hemihypertonia  postapoplectica.^  Athetosis  consists  of 
peculiar  slow,  worm-like  movements,  in  some  cases  only  of  the  fingers 
and  toes ;  in  others  the  arms  and  legs  are  also  affected,  and  more  rarely 
the  muscles  of  the  face.  There  is  a  marked  tendency  in  the  movements 
to  overextension,  and  they  are  increased  by  attempts  to  move  the  limbs. 
When  the  face  is  affected  various  grimaces  and  contortions  occur.  In 
some  cases  these  movements  are  the  most  prominent  feature  of  the  case, 
the  motor  paialysis  being  slight. 

Diagnosis. — This  should  not  be  difficult  if  attention  is  paid  to  the 
history  and  symptoms.  Paralysis  due  to  neuritis  or  anterior  poliomyelitis 
is  distinguished  by  muscular  atrophy,  absent  reflexes,  etc.   The  paraplegic 

I  Spiller,  PhUa  Med.  Jour.,  Dec.  16,  1899. 


APHASIA.  1175 

type  might  be  mistaken  for  the  hereditary  spinal  form  (p.  1143),  'J'he 
history  of  the  development  of  this  condition  and  absence  of  cerebral  symp- 
toms easily  distinguish  the  two.  Athetosis  may  be  mistaken  for  chorea; 
the  history  and  presence  of  evidence  of  disease  of  the  pyramidal  tracts 
and  rhythmic  character  of  the  movements  are  sufficient  to  make  the  dis- 
tinction. 

Prognosis  as  regards  duration  of  life  is  good,  as  regards  disability 
and  cure,  is  bad.  The  symptoms  may  be  relieved.  If  the  diagnosis 
of  hemorrhage  during  labor  can  be  made,  the  skull  may  be  opened  and 
the  clots  removed,  as  has  been  successfully  done  by  Cushing.i  If  spas- 
ticity is  much  greater  than  paralysis,  relief  may  be  obtained  by  cutting 
some  of  the  posterior  nerve-roots,  as  recommended  for  lateral  sclerosis 
(p.  1141).  Usually  the  treatment  consists  in  passive  movements  and 
electricity  applied  to  the  extensor  muscles  to  overcome  the  spasticity. 
Tenotomies  and  tendon  transplantations  may  also  be  necessary.  The 
failure  of  mental  power,  if  it  exists,  must  be  treated,  if  not  too  extreme, 
by  proper  educational  measures,  and  the  epileptiform  convulsions,  if  they 
occur,  by  the  measures  recommended  for  that  disease  (p.  1208). 


APHASIA. 


Definition. — By  aphasia  is  meant  either  a  partial  or  complete  loss 
of  the  power  of  either  expression  or  comprehension  (or  of  both  combined) 
of  any  of  the  usual  signs  of  language,  not  dependent  upon  lesions  of  the 
peripheral  nerves  or  organs,  but  upon  lesions  of  the  cortical  centers  con- 
cerned in  speech,  or  the  tracts  connecting  them. 

Htiology. — Aphasia,  in  most  cases,  and  practically  always,  if  per- 
manent, is  due  to  a  destructive  lesion  of  either  the  centers  or  tracts  above 
mentioned.  Usually  this  is  either  caused  by  a  cerebral  hemorrhage  or 
acute  softening  (vide  apoplexy),  and  is,  therefore,  frequently  associated 
with  hemiplegia.  It  may,  however,  be  caused  by  any  organic  lesion,  as 
tumor,  encephalitis,  or  abscess.  Transient  aphasia  may  be  caused  by  so- 
called  functional  disturbances.  It  may  follow  severe  fright,  anger, 
hemorrhage,  and  exhaustion ;  occur  as  a  symptom  of  migraine,  or  be 
caused  by  toxemias,  as  uremia,  gout,  vegetable  and  mineral  poisons,  and 
infectious  diseases. 

The  Gf-enesis  of  Speech  and  Location  of  Centers. — To  properly  under- 
stand the  development  of  the  symptoms  of  aphasia,  some  knowledge  of 
the  evolution  of  lanaruao-e  is  es£::"atial.  The  child  learns  to  understand 
language  before  he  can  utter  it.  Through  the  different  senses  he  per- 
ceives the  different  characteristics  and  appearance  of  an  object.  These 
percepts  are  stored  away  in  the  brain,  and  gradually  the  child  learns  to 
associate  the  name  that  he  hears  applied  to  a  certain  object  with  that 
object.  The  memory  of  the  sound  of  this  word  is  stored  in  the  center 
for  word  memories,  which  is  in  the  first  temporal  convolution  of  the  left 
side  in  right-handed  persons,  and  vice  versa  in  those  who  are  left  handed. 
Whenever  this  word  is  used,  the  various  characteristics  of  the  object  are 

^  Amer.  Jour.  Med.  Sci.,  Oct.,  1905,  p.  563. 


1176  DISEASES  OF  TflE  yERVOUS  SYSTEM. 

at  once  brought  into  consciousness  by  a  stimulation  of  the  different  centers 
where  the  memories  of  these  characteristics  are  stored.  Eventually  the 
child  learns  to  make  the  various  coordinated  muscular  movements  neces- 
sary to  pronounce  the  word.  The  memory  of  necessary  movements  of 
the  lips  (tonj^ue,  larynx)  required  to  pronounce  a  word  ax"e  also  stored  in 
a  center,  which  in  right-handed  persons  is  the  foot  of  the  third  left  frontal 
convolution  (Brocas  convolution  psychomotor  center,  glossokinesthetic 
center  of  Bastian).  The  exciting  of  one  of  these  centers  excites  the 
others  ;  thus,  if  we  hear  the  ringing  of  a  bell,  a  mental  imatje  of  the  other 
characteristics  of  the  bell  is  formed,  and  the  proper  word  designating  that 
image  comes  into  consciousness  by  stimulation  of  the  center  for  word 
memories.  If  it  is  desired  to  pronounce  the  word,  an  impulse  is  sent  from 
this  center  to  Brocas  convolution,  which  starts  in  motion  the  various 
movements  of  the  organs  of  speech  necessary  to  pronounce  the  word. 

Even  if  a  word  is  not  audibly  pronounced,  mental  images  of  Avords 
enter  into  thought  processes,  as  do  also  the  muscular  movements  necessary 
to  pronounce  the  Avord.  This  is  constantly  being  done  in  silent  thinking, 
when  the  sounds  of  words  are  mentally  recalled  without  visible  move- 
ments of  the  muscles  necessaiy  to  pronounce  the  word  being  made.  This 
has  been  termed  the  internal  language. 

We  learn  to  read  by  associating  the  visual  appearance  of  certain  sym- 
bols with  the  sound  previously  acquired  of  the  respective  letters  and 
words.  These  so-called  visual  memories  are  also  stored  in  the  cerebral 
cortex,  probably  in  the  angular  gyrus  and  its  vicinity.  When  one  reads 
aloud,  the  words  are  first  recognized  by  the  visual  center,  which  calls  up 
the  corresponding  sound  in  the  auditory  center,  from  which  the  glosso- 
kinesthetic center  is  stimulated,  and  the  memory  of  the  required  muscle- 
movements  necessary  to  articulate  the  word  is  called  up.  Then  through 
the  centers  for  these  muscles  in  the  foot  of  the  precentral  convolution 
(Fig.  79)  the  word  is  pronounced.  When  we  read  silently,  the  same 
process  takes  place  by  means  of  the  internal  language. 

In  learning  to  write  the  visual  perception  of  the  letters  is  associated 
with  certain  muscular  movements  of  the  fingers  and  arms  necessary  to 
make  them.  These  memories  are  kept  in  the  second  frontal  convolution 
of  the  left  side  (in  right-handed  people).  This  center  has  been  termed  the 
writing  or  cheirokinesthetic  center.  As  in  writing,  each  letter  is  self-dic- 
tated by  means  of  either  the  spoken  or  internal  language,  the  other  centers 
involved  in  these  processes  are  first  excited.  Reference  to  Fig.  79  will 
show  the  location  of  the  centers  mentioned  andtlieir  probable  connections. 

From  the  foregoing  it  will  be  seen  that  while  each  center  has  certain 
functions,  these  are  more  or  less  dependent  upon  each  other.  It  has  been 
observed  that  a  lesion  developing  suddenly  in  one  center  causes  more  or 
less  interference  in  the  function  of  the  others ;  this  is  especially  the  case 
soon  after  the  onset;  later,  permanent  symptoms  more  closely  related  to  the 
affected  center  remain.  These  early  symptoms  have  been  explained  by 
von  Monakow'  to  be  due  to  a  lowering  of  functional  activity  in  a  more  or 
less  distant  part  of  the  speech  mechanism,  due  to  the  upsetting  of  the  bal- 
ance between  the  several  parts  of  this  mechanism  produced  by  the  de- 
struction of  one  of  the  integral  parts  by  the  lesion.  lie  termed  this 
diaschisis. 

'  Neurol.  CentralbUUt,  November,  1906,  p.  1026. 


APHASIA. 


1177 


Classification. — Based  on  whether  the  receptive  or  emissive  func- 
tion is  affected,  aphasia  has  been  divided  into  sensory  and  motor.  Sensory 
aphasia  (Wernicke)  is  present  when  the  perif)heral  apparatus  being 
intact,  the  patient  is  either  unable  to  understand  the  ];iniriiage  which  he 
has  been  accustomed  to  use  or  is  unable  to  recognize  the  meaning  of  the 


1/  W 


Fig.  79.— Diagram  showing  probable  pathways  of  nervous  impulses  concerned  in  speech  and 
■writing:'  A,  Center  for  auditory  word  memories  in  first  temporal  convolution;  V,  center  for  vis- 
ual word  memories  in  angular  gyrus ;  GK,  glossokinesthetic  center  (Bastian),  or  psychomotor 
center,  at  foot  of  third  temporal  convolution ;  U,  centers  for  muscles  involved  in  articulation  at 
foot  of  central  convolution ;  CK,  probable  centers  for  memory  of  muscular  movements  involved  in 
writing  (cheirokinesthetic  center  of  Bastian) ;  W,  centers  for  controlling  muscles  of  arm  and  hand 
in  central  convolutions ;  A-A',  tract  from  cortex  of  temporal  lobe  (auditory  centers)  to  center  for 
word  memories  ;  V-V,  tract  from  cuneus  to  center  for  visual  memories  ;  AV-W',  tract  from  arm  and 
hand  centers  to  cells  in  anterior  horns  of  cord  and  peripheral  nerves  controlling  these  muscles 
(pyramidal  tract) ;  U-U',  tract  from  centers  for  muscle-s  of  articulation  to  centers  in  pons  and  me- 
dulla and  nerves  controlling  those  muscles  (pyramidal  tract).  In  speaking,  impulses  travel  from 
A-GK-U-U' ;  in  reading  aloud,  from  V-A-GK-U-U' ;  in  silent  reading,  from  V-A-GK ;  in  writing 
spontaneously,  V-A-GK-CK-W-W' ;  in  writing  from  dictation,  A-V-GK-CK-W-W" ;  in  copying, 
V-CK-W-W' ;  N,  naming  center  (?) ;  S,  center  for  stereognostic  sense  in  parietal  lobe  (Potts). 

symbols,  either  written  or  printed,  with  which  he  was  once  familiar.  In 
other  words,  he  hears,  but  the  once  familiar  sounds  are  to  the  patient  as 
a  foreign  language ;  he  sees  them,  but  they  look  to  him  as  those  of  a  for- 
eign language,  and  he  cannot  read  understandingly.  The  former  is  known 
as  word-deafness  or  auditory  aphasia,  the  latter  as  ivord-hlindness,  alexia, 
or  visual  aphasia. 

Closely  related  to  this  is  a  form  termed  by  Freund  optic  aphasia,  in 
which  the  patient  when  shown  an  object  with  which  he  was  once  familiar 
is  unable  to  call  up  its  name.  He  is,  however,  able  to  pronounce  the 
name  when  he  hears  it.  This  symptom  is  termed  anomia,  and  is  prob- 
ably due  to  a  lesion  in  the  center  N  (Fig.  79)  or  one  of  the  tracts,  SX, 
VN,  or  AN,  for  the  reason  that  naming  an  object  depends  upon  the  rec- 
ognition of  its  visual,  auditory,  or  tactile  characteristics.  Another  is  the 
form  known  as  mind  or  psychic  blindness,  in  which,  in  addition  to  loss  of 
the  power  of  reading,  there  also  is  inability  to  distinguish  between  objects 
and  persons  and  to  know  the  proper  use  of  things.     This  last  is  known 

'  In  right-handed  persons  these  centers  and  tracts  are  situated  in  the  left  side  of  the 
bi-ain ;  in  left-handed  persons  they  are  situated  in  the  right  side  of  the  brain. 


1178  DISEASES  OF  THE  NERVOUS  SYSTEM. 

as  apraxia  (p.  1179).  Miiul-blindness,  therefore,  is  Avord-blindness  plus 
apraxia. 

Motor  aphasia  (Broca's),  or  aphemia,  is  present  when  the  patient,  the 
peripheral  spoecli  a])paratus  (lips,  tongue,  larynx)  being  intact,  is  unable 
either  jiartially  <»r  eonipletely  to  give  utterance  to  his  thoughts.  Loss  of 
the  power  of  writing,  not  dependent  upon  paralysis  of  tiie  muscles,  is 
termed  auraphia.  It  is  usually  associated  either  with  motor  aphasia  or 
word-blindness. 

When  a  patient  is  able  to  speak  and  read  several  languages,  he  may, 
in  some  cases,  only  be  aphasic  for  one  of  them.  He  may  be  able  to  read 
letters  when  he  cannot  words  ;  printed  symbols,  when  he  cannot  written 
ones  ;   figures  and  not  letters,  and  vice  versd. 

Holated  to  speech  is  gesture.  Loss  of  tbe  power  of  understanding  or 
employing  gesture  is  known  as  amimia.  Sometimes,  either  with  or  with- 
out defects  of  ordinary  speech,  there  is  loss  of  the  power  in  those  who 
once  possessed  it  to  either  produce  or  comprehend  musical  sounds.  This 
is  termed  amima. 

In  some  cases  the  patient  may  be  able  to  speak,  but  he  skips  words 
and  uses  wrong  ones.  This  is  termed  paraj)hasia  or  conduction  aphasia, 
being  due  to  a  lesion  in  the  tract  A-GK,  Fig.  7'J.  Aphasia  is  also  di- 
vided into  cortical  and  subcortical ;  the  symptoms  of  each  follow : 

Cortical  Auditory  Aphasia. — The  lesion  is  at  A.  There  would  be  loss 
of  the  power  of  understanding  spoken  words  ;  words  could  not  be  re- 
peated or  written  from  dictation.  Stimulation  of  this  center  being  neces- 
sary to  activate  GK,  spoken  speech  would  be  defective,  wrong  words  used, 
and  paraphasia  result.  The  internal  language  also  being  interfered  with, 
the  power  of  reading  and  writing  is  defective  (tracts  V— A— GK.  Fig.  79). 

Subcortical  Auditory  Aphasia. — The  lesion  is  in  the  tract  A-A',  the 
center  A  being  intact.  The  patient  is  unable  to  understand  spoken 
words  Reading  and  writing  from  dictation  are  not  well  performed. 
Some  paraphasia  is  present,  as  the  patient,  when  he  pronounces  a  word, 
is  unable  bv  hearinji  to  recognize  its  cori'ectness.  The  internal  language 
is  intact  and  word  memories  can  be  recalled  (A) ;  hence  silent  reading 
and  writing  are  not  interfered  with  (tract  V-A-GK,  Fig.  79). 

Cortical  Visual  Aphasia. — Lesion  in  center  V.  There  is  inability  to 
read  (alexia)  aloud  or  silently,  to  write  spontaneously  from  dictation,  or 
to  Copy  understandingly.      Speech  is  not  interfered  with. 

Subcortical  Visual  Aphasia. — Lesion  in  tract  V— V,  loss  of  ability  to 
read  and  copy  understandingly.  Through  the  tract  V— CK  he  can  copy 
mechanically.  The  center  V  being  intact,  visual  memories  can  be  re- 
called ;  hence  he  can  write  imperfectly,  as  one  with  his  eyes  closed. 

Cortical  Motor  Aphasia. — Lesion  in  center  GK.  Spontaneous  speech, 
repeating  words,  and  reading  aloud  are  either  completely  or  partially 
lost.  Owing  10  the  loss  of  the  internal  language,  the  ])Ower  of  silent 
reading  and  writing  is  also  lost  (V-A-GK,  Fig.  79).  Language  is 
understood. 

Subcortical  Motor  Aphasia. — Lesion  in  tract  GK-U.  Spontaneous 
speech,  repeating  Avords,  and  reading  aloud  are  lost.  The  internal  lan- 
guage being  intact  (A  and  GK),  silent  reading  and  writing  are  not  inter- 
fered with.     Language  is  understood. 


APHASIA.  1179 

Two  or  more  of  these  ceutei'S  or  tlieir  connecting  tracts  may  be  dis- 
eased, and  then  a  com]jined  motor  and  sensory  aphasia  will  result.  See 
also  p.  117(5. 

Marie's  Theory  of  Aphasia. — The  above  is  a  presentation  of  the  com- 
monly accepted  views  upon  this  snijject.  In  1906  Marie  ^  denied  the 
truth  of  these  views  and  advanced  those  entirely  different.  While  these 
in  their  entirety  have  not  been  generally  accepted,  a  brief  mention  of 
them  should  be  made.  Tie  denies  that  the  third  frontal  convolution  has 
anything  to  do  with  speech.  lie  believes  that  the  only  speech  center  is 
the  zone  of  Wernicke,  which  consists  of  the  supramarginal  and  angular 
gyri  and  the  posterior  part  of  the  first  two  temporal  convolutions.  This 
region  is  not  one,  however,  in  which  sensory  imnges  or  memories  are 
stored  up,  but  is  a  purely  intellectual  center.  A  lesion  in  this  region 
causes  the  symptoms  described  above,  under  Sensory  Aphasia,  and 
termed  by  him  Wernicke's  aphasia.  He  denies  the  existence  of  either 
pure  word-deafness  or  pure  word-blindness,  and  of  cortical  and  subcortical 
varieties.  What  is  generally  termed  motor  aphasia  is  the  above  form 
plus  anarthria.  Anarthria  occurs  when  the  lesion  involves  the  lenticular 
zone,  which  is  an  area  comprised  between  a  line  passing  in  a  transverse 
direction  from  the  anterior  fissure  of  the  island  of  Reil  to  a  corresponding 
point  in  the  lateral  ventricle,  and  a  line  in  a  similar  direction  from  the 
posterior  fissure  of  the  island  of  Reil  to  a  corresponding  point  of  the 
lateral  ventricle.  Within  this  are  situated  the  caudate  and  lenticular 
nuclei,  the  external  capsule,  the  cortex  of  the  island  of  Reil,  and  the 
internal  capsule.  The  anarthria  or  aphemia  of  Marie  is  characterized  by 
loss  of  speech,  with  preservation  of  the  understanding  of  words,  of  reading 
and  writing.  It  is  an  interference  with  the  coordination  of  movements  re- 
quired for  phonation,  without  motor  paralysis.  As  has  been  previously 
stated,  what  is  commonly  termed  motor  or  Broca's  aphasia  is  this,  plus  a 
lesion  of  Wernicke's  zone,  which  produces  the  symptoms  usually  known 
as  sensory  aphasia. 

Closely  related  to  aphasia  are  apraxia  and  the  stereognostic  sense. 

Apraxia  has  been  divided  into  sensory  and  motor  or  dyspraxia.-  In 
the  former,  also  known  as  agnosia,  there  is  inability  to  recognize  a  hereto- 
fore familiar  object  by  any  one  of  the  senses,  and  hence  there  is  inability 
to  name  it.  Thus,  if  an  object  is  not  recognized  by  sight,  there  is  visual 
apraxia,  or  agnosia,  by  hearing,  auditory  apraxia,  or  agnosia,  and  so  on. 
Visual  agnosia  is  also  known  as  mind-blindness  (p.  3  095).  In  the  latter 
the  object  is  recognized,  but  the  patient  has  forgotten  how  to  use  it  in  the 
proper  way ;  thus  a  pencil  is  recognized  and  named,  but  the  patient  does 
not  know  Avhat  to  do  with  it.  These  symptoms  are  usually  due  to  lesions 
of  the  left  hemisphere  in  right-handed  people.  Motor  apraxia  has  been 
frequently  observed  when  the  lesion  was  either  in  the  first  and  second 
frontal  convolutions  of  the  left  side  or  in  the  corpus  callosum.  Stereog- 
nostic sense  is  the  name  given  to  memories  preserved  in  the  cerebral 
cortex  (parietal  lobe,  Fig.  79)  of  the  characteristics  of  objects  by  which 
we  are  enabled  to  recognize  them  without  seeing  them.  Thus,  when  a 
person  who  is  blindfolded  recognizes  that  an  object  placed  in  his  hand  is 

^  La  Semaine  Medicale,  May  23,  1906,  p.  241 ;  also  Dercum,  New  Yorfc  Med.   Jour., 
Jan.  5,  1907,  p.  7. 

2  Wilson,  Brain,  1908,  p.  164. 


1180  DISEASES   OF  THE  yERVOUS  SYSTEM. 

a  dollar,  he  does  so  by  his  memory  of  the  peculiar  shape,  hardness, 
weight,  etc.,  of  previous  dollars.  The  sense  depends  ajjon  a  eurrt'lation 
of  tactile,  jiressure,  muscle,  and  temperature  perceptions,  and  its  inter- 
pretation by  the  higher  psychic  centers  (parietal  lobe.  Fig.  79).  Loss  or 
diminution  of  any  one  of  the  above  forms  of  sensation  causes  loss  of  this 
sense,  which  has  been  termed  astercoc/nosis,  or  tactile  agnosia.  Lately  it 
has  been  proposed  to  restrict  this  term  to  inability  to  recognize  the  shape 
and  consistence  of  objects,  while  inability  to  recognize  them  has  been 
termed  nsi/rnbolia. 

Diagnosis  of  Aphasia. — This  depends  upon  the  presence  of  the 
symptouis  detailed  above,  the  peripheral  apparatus  being  intact.  This 
will  serve  to  differentiate  it  from  speech  defects  due  to  paralysis  of  the 
muscles  concerned  in  speech,  such  as  occurs  in  bulbar  and  pseudo-bulbar 
palsy.  Motor  aj)hasia  is  more  common  than  sensory.  The  condition  is 
usually  associated  with  a  right-sided  hemiplegia,  due  to  a  lesion  (throm- 
bosis) in  the  middle  cerebral  artery,  but  may  be  due  to  any  destructive 
lesion,  as  tumor,  encephalitis,  etc. 

Prognosis. — The  younger  the  patient,  the  better  the  outlook  for 
some  return  of  speech.  Improvement  may  continue  for  a  considerable 
time,  and  eventually  fiiir  power  return.     Many,  however,  never  improve. 

Treatment. — This  consists  of  reeducation  by  the  same  methods  as 
in  teaching  children  to  speak,  read,  and  write. 


PROGRESSIVE  LENTICULAR  DEGENERATION. 

This  is  a  rare  condition  described  by  Wilson.^  It  may  attack  several 
members  of  a  family,  but  is  not  hereditary.  It  always  occurs  in  young 
people,  and  may  be  either  acute  or  chronic.  The  symptoms  consist  of 
bilateral  tremor  of  the  limbs  Avhich  is  increased  by  volitional  movement 
(sometimes  the  head  also  is  affected) ;  spasticity  of  the  limbs  and  face  ; 
dysphagia  and  dysarthria  and  finally  anarthria ;  sometimes  causeless 
laughter  and  emotionalism ;  difficulty  in  maintaining  the  equilibrium 
owing  to  the  spasticity ;  sometimes  transitory  mental  symptoms.  There 
is  no  real  motor  weakness,  and  the  reflexes  are  normal.  Cirrhosis  of  the 
liver  is  always  associated,  but  no  evidence  of  disease  of  the  liver  is  present 
during  life.  Death  occurs  in  from  six  months  to  five  years,  and  in  all 
the  cases  examined  a  bilateral  symmetrical  softening  of  the  lenticular 
nucleus  was  found.  Wilson  believes  it  to  be  due  to  a  toxin  which  prob- 
ably has  some  relation  to  the  cirrhosis  of  the  liver.  In  this  connection 
the  softening  of  the  lenticular  nuclei,  due  to  carbon  monoxid  poisoning, 
is  of  interest.^  These  cases,  the  symptoms  of  which  may  appear  several 
days  after  the  patient  has  apparently  recovered,  have  spasticity  of  the 
limbs  and  stupor,  the  reflexes,  however,  may  be  increased  and  the  Babinski 
phenomenon  present.^ 

J  Brain,  1912,  p.  295. 

'■^  Dana,  Jour.  Nerv.  and  Menl.  Dis.,  1908,  p.  65. 

8  McConnell  and  Spiller,  Jour.  Amer.  Mel.  -l.ssoc,  Dec  14,  1912,  p.  2122. 


surruRATTVE  ENCjEriiMjrrs.  llHl 

INFLAMMATION  OF  THE  BRAIN. 

{Encephalitis.) 

Definition. — Encephalitis,  strictly  speaking,  is  an  inflammation  of 
the  brain-substance,  and  does  not  include  inflammation  of"  the  meninges, 
though  in  many  instances  the  two  conditions  coexist  as  the  result  of  a 
common  cause,  or  one  may  precede  and  give  rise  to  the  other.  Encepha- 
litis is  met  with  in  two  forms — (a)  Suppurative  and  (Ij)  Hemorrhagic. 

SUPPURATIVE   ENCEPHALITIS. 
{Abscess.) 

Pathology. — In  very  acute  cases  no  time  is  given  for  encapsulation  ; 
when  of  longer  duration,  however,  the  abscess  is  well  circumscribed, 
having  a  well-defined  wall,  within  which  there  are  cell-detritus,  j)U8,  and 
sometimes  more  or  less  altered  blood.  It  may  be  offensive.  About  it 
the  brain-substance  is  generally  softened  and  edematous.  The  abscess  is 
generally  single,  except  in  pyemic  cases,  and  varies  greatly  in  size  in 
different  instances. 

etiology. — Abscess  of  the  brain  is  a  more  or  less  circumscribed 
process,  due  to  (1)  Injury. — In  the  majority  of  cases  of  abscess  following 
head-injuries  either  a  compound  fracture  of  the  skull  exists,  with  or  with- 
out hernia  cerebri  (fungus  cerebri),  or  a  punctured  wound  has  been  made. 
Less  commonly  it  may  follow  a  simple  fracture,  and  rarely  it  is  said  to 
occur  when  neither  a  fracture  nor  even  an  abrasion  of  the  scalp  has  been 
produced.  Meningitis  is  an  almost  invariable  concomitant.  (2)  Exten- 
sion from  some  neighboring  injlammatori/  focus,  as  from  orbital,  nasal,  or 
aural  disease,  in  which  the  bones  have  usually  become  affected.  (3) 
Pyemia,  in  which  case  the  abscesses  are  apt  to  be  small  and  multiple. 
It  is  also  met  with  occasionally  in  gangrene  of  the  lung,  bronchiectasis, 
ulcerative  endocarditis,  suppurative  hepatitis,  or  bone-disease,  and  rarely 
in  chronic  septic  processes.  (4)  Congenital  Heart-disease. — Little  is 
known  of  this  condition.  Within  the  past  two  or  three  years  Northrup, 
Packard,  Sir  Dyce  Duckworth,  and  Osier  have  reported  such  cases.  (5) 
Obstruction  of  an  artery,  vein,  or  sinus,  whether  of  spontaneous  origin 
or  the  result  of  ligature,  may  give  rise  to  abscess.  Generally,  however, 
the  cerebral  change  is  that  of  softening,  and  not  of  true  suppuration. 
(6)  Intracranial  tumors.  (7)  Infectious  fevers.  Inflammation  of  the 
middle  and  internal  ear  is  the  most  common  cause,  especially  if  the  tym- 
panum and  mastoid  cells  are  affected.  Most  cases  occur  between  the  ages 
of  ten  and  thirty. 

Symptoms. — These  vary  greatly  according  to  the  nature,  situation, 
and  size  of  the  abscess,  and  are  frequently  masked  or  confused  by  the 
coexistence  of  various  complications,  such  as  injury  to  the  head,  menin- 
gitis, septicemia,  or  an  infectious  disease.  In  acute  abscess  there  are  the 
symptoms  of  acute  septic  infection,  to  which  are  added  those  of  focal  dis- 
ease of  the  brain.  As  the  abscess  is  secondary,  the  septic  manifestations 
usually  appear  first.  They  are,  of  course,  chills,  fever,  leukocytosis,  etc. 
Often  the  primary  focus  can  be  recognized  as  endocarditis  or  pneumonia. 
The  febrile  process  continues,  there  is  usually  severe  delirium,  and 
finally  the  symptoms  of  brain  disease   develop,  either  slowly  or  abruptly. 


1182  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  general  symptoms  are  headncho.  vortisio.  vomiting,  and  convulsions, 
all  of  which  arc  very  constant  and  develop  early  ;  later,  depending  upon 
the  situation  of  the  abscess,  motor  and  sensory  disturliances  ajipear.  The 
most  common  are  hemiplegia,  clonic  Sjiasms.  irregular  involuntary  move- 
ments, aphasia,  hemiparesis,  and  hemianopsia.  Kcrnig's  sign  may  be 
present  if  the  motor  region  is  involved,  and  the  reflexes  are  usually 
greatly  exaggerated.  Congestion  of  the  eye-grounds  is  common,  but 
choked  disks  are  rare.      The  course  is  rapid  and  severe. 

Chronic  abscess  develops,  as  a  rule,  insidiously  ;  of  the  general  symp- 
toms, fever  of  a  hectic  type  is  most  important,  and  there  is  usually  a 
moderate  leukocytosis.  The  pulse  may  be  very  slow.  Headache,  often 
severe  and  localized,  is  common,  and  there  may  be  frequent  vomiting. 
There  is  often  vertigo,  occasionally  convulsions,  and  sometimes  choked 
disks.  Cachexia  may  also  occur.  The  focal  symptoms  are  of  the  utmost 
importance.  The  commonest  is  hemiparesis  of  the  opposite  side,  but  hemi- 
anopsia, hemihypesthesia,  or  unilateral  loss  of  the  muscle  sense,  and  aste- 
reognosis  may  also  be  piesent.  A  peculiar  feature  of  chronic  abscess  is  the 
slowly  progressive  character  of  the  symptoms,  indicating  extension  for- 
ward or  backward  in  the  line  of  least  resistance,  and  not  increasing  pressure 
in  one  place,  as  in  the  case  of  tumor.  Occasionally  the  abscess  ruptures 
spontaneously  into  one  of  the  cavities  of  the  head  (nasal,  aural),  and  tem- 
porary relief  may  be  experienced.  An  abscess  may  be  "  latent  "  in 
almost  any  region,  these  latent  abscesses  being  typified  in  certain  cases 
of  congenital  heart-disease.  I  do  not  think  they  were  suspected  during 
life  in  any  of  the  cases  reported  thus  far,  and  therefore  optic  neuritis  has 
not  been  looked  for.  When  the  abscess  is  due  to  ear  disease,  phlebitis  of 
the  lateral  and  superior  petrosal  sinuses  frequently  coexists ;  in  such 
cases  there  will  be  edema  about  the  ear  and  neck  and  hardness  of  the 
jugular  veins. 

Diagnosis. — In  the  acute  cases  following  injury  little  difficulty  pre- 
sents as  a  rule,  though  even  in  this  group  a  latent  period  may  exist. 
With  such  a  history,  however,  the  onset  of  headache,  fever,  delirium, 
and  convulsive  movements  is  decidedly  suspicious,  and,  should  optic 
neuritis  also  exist,  practically  no  doubt  can  remain.  When  aural  or  nasal 
disease  exists  the  head-symptoms  should  be  carefully  studied,  since  they 
are  prone  to  develop  in  ear  disease  soon  after  a  cessation  in  the  discharge. 
A  slow  pulse  associated  with  fever  is  very  characteristic  of  abscess. 

Differential  Diagnosis. — Brain-tumor  usually  runs  a  more  chronic 
course,  and  is  seldom  accompanied  by  fever,  at  least  not  until  its  final 
stage.  The  causes  of  abscess  are  absent,  excepting  in  the  case  of  tubercu- 
lar tumors,  when  abscess  may  be  associated.  It  may  be  impossible  to 
differentiate  cerebral  abscess  from  meningitis,  and  the  two  conditions 
often  coexist,  as  already  stated. 

The  prognosis  is  always  grave. 

Treatment. — When  an  abscess  is  diagnosed  immediate  operation  is 
indicated.  Suspected  cases  may  be  treated  symptomatically  unless  focal 
symptoms  develop.  It  must  be  remembered,  however,  that  in  a  great 
many  cases  no  localizing  symptoms  appear,  and,  since  Ave  know  that 
most  abscesses  occur  either  in  the  temporo-sphenoidal  lobe  or  in  the 
cerebellum,  when  we  have  reason  to  suspect  the  presence  of  one,  these 
regions  should  be  explored. 


INTRACRANIAL  GROWTHS.  1183 

ACUTE   HEMORRHAGIC   ENCEPHALITIS. 

Definition  and  Varieties. — This  is  a  condition  cliaracterized  by 
foci  of  inllamuiation  scattci-ed  tliroughout  the  gray  matter  of  the  brain 
that  are  not  accompanied  by  suppuration,  'i'iie  cortex  alone  may  be 
aifected  (encephalitis  of  Striimpell),  and  a  certain  number  of  cases  of 
cerebral  palsy  in  children  (p.  1173)  are  due  to  the  process  being  localized 
in  the  motor  region.  Adults  may  be  also  attacked.  The  gray  matter 
about  the  aqueduct  of  Sylvius,  with  involvement  of  the  nuclei  of  motor 
nerves  of  the  eye,  is  a  frequent  seat  (polioencephalitis  superior  of  Wernicke). 
The  nuclei  of  other  motor  cranial  nerves  may  be  affected  (acute  bulbar 
palsy  or  polioencephalitis  inferior).  The  cerebellum  may  also  be  involved. 
These  forms  may  occur  either  separately  or  combined. 

Etiology. — These  are  chiefly  chronic  alcoholism  and  the  acute  in- 
fectious diseases,  especially  influenza.  Lead-,  ptomain-poisoning,  and 
trauma  may  also  be  causes.  It  is  more  common  in  children  and  young 
adults. 

Morbid  Anatomy. — This  consists  of  hyperemia,  hemorrhage, 
round-cell  infiltration,  degenerated  blood-vessels  and  nerve  cells  in  the 
affected  areas.  Poliomyelitis  may  be  associated,  they  being  similar 
affections. 

S3miptoniS. — General  symptoms,  as  headache,  convulsions,  vertigo, 
stupor,  delirium,  rigidity  of  the  neck,  more  or  less  elevation  of  tempera- 
ture, sometimes  preceded  by  chills,  may  be  present.  The  focal  symptoms 
depend  on  the  areas  involved.  The  symptoms  of  acute  polioencephalitis 
Buperior  and  inferior  are  given  on  pages  1098  and  1129.  If  the  motor 
cortex  is  involved,  there  may  be  convulsions  of  the  Jacksonian  type, 
paralysis,  either  monoplegic,  hemiplegic,  or  diplegic,  with  increased 
reflexes  and  the  Babinski  phenomenon.  Ataxia,  hemianesthesia, 
aphasia,  and  optic  neuritis  may  also  be  present.  Either  the  symptoms 
of  poliomyelitis  or  a  general  diffuse  myelitis  may  co-exist. 

Diagnosis.  Any  combination  of  the  above  symptoms  following 
one  of  the  causes  given,  especially  if  any  of  the  general  symptoms  are 
also  present,  would  be  suggestive.  Meningitis  might  be  confounded,  es- 
pecially in  the  early  stages.  Lumbar  puncture  might  be  of  service  in 
distinguishing  the  two. 

Prognosis. — This  is  grave,  but  recovery  may  occur.  In  those  that 
do,  some  permanent  paralysis  or  epilepsy  may  remain. 

Treatment. — This  consists  of  ice-bags  to  the  head,  purgation  with 
calomel,  hexamethylenamin  in  full  doses,  and  bromids  and  other  seda- 
tives if  there  are  restlessness  and  delirium.  Otherwise  the  treatment  is 
symptomatic. 

INTRACRANIAL  GROWTHS. 

{Brain  Tujnors.) 

Owing  to  their  close  relationship,  new  growths,  both  of  the  brain  and 
membranes,  are  here  considered. 

Pathology. — Rindfleisch  has  classified  intra-cranial  tumors  according 
to  the  tissue  from  which  they  spring,  thus : 

1.   Having  their  origin  in  the  membranes,  either   extra-cerebi'al   or 


1184  DISEASES  OF  THE  yERVOUS  SYSTEM. 

iiitra-ventricular ;  these  include  tubercle,  gumma,  carcinoma,  sarcoma, 
myxoma,  lipoma,  cholesteatoma,  and  psanimoma  ;  small  fibroids  have 
also  been  described.  Enchondroma  and  osteoma  may  arise  from  the  falx 
or  from  the  bones  of  the  skull. 

2.  From  blood-vessels :  to  this  group  belong  aneurysms,  tubercles, 
and  gummata. . 

3.  Oriijinating  in  the  neurogb'ar  tissue  :  glioma. 

4.  Originating  in  the  connective  tissue  :  sarcoma. 

I  will  here  consider  these  new  growths  in  the  order  of  frequency 
with  which  they  are  met. 

1,  Tubercle  is  most  common  in  children  and  young  adults,  and  is  gen- 
erally multiple  (see  Tuberculosis,  p.  286). 

2.  Sarcoma  is  usually  of  the  round-  or  spindle-celled  variety ;  there 
may  also  be  melanotic  lympho-  or  fibro-sarcomata.  Sarcomata  are  apt  to 
diffuse  themselves  through  the  brain-substance  quite  rapidly. 

8.  Glioma. — Infiltrating  tumors,  generally  single,  and  showing  no  def- 
inite line  of  demarcation  from  the  surrounding  brain-structure.  They 
may  be  soft,  even  telangiectatic,  or  quite  firm.  They  often  run  a  very 
chronic  course. 

4.  Gummata  are  generally  small  and  often  multiple.  They  spring 
from  the  membranes  or  the  adventitia  of  blood-vessels,  or  from  connective- 
tissue  septa.  Frequently  they  are  attached  to  the  periosteum  of  the 
skull. 

5.  Carcinomata  are  secondary  growths,  and  are  generally  small  and 
round,  but  in  some  cases  they  perforate  the  bones  of  the  skull,  producing 
a  fungus  hematoides. 

6.  Fibromata  are  not  common.  They  either  grow  in  the  membranes 
or  aid  in  the  formation  of  a  mixed  tumor;  as  fibro-sarcoma.  Other  tumors 
met  with  less  frequently  are  as  follows :  7.  Osteoma;  <S.  Enchondroma; 
9.  Myxoma;    10.  Lipoma;    11.  Angioma;    12.  Cholesteatoma. 

13.  Hydatids  are  rare,  especially  in  America.  They  may  develop 
in  any  part  of  the  brain  or  its  membranes,  and  are  said  to  occur  most 
frequently  in  children.  14.  Cysticerci  may  also  occur  in  the  brain  or 
its  membranes. 

15.  Brain-cysts  are  probably  most  often  due  to  absorption  of  areas  of 
softening  from  any  cause,  but  they  also  occur  between  the  dura  and  skull, 
as  has  been  described.  The  lack  of  cerebral  substance,  due  either  to 
imperfect  development  or  to  atrophy  following  vascular  obstruction  or 
injury  at  birth,  has  been  termed  porencephalia  by  Hesche. 

l^tiologfy. — Age  and  sex  are  the  chief  factors ;  tuberculosis  is  far 
more  common  in  children  than  in  adults,  while  gummata  when  found 
appear  almost  invariably  in  adults,  as  do  malignant  growths.  As  a  whole, 
new  growths  are  more  common  between  the  twentieth  and  fortieth  years, 
and  males  are  more  often  affected  than  females.  Traumatism  seems  to  be 
an  exciting  cause  in  some  instances. 

Symptoms. — These  are  (1)  General,  and  (2)  Focal. 

General  Symptoms. — Headache  varies  in  degree  and  character ;  it  is 
not  of  any  value  as  a  localizing  symptom,  nor  is  tenderness  on  pressure. 
Tenderness  upon  percussion,  however,  is  often  detected  in  the  neighbor- 
hood of  the  tumor. 


JNTRAGRANTAL   (JROWTIIS.  1185 

Vertigo  in  a  mild  form  is  ({uitc  a  common  symptom.  Tn  cer(;]jcllur 
cases  it  is  often  very  marked. 

Vomiting  occurs  in  most  cases,  and  generally  bears  no  relation  to  the 
time  of  taking  food;  this  constitutes  an  important  point  in  the  diagnosis. 
The  vomiting  is  apt  to  be  exaggerated  in  cerebellar  tumor. 

Papilledema  or  choked  disk  (p.  1092)  is  present,  according  to  Gowers, 
in  four-fifths  of  all  cases  ;  in  82  per  cent,  according  to  Oppenheim,  and 
in  two-thirds  according  to  Knapp.  It  occurs  most  frequently  and  early 
in  tumors  beneath  the  tentorium.  It  may  develop  rapidly  and  ](;ad  to 
complete  blindness  by  the  development  of  consecutive  atrophy,  or,  more 
slowly,  and  even  show  very  little  if  any  loss  of  sight  for  a  long  time.  It 
is  usually  bilateral,  but  often  more  pronounced  on  one  side  than  the  other. 
In  many  cases  this  is  on  the  side  of  the  growth.  In  rare  cases  there  is 
progressive  atrophy  of  the  nerves  without  swelling.  Headache,  vomiting, 
and  cliohed  disk  are  "  classical  symptoms  "  of  brain-tumor,  and  when  met 
with  simultaneously  are  quite  characteristic.  Reversal  and  interlacing 
of  the  color  fields  may  also  be  met  with  (p.  1231). 

Mental  disturbance  is  very  common.  Dulness  and  stupor  are  most 
reliable  evidences  of  intracranial  growth,  and  especially  when  occurring 
with  any  of  the  above  symptoms.  The  patient  may  be  emotional  or 
hysteric.  Pseudo-apoplexy  may  occur  as  the  result  either  of  the  growth 
or  of  hemorrhage  taking  place  about  it. 

Convulsions  are  focal,  either  Jacksonian  (p.  1207)  or  general,  depend- 
ing on  the  location  of  the  lesion. 

Constitutional  ayid  other  symptoms  may  include  progressive  weakness, 
loss  of  appetite  and  of  flesh,  amenorrhea,  infantilism,  pupillary  changes, 
and  changes  in  the  pulse,  respiration,  etc.,  and  possibly  slight  fever.  In 
certain  tumors  in  the  basal  ganglia  hyperpyrexia  occurs.  High  fever  is 
often  significant  of  meningeal  inflammation,  as  in  syphilitic  cases. 

The  focal  symptoms  are  of  two  kinds :  first,  those  due  to  direct  local 
action  (irritation  or  compression),  and  second,  those  due  to  changes 
occurring  about  the  growth — indirect  irritation,  hemorrhage  or  softening, 
or  merely  congestion  ;  thus  can  intermission  or  remission  in  symptoms  be 
explained.     The  chief  regional  symptoms  are  as  follows  in — 

(a)  Tumors  in  the  prefrontal  region.  Headache,  not  limited  to  the 
frontal  region,  with  more  or  less  mental  impairment  and  drowsiness 
(though  this  is  not  constant  by  any  means) ;  and  perhaps  a  disturbance  of 
the  sense  of  smell.  No  motor  or  sensory  symptoms  are  present,  as  a  rule, 
although  vertigo  and  ataxia  of  the  cerebellar  type  have  been  observed. 
The  tumor  may,  however,  grow  backward,  and  either  encroach  on  the 
motor  region  or  cause  motor  symptoms  indirectly.  Downward  growth 
would  result  in  aphasia.  A  tendency  to  punning  or  joking  has  been 
noticed  in  some  cases. 

(6)  Tumors  in  the  motor  region.  The  early  symptoms  are  irritative 
and,  later,  paralytic.  The  former  give  rise  to  spasm,  which  is  often  very 
localized  at  first,  possibly  in  a  few  muscles  (Jacksonian  epilepsy).  The 
point  of  origin  and  direction  of  spread  of  the  spasm  are  valuable  local- 
izing symptoms.  Sooner  or  later  destruction  of  the  area  eauses  paralysis. 
We  may  have  spasm  in  one  limb  and  monoplegia  of  the  other  on  the 
same  side.  It  may  be  necessary  at  times  to  decide  if  a  growth  involved 
the    cortex   primarily   or  is  subcortical.     In  the  former  case  muscular 

75 


1186  DISEASES  OF  THE  XERVOUS  SYSTEM. 

spasm  usually  occurs  before  paralysis,  while  in  the  latter  paralysis  appears 
first,  the  Jacksonian  attack  not  occurrin<^  until  the  tumor  has  extended 
to  the  cortex.  Involvement  of  the  left  thiril  frontal  rejiion  causes  motor 
aphasia. 

(c)  Tumors  in  the  parietal  lobes.  There  is  usually  ataxia  of  the 
limbs  of  the  opposite  side  and  astereognosis ;  later  on,  homonymous 
hemianopia.  and  if  the  ascending  parietal  convolution  (Fig.  68)  is  in- 
volved, diminution  of  tactile  sensibility  may  be  present.  AVhen  the  pos- 
terior part  of  the  loft  side  is  involved  (angular  or  supramarginal  gyri)  we 
may  meet  with  word-blindness  or  mind-])lindness. 

((/)  Tumors  in  the  temporal  lobes  may  be  latent,  or  there  ma}-  be  dis- 
turbances of  taste  and  smell.  If  the  posterior  part  of  the  first  convolu- 
tion of  the  left  side  is  involved,  we  have  word-deafness  or  other  psychical 
disturbance  of  hearing,  giving  rise  to  auditory  aphasia. 

[e)  Tumors  in  the  occipital  lobes.  A  unilateral  tumor  produces  lateral 
homonymous  hemianopsia,  in  Avhich  the  Wernicke  hcmi:mopic  pupillary 
inaction  sign  is  absent,  while  a  bilateral  lesion  may  cause  blindness.  In 
certain  cases,  too,  mind-blindness  results,  or  "soul-blindness,"  as  it  was 
at  one  time  called  (p.  1178).  Visual  hallucinations,  as  flashes  of  light, 
may  also  occur. 

(/)  Tumors  of  the  corpus  eallosum  are  often  latent;  they  may,  how- 
ever, cause  unilateral  or  bilateral  motor  symptoms.  Often  some  mental 
aberration  is  noted.     Motor  apraxia  may  also  be  present  (p.  1179). 

((jr)  Tumors  of  the  corpora  quadrigemiyia,  owing  to  their  relations  to 
the  cerebellum,  often  cause  disturbances  of  gait  similar  to  that  caused  by 
disease  of  that  organ.  There  is  also  more  or  less  paralysis  of  the  motor 
nerves  of  the  eye  and  loss  of  the  power  of  associated  movements  of  the 
eyes  upward.  There  may  also  be  lateral  homonymous  hemianopsia 
(Wernicke  hemianopic  pupillary  inaction  sign  present)  and  deafness. 
There  may  also  be  weakness  of  the  opposite  side. 

(h)  Tumors  of  the  crus  often  cause  a  peculiar  type  of  crossed  hemi- 
plegia, in  which  the  face,  arm,  and  leg  are  involved  on  the  opposite,  and 
the  muscles  sup))lied  by  the  third  nerve  (eye-muscles)  on  the  same  side. 
There  may  also  be  hemianesthesia  (syndrome  of  Weber). 

(i)  Tumors  involving  the  ba.^e,  when  growing  in  the  anterior  fossa, 
give  rise  to  exophthalmos,  disturbances  of  smell  and  vision,  and  possibly 
to  mental  impairment.  When  in  the  middle  fossa  the  symptoms  are 
chiefly  those  of  involvement  of  the  third  and  fifth  nerve,  consisting  of 
ptosis  and  other  oculomotor  symptoms  and  facial  neuralgia,  Avith  anes- 
thesia in  the  distribution  of  the  fifth  nerve.  When  such  anesthesia 
associated  witli  pain  is  alone  present,  it  indicates  tumor  or  other  destruc- 
tive disease  of  the  Gasserian  ganglion.  When  the  tumor  involves  the 
pituitary  gland,  temporal  hemianopsia,  amblyopia  or  amaurosis,  optic 
atrophy,  and  frontal  headache  occur.  If  the  functions  of  the  gland  are 
diminished,  the  syndrome  of  Frrihlich  {di/stropJiia  adiposogenitalis,  adi- 
posis cerebralis)  develops.  In  this  we  may  find  adiposity,  lack  of  sexual 
development,  abnormal  tolerance  for  sugar,  lack  of  hair,  subnormal  tem- 
perature, polyuria,  polydipsia,  dry  skin,  and  sometimes  epileptiform  con- 
vulsions (see  Acromegaly).  Tumors  have  been  found  in  this  region  in 
cases  of  acromegaly  {q.  v.).    When  in  the  posterior  fossa,  facial  neuralgia, 


INTRACRANIAL   GROWTHS.  1187 

neuroparalytic  ophthalmia,  or  seventh  or  eighth  nerve  involvement  and 
crossed  hemiplegia  are  met  with. 

{j)  Tumors  in  or  about  the  hai^al  ganc/lia,  if  quite  small,  cannot  be 
diagnosed.  When  of  larger  size  those  involving  the  thalamus  may  cause 
hemiplegia  and  hemianesthesia  by  pressure  upon  the  internal  capsule, 
and  lateral  homonymous  hemianopsia  by  pressure  on  the  optic  radiation. 
They  may  also  cause  obstruction  and  consequent  distention  of  the  ven- 
tricles (internal  hydrocephalus).  They  may  also  give  rise  to  amimia 
(contralateral  paresis  of  the  face  only  during  laughing  or  weeping)  and 
hemichorea  or  athetosis.  The  functions  of  the  corpus  striatum  are  not 
well  understood,  but  lesions  of  the  lenticular  nucleus  are  believed  to 
cause  either  anarthria  or  dysarthria  (pp.  1179  and  1180).  Weakness  of 
a  monoplegic  or  hemiplegic  type  may  also  be  caused. 

{k)  Tumors  in  the  Gerehetlum  are  comparatively  frequent,  both  in 
children  and  adults.  When  toward  the  outer  surface  of  the  lateral  lobes 
the  localizing  symptoms  may  not  be  marked.  By  pressure  upon  either 
the  aqueduct  of  Sylvius  or  foramen  of  Magendie  they  often  cause  internal 
hydrocephalus  (p.  1190),  and  the  symptoms  due  to  that  condition  may 
complicate  those  due  to  the  tumor.  The  symptoms  of  growths  in  this 
region  depend  upon  their  situation,  whether  in  either  the  middle  or  one 
of  the  lateral  lobes.  Tumors  in  the  space  between  the  cerebellum,  pons, 
and  medulla,  known  as  the  cerehellopontile  angle,  cause  symptoms  similar 
to  growths  in  the  lateral  cerebellar  lobes  and  may  be  here  also  con- 
sidered. 

If  the  middle  lobe  is  alone  aifected,  the  usual  symptoms  are  rapidly 
developing — choked  disk,  severe  headache,  marked  ataxia  of  the  cere- 
bellar type,  vertigo,  nystagmus,  the  Romberg  symptom,  weakness  of  the 
muscles  of  the  back,  and  sometimes  of  those  of  the  legs.  Occasionally, 
rigidity  of  the  muscles,  retraction  of  the  head,  and  tetanic-like  seizures 
have  been  observed.  The  knee-jerks  may  be  either  increased,  normal, 
or  absent,  and  may  vary  to  this  extent  in  the  same  patient.  Palsies  of 
cranial  nerves,  especially  the  ocular,  due  to  pressure  and  usually  bilateral, 
may  occur. 

GroAvths  involving  one  of  the  lateral  lobes  do  not  cause  localizing 
symptoms  unless  they  press  upon  the  middle  lobe,  when  those  described 
above  occur.  They  are  apt  to  be  more  marked  upon  the  side  of  the 
lesion,  and  the  patient  usually  has  a  tendency  to  fall  toward  this  side 
(the  opposite  may  occur,  however).  When  vertigo  occurs,  external  ob- 
jects move  from  the  side  of  the  lesion  to  the  opposite  side,  the  rotation 
of  the  body  being  in  the  same  direction.^  The  sixth  and  seventh  cranial 
nerves  are  those  usually  affected  in  lesion  of  the  lateral  lobes,  the  paral- 
ysis being  unilateral  and  on  the  homolateral  side.  Others  may  be  affected. 
Inability  to  rapidly  pronate  and  supinate  the  forearm  upon  the  side  of 
the  lesion  may  be  present  (diadococinesia  of  Babinski).  Hemiasynergia, 
or  the  straightening  of  the  leg,  after  the  thigh  has  been  flexed  on  the 
body  and  the  leg  on  the  thigh,  in  a  jerky  incoordinate  manner,  may  also 
be  noticed  on  the  side  of  the  lesion.  The  head  is  also  sometimes  held 
inclined  to.  the  shoulder  of  the  opposite  side.^ 

^  Stewart  and  Holmes,  Brain,  1904,  p.  525. 
2  Batten,  Brain,  1903,  p.  71. 


1188 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Tumors  of  the  cerebellopontile  (irijih'  are  usually  encapsulated  fibro- 
mata attached  to  either  the  auditory  or  trigeminal  nerves,  usually  the 
former.  The  early  symptoms  depend  upon  the  cranial  nerve  from  wiiich 
the  growth  arises.  If  the  auditory,  there  are  attacks  resembling  those 
of  M(5niere's  syndrome  (p.»nor));  if  the  trigeminal,  there  are  neuralgic 
pains  in  the  eourse  of  that  nerve,  with  possibly  sensory  paralysis  in  its 
distribution.  Other  cranial  nerves,  especially  the  seventh,  soon  become 
affected,  and  the  symptoms  of  tumor  of  the  lateral  lobe  become  more  or 
less  marked.  The  differential  points  between  growths  involving  the  lat- 
eral lobe,  cerebellopontile  angle,  and  pons  are  well  given  in  the  table  of 
Stewart  and  Holmes  :  ' 


Symptoms  and 

Lateral  Ckkkbellar 

EXTRACEREBKLLAR 

Intra PONTINE 

Signs. 

TlMOKS. 

TlMORS. 

Tumors. 

Optic  neuritis. 

Early  and  intense. 

Variable. 

Often  absent  or 
late. 

A'ertigo. 

Subjective    rotation  of 
self  from  the  side  of 
the  lesion. 

Subjective  rotation  of 
self  to  the  side  of 
the  lesion. 

Indefinite. 

Ci-anial  nerves 

—  ^^ 

Rarely  affected. 

Often  affected. 

.VHection  of  these 

u 

VI. 

Weakness  of  conjugate 

Same  as  in  unilateral 

nerves  often  bi- 

deviation to  side  of 

cerebellar  turaoi-s. 

lateral.  Paresis 

lesion.    Weakness  of 

may  be   supra- 

external   rectus    on 

nuclear  or  nu- 

side of  lesion.     Slow 

de  a  r ,      and 

delibei-ate  nystagmus 

grouped   ac- 

to side  of  lesion. 

cording  to  nu- 

« 

vir. 

Paresis  slight  if  present. 

Paresis  more  marked. 

clear    arrange- 

« 

VIII. 

Deafness  on  side  of  le- 

Deafness on  side  of  le- 

ment. 

sion  incomplete  and 

sion   marked— gen- 

Paralysis    of     a 

variable.       Tinnitus 

erally    complete. 

nerve    on    one 

general. 

Tinnitus  referred  to 
ear  on  side  of  lesion. 

side  and  of  an 
adjacent  or  dis- 

it 

IX. 

Never  affected. 

Occasional  paresis  on 
side  of  lesion. 

tant  nerve  on 
the     opposite 

tl 

X. 

(( 

<(              « 

side. 

i( 

XI. 

(( 

li                  a 

Permanent  paral- 

« 

XII. 

11 

Supranuclear   paresis 
on       contralateral 
side. 

ysis  of  conju- 
gate deviation 
of  the  eyes. 

Motor  system. 

Homolateral      pai'esis, 

Homolateral     paresis 

Paresis   often   bi- 

ataxia, and  atonia. 

and  ataxia;  contra- 
lateral spastic  pare- 
sis   common — occa- 
sionally bilateral. 

lateral,  with 
spasticity. 
Ataxia  general. 

Sensoiy  system. 

No  change. 

No  change. 

Occasionally    he- 

mianesthesia. 

Reflexes — Tendon. 

Variable,  often  dimin- 

Generally   increased, 

Increased      often 

ished. 

especially   on    con- 
tralateral side. 

unequally. 

Superficial. 

Noj-maL 

Often   diminished  on 
contralateral  side. 

Diminished  often 
unequally. 

Plantar. 

Flexor. 

Flexor    or    extensor. 
Extensor  on  contra- 
lateral or  both  sides. 

Extensor  on  one 
or  both  sides. 

Sphincters. 

Not  affected. 

Rarely  affected. 

General  Iv  affect- 
ed. 

(l)  Tumors  in  the  jfjows  produce  symptoms  according  to  their  size  and 
location.  If  high  up,  a  crossed  paralysis,  similar  to  that  caused  by  a 
growth  in  the  crus,  will  result.     When  a  little  lower  down  a  motor  and 

1  Brain,  1904,  p.  549. 


INTRA  CRA  NfA  L   CJR 0  WTJIS.  1189 

sensory  paralysis  of  the  arm  and  log  of"  tlie  opposite  side  with  paralysis  of" 
the  sensory  portion  oftlie  cranial  nerve  on  the  same  side  may  result.  If 
the  lower  portion  is  affected,  paralysis  of  the  arm  and  leg  of  the  opposite 
side  with  paralysis  of  the  sixth,  seventh,  and  eighth  nerves  will  occur. 
More  or  less  sensory  paralysis  may  also  be  present.  If  the  cerebellar 
peduncles  are  involved,  forced  movements  and  ataxia  (cerebellar  type) 
will  result.  If  either  the  nucleus  of  the  sixth  nerve  or  the  fibers  of  the 
posterior  longitudinal  fasciculus  is  involved,  there  will  be  loss  of  asso- 
ciated lateral  movements  of  the  eyeballs  toward  the  side  of  the  lesion, 
while  the  poAver  of  convergence  remains. 

Tumors  of  the  medulla  cause  symptoms  of  progressive  bulbar  palsy 
(p.  1129)  plus  more  or  less  hemiplegia  and  hemianesthesia.  If  the  growth 
is  small,  the  symptoms  may  be  more  marked  on  one  side. 

Course. — Many  cases  run  a  very  chronic  course.  Others  may  have 
existed  months  or  years  without  symptoms,  and  then  develop  suddenly, 
owing  to  hemorrhage,  thrombosis,  or  acute  softening  about  the  tumor. 
Either  improvement  may  take  place  or  the  case  may  speedily  progress  to 
a  fatal  termination. 

Diagnosis. — The  general  symptoms  are  usually  sufficient  to  warrant 
a  diagnosis.  The  gradual  onset  and  progressive  character  without  fever, 
in  the  apparent  absence  of  any  etiologic  factor,  are,  as  a  rule,  enough  to 
indicate  that  a  tumor  is  present,  while  its  location  can  only  be  deter- 
mined by  the  focal  symptoms.  Recently  the  a;-ray  has  been  used  with 
some  success  for  the  localization  of  tumors  that  have  undergone  calcareous 
degeneration. 

The  prognosis  is  always  grave.  Syphilitic  growths  are  the  only 
ones  amenable  to  medical  treatment.  Cortical  growths,  especially  if  in  the 
motor  region  or  its  neighborhood,  if  encapsulated,  are  amenable  to  sur- 
gical treatment.  Growths  in  both  the  lateral  cerebellar  region  and  cere- 
bellopontile  angle  and  pituitary  gland  have  also  been  removed,  but  the 
operation  is  more  serious ;  tubercle  may  recover  by  the  growth  becoming 
encapsulated  and  calcified.  Nothing  can  be  said  as  to  the  possible  dura- 
tion of  life.  Several  years  may  elapse  between  the  appearance  of  the 
symptoms  and  their  fatal  termination,  or  death  may  occur  suddenly. 

Treatment. — In  any  case  recourse  should  be  had  to  mercury  and 
the  iodids,  and  this  treatment  should  be  pushed,  since  it  will  certainly 
benefit  syphilitic  cases,  and  it  is  believed  to  be  of  some  value  even  in  the 
non-syphilitic.  Other  symptoms  should  be  met  as  they  arise.  The 
question  of  operation  must  be  considered  where  medical  measures  have 
proved  of  no  avail.  If  the  situation  of  the  growth  is  favorable  and  the 
nature  of  the  tumor  is  not  malignant,  an  operation  is  likely  to  be  suc- 
cessful. The  percentage  of  recoveries  is  increasing  as  the  technic  becomes 
more  perfect  (see  Bruns,  G-eschivulste  des  Gehirns,  etc.).  When  the 
growth  cannot  be  localized,  or  is  in  a  position  unfavorable  for  operation, 
much  benefit  may  be  obtained  by  relieving  pressure  by  the  so-calleil 
operation  of  decompression.  Blindness,  which  will  surely  result  if  choked 
disk  is  allowed  to  persist  any  length  of  time,  and  the  severe  headache 
may  thus  be  prevented.^ 

^  Frazier  and  Spiller,  TJniver.  of  Penna.  Med.  Bull.,  Sept.,  1906  ;  Gushing,  "Principles 
of  Cerebral  Surgery,"  Jour.  Amer.  Med.  Assoc,  Jan.  16,  1909,  p.  184. 


1190  DISEASES  OF  THE  yERVOUS  SYSTEM. 

CHRONIC  HYDROCEPHALUS. 
This  afFectiou  is  divided  into  external  :ind  internal  hydrocephalus. 

EXTERNAL   HYDROCEPHALUS. 

Ktiology. — External  liydroeephalus  may  depend  upon  a  congenital 
smalliR'ss  (if  the  brain  or  ujion  a  eongenital  enlargement  of  the  skull. 
The  space  between  the  brain  and  the  bone  is  filled  by  an  excess  of  sub- 
arachnoid fluid  (vacuum  dropsy),  or  there  may  be  a  wasting  of  the  brain, 
such  as  occurs  in  old  age  or  in  chronic  cachectic  conditions. 

Pathology. — When  the  skull  is  opened,  the  bone  is  usually  found 
to  be  thin  ;  the  dura  is  normal ;  the  arachnoid  is  lifted  from  the  surface 
of  the  cortex  by  a  C(msiderable  accumulation  of  clear  fluid  of  low  specific 
gravity ;  the  convolutions  may  be  somewhat  ilattened  and  the  cortex 
slightly  thinned.  Upon  microscopic  examination  no  changes  are  found 
in  the  brain-substance.  Sometimes  the  effusion  is  general ;  sometimes  it 
is  sacculated. 

The  symptoms  depend  upon  the  form.  In  cases  in  which  there  is 
hypoplasia  of  the  brain  or  in  which  the  brain  has  wasted,  no  pressure- 
symptoms  are  ])resent.  All  the  manifestations  are  purely  psychic  in 
nature,  and  similai  to  those  oi  microcephaly  ov  senile  dementia.  In  cases, 
however,  in  which  the  cranium  cavity  is  abnormally  large,  it  is  probable 
that  the  real  cause  resides  in  a  congenital  excess  of  subarachnoid  fluid. 

The  prognosis  is  gloomy  ;  nevertheless,  it  is  possible  that  the  disease 
may  undergo  spontaneous  cure  as  a  result  of  rupture  into  the  nasal  fossa. 

The  treatment  is  the  same  as  for  the  internal  variety  {vide  infra). 

INTERNAL   HYDROCEPHALUS. 

This  is  a  condition  in  which  one  or  more  of  the  ventricular  cavities  of 
the  brain  are  distended  by  the  cerebro-spinal  fluid.  In  the  congenital 
form  and  in  that  occurring  in  early  childhood,  this  is  associated  with  more 
or  less  enlargement  of  the  skull.  In  the  later  acquired  forms  the  cranium 
does  not  yield  so  readily,  and  the  enlargement  does  not  exist  or  is  slight. 

The  etiology  of  the  congenital  form  is  unknown,  though  the  fact 
that  it  frequently  occurs  in  several  children  of  the  same  family  has  led 
to  the  supposition  that  it  is  dependent  upon  some  hereditary  influence. 
In  some  cases  it  has  been  referred  to  emotional  disturbances  suffered  by 
the  mother  during  pregnancy,  and  in  still  other  cases  an  anatomic  foun- 
dation has  been  discovered,  such  as  enlargement  of  the  pineal  gland.  It 
is  generally  supposed  that  the  immediate  cause  is  chi'onic  ependymitis. 

The  ac({uircd  form  is  usually  secondary  to  inflammatory  conditions 
(particularly  meningitis)  or  to  brain-tumor.  Some  cases,  however,  occur 
in  childhood  that  are  apparently  not  due  to  either  of  these  causes. 

The  pathology  of  the  condition  varies  with  its  nature.  In  the  con- 
genital forms,  upon  opening  the  head  the  skull  is  found  to  be  thin.  The 
fontanels  and  sutures  are  either  still  open  and  connected  only  by  a  mem- 
brane, or  closed  by  Wormian  bones.  The  dura  may  be  thickened,  but 
usually  is  normal ;  the  substance  of  the  brain  is  slightly  softened — although 
this  is  not  invariably  the  case — and  very  much  thinned.  This  thinning  is, 
as  a  rule,  particularly  noticeable  in  the  corpus  callosum  and  commissures, 


Clin ONW  H YDROCEPHA  L  US.  1191 

which  may,  indeed,  cither  be  torn  apart  or  completely  atrophied.  Tlie 
enlargement  ordinarily  affects  the  two  lateral  ventricles,  the  third  ventri- 
cle, and  the  aqueduct  as  for  as  its  entrance  into  the  fourth  ventricle, 
which  is  commonly  less  involved  than  the  other  cavities.  The  ependyma 
is  sometimes  smooth,  but  more  often  shows  small  projections,  which,  ac- 
cording to  Virchow,  are  composed  of  brain-substance,  but  in  some  cases 
are  due  to  proliferation  of  the  glia  tissue  beneath  the  ependyma.  The 
enlargement  may  not  be  uniform.  If  due  to  obstruction  of  the  foramen 
of  Monro,  one  or  both  lateral  ventricles  are  usually  enlarged,  whilst  the 
third  ventricle  either  remains  of  normal  size  or  is  diminished.  If  due  to 
enlargement  of  the  pineal  gland,  the  aqueduct  docs  not  show  the  funnel- 
shaped  distention.  Another  cause  upon  which  considerable  weight  has 
been  laid  is  the  closure  of  the  transverse  jfissure  between  the  cerebellum 
and  medulla.  The  quantity  of  fluid  may  be  enormous,  as  much  as  4  or 
5  liters  (5  or  6  quarts)  having  been  recorded.  The  thinning  of  the  brain- 
substance  is  also  remarkable  when  one  considers  that  a  cerebrum  5  mm. 
{\  in.)  in  thickness  is  apparently  able  to  perform  a  large  proportion  of  its 
ordinary  psychic  functions.  The  atrophy  seems  to  affect  particularly  the 
white  substance,  especially  the  myelin-sheaths. 

In  cases  of  the  acquired  form,  unless  they  occur  early  in  life,  the  en- 
largement of  the  skull  is  not  very  noticeable ;  the  substance  of  the  brain 
shows  considerable  softening ;  the  ventricles  are  moderately  enlarged, 
and,  particularly  in  the  chronic  forms  due.  to  tuberculosis,  are  consider- 
ably roughened.  The  most  pronounced  cases  are  those  that  occur  when 
there  is  a  tumor  in  the  occipital  fossa  which  compresses  the  veins  of  Galen. 
Basal  meningitis  causing  an  obliteration  of  the  foramen  of  Majendie  is 
also  a  ca.use.  In  these  cases  the  accumulation  of  liquid  is  slower,  the 
brain  yields  more  gradually  to  pressure,  and  the  dilatation  is  more  pro- 
nounced. Ordinarily,  there  is  considerable  flattening  of  the  convolutions. 
In  a  few  of  these  cases  inflammatory  changes  in  the  ependyma  have  led 
to  partial  obliteration  of  the  ventricles,  particularly  in  the  anterior  horns 
or  the  lateral  ventricles.  Occasionally  also  bands  of  organized  lymph 
may  cross  the  ventricles  in  various  directions ;  the  liquid  is  of  higher 
specific  gravity  and  contains  more  albumin  than  in  the  non-inflammatory 
varieties. 

Symptoms. — The  most  characteristic  appearance  in  congenital  hy- 
drocephalus is  the  globular  enlargement  of  the  head.  Upon  palpation 
the  fontanels  are  found  to  be  still  patulous  and  usually  bulging,  and  the 
sutures  are  open.  The  head  is  usually  so  heavy  that  it  cannot  be  held 
upright,  but  falls  backward  or  to  one  side.  The  face  appears  propor- 
tionately very  small.  Motility  is  usually  disturbed,  the  legs  are  spastic, 
and  the  child  either  does  not  learn  to  walk  at  all  or  only  long  after  the 
usual  time.  There  are  sometimes  choreic  movements  of  the  upper  ex- 
tremities. The  eyes  frequently  show  nystagmus  and  conjugate  deviation, 
and  often  there  is  either  choked  disk  or  atrophy  of  the  optic  nerve. 
Fischer  has  described  a  systolic  murmur  that  can  be  heard  if  the  stetho- 
scope is  placed  over  the  anterior  fontanel.  Its  cause  is  unknown  Con- 
vulsive attacks  are  common ;  they  are  epileptic  in  type,  and,  as  a  rule, 
ultimately  cause  death.  Intelligence  is  usually  considerably  impaired, 
and  sometimes  the  children  are  idiots ;  more  often  they  merely  show  re- 
tardation of  intellectual  development.     Occasionally — and  this  even  in 


1192  DISEASES  OF  THE  yERVOUS  SYSTEM. 

the  most  pronounced  cases— the  intelligence  is  well  preserved.  Henoch 
records  the  case  of  a  boy  three  years  of  age  -whose  head  was  75  cm.  (29.6 
in.)  in  circumference,  and  who  could  speak  both  French  and  German. 
Ordinarily,  the  children  are  quiet  and  apathetic,  but  they  may  be  queru- 
lous. jS'utrition  is  commonly  seriously  disturbed,  the  children  sometimes 
exhibiting  pronounced  cachexia.  They  may,  however,  be  well  nourished 
and,  to  a  certain  degree,  vigorous.  The  symptoms  of  the  chronic  form 
in  adults  are  tliose  of  brain-tumor  without  focal  symptoms. 

The  diagnosis  is  ordinarily  very  easy.  Careless  observation  may 
lead  to  confusion  with  rachitis  but  the  square  shape  of  the  head  and  the 
presence  of  other  rachitic  deformities  in  the  skeleton  should  lead  to  a 
prompt  recognition  of  the  true  nature  of  the  case. 

The  prognosis  is  extremely  unfavorable,  the  majority  of  the  children 
dying  about  the  fifth  year.  A  few  cases,  however,  may  live  until  they 
reach  voung  adult  life,  and  still  fewer  apparently  recover  entirely. 

Treatment  is  of  course  difficult.  Potassium  iodid  and  mercury  have 
been  employed  without  much  beneficial  effect.  Cod-liver  oil  may  be  given 
to  stimulate  nutrition,  and  purgatives  occasionally  relieve  pressure-symp- 
toms temporarily.  Among  the  mechanical  procedures  constant  pressure 
upon  the  head  seems  the  most  valuable.  This  can  be  obtained  by  means 
of  strips  of  adhesive  jilaster  or  by  the  application  of  an  elastic  band. 
Drainage  of  the  ventricles  has  given  good  results  in  some  cases.'  If  con- 
vulsions develop,  they  should  be  combated  by  bromids  and  purgatives. 
At  times  there  may  be  difficulty  in  making  the  diagnosis  from  brain- 
tumor  ;  .r-rays  may  prove  of  service  in  distinguishing  between  the  two.^ 


ACUTE  DELIRIUM. 

{Acvtr  Delirious  Mania;   I'l/pho-mania  ;  AciUe  I'eriencephaliti.v ;  BelVs  Mania.) 

Definition. — An  acute  maniacal  delirium  associated  with  hallucina- 
tions, with  a  febrile  course,  of  limited  duration  and  of  grave  prognosis. 

Pathology. — Visible  changes  are  usually  absent,  there  may  be 
found  minute  pericapillary  hemorrhages  and  degenerative  changes  in  the 
ganglion-cells.  Sometimes  injection  of  the  pia  and  minute  hemorrhages 
into  the  gray  matter  may  be  observed  with  the  naked  eye.  Cramer  has 
reported  a  case  in  which  the  pericapillary  spaces  of  the  brain  were  filled 
with  mononuclear  leukocytes,  surrounding  which  were  recent  hemor- 
rhages; he  also  noted  the  fact  that  the  ganglion-cells,  instead  of  exhibit- 
ing normally  formed  chromophilic  bodies,  were  filled  apparently  with 
fine  dust. 

l^tiology. — The  disease  occurs  in  either  sex  with  about  equal  fre- 
quency. Predisposing  conditions  are  neuropathic  heredity,  nervous  dis- 
position, the  presence  of  other  nervous  diseases,  particularly  neurasthenia 
and  epilepsy,  alcoholic  or  sexual  excesses,  and  severe  prolonged  anxiety. 

'  Rev.  Neurol,  and  Pnychiai.,  Jan.,  1911,  p.  1. 

^  Spiller,  Review  of  Neurology  and  Psychiatry,  Jan.,  1911,  p.  8. 


ACUTE  DELIRIUM.  1193 

It  frequently  occurs  apparently  as  the  irriTriediate  result  of  menstruation, 
parturition,  injuries  to  the  head,  sunstroke,  acute  infectious  diseases,  par- 
ticularly pneumonia  and  typhoid  fever,  and  it  may  develop  in  the  course 
of  chronic  mental  diseases.  Occasionally,  however,  it  appears  to  arise 
without  any  definite  cause. 

Symptoms. — The  disease  usually  commences  with  certain  indefinite 
prodromes.     These  consist  of  restlessness,  associated  either  with  melan- 
cholia, preoccupation,  or  anxiety.     The  intelligence  becomes  distinctly 
decreased ;  the  patient  loses  appetite,  is  constipated,  and  commences  to 
emaciate.     During  sleep  unpleasant  dreams  or  nightmares  almost  invari- 
ably occur.     Sometimes  there  is  a  sense  of  impending  mental  disorder. 
This  period  gradually  changes  to  one  of  defiance,  which  perhaps,  even  in 
the  prodromal  stage,  may  lead  to  violence  and  injury  to  those  in  the  neigh- 
borhood.    The  prodromal  stage  rapidly  passes  to  acute  delirium,  in  which 
two  steps  may   be  recognized — excitation  and   collapse.      The   excited 
stage  commences  suddenly  ;  there  is  great  confusion;  the  patients  ejacu- 
late disconnected  sentences  or  words  or  even  syllables.     There  is  great 
anxiety,  and  even  fear,  and  the  patients  exhibit  intense  excitement,  suf- 
fering very  often  with  delusions  of  persecution  b.y  their  environment,  and 
nearly  always  having  hallucinations,  either  of  sight  or  sound.    Often  their 
minds  are  occupied  by  some  subject  that  had  previonslv  caused  them  great 
anxiety — either  disgrace,   business,  or   other  misfortune.      The   mania 
is   often   dangerous ;    indeed,  it   is   likely   that   the    disease    known    as 
"running  amuck  "  in  the  Malay  Peninsula  is  simply  one  of  the  forms 
of  acute  delirium.     The  patient  soon  becomes  restless,  throws  himself 
from  one  side  of  the  bed  to  the  other,  and  makes  efforts  to  rise  and  escape 
from  the  room.     The  tongue  is  dry,  the  pulse  rapid  and  weak.     Petechiae 
may  appear  upon  the  skin,  and  there  is  nearly  always  more  or  less  fever, 
not  rarely  rising  to  105°  (40.5°  C.)  or  even  more.     Rapid  emaciation  super- 
venes.    There  are  all  the  objective  symptoms  of  irritation  of  tlie  lirn  n — 
myosis  and  increased  reflexes,  and  often  hyperesthesia,  although  the  patients 
pay  little  attention  to  any  injury  they  may  inflict  upon  themselves.    Some- 
times there  seem  to  be  curious  imperative  movements ;  at  others,  impera- 
tive ideas.     In  a  case  that  I  observed  the  patient  rhymed,  very  imper- 
fectly it  is  true,  each  two  successive  sentences.      This  stage  of  excitation 
soon   passes  into  one  of  stupor  and  collapse ;   fever  may  become  even 
higher,  and  the  pulse  still  more  rapid  and  weaker.      The  patient  lies  in  a 
©ondition  of  muttering  delirium,  with  carphologia.     All  the  symptoms  are 
those  of  profound  exhaustion :   the  eyes  are  hollow,  the  lips  and  teeth 
covered  with  sordes,   and  the  emaciation  extreme.     The  skin   becomes 
dryer,  and  finally  cyanotic,  the  pupils  dilate,  and  there  may  be  marked 
anesthesia.     Death  ordinarily  occurs  at  the  end  of  two  or  three  days 
after  the  commencement  of  this  condition.     Occasionally  the  course  of 
the  disease  is  interrupted  by  intervals  in  which  the  patients  exhibit  more 
or  less  lucidity.     The  disease  is  related  to  an  asthenic  condition  known 
as  confusional  insanity,  which  is  due  to  the  same  causes,  but  in  it  the 
patients  exhibit,  in  place  of  excitement,  depression,  with  fear  of  poison- 
ing  and  positive   refusal  of  all  food,   mental  confusion,   disorientation, 
failure  of  memory,  slight  elevation  of  temperature,  or,  indeed,  a  sub- 
normal temperature,  and  very  rapid  emaciation.     It  is  most  apt  to  occur 
in  patients  previously  debilitated.     In  the  paralytic  form  there  is  vaso- 


1194  DISEASES  OF  THE  NERVOUS  SYSTEM. 

motor  paralysis  with  cyanosis,  depression,  and  often  stupor.  From  these 
the  patient  passes  into  an  al<z;id  state,  in  which  death  occurs. 

The  differential  diag^nosis  is  frequently  difficult.  In  many  infec- 
tious diseases,  -particularly  pnciwumia  and  typhoid.,  hallucinatory  delirium 
may  develop.  This,  of  course,  must  be  suspected  in  these  diseases,  and 
it  is  advisable,  if  possible,  to  examine  the  blood  in  all  cases  of  acute 
delirium  by  Widal's  method.  In  acute  mania  fever  is  rare,  emaciation 
is  not  so  rapid,  and  the  mental  symptoms  are  more  purely  psychical..  In 
general  pardli/sis,  toward  the  end  maniacal  attacks  may  develop,  but  the 
history  of  the  previous  existence  of  the  disease,  the  presence  of  the 
Argyll-Robertson  pupil,  and  the  absence  of  fever  lead  one  to  suspect  the 
true  diagnosis.  Finally,  in  delirium  tremens  the  fine  tremor  of  the 
hands  and  tongue,  and,  if  possible  to  obtain  it,  a  history  of  recent 
debauch  should  clear  up  the  diagnosis.  The  course  of  the  disease  is 
variable  ;  it  may  vary  from  three  or  four  days  to  as  many  weeks.  Those 
cases  are  most  rapid  in  which  excitation  is  most  profound. 

The  prognosis  in  acute  delirium  is  most  unfavorable,  and  is  more  so 
for  men  (according  to  Krafft-Ebing)  than  for  Avomen.  Those  cases  that 
were  previously  debilitated,  either  as  a  result  of  chronic  alcoholism,  or 
chronic  exhaustive  diseases,  or  childl)irth,  are  the  most  serious.  Those 
that  develop  suddenly,  and  from  the  beginning  are  very  severe,  are  also 
nearly  alw  ays  fatal ;  if  there  are  no  lucid  intervals,  or  if  those  that  occur 
are  short  and  imperfect,  the  prognosis  is  graver ;  and  the  same  is  true  of 
those  who  suffer  from  obstinate  insomnia.  In  confusional  insanity  it  is 
better  although  serious. 

The  treatment  is,  of  course,  unsatisfactory.  Calomel  should  be 
administered  in  the  earlier  stages  of  the  disease.  At  the  same  time  the 
temperature  sliould  be  combated  by  cool  baths  or  packs  and  an  ice-bag 
should  be  applied  to  the  head.  Sleep  should  be  obtained  by  the  use  of 
chloral,  bromid,  and  the  more  modern  hypnotics,  which  are  to  be  preferred 
to  morphin.  Hyoscin  seems  to  be  particularly  indicated.  In  the  later 
stages  of  the  disease  stimulants  should  be  administered  freely.  Excellent 
results  have  been  obtained  (Solivetti)  by  the  hypodermic  administration 
of  Bonj can's  ergotin.  Nutrition  must  be  maintained  by  forced  feeding 
with  milk,  eggs,  broths,  etc. 


SENILE    DEMENTIA. 

Tins  is  a  condition  symptomatic  of  sclerosis  of  the  cerebral  arteries. 
Some  of  the  manifestations,  indeed,  are  those  of  general  arteriosclerosis. 
It  usually  comes  on  after  fifty  years  of  age,  and  is  slightly  more  common 
— at  least  more  noticeable — in  the  male  than  in  the  female  sex.  The 
first  symptoms  are  loss  of  memory,  especially  for  recent  events,  failure 
to  keep  engagements,  and  slight  querulousness.  These  steadily  progress. 
The  patient  forgets  not  only  facts,  but  words,  and  the  speech  may,  in 
consequence,  resemble — to  a  certain  extent — some  of  the  manifestations 
of  aphasia.     At  the  same  time  judgment  is  impaired  ;   the  patient  is  irri' 


MULTIPLE  SCLEROSIS.  1195 

table,  occasionally  ridiculous ;  becomes  suspicious,  particularly  of  his 
immediate  family  and  friends,  and  is  apt,  at  times,  to  become  violent 
toward  them.  He  becomes  careless  about  his  person  and  clothing,  spills 
food  while  eating;  often  sleeps  during  the  day,  especially  after  eating, 
and  heavily  at  niglit.  Finally,  the  dementia  may  become  complete,  and 
the  patient  become  entirely  unable  to  care  for  himself.  Tlie  objective 
signs  are  usually  the  hardened  arteries,  tremor  of  the  hands  and  lips, 
the  arcus  senilis,  the  wrinkled,  dry  skin  with  prominent  veins,  and  the 
progressive  emaciation.  Often  the  urine  is  of  low  specific  gravity,  and 
contains  a  slight  amount  of  albumin.  Death  usually  occurs  from  some 
complication,  such  as  cerebral  hemorrhage  or  uremia,  or  from  some  inter- 
current condition,  such  as  broncho-pneumonia.  The  treatment  is  that 
for  arterio-sclerosis. 


V.  DISEASES  OF  BRAIN  AND  CORD. 
MULTIPLE  SCLEROSIS. 

{Insular  or  Disseminated  Sclerosis.) 

Definition. — A  disease  due  to  the  development  of  sclerotic  patches, 
occurring  in  an  irregular  manner  throughout  either  or  both  the  brain  and 
spinal  cord.  It  is  characterized  by  paresis,  intention-tremors,  scanning 
speech,  nystagmus,  and  mental  disturbances. 

etiology. — It  is  not  certain  that  there  is  a  single  cause  for  all  cases 
of  multiple  sclerosis.  Most  frequently  it  follows  some  infectious  condi- 
tion, particularly  the  exanthemata,  typhoid,  malaria,  pneumonia,  and  per- 
haps influenza  and  sunstroke.  The  metallic  poisons,  as  lead,  also  seem 
to  have  an  etiological  significance.  A  history  of  trauma,  of  exposure,  or 
profound  emotional  shock  is  often  obtained.  Neuropathic  heredity  often 
exists.  The  majority  of  cases  apparently  begin  between  the  ages  of 
twenty  and  thirty,  but  children  may  be  affected.  Sex  is  not  an  import- 
ant factor.  The  disease  is  far  more  common  than  was  formerly  believed 
(Taylor),  as  the  atypical  forms  are  often  not  recognized. 

Pathology. — The  sclerotic  tissue  occurs  especially  in  the  white 
matter,  though  any  part  of  the  cerebrospinal  axis  may  suffer.  The  cor- 
tex is  rarely  implicated.  The  spots  are  usually  well  circumscribed,  gray 
or  grayish-red  in  color,  and  on  section  may  be  level  with,  raised  from, 
or  depressed  beneath  the  normal  line  of  section  according  as  to  whether 
it  is  in  the  early,  hypertrophic,  or  cirrhotic  stage.  The  cranial  nerves 
may  be  involved  at  their  origin,  the  first,  second,  and  tenth  being  partic- 
ularly vulnerable.  The  medullary  sheath  of  nerve-fibers  in  the  affected 
region  degenerates  early,  but  the  axons  are  markedly  resistant.  Since 
they  are  not  cut  off  from  their  trophic  center,  secondary  degeneration  is 
rarely  met  with.  The  blood-vessels  show  more  or  less  proliferation  of  the 
adventitia,  and  endarteritis  is  not  an  uncommon  coiidition.  Whether 
this  vascular  change  is  primary  or  secondary  is  unknown.  Microscop- 
ically, the  sclerotic  areas  are  made  up  of  an  overgrowth  of  neuroglia-cells 
and  fibers  and  of  the  ordinarv  connective  tissue.     In  certain  cases  these 


1196  DISEASES   OE  THE  XERVOUS  SYSTEM. 

patches  exhibit  some  tendency  to  involve  special  jiarts  of  the  nervous 
system,  as  the  lateral  or  posterior  columns. 

Symptoms. — These  may  be  described  under  two  headings  :  first, 
the  general  symptoms,  or  those  common  to  all  cases  of  the  disease,  and 
not  explicable  from  the  position  of  the  sclerosis ;  and,  secondly,  those 
dependent  on  the  locality  of  the  lesions.  The  disease  is  always  chronic, 
and  either  remissions,  or  one  or  more  intermissions  occur,  and  in  some 
cases  may  extend  over  several  years.  The  first  evidence  of  the  disease 
is  loss  of  poire  )\  first  in  one.  then  in  the  other,  lower  extremity.  Later, 
paresis  develops  in  the  upper  extremity.  Sooner  or  later  other  general 
symptoms  appear — viz.,  tremors,  nystagmus,  scanning  speech,  increased 
reflexes,  an(l  optic-nerve  atrophy.  The  tremor  is  volitional  {intention- 
tremor),  and  when  the  patient  is  at  rest  no  abnormal  movement  is  mani- 
fest, as  a  rule.  On  attempting  to  use  the  hands,  or  in  walking,  more  or 
less  coarse  tremor  is  ol)served.  This  may  be  well  brought  out  by  the 
finger-to-nose  test.  The  head  may  be  similarly  involved,  and  some  inco- 
ordination is  commonly  associated  therewith.  As  the  paresis  is  spastic, 
the  tendon  reflexes  are  increased,  and  even  ankle-clonus  and  the  Babinski 
phenomenon  may  be  present.  The  abdominal  reflex  is  often  absent.  In 
addition,  a  certain  degree  of  ataxia  or  incoordination  of  motion  is  present, 
which  is  independent  of  the  tremor.  Striimpell  has  studied  this  especially. 
The  nystagmus  is  sometimes  only  noticeable  Avhen  the  eyes  are  moved, 
but  usually  it  is  constant.  It  is  more  marked  in  lateral  than  in  vertical 
movements.  Speech  is  at  first  slow  and  drawling,  and  of  a  peculiar 
monotonous  character ;  later  it  becomes  even  more  deliberate,  and  is  then 
spoken  of  as  scanning,  each  syllable  being  pronounced  separately  with  a 
slight  rising  and  falling  cadence.  Optic-nerve  atrophy  is  of  frequent 
occurrence.  It  begins  witli  pallor  of  the  temporal  edges  of  the  discs,  a 
valuable  sign  (Miiller).  Other  cranial  nerves,  particularly  the  motor 
nerves  of  the  eyes,  may  be  aff'ected,  and  at  times  are  early  symptoms. 
The  sensory  disturbances  are  less  important  than  the  motor  phenomena. 
They  consist  of  areas  of  liyperesthesia,  particularly  in  the  extremities, 
that  are  usually  transient,  and  occasional  tingling  or  numbness  in  the 
limbs.  There  is  usually  no  wasting  of,  nor  electric  change  in,  the  muscles, 
nor  do  bed-sores  occur.  Vertigo  is  usually  present.  The  patients  are 
usually  emotional,  and  laugh  or  cry  upon  slight  provocation ;  often  the 
outbursts  of  laughter  are  Avholly  causeless.  In  other  cases  dementia,  or 
even  acute  maniacal  outbursts,  are  met  with,  but  these  are  rare.  During 
this  stage  epileptiform  or  apoplectiform  attacks  may  occur.  The  symp- 
toms directly  resulting  from  the  local  lesions  cannot  be  given  in  detail. 
Certain  types  result.  hoAvever,  that  depend  upon  the  tendency  of  the  scle- 
rotic areas  to  involve  certain  tracts,  and  these  are — first,  a  form  resembling 
lateral  sclerosis,  either  bilateral  or  unilateral  (p.  1140),  due  to  implica- 
tion of  the  lateral  tract;  and,  secondl}',  a  form  similar  to  locomotor 
ataxia,  in  which  the  posterior  columns  especially  suffer.  In  some  of 
these  cases  the  general  symptoms  described  above  are  nf)t  very  apparent, 
or  only  one  or  two  of  them  may  be  present.  Such  are  diflficult  of  diag- 
nosis ("formes  frustes  "  of  Charcot). 

The  diagnosis  is  generally  easy  after  the  disease  has  lasted  some 
time.  The  intention-tremor  and  the  gradual  and  progressive  loss  of 
power,  with  increased  reflexes,  scanning  speech,  and  mental  deterioration, 


MULTIPLE  SCLEROSIS. 


1197 


arc  sufficient.     The  following  table  gives  the  differential  points  between 
this  disease  and  paralysis  agitann^  tabes  dorsatis,  and  hereditary  ataxia  : 


Disseminated 
scj.erosis. 

Rarely  occurs  in 
children.  Gen- 
erally between 
the  twentieth  and 
thirtieth  years. 

No  sensory  symp- 
toms, as  a  rule. 
Sight  may  be  im- 
paired, the  hear- 
ing less  frequent- 
ly. The  Argyll- 
Robertson  pupil 
is  absent. 

Nystagmus  is  pres- 
ent, as  a  rule. 

Reflexes  are  exag- 
gerated ;  ankle- 
clonus  is  present. 
There  may  be 
muscular  rigid- 
ity. 

Scanning  speech. 


A  tremor  is  gener- 
ally present  on 
voluntary  move- 
ments only.  If 
the  tremor  occurs 
during  rest,  it  is 
fine.  Oscillations 
of  the  head  are 
frequent ;  of  the 
trunk,  less  so. 

Mental  disturbance 
may  occui*. 

Gait  is  usually  spas- 
tic and  paretic, 
and  often  uncer- 
tain. 


Paralysis  Agi- 

TANS. 

Occurs  in  persons 
over  forty  years 
of  age. 


No  sensoiy  or  spe- 
cial-sense symp- 
toms of  any  im- 
portance. A  r  - 
g  y  1 1  -  Robertson 
pupil  is  absent. 


No  nystagmus. 

Reflexes  are  nor- 
mal ;  very  rarely 
they  may  be  plus. 
Permanent  mus- 
cular rigidity. 

Speech  is  slow  and 
deliberate  oncom- 
mencing  a  sen- 
tence, but  soon  it 
becomes  hurried. 

Tremor  when  at 
rest.  Voluntary 
movement  may 
make  it  cease 
temporarily.  The 
head  may  shake, 
with  rather  a 
vertical  than  an 
oscillatory  move- 
ment. 

No  mental  phenom- 
ena. 

The  face  is  immo- 
bile and  mask- 
like. The  gait  is 
propulsion,  festi- 
nation,  retropul- 
sion,  or  latero- 
pulsion. 


Tabes  Doksalis. 

Rarely    before    the 
twentieth  year. 


Fulgurant  pains  an 
early  symptom. 
Sight  and  hear- 
ing are  commonly 
affected.  Often 
diplopia  and  Ar- 
g  y  1 1- Robertson 
pupil  are  present. 

No  nystagmus. 

The  knee-jerk, 
ankle-clonus,  and 
rigidity  are  all 
absent. 


No  speech-defects. 


No  tremor.  Inco- 
ordi nation  is 
marked.  No  os- 
cillations of  the 
head  or  trunk. 
Romberg's  symp- 
tom is  present. 
Trophic  disturb- 
ances are  com- 
mon. 

Mental  disturbance 
is  rare. 

The  gait  is  stamp- 
ing in  character  ; 
the  legs  are 
moved  stiffly. 
There  is  difficulty 
in  urination. 


HEREniTARY 

Ataxia. 

Usually  before  the 
twentieth  year. 
Generally  affects 
several  in  the 
same  family. 

Sensoiy  symptoms 
are  rarely  pres- 
ent. Diplopia 
and  Argyll-Rob- 
ertson pupil  ar^ 
absent. 


Nystagmus  is  fre- 
quent. 

The  knee-jerk  is  lost 
in  the  course  of 
the  disease  ;  it  is 
rarely  increased. 
No  rigidity. 

Speech  is  slow  and 
irregularly  scan- 
ning. 


Incoordination  is 
present,  is  in- 
creased by  closing 
the  eyes.  Static 
ataxia  may  be 
noted. 


No  mental  disturb- 
ance. 

The  gait  is  swaying 
and  irregular, 
like  that  of  a 
drunken  man. 
The  legs  are  not 
kept  wide  apart 
as  in  locomotor 
ataxia. 

The  most  difficult  differential  diagnosis  is  from  syphilis  of  the  central 
nervous  system.  This  is  characterized,  as  a  rule,  by  the  more  rapid  de- 
velopment, the  presence  either  of  the  Argyll-Robertson  pupil  or  complete 
pupillary  immobility,  the  absence  of  the  typical  group  of  symptoms,  and 
the  response  to  antisyphilitic  treatment.  It  should  not  be  forgotten  that 
any  of  the  symptoms  of  disseminated  sclerosis  may  be  present  in  cerebro- 
spinal syphilis,  and  that  cases  of  the  former  disease  may  lack  one  or  more 
of  the  fundamental  symptoms,  and  cases  will  sometimes  occur  in  which 
the  differential  diagnosis  cannot  be  made.     Examination  of  the  cerebro- 


1198  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Spinal  fluid  may  be  of  assistance,  as  in  sypliilis  a  markeci  pleocytosis,  an 
increase  of  globulin,  as  shown  by  Noguclii's  butyric  acid  or  other  test, 
and  possibly  the  AVasserniann  reaction  will  be  found.  The  latter  will 
also  be  found  in  the  blood  if  the  patient  has  not  had  antisyphilitic  treat- 
ment within  six  months,  in  which  event  it  may  not.  Arterio-sclerosis 
may  produce  nniltiple  areas  of  softening,  causing  a  symptom  group  re- 
sembling multiple  sclerosis.  This,  however,  is  more  apt  to  occur  in  old 
peo|)le,  while  multiple  sclerosis  is  more  common  in  early  middle  life. 
Disseminated  myelo-encephalitis  (p.  1135)  may  also  be  mistaken.  In 
this  there  may  be  fever  and  a  history  of  previous  infection. 

The  course  usually  extends  over  five  to  ten  or  even  fifteen  years, 
and  death  is  generally  the  result  of  some  intercurrent  affection,  though 
it  may  occur  during  an  apoplectiform  or  convulsive  attack.  Karely  it 
is  due  to  failure  of  the  heart  or  respiration.  Remissions  of  considerable 
length  of  time  may  occur. 

The  prognosis  is  favorable  as  far  as  life  is  concerned,  and  some 
improvement  may  even  occur,  but  entire  recovery  cannot  be  expected. 

Treatment. — Silver  nitrate,  mercury,  the  iodids,  quinin,  and 
arsenic  may  be  tried.  Rest  and  easily  assimilable  food  are  of  prime 
importance. 

PSEUDOSCLEROSIS   AND    DIFFUSE    SCLEROSIS. 

In  1883  Westphal  described  a  case  characterized  by  disturbance  of 
speech,  slowness  of  the  movements,  decrease  of  intelligence,  increased 
irritability,  apoplectiform  attacks,  pronounced  tremor,  spasticity  and  in- 
creased reflexes,  slight  disturbance  of  sensation,  and  no  involvement  of 
the  sphincters.  The  autopsy  "was  entirely  negative.  Since  then  similar 
cases  have  been  reported,  especially  by  Striimpell.  Later  investigations 
seem  to  show  that  these  cases  are  realh^  due  to  a  diffuse  sclerosis,  such  a 
condition  having  been  found,  those  cases  heretofore  characterized  as 
pseudosclerosis  being  a  mild  degree  of  it.' 

The  diagnosis  cannot  be  made  from  multiple  sclerosis  during  life. 

Treatment  is  without  avail. 


CEREBROSPINAL  SYPHILIS. 

Syphilis  also  affects  both  the  brain  and  spinal  cord.     The  symptoms 
are  detailed  on  p.  394.     (See  also  Apoplexy,  Tabes,  and  Paresis.) 


GENERAL  PARALYSIS   OF  THE  INSANE. 

{General  Parexiit ;  Paresis;  Chronic  Diffuse  Meningo-encephalilis ;  Dementia  Paralytica.) 

Definition. — A  chronic  disease  involving  the  cerebrum,  spinal  cord, 
and  the  meninges,  and  characterized  by  a  gradual  loss  of  power,  tremors, 
and  progressive  mental  decay. 

^  Jour.  Amer.  Med.  Assoc,  Nov.  11,  1905. 


GENERAL  PARALYSIS  OF  THE  INSANE.  1109 

Pathologfy. — The  intima  and  adventitia  of  the  blood-vessels  undergo 
proliferative  changes,  and  the  perivascular  spaces  are  dilated  and  contain 
an  excessive  quantity  of  fluid,  also  cellular  elements.  Obliterative  endar- 
teritis occurs  also.  Atrophy  and  degeneration  of  the  cerebrum  are  met 
with,  chiefly  involving  the  cortex,  particularly  that  of  the  frontal  or  pari- 
etal regions  and  the  anterior  basal  region.  The  ventricles  are  dilated  and 
the  ependyma  is  granular.  The  membranes  are  thickened  and  opaque, 
and  adherent  to  the  surface  of  the  convolutions,  so  that  the  cortex  is  torn 
upon  their  removal.  Hemorrhage  may  take  place  into  the  subdural 
spaces,  and  may  vary  in  amount  from  a  mere  stain  to  the  formation  of 
a  pseudo-membrane. 

Secondary  sclerotic  and  degenerative  changes  are  found  in  the  posterior 
and  pyramidal  tracts  of  the  cord  in  most  cases. 

Btiology. — As  in  locomotor  ataxia,  a  history  of  syphilitic  infection 
is  obtained  in  a  large  majority  of  all  cases.  Noguchi  and  Moore  have 
demonstrated  the  spirochaeta  pallida  in  all  the  layers  of  the  brain  cortex 
except  the  outer  one  in  12  cases  out  of  70  examined.'^  The  condition  occurs 
more  frequently  in  men  than  in  women,  and  usually  between  the  thirtieth 
and  fiftieth  years.  Business  or  domestic  troubles,  and,  in  fact,  great  anxiety 
of  mind  from  any  cause,  also  venereal  or  alcoholic  excesses,  serve  mor6 
or  less  directly  to"^  induce  the  disease.  Trauma  and  heredity  play  but  a 
minor  part,  if  any.  The  white  races,  Hebrew  and  Caucasian,  seem  to 
be  especially  predisposed,  the  yellow  and  black  races  less  so,  although  it 
is  occasionally  observed  among  the  negroes  of  America.  It  is  undoubtedly 
increasing  in  frequency. 

Symptoms. — The  prodromal  stage  may  last  for  months.  The  symp- 
toms are  both  mental  and  physical,  either  of  which  may  appear  first 
and  exist  alone  for  some  time,  or  they  may  be  contemporaneous  in  point 
of  onset.  As  a  rule,  some  altp-ration  of  the  character  and  demeanor  of 
the  patient  is  the  first  evidence  of  the  trouble.  The  patient  sufl"ers  from 
insomnia  and  is  generally  restless,  as  well  as  incapable  of  sustained  effort. 
He  will  be  forgetful  and  perhaps  careless  where  he  was  formerly  careful 
and  attentive.  The  sexual  desire  may  be  excessive.  The  ego  will  figure 
prominently  in  his  sayings  and  doings.  Sometimes  he  is  hypochondriacal, 
sometimes  exalted,  and  feels  strong  and  competent.  Among  the  physical 
signs  are  frequent  twitchings  and  tremors  of  the  facial  muscles,  particu- 
larly of  those  about  the  mouth  and  the  tongue.  Tremors  of  the  hand  and 
arm  seriously  interfere  with  writing ;  tremor  of  the  lips  and  tongue  renders 
the  speech  thick,  blurred,  and  hesitating,  and  syllables  are  omitted  from 
words,  or  even  whole  words  lost  from  sentences ;  and  the  pupils  are  fre- 
quently unequal  and  fail  to  react  to  light,  but  do  in  convergence  and 
accommodation  (Argyll-Robertson  pupil),  primary  optic  atrophy  may 
also  be  present.  The  tendon  reflexes  may  be  either  diminished,  lost,  or 
exaggerated.  These  symptoms  extend  over  a  variable  period,  with  one 
or  more  remissions  as  a  rule,  and  sometimes  with  a  complete  intermission 
and  an  apparent  cure.  Sooner  or  later,  however,  the  next  stage  develops. 
Stage  of  Excitement  or  Depression, — The  symptoms  of  this  stage  are 
superadded  to  those  of  the  first,  which  by  this  time  have  grown  gradually 
more  pronounced  ;  loss  of  power  usually  is  already  a  prominent  feature. 

1  Jour.  Amer.  Med.  Assoc,  Mar.  29,  1913,  1002. 


1200  DISEASES  OF  THE  yEliVOl'S  SYSTEM. 

A  state  of  exciteraeut  is  most  couimonly  met  ^\■itll,  and  is  characterized 
by  a  most  remarkable  prodigality  of  tboiiLdit  and  speech.  The  patient 
believes  himself  to  be  possessed  of  enormous  wealth  or  of  great  rank  and 
power.  Extravagance,  unsafe  business  ventures,  and  irrational  generosity 
are  common.  He  is  boisterous,  sleepless,  and  constantly  and  actively 
engaged  in  pursuing  his  extravagant  ideas.  Women  are  apt  to  believe 
themselves  pregnant.  In  many  cases,  however,  this  state  is  characterized 
by  nothing  more  than  a  feeling  of  well-being  and  satisfaction  with  one's 
self  and  freedom  from  care  and  Avorry  wlien  such  would  be  Justified.  In 
other  cases  this  delusion  of  grandeur  [crpans/re  Jelir/uni)  is  absent  and 
the  patient  is  melancholic  with  delusions  of  persecution.  Tliis  is  especially 
apt  to  be  the  case  if  his  physical  condition  is  lowered  by  some  intercurrent 
disease.  Remissions  of  all  these  symptoms  are  not  rarely  met  with. 
These  states  may  alternate,  epileptiform  or  apoplectiforfu  attacks  may 
occur,  followed  by  paralysis  in  this  stage  and  also  as  early  symptoms.  In 
the  large  majority  of  cases  the  mental  decay  is  progressive,  until  finall}" 
complete  dementia  is  reached ;  the  patient  then  becomes  bedridden,  bladder 
and  rectal  symptoms  develop,  and  possibly  bed-sores.  Death  results  from 
exhaustion  or  from  some  intercurrent  disease. 

Diagnosis. — This  is  sometimes  difficult  in  the  earliest  stages,  par- 
ticularly when  the  mental  phenomena  alone  exist.  The  slight  change 
of  character  and  the  occasional  outbursts  of  temper  or  unrestrained  jollity 
may  be  regarded  as  mere  moods  more  or  less  directly  dependent  upon  the 
daily  routine.  When  mental  depression  exists  it  may  be  mistaken  for 
neurasthenia.  When  to  these  symptoms  are  added  the  tremor,  the  defects 
of  speech,  the  inequality  of  the  pupils,  and  paresis,  the  clinical  picture 
gradually  assumes  definite  shape,  and  ofttimes,  long  before  expansive 
delirium  or  melancholia  develops,  a  positive  diagnosis  is  made.  The 
tabetic  type  of  the  disease  presents  many  points  of  resemblance  to  tabes 
dorsalis.  There  are  ataxia,  loss  of  knee-jerks,  disturbance  of  micturition, 
fulgurant  pains,  visceral  anesthesia,  and  Biernacki's  symptom  (absence 
of  tenderness  over  the  ulnar  nerve).  To  these  are  added  tremor  of  the 
lips,  disturbance  of  speech,  and  the  peculiar  mental  symptoms.  In  the 
cerebrospinal  fluid  obtained  by  lumbar  puncture  will  be  found  the  globu- 
lin reaction,  an  increased  number  of  lymphocytes,  and  plasma  cells,  and 
in  many  cases  the  Wassermann  reaction  with  both  the  blood-serum  and 
cerebrospinal  fluid. 

Differential  Diagnosis. — The  diseases  with  which  it  is  most  likely  to 
be  confounded  are — (1)  Bisaetimiated  sclerosis,  (2)  Paralysis  agitans, 
(3)  Cerebral  sy/jhilis,  (4)  Neurasthenia,  (5)  Chronic  alcoholism,  (6) 
Chronic  lead-poisoning  with  cerebral  symptoms,  (7)  Bulbar  jjalsy,  (8) 
Chronic  mania,  (9)  Dementia  from  any  cause,  as  senile  or  terininal 
dementia. 

(1)  In  disseminated  sclerosis  the  mental  symptoms  are  even  less  ob- 
trusive in  the  earlier  stages,  the  first  evidence  of  the  disease  being  paresis 
in  the  lower  extremities.  The  tremor,  too,  is  volitional,  the  speech  is 
scanning,  and  nystagmus  is  present.  Mental  phenomena  develop  late  if 
at  all,  and  are  not  expansive  in  nature. 

(2)  In  paralysis  agitans  there  are  frequently  no  mental  changes,  and 
in  any  case  they  consist  of  nothing  more  than  dulness.  The  characteristic 
attitude  and  gait ;  the  tremor  when  at  rest,  which  sometimes  ceases  on 


GENERAL  PARALYSIS  OF  THE  INSANE.  1201 

movement;  the  speech,  which  is  hesitating  at  first,  tlien  hurried;  the 
high-pitched  voice  ;  the  absence  of  pupillary  changes — all  mark  paralysis 
agitans.     Remissions  are  uncommon. 

(3)  Cerebral  s't/philia  may  also  simulate  paretic  dementia.  In  cerebral 
syphilis  the  tremor  may  or  may  not  be  present,  but  no  speech-defect  occurs  ; 
and  attacks  of  severe  headache  are  frequent  and  usually  severe.  Palsies 
of  cranial  nerves  and  complete  immobility  of  the  pupils  are  more  liable 
to  be  due  to  syphilis.  The  condition  often  passes  into  dementia,  but  the 
peculiar  expensive  delusions  of  paresis  rarely,  if  ever,  occur.  Mott  states 
that  in  syphilitic  pseudo-paresis  the  lymphocytes  in  the  cerebrospinal  fluid 
disappear  under  antisyphilitic  treatment,  but  in  true  paresis  they  do  not. 
Plasma  cells  are  not  present  in  the  fluid  in  syphilis,  and  the  lymphocytes 
are  usually  much  greater  in  number  (95-451  per  c.mm.)  than  in  true 
paresis  (8-78  per  c.mm.). 

(4)  The  characteristic  physical  symptoms  will  distinguish  the  two. 

(5  and  6)  Both  of  these  poisons  may  cause  symptoms  resembling 
those  of  paresis.  The  history  and  recurrence  of  hallucinations,  which  are 
very  uncommon  in  paresis,  will  often  serve  to  differentiate  the  two  con- 
ditions. Often,  however,  the  diagnosis  can  only  certainly  be  made  when 
the  patient  recovers,  which  he  will  not  do  if  he  has  true  paresis. 

(7)  The  absence  of  mental  symptoms  and  the  occurrence  of  atrophy 
of  the  tongue,  paralysis  of  the  vocal  cords,  etc.  (p.  1129),  distinguishes 
bulbar  palsy. 

(8)  Patients  with  chronic  mania  do  not  have  the  peculiar  physical 
symptoms  of  paresis,  and  there  will  usually  be  a  history  of  a  previous 
attack  of  acute  mania.  Spells  of  acute  excitement  may,  however,  occur 
during  the  course  of  paresis. 

The  presence  of  an  increase  of  the  lymphocytes  in  the  cerebral 
spinal  fluid  and  the  Wassermann  test  or  some  of  its  modifications  will 
distinguish  paresis  from  any  of  the  above,  excepting  syphilis  {vide  supra). 
There  is  also  a  possibility  that  a  patient  having  alcoholic  pseudo-paresis 
may  have  had  syphilis,  which  might  render  these  tests  fallacious. 

The  prognosis  is  gloomy  and  recovery  never  occurs.  The  tendency 
is  toward  a  fatal  termination  in  from  two  to  three  years.  In  rare  cases 
the  progress  may  be  slow  or  remissions  may  delay  the  termination  for 
several  years  longer. 

Treatment. — Drugs  are  of  no  value  in  a  curative  sense,  except  in 
those  cases  that  are  due  to  syphilis,  when  mercury  and  the  iodids  must 
be  pushed.  The  use  of  salvarsan  ("  606  ")  may  be  of  service  in  incipient 
cases,  if  none  of  the  contra-indications  to  its  use  are  present,  otherwise 
it  has  been  of  very  little  value.  Bromids,  morphin,  chloral,  or,  still 
better,  sulfonal,  trional,  or  hyoscin,  may  be  used  in  combating  the  in- 
somnia and  attacks  of  delirium.  These  cases  cannot  be  properly  cared 
for  at  home ;  indeed,  their  removal  to  an  asylum  is  generally  imperative. 
The  tendency  to  bed-sores  must  not  be  forgotten,  and  continuous  rest  in 
bed  must,  therefore,  be  postponed  as  long  as  possible. 

76 


1202  DISEASES  OF  THE  ^'ERVOUS  SYSTEM. 

VI.  GENERAL  AND  FUNCTIONAL  DISEASES. 
INFANTILE  CONVULSIONS. 

{Eclampsia  JnJ'antilis.) 

Under  this  term  are  grouped  a  number  of  conditions,  with  convulsive 
attacks  as  the  common  symjitoms. 

The  causes  are:  1.  Organic  brain  lesions  (pp.  11G3  and  1183). 
2.  Xeuropatiiic  tendency,  that  is  manifested  later  as  hysteria  or  epilepsy, 
o.  Emotional  disturbances,  as  fright.  4.  Rickets,  in  about  30  per  cent,  of 
all  cases.  5.  Acute  infectious  disease,  especially  as  an  initial  symptom  of 
pneumonia,  and  more  rarely  of  scarlet  fever,  small-pox,  and  pernicious 
malarial  infection.  G.  Inflammation  of  the  serous  membranes,  as  menin- 
gitis, where  the  relation  is  direct,  or  pleuritis  or  peritonitis.  7.  Kidney 
disease,  in  which  they  are  uremic.  8.  Peripheral  irritation  ;  dentition 
has  long  been  supposed  to  be  a  chief  factor  in  their  causation,  but  it  is 
now  believed  that  the  chief  cause  is  the  presence  of  rickets.  Intestinal 
parasites  have  also  been  found,  particularly  the  ascaris  lumbricoides, 
and  the  convulsions  have  ceased  after  their  expulsion.  9.  Debility, 
especially  tliat  resulting  from  gastro-intestiual  disorders. 

Pathology. — The  pathologic  changes  may  be  divided  into  two 
groups:  (1)  those  bearing  an  etiologic  relation  to  the  convulsive  attacks, 
and  (2)  those  that  are  mei'ely  consecutive.  Among  the  former  are  me- 
ningeal bleeding,  tumor,  gliosis  (either  hypertrophic  or  atrophic),  and 
hydrocephalus.  Then  there  are  general  conditions  that  seem  to  predis- 
pose to  this  condition  or.  at  any  rate,  are  frequently  associated  with  it, 
such  as  rachitis.  The  consecutive  lesions  are  hemorrhages  into  the 
meninges  or  into  the  substance  of  the  brain  and  the  spinal  cord,  an  in- 
crease in  the  amount  of  cerebro-spinal  fluid,  and  congestion  of  the  pia 
or  the  substance  of  the  brain. 

The  symptoms  of  the  attack  vary  according  to  its  intensity.  In  the 
most  severe  form  they  resemble  in  all  respects  those  of  an  epileptic  seizure. 
At  first  the  eyes  deviate  upward  or  to  one  or  the  other  side,  and  the  gaze 
becomes  fixed  and  staring  ;  next  there  are  ttvitchings  of  the  muscles  of  the 
face,  sometimes  slight  and  limited  to  one  side,  and  sometimes  general, 
often  involving  the  muscles  of  mastication  and  giving  rise  to  trismus  or 
gnashing  of  the  teeth.  Next  there  are  ti'taytic  contractions  of  the  extrem- 
ities, the  fingers  being  strongly  flexed,  the  hands  flexed  upon  the  arms, 
and  the  feet  in  the  position  of  pes  equinus  or  sometimes  in  the  dorsal 
flexion,  and  both  legs  and  arms  rigidly  extended.  Often  the  muscles  of 
the  trunk  are  involved,  and  there  is  either  opisthotonos  or  respiratory 
cramp,  with  excessive  hardness  of  the  abdominal  muscles.  This  rigid 
condition  is  interrupted  at  brief  intervals  by  sudden  twitchings,  or  occa- 
sionally the  convulsion  becomes  clonic  instead  of  tonic,  and  there  are  re- 
peated extensions  and  contractions  of  the  extremities,  shaking  of  the  head, 
and  quivering  of  the  whole  body.  As  a  result  of  the  respiratory  cramp, 
cyanosis  rapidly  develops  and  may  reach  an  extreme  degree.  The  forced 
respirations  give  rise  to  a  foam  that  collects  about  the  lips,  and  is  often 
mixed  with  blood  from  the  bitten  tongue.  Urine  is  often,  and  feces  occa- 
sionally,  passed   involuntarily.     In   nearly  all   cases  unconsciousness  is 


INFANTILE  (JONVin.SIONS.  1203 

complete.  Many  of  the  sliglit  attacks  arc  accompanied  by  a  cry  or  by  an 
attack  of  screaming.  The  tetanic  state  usually  lasts  for  a  minute  or  two  ; 
then  there  are  a  few  clonic  movements,  relaxation  becoming  rapidly  com- 
plete, and  the  spasm  is  ended  by  a  few  deep  respirations.  The  child  may 
return  to  consciousness,  although  it  is  usually  drowsy  or  stupid,  or  it  may 
pass  into  a  deep  sleep  from  which  it  cannot  be  aroused.  Often  in  the  lat- 
ter condition  attacks  will  recur  at  irregular  intervals,  and  sometimes  a 
single  attack  may  continue  for  some  time,  although  from  time  to  time 
there  are  slight  twitchings  followed  by  partial  relaxation  [status  eclamp- 
ticus — Lewis).  The  attack  may  come  on  suddenly,  or,  as  is  more  fre- 
quently the  case,  it  may  be  preceded  by  a  period  of  restlessness  and  irri- 
tability, A  milder  form  of  the  spasm  consists  of  sudden  fixation  of  the 
eyes,  slight  twitching  of  the  body,  and  a  peculiar  dusky  pallor  that  passes 
away  in  a  few  moments.  In  other  rare  cases  consciousness  may  persist, 
although  the  patient  is  aphasic.  Laryngismus  stridulus  is  an  analogous 
condition  (vide  Diseases  of  the  Larynx,  p.  517). 

The  diagnosis  of  the  condition  is  very  easy.  The  recognition  of 
the  cause,  however,  is  very  important  and  often  difficult.  Every  case 
should  be  first  examined  for  rickets,  and  then  the  gums  should  be  inves- 
tigated ;  also  the  condition  of  the  child's  nutrition  and  the  presence  of 
symptoms  of  gastric  or  enteric  irritations.  If  fever  exists,  it  is  import- 
ant to  discover  its  cause.  The  .character  of  the  convulsion  is  often  of 
value  in  distinguishing  between  the  idiopathic  or  reflex  type  and  that 
due  to  organic  brain-disease.  Convulsions  beginning  immediately  after 
birth,  or  an  injury,  either  persisting  or  else  disappearing  gradually,  are  prob- 
ably caused  by  meningeal  hemorrhage  (p.  1173).  An  attack  of  a  Jacksonian 
type  would,  of  course,  indicate  the  presence  of  a  focal  lesion  ;  and  if  this  be 
a  tumor,  there  will  probably  be  bulging  of  the  anterior  fontanel,  severe 
headache,  and  the  ophthalmoscope  will  reveal  a  neuro-retinitis.  If,  after 
the  attack,  pareses  or  paralyses  are  present,  a  focal  lesion  is  still  more 
likely.  Hydrocephalus  is  usually  recognized  with  ease.  Some  cases 
exist,  however,  in  which  it  is  impossible  to  discover  any  adequate 
cause. 

The  prognosis  varies  according  to  the  etiology.  In  cases  with 
organic  brain-disease  it  is  unfavorable  as  regards  cure.  In  those  forms 
that  precede  epilepsy  or  functional  nervous  diseases  the  spasms  usually 
disappear  after  the  first  dentition,  and  the  patients  appear  to  have  recov- 
ered for  a  time.  In  those,  however,  in  whom  the  symptoms  are  due  to 
some  peripheral  irritation  or  to  rachitis,  the  outlook  is  fair,  although 
even  these  now  and  then  develop  into  permanent  epilepsy.  The  convul- 
sions themselves  are  either  often  immediately  fatal,  or  so  exhausting  to 
the  patient  that  he  succumbs  readily  to  the  disease  that  produced  them. 
In  these  cases  the  prognosis  depends  upon  the  frequency  and  severity  of 
the  attacks,  death  usually  terminating  those  in  which  the  status  eclampti- 
cus  has  been  established.  The  prognosis  for  ultimate  cure  depends  also  in 
part  upon  the  length  of  time  that  the  condition  has  existed  ;  if  but  for  a 
short  time  before  an  arrest  has  been  established,  recurrence  is  much  less 
likely.  Gowers,  however,  says  that  even  after  a  year's  duration  perma- 
nent cure  may  sometimes  be  obtained. 

The  treatment  naturally  falls  into  two  parts — that  of  the  attack  and 
that  of  the  interval.     Unquestionably,  the  most  efficacious  antispasmodic 


1204  DISEASES  OF  THE  SERVOUS  SYSTEM. 

that  wo  possess  for  this  condition  is  chloroform.  A  few  drops  may 
be  put  upon  a  handkerchief  and  liehl  carefully  over  the  nose  and 
mouth  of  the  little  patient.  A  very  small  quantity  usually  suffices, 
and  the  eft'ect  is  almost  instantaneous.  In  addition  to  this,  chloral 
and  the  bromids  may  be  given  by  the  rectum,  and  it  is  often  useful 
to  add  to  these  one  of  the  coal-tar  antipyretics,  j)articularlv  antipyrin. 
Formerly  hot  mustard-baths  were  much  in  favor,  but  unless  they  do 
good  at  once  they  are  not  likely  to  be  of  any  use.  In  a  very 
obstinate  case  under  my  care  they  were  absolutely  valueless,  and  were  re- 
placed by  momentary  immersion  in  ice-cold  baths  and  vigorous  friction, 
Avhich  seemed  to  act  very  fiivorably.  If  any  known  source  of  irritation 
is  present,  as  an  overloaded  stomach,  it  should  be  relieved  at  once,  if  pos- 
sible, by  the  stomach-tube  or  an  emetic.  An  enteritis  may  be  tempo- 
rarily benefited  by  an  enema  or  by  a  moderate  dose  of  calomel.  The 
treatment  during  the  interval  depends  upon  the  nature  of  the  cause.  If 
rachitis  exists,  it  should  be  treated  according  to  the  principles  laid  down 
in  my  discussion  of  this  disease.  If  dentition  is  suspected,  the  gums  may 
be  lanced,  but  this  should  only  be  done  when  they  present  distinct  signs 
of  irritation.  Gastro-intestinal  disorders  of  any  kind  should  be  relieved 
as  soon  as  possible,  and  intestinal  parasites  must  be  expelled.  In  infec- 
tious diseases  the  convulsions  usually  disappear  after  the  initial  stages,  and 
require  no  further  attention.  In  orgarjic  brain-disease,  providing  it  be 
not  syphilitic  in  nature,  very  little  can  be  done.  Finally,  in  those  cases 
in  which  no  cause  can  be  discovered  bromids  are  the  only  resource,  and 
should  be  given  in  sufficient  doses:  from  gr.  iij-v  (0.194  to  0.324)  per 
day  to  children  of  six  months,  and  from  gr.  v  to  x  (0.324  to  0.648)  to 
those  between  six  and  sixteen  months. 


EPILEPSY. 

Definition. — A  condition  characterized  by  attacks  of  unconscious- 
ness, with  or  without  convulsions.  We  are  scarcely  justified  in  speaking 
of  epilepsy  as  a  disease.  It  seems,  in  reality,  to  be  a  symptom,  though  in 
many  cases  (the  so-called  idiopathic  cases)  we  do  not  know  the  underly- 
ing cause.  The  type  of  cases  in  which  the  unconscious  period  is  very  brief 
(momentary),  with  no  convulsion  following  or  at  most  but  a  slight  rigidity, 
is  termed  petit  mal.  The  more  pronounced  type,  with  prolonged  uncon- 
sciousness and  severe  general  convulsions,  constitutes  grand  mal.  That 
form  first  described  by  Hughlings  Jackson  in  which  the  convulsion  is 
localized,  and  in  which  unconsciousness  may  or  may  not  occur,  is  called 
Jacksonian^  focal,  or  cortical  epilepsy. 

Pathology. — Epilepsy  is  a  symptom,  and  the  inevitable  question 
must  be,  ••  Of  what?"  In  certain  cases  this  can  be  answered  (in  the 
organic  cases),  since  the  lesion  is  demonstrable  ;  but  in  others  (functional 
or  idiopathic)  there  is  no  demonstrable  lesion.  Among  the  causes  of  the 
f  )rmcr  are  brain-tumors,  meningitis,  traumatism  inflicted  either  at  birth 
or  subsequently,  atrophy  and  sclerosis,  vascular  disturbances,  sj^philis, 
and  toxemia,  both  autogenous  and  exogenous.     Peripheral   lesions  too 


EPILEPSY. 


1205 


may  givB  rise  to  it.  Little  can  be  said  about  the  idiopathic  variety,  we 
can  only  enumerate  causes ;  we  do  not  know  in  any  case  how  tliese  act, 
and  we  do  not  know  the  ultimate  pathology.  Many  writers  apply  the 
name  "epilepsy"  only  to  the  idiopathic  form,  while  others  include  all 
apyretic  affections  clin-racterized  by  the  occurrence  of  fits,  wlicthcr  of 
centric  or  peripheral  origin.  Brown-S(!(|uard  believes  tliat  the  distinction 
between  the  various  kinds  of  convulsions  is  artificial,  and  that  tlju  cor- 
rect clasaifijcation  should  be  based  on  the  knowledge  of  the  cause. 

Ktiologfy. — The  causes  are  (1)  predisposing,  (2)  exciting  or  deter- 
mining. Among  the  former,  which  refer  particularly  to  the  idiopathic 
form,  are — 

{a)  Age. — The  following  tables  show  the  early  onset  in  a  large  ma- 
jority of  cases  analyzed  by  Gowers,  Hesse,  and  Osier  : 


Age  at  onset. 


Proportion  affected. 
Observers. 


Gowers 
Before  10 422  . 


From  11  to  20 
"  21  "  30 
"  31 
"  41 
"  51 
"      61 


40 
50 
60 
70 
71 


Total, 

Age  at  onset  (Osier). 
1 


.  665 
.  224 
.  87 
.  31 
.  16 
.  4 
^ 1 

1450 


Ilesse 

393  . 

364  . 

Ill  . 

59  . 

51  . 

13. 

4  . 

0  . 


Per  cent. 
.  33.3 
.  42. 
.  13.7 


3.4 
1.2 
0.3 


995 


Number. 

.  .  74 

.  .  62 

.  .  51 

.  .  24 

.  .  17 

.  .  18 

.  .  19 

.  .  23 


Age  at  onset  (Osier). 
9 


10 
11 
12 
13 
14 
15 


Number. 
.  .  17 
.  .  27 
.  .  17 
.  .  18 
.  15 
.  .  21 
.    .  34 


Total, 


437 


(6)  Heredity. — Family  neuroses,  such  as  insanity,  hysteria,  chorea, 
etc.,  are  common,  but  it  is  decidedly  more  the  exception  than  the  rule  to 
find  either  parent  epileptic. 

((?)  Alcohol. — The  causal  relationship  between  an  abuse  of  alcohol  by 
the  parents  and  epilepsy  seems  rather  pronounced.  F^re  says  that  of 
594  epileptics  examined  by  him,  258  had  parents  who  were  hard  drinkers. 
Echeverria  refers  to  572,  257  of  which  he  believed  could  be  traced  directly 
to  the  abuse  of  alcohol. 

(d)  Syphilis  does  not  predispose.  When  it  gives  rise  to  changes  in 
the  brain  and  cord,  which  in  turn  cause  epilepsy,  it  is  in  reality  a  deter- 
mining cause. 

(e)  Eye-strain  is  no  longer  regarded  seriously  as  a  predisposing  influ- 
ence. 

The  exciting  or  determining  causes  are  traumatism  to  the  head  with 
or  without  actual  lesion  of  the  skull  or  brain,  mental  shock,  various  mor- 
bid conditions  of  the  membranes  of  the  brain  or  of  the  brain  proper  {e.  </., 
after  hemiplegia),  or  peripheral  irritation  (dentition,  worms,  a  cicatrix,  an 
adherent  prepuce,  etc.).  Not  a  few  cases  are  dependent  upon  toxic  sub- 
stances in  the  blood,  as  in  uremia  and  lead-poisoning.     Excessive  indul- 


1206  DISEASES'  OF  THE  yEnVOUS  SYSTEM 

gence  in  alcohol  or  over-eating  often  precijiitates  tlie  attack.  Great 
emotion  and  nervous  shock  (fright)  seem  to  be  exciting  causes  in  some 
cases.  There  are  cases  of  bradycardia  in  wliich  epileptiform  attacks 
occur  (Stokes- Adams  disease).  And  cerebral  arteriosclerosis  may  cause 
the  epileptiform  attacks  that  occur  in  old  people. 

Symptoins. — Petit  Mai. — In  this  condition  the  majority  of  ca,ses 
belong  to  the  following  typo:  The  attack  begins  suddenly;  perhaps  while 
talking  to  the  patient  his  expression  suddenly  becomes  blank,  the  face 
pales,  the  pupils  dilate,  and  he  is  evidenth'  not  conscious.  In  a  moment 
or  two  he  gathers  his  scattered  senses  and  picks  up  the  thread  of  the 
conversation.  Very  often  he  is  not  cognizant  of  any  lapse  of  time  or 
has  hut  a  vague  idea  that  something  has  occurred.  If  carefully  observed, 
fine  clonic  movements  may  be  detected  in  many  cases,  it  may  be  of  the 
facial  muscles  or  of  the  hands.  Convulsions  never  occur,  the  dominant 
feature  being  the  unconsciousness.  On  regaining  consciousness  the  pati- 
ent may  act  strangely  and  appear  dazed ;  it  is  seldom,  however,  that  he 
falls  in  attacks  of  this  kind.  Occasionally  a  peculiar  dreamy  state  takes 
the  place  of  an  ordinary  attack,  or  the  individual  may  be  the  victim  of 
imperative  ideas.  Falret  has  described  a  condition  {epilepsie  larve) 
known  as  masked  epilepsy,  in  which  maniacal  outbursts  or  explosions 
of  passion  occur. 

Grand  Mai  or  Haut  Mai. — In  many  cases  some  subjective  symptom 
precedes  the  actual  attack.  In  its  most  specialized  form  it  is  termed  an 
aura,  and  includes  any  phenomenon,  motor  and  sensory,  that  ushers  in  an 
attack.  While  the  aura  differs  in  different  cases,  it  is  almost  invariably 
constant  in  the  same  case,  so  that  one  Avill  have  a  subjective  sensation  of 
sound,  another  of  light,  either  flashes  or  colors,  etc.  There  are  other 
signs  that  occasionally  antedate  an  attack,  and  which  may  or  may  not 
precede  each  attack  (headache,  drowsiness,  change  of  di.sposition,  palpita- 
tion, perverted  appetite,  sexual  or  other,  etc.).  Many  attacks  begin  pre- 
cipitately with  absolutely  no  previous  warning.  In  such  cases  the  patient 
may  or  mav  not  utter  a  piercing  sound  {epileptic  cry),  falling  at  the  same 
time,  no  matter  where  or  in  what  position  he  may  be.  Hence  the  danger 
to  which  epileptics  are  always  subjected.  A  peculiar  onset  occurs  in  the 
so-called  '■'■procursive  epilepsy  "  in  which  the  patient  suddenly  starts  off 
and  runs  some  distance  before  the  paroxysm  begins. 

Paroxysmal  Period. — In  many  cases,  whether  preceded  by  an  aura  or 
not,  this  stage  is  ushered  in  by  a  spasm  that  is  tonic  in  character.  The 
patient  falls,  perhaps  because  of  the  loss  of  consciousness,  though  in  tho.se 
cases  in  which  he  drops  precipitately  he  is  probably  thrown  by  the  vio- 
lence of  the  spasm.  The  head  is  usually  extended,  the  nmscles  of  the 
larynx  and  trunk  contracted,  and  hence  the  epileptic  cry  and  the  dysp- 
nea, Avhile  the  lower  limbs  are  generally  extended,  the  upper  semiflexed, 
and  the  fingers  tightly  clenched.  This  period  of  rigidity  lasts  but  a  few 
seconds  before  clonic  ronruhinns  appear. 

Intercurrent  contractions  vary  in  diflerent  cases  from  very  mild  move- 
ments to  those  so  severe  as  to  toss  the  individual  about.  The  face,  pale 
at  first,  becomes  congested,  and  the  jaw  works  in  churning  the  saliva  into 
a  froth  ;  this  is  blood-tinged  when  the  tongue  is  bitten.  The  respiration 
is  jerky,  gasping,  and  there  may  be  a  loss  of  control  of  the  bladder  and 
bowels.     In  idiopathic  cases  this  stage  lasts  from  one  to  five  or  six  min- 


EPILEPSY.  1 207 

utes.  TTae  spasms  gi'adually  diiiiinisli,  and  without  regaining  conscious- 
ness the  patient  passes  into  a  deep  sleep,  immediately  preceded  in  some 
cases,  however,  by  coma  in  which  the  breathing  is  stertorous.  During 
the  sleep,  which  lasts  about  an  hour,  the  patient  is  completely  relaxed. 
On  waking  he  usually  appears  confused  and  complains  of  feeling  tired. 
His  limbs  may  ache  for  several  days. 

Occasionally  attacks  follow  one  another  in  quick  succession,  with  no 
period  of  consciousness  intervening  (status  epileptieus) — a  very  dangerous 
condition. 

Fost-epileptic  phenomena  are  variable.  The  patient  may  become 
maniacal,  homicidal,  or  may  simply  be  mentally  deficient  for  a  few  days, 
with  perhaps  some  slight  speech-disturbance.  A  condition  known  as 
epileptic  automatism  may  follow  or  take  the  place  of  the  convulsion.  In 
this  state  the  patient  may  go  about,  converse,  and  perform  apparently 
purposive  acts  of  which  he  has  no  recollection  afterward.  In  the  course 
of  time  every  epileptic's  brain-power  deteriorates.  Paralysis  sometimes 
occurs,  is  usually  transient,  and  may  be  unilateral  or  bilateral. 

Nocturnal  Epilepsy. — In  this  condition  the  attacks  occur  at  night,  and 
may  be  entirely  unknown  either  to  the  patient  or  his  friends.  He  com- 
plains from  time  to  time  of  feeling  tired  on  rising  in  the  morning,  his 
limbs  and  head  ache,  and  he  is  generally  duller  than  usual ;  he  may  even 
be  confused.  Such  a  history  is  suggestive,  and  the  suspicion  is  strength- 
ened if  in  addition  he  has  urinated  involuntarily  or  if  blood-spots  are 
found  on  his  pillow. 

Jacksonian  epilepsy  is  characterized  by  spasm  that  is  generally  local 
in  character ;  in  fact,  it  is  always  so  in  the  beginning,  though  occasionally 
it  may  spread  and  become  general.  Consciousness  is  preserved  in  the 
milder  forms.  Tingling  or  other  subjective  sensations  may  precede  an 
attack.  They  are  usually  due  to  some  irritation  of  the  motor  cortex 
(tumors,  meningitis,  softening,  trauma,  etc.).  Subcortical  lesions  and 
certain  toxemic  conditions  can  also  give  rise  to  it. 

Myoclonus  epilepsy  is  characterized  by  epileptic  seizures  of  the  ordi- 
nary type,  while  in  the  interval  between  the  attacks  the  patient  suffers 
from  clonic  spasms  of  various  muscles.  The  spasms  vary  in  intensity 
from  fibrillary  tremors  (myokymia)  to  violent  spasms  of  the  large  mus- 
cles (myoclonus,  p.  1214),     It  may  be  a  family  disease.^ 

Diagnosis. — When  a  definite  history  is  obtainable  the  difiiculty  of 
the  diagnosis  is  less,  particularly  if  an  aura  occurs.  The  attack  can  be 
frequently  diagnosed  from  other  epileptoid  conditions  at  the  time  by  the 
explosive  onset,  the  brief  tonic  and  somewhat  longer  clonic  spasm,  pro- 
found unconsciousness  followed  by  a  deep  sleep,  and  when  these  are  pres- 
ent by  an  involuntary  passage  of  urine,  frothing  at  the  mouth,  and 
biting  of  the  tongue. 

Differential  Diagnosis. — In  uremia  the  state  of  the  urine  (catheterize 
if  necessary),  and  often  the  odor,  serve  to  differentiate  it.  It  may  be 
impossible  to  detect  fraud,  so  perfectly  is  the  disease  simulated  by  those 
anxious  to  excite  pity,  judicial  or  otherwise,  or  by  those  whose  accom- 
plices rifle  the  pockets  of  sympathetic  bystanders.  Hysteria  may  also 
resemble  it  very  closely.  Oowers  has  tabulated  the  chief  differences  as 
follows : 

1  Clark,  Rev.  Neurol,  and  Psychit.,  July,  1907,  p.  532. 


1208  DISEASES  OF  THE  NERVOUS  SYSTEM. 


Epilepsy.  Hysteroid. 

Apparent  cause     .    .    .  None.  Emotion. 

Warning Any,  but  especially  unilateral     Palpitation,  malaise,  choking, 

or  epigastric  aura.  bilateral  foot-aura. 

Onset     Always  sudden.  Often  <rradual. 

Scream At  onset.  During  course. 

Convulsion Rigidity  followed   by   "jerk-     Rigidity     or      "  struggling," 

ing ;  "  rarely  rigidity  alone.         throwing  about  of  limba  ox 

head,  arching  of  back. 

Pupils Dilated  and  immobile.  Mobile  and  active. 

Biting Tongue.  Lips,  hands,  or  other  people 

or  things.     Very  rare. 

Micturition Frequent.  Never. 

Defecation Occasional.  Never. 

Talking Never.  Frequent. 

Duration A  few  minutes.  More  than  ten  minutes,  often 

much  longer. 
Restraint  necessary  .    .  To  prevent  accident.  To  control  violence. 

Termination Spontaneous.  Spontaneous       or       induced 

(water,  etc.). 

Epileptiform  seizures  may  occur  in  the  course  of  multiple  sclerosis, 
paresis,  and  dementia  praecox. 

Prognosis. — Idiopathic  epilepsy  very  rarely  is  cured.  In  most 
cases  it  will  be  found  that  an  apparent  recovery  is  merely  a  prolonged 
intermission.  Cases  that  are  evidently  symptomatic  are  sometimes 
curable  if  the  cause  can  be  removed.  Death  is  seldom  due  directly  to 
an  attack.      Fatal  accidents  may,  however,  be  caused  by  an  attack. 

Treatment. — When  an  aura  occurs,  advantage  may  indirectly  be 
taken  of  it  to  aid  in  aborting  the  attack.  The  only  efiBcient  remedy  is 
nitrite  of  amyl  inhaled  as  in  angina  pectoris.  In  Jacksonian  epilepsy, 
constriction  of  the  limb  in  which  the  aura  occurs  may  sometimes  be  suffi- 
cient. Salt,  a  popular  remedy,  is  useless.  Every  effort  should  be  made 
to  lessen  the  liability  of  danger  to  the  patient — first  from  falling,  and 
secondly,  from  the  violence  of  the  spasms.  One  may  at  times  be  justified 
in  using  ether  or  chloroform  by  inhalation  to  control  the  severity  of  the 
convulsions.  After  loosening  the  clothing,  and  putting  a  cork  or  some- 
thing between  the  teeth  to  prevent  biting  the  tongue,  nothing  more  can 
be  done  at  the  time.  Between  the  attacks  special  care  should  be  taken 
to  put  the  system  in  good  condition,  and  all  sources  of  worry  and  irrita- 
tion should  be  removed  so  far  as  possible.  Particular  attention  should 
be  given  to  the  stomach  and  bowels  and  the  removal  of  all  sources  of 
reflex  irritations,  as  eye-strain,  adenoids,  intranasal  obstructions,  bad 
teeth,  adherent  prepuce,  etc.  The  food  should  be  light  and  easily  digest- 
ible, and  systematic  colonic  flushing  is  often  advnntagcDUS. 

As  to  medicinal  measures,  the  bromids  are  of  the  greatest  value.  The 
sodium  and  potassium  salts  are  most  commonly  employed,  the  former, 
as  a  rule,  being  better  borne  by  the  stomach.  1'hey  may  be  given 
in  milk  or  in  one  of  the  medicated  waters.  Strontium  brornid  has  oeen 
used  rather  extensively  of  late,  and  has  yielded  excellent  results.  While 
idiosyncrasies  are  met  with,  it  may  generally  be  given  in  from  10-  to  20- 
gr.  doses  (0.972-1.944)  three  or  four  times  a  day,  and  preferably  after 
meals.  Each  case  must  be  treated  according  to  its  special  indications. 
Symptoms  of  bromism  (acne,  sore  throat,  drowsiness,  and  gastric  disturb- 
ance) should   be   carefully  guarded   against.      Should   they  develop,  the 


MIGRAINE.  ]  209 

dose  of  bromid  must  be  reduced,  and  Fowler's  solution  ;i(l)iiinistf;r(,Ml  for 
a  few  days.  H.  C.  Wood  recommends  tliat  the  latter  should  be  ffiven 
continuously  with  the  bromids,  thereby  preventing  or,  at  all  events,  les- 
sening the  liability  to  bromism.  Other  remedies  sometimes  employed  are 
nitroglycerin  (hypodermically),  ciinnabis  indica,  silver  nitrate,  zinc,  borax, 
solanum  or  horse-nettle,  chloral,  antipyrin,  veronal,  and  chloretone.  Sur- 
gical measures  occasionally  yield  good  results,  this  being  particularly  true 
in  focal  epilepsy — i.  e.,  when  the  cortical  centers  are  the  seat  of  an  irri- 
tating lesion,  as  a  tumor  or  depressed  fracture  which  can  be  removed. 
Even  in  these  cases,  if  the  convulsions  have  continued  for  two  years  or 
over,  the  outlook  is  not  go.od.  In  idiopathic  epilepsy  removal  of  the 
motor  cortex  has  been  tried  in  those  cases  in  which  an  aura  suggested  a 
local  origin — e.  g.,  in  a  center  for  a  particular  group  of  muscles.  The 
results  have  been  discouraging,  in  all  cases  the  attacks  recurring  with 
increased  severity  after  an  interval  of  remission.  It  is  a  curious  fact  that 
almost  any  surgical  operation  will  diminish  or  check  the  epileptic  attacks 
for  a  time,  and  I  have  known  as  simple  a  procedure  as  venesection  to 
afford  complete  relief  in  a  severe  case  for  several  months.  The  results 
ascribed  to  various  operations  may  be  explained  in  large  part  by  this  fact. 


MIGRAINE. 

{Hemicrania ;  Sick  Headache.) 

Definition. — A  neurosis  characterized  by  severe  attacks  of  headache, 
often  paroxysmal  and  more  or  less  periodic,  with  disturbances  of  vision 
and  with  or  without  nausea  and  vomiting. 

Ktiology. — The  condition  is  frequently  hereditary,  and  in  the  large 
majority  of  the  cases  that  I  have  seen  it  has  been  transmitted  by  or 
through  the  mother.  It  usually  appears  early  in  life.  Various  other 
neuroses  are  common  in  families  subject  to  this  condition.  Females  are 
more  frequently  affected  than  males,  and  migraine  seems  to  be  associated 
■with  diseases  peculiar  to  women,  especially  menstrual  disorders.  Among 
the  exciting  causes  may  be  mentioned  gastric  disturbances,  dental  irrita- 
tion, naso-pharyngeal  diseases  (adenoids,  etc.),  eye-strain,  grief,  emotion 
— in  short,  anything  that  tends  to  lower  the  physical  or  mental  tone  oc- 
curring in  those  hereditarily  predisposed.  Recently  attention  has  been 
called  to  auto-intoxication  (leucomainic  poisoning)  as  a  cause  of  certain 
cases.     A  gouty  diathesis  seems  to  be  operative  in  many  cases. 

Pathology. — This  is  profoundly  obscure,  since  no  lesion  has  ever 
been  discovered.  By  some  it  is  thought  to  be  a  vasomotor  disturbance, 
and  the  transient  paralytic  symptoms  that  may  occur  are  believed  to  be 
due  to  arterial  spasm.  Very  rarely  the  disease  has  been  observed  in 
some  subjects  to  replace  an  attack  of  epilepsy  or  even  to  alternate  with 
true  epileptic  attacks. 

Symptoms. — As  a  rule,  the  patient  can  prognosticate  an  attack.  In 
the  cases  of  slow  onset  he  may  feel  indisposed  for  some  hours  before,  being 
languid,  drowsy,  with  general  discomfort  and  perhaps  nausea.  In  other 
cases  various  subjective  sensations  occur,  lasting  from  a  few  minutes  to 
several  hours.  Of  these,  disturbances  of  vision  are  most  common,  such 
as  flashes  of  light,  spectra,  visions  of  animals  or  weird  forms,  or  scotoma, 
etc.     Lateral  homonymous  hemianopsia  has  also  been  observed.     Audi- 


1210  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tory  sensations  are  rare,  as  are  those  of  the  other  special  senses.  Tran- 
sient palsies  and  aphasia  also  may  appear,  the  latter  occurrins;  -when  the 
pain  is  on  the  right  side.  The  palsies  are  often  hemiplegic,  being  present 
on  the  side  opposite  to  that  in  -which  the  pain  is.  Numbness  and  tingling 
may  also  be  symptoms.  Comi)li'te  ()cuiomot(.)r  palsy,  lasting  sevoral  days, 
may  occur.  After  these  phemimona  have  existed  for  some  time  Jnunhwhe 
supervenes,  when,  as  a  rule,  they  cease.  The  pain,  at  least  in  the  begin- 
ning, is  usually  unilateral,  as  the  name  suggests,  though  later  it  may  and 
often  does  involve  the  entire  cranium,  spreading  from  a  single  point  of 
origin — over  one  eye,  for  instance.  The  aft'ectod  region  mav  be  tender 
to  the  touch  or  it  may  be  the  seat  of  numbness  or  tingling.  Nausea  and 
vomititi;!  are  common  sym{)to!us,  with  or  without  vertigo.  Vasomotor 
symptoms  are  fre([uent,  usually  the  face  is  pale  (angiospastic  type),  but 
it  may  be  flushed  (angioparalytic  type).  A  brief  period  of  unconscious- 
ness occurs  in  some  cases,  and  spasmodic  movements  may  also  be- observed 
occasionally.  This  fact  is  of  particular  interest,  since  it  serves  to  support 
the  view  that  migraine  is  in  some  way  related  to  epilepsy,  and,  as  has 
been  stated,  attacks  of  migraine  and  epilepsy  may  alternate.  Unlike 
epilepsy,  migraine  does  not  tend  to  impair  the  mental  faculties,  no  matter 
how  long  the  patient  has  been  afflicted.  During  an  attack,  however,  he 
may  have  melancholia  or  be  incapacitated  mentally  and  physically  for 
two  or  three  days. 

Course. — The  disease  generally  begins  in  early  life,  and  in  nearly 
half  of  the  cases  before  the  fifteenth  year,  recurring  with  a  certain  degree 
of  periodicity  until  old  age,  when  it  often  passes  aAvay.  It  may  cease  in 
women  at  the  menopause,  and  in  men  between  the  fortieth  and  fiftieth 
years. 

The  prognosis  is  good  as  far  as  life  is  concerned.  This  disease  is 
incurable,  though  the  condition  of  the  patient  may  be  alleviated. 

Treatment. — The  management  of  the  disease  may  be  considered 
under  two  heads :  (1)  treatment  of  the  attack,  and  (2)  the  treatment  be- 
tween the  attacks,  which  necessarily  includes  prevention.  The  patient 
should  be  put  to  bed  in  a  slightly  darkened  room,  and  all  sources  of  noise 
and  confusion  should  be  removed  as  far  as  possible.  The  attack  may  be 
so  severe  as  to  justify  the  use  of  morphin  hypodermically.  The  coal-tar 
derivatives  have  met  with  most  favor,  however,  as  remedial  measures,  and 
preferably  antipyrin  and  phenacetin,  though  their  occasional  depressing 
effect  should  be  borne  in  mind.  Caffein  may  be  given  with  phenacetin 
with  advantage,  and  aromatic  spirits  of  ammonia  is  a  useful  adjuvant  to 
antipyrin. 

Acetanilid  may  often  be  substituted  for  phenacetin  with  apparent  ad- 
vantage. In  twenty-four  hours  this  may  be  discontinued,  and  potassium 
bromid  should  be  given  in  liq.  ammon.  acetatis  in  doses  of  gr.  x  to  xt 
(0.648-0.972).  Local  applications  of  menthol,  or  fly-blisters  may  be 
employed,  or  even  superficial  points  may  be  made  with  the  actual  cautery. 
The  rapidly  interrupted  faradic  current  applied  with  a  dry  wire  brush 
over  the  painful  side  of  the  head  may  give  temporary  relief.  Washing 
out  the  lower  bowel  has  been  recommended. 

In  the  angio-spastic  type  full  doses  of  nitroglycerin  may  be  of  service. 

Between  the  attacks  the  general  health  should  be  carefully  looked 
after.     The  so-called  uric-acid  diathesis  is  common  in  subjects  of  migraine. 


ACUTE  CHOREA.  1211 

Haig  staunchly  advocates  the  use  of  salicylates  in  such  cases  in  addition 
to  the  dietetic  measures.  Anemia  should  be  treated  by  iron  in  some 
form,  dialyzed  or  Blaud's  pill.  The  bowels  should  be  kept  normal  by 
means  of  some  saline  (Ilunyadi,  etc.),  or  by  the  fluid  extract  of  cascara 
sagrada.  An  examination  of  the  stomach-contents  often  shows  the 
existence  of  anacidity ;  when  this  is  corrected  there  is  usually  marked 
improvement  in  the  migraine.  The  extract  of  cannabis  indica  is  em- 
ployed by  some  over  a  long  period  of  time,  just  as  the  bromids  are  in 
epilepsy.  It  is  given  in  doses  of  gr. '  ;^  to  |  (0.0162-0.0324),  two  or 
three  times  a  day,  after  meals.  While  exercise  and  fresh  air  are  admir- 
able adjuvants  to  any  form  of  treatment,  it  must  not  be  forgotten  that 
fatigue  invites  an  attack.  Proper  rest,  care  and  regularity  in  dieting, 
and  the  avoidance  of  excitement  are  the  chief  points  to  be  observed. 


ACUTE  CHOREA. 

{Sydenham's  Chorea;  St.  Vitus'  or  St.  Anthony's  Dance.) 

Definition. — The  type  of  chorea  described  by  Sydenham  is  a  more 
or  less  acute  disease,  due  to  an  infectious  agent  or  its  toxin.  It  has  a 
special  predilection  for  children,  and  is  characterized  by  involuntary, 
irregular,  non-purposive  muscular  movements,  more  or  less  marked  mental 
change,  by  a  great  liability  to  endocarditis  and  a  tendency  to  recurrence, 
particularly  during  the  spring  and  fall.  It  has  a  close  relation  to  acute 
articular  rheumatism. 

Pathology. — No  definite  lesion  can  be  ascribed  to  the  disease, 
though,  as  is  usual  in  such  cases,  a  great  variety  of  lesions  have  been 
described.  Chief  among  these  is  the  embolic  theory,  advanced  by 
Kirkes  and  subscribed  to  by  Bastian  and  Hughlings  Jackson.  Since 
emboli  are  not  found  in  every  case,  however,  they  cannot  be  the  sole 
cause.  The  disease  is,  however,  probably  due  to  the  action  of  a  bacterial 
poison  upon  the  brain  cortex.  In  about  25  per  cent,  of  the  cases  there 
is  an  association  of  chorea  and  acute  articular  rheuipiatism. 

etiology. — (1)  Age. — By  far  the  greatest  number  of  cases  occur 
before  the  twentieth  year,  but  it  may  develop  at  any  age.  Most  cases 
occur  between  the  tenth  and  fifteenth  years. 

iSex. — Females  are  most  frequently  attacked,  and  probably  in  two- 
thirds  of  all  cases. 

Mace. — Acute  chorea  is  rarely  met  with  except  among  the  white  races. 

Heredity. — A  history  of  other  neuroses  (hysteria,  epilepsy,  etc.)  in  the 
ancestors  may  be  obtained,  and  an  unstable  nervous  system  obtained 
from  such  stock  may  pi-edispose  to  the  disease.  Children  who  develop 
chorea  are  especially  apt  to  be  of  a  nervous,  excitable  temperament,  and 
may  be  hysterical  as  well  as  choreic.  It  is  in  cases  of  this  type  par- 
ticularly thsbt  fright  acts  as  an  exciting  cause. 

Infectious  Diseases. — There  seems  to  be  a  relationship  between  some 
cases  of  chorea  and  other  infectious  diseases.  This,  however,  is  only  at 
all  marked  in  acute  articular  rheumatism  and  scarlatina.  It  is  not  yet 
proved,  however,  as  has  been  claimed,  that  chorea  and  rheumatism  are 
due  to  the  same  cause. 


y-2V2  DISEASES   OF  THE  SERVOUS  SYSTEM. 

Prcijnancii  is  ;i  fretiuoiit  cause  ui  chori-a  in  adult  life.  When  so 
caused,  it  is  apt  to  be  severe.  It  is  most  prone  to  develop  during  the 
earlier  months,  and  especially  in  primiparte.  It  often  assumes  the 
maniacal  type. 

The  intiuence  of  ri'jiex  irritation  is  probably  much  overrated,  whether 
intestinal,  genital,  or.  from  ocular  defects,  but  these  may  aggravate  the 
disease. 

Symptoms. — The  common  or  ordinary  form  is  fre(juently  mot  with, 
especially  during  the  spring  and  fall.  Primary  attacks  may  occur  at  any 
time,  but  recurrent  outbreaks  are  most  prone  to  develop  in  the  spring. 
There  is  a  slight  affection  manifested  by  restlessness,  disturbed  rest  at 
ni^lit,  and  bv  irregular  and  purposeless  inuKcular  movements,  that  are  most 
marked  in,  or  entii'ely  confined  to,  the  upjjcr  extremities,  the  head,  or  the 
facial  muscles  ;  or  the  condition  may  be  unilateral.  They  usually  cease 
during  sleep.  Endocarditis  may  not  give  rise  to  characteristic  signs.  More 
or  less  iniiscnlar  weakness  is  present  and  the  patient  tires  very  readily. 
The  childs  disposition  is  changed,  outbursts  of  temper  being  (juite  common 
on  the  slightest  provocation.  Fever  is  absent  in  this  form  unless  compli- 
cations exist,  though  ^Yhen  severe  joint-troubles  or  endocarditis  are  present, 
the  temperature  will  rise.  Anemia  is  often  present,  and  with  it  headaches, 
irritable  heart,  and  hemic  murmurs.  Indeed,  in  some  instances  not  even 
a  murmur  can  be  heard,  though  jt?osf?7?or<^m  records  of  cases  with  a  his- 
tory of  chorea  show  that  in  most  of  them  the  valves  are  aflfected.  The 
mitral  valve  is  most  commonly  involved,  the  endocarditis  usually  being 
of  the  verrucose  type.  There  are  rarely  any  sensory  symptoms,  severe 
pain,  at  all  events,  being  extremely  rare.  Little  dependence  can  be 
placed  on  complaints  of  tingling  or  burning  pain  unless  they  are  volun- 
tary, for  the  mental  make-up  of  choreic  patients  is  such  that  they  are  apt 
to  dwell  upon  slight  ailments  suggested  to  them  through  leading  ques- 
tions.    The  reflexes  do  not  differ  from  those  of  normal  children. 

There  is  a  more  severe  type  of  chorea,  in  which  the  movements  are 
extremely  violent,  causing  severe  injuries,  even  fractures,  and  leading  in 
some  cases  to  death  from  exhaustion.  The  fnychic  symptoms  are  often 
marked,  and  speech. may  be  impaired  to  such  an  extent  as  to  render 
articulation  unintelligible.  Such  a  condition  may  occur  in  the  first,  but 
it  is  probably  met  with  more  often  after  one  or  more  mild  attacks.  The 
gravest  form  of  chorea  is  chorea  insaniens,  in  Avhicli  the  movements  are 
violent  and  constant.  Speech  is  much  affected,  insomnia  is  marked,  and 
fever  and  maniacal  delirium  develop,  followed  in  some  cases  by  exhaustion 
and  death.     Various  forms  of  skin  eruptions  may  be  seen. 

The  course  is  from  six  to  twelve  weeks,  though  the  most  trifling 
cases  may  recover  in  a  month  or  less.  Others  persist  six  months  or  even 
more.  In  about  two-fifths  of  all  cases  there  is  more  than  one  attack, 
while  Gowers  has  reported  one  case  in  which  there  Avere  nine  recurrences. 
In  one  of  my  own  cases  two  attacks  occurred  annually — spring  and 
autumn — for  two  years.  A  fatal  issue  is  very  rare  in  children,  and  abso- 
lute recovery  is  the  rule.  The  maniacal  form,  which  usually  develops  in 
adults,  especially  in  pregnant  women,  as  previously  stated,  is  more  often 
fatiil,  though  recovery  is  also  the  rule  in  such  cases. 

Diagnosis. — As  a  rule,  this  is  quite  simple.  The  age  of  the  patient, 
the  mode  of  onset,  and  the  character  of  the  movements  suffice  to  prevent 


HUNTINGDON'S  CHOREA.  1213 

mistakes.  It  may  be  mistaken  for  hereditary  cliorea  fp.  1213),  and 
for  the  various  spasmodic  movements  due  to  hysteri;i,  (p.  122S),  tics 
(p.  1216),  iind  myoclonus  (p.  1214),  and  attention  hns  been  called 
(p.  1174)  to  the  possibility  of  mistaking  athetosis  and  other  spasniodic 
movements  associated  sometimes  with  co'cbral  palsies  for  it.  'fremor 
from  any  cause  is  characterized  by  the  rhythmic,  regular  character  of 
the  movements. 

Treatment. — This  is  largely  hygienic — a  fact  that  must  be  strongly 
dwelt  upon  in  discussing  with  the  parent  the  management  of  the  patient. 
The  avoidance  of  all  forms  of  nerve-strain  is  of  the  utmost  importance,  and 
the  amount  of  school-work  and  home-study  shoidd  be  carefully  inquired 
into,  and  all  excess  absolutely  prohibited.  In  the  milder  forms  rest  in 
bed  is  not  imperative,  but  active  exercise  must  be  forbidden,  since  it 
invites  cardiac  troubles,  the  tendency  to  heart-involvement  already  being 
great  in  chorea.  In  tlio  more  severe  forms  rest  in  bed  is  a  sine  qud  non. 
In  any  case  an  abundance  of  rest  is  called  for,  and  when  insomnia  is 
present  it  should  be  promptly  handled.  An  important  element  of  the 
treatment  that  is  sometimes  indispensable  is  the  change  of  environ- 
ment, associated  with  rest.  As  a  rule,  the  patients  do  best  in  a 
warm  climate  and  at  the  seashore.  In  severe  cases  the  bromids  should 
first  be  tried  internally,  and  a  warm  bath  administered  just  before  bed- 
time. Hyoscin  hydrobromate  may  also  prove  useful  to  lessen  the  severity 
of  the  movements.  In  other  cases  morphin  or  chloral  may  be  required, 
though  it  must  not  be  forgotten  that  the  latter  is  a  cardiac  depressant ; 
veronal  or  trional  should,  therefore,  be  given  the  preference.  The  bowels 
must  be  regulated  and  the  diet  should  be  light  and  wholesome,  with  an 
abundance  of  fruit  and  fresh  vegetables.  Cod-liver  oil  is  usually  indicated. 
When  anemia  is  present,  it  is  to  be  met  by  the  use  of  some  one  of  the  prep- 
arations of  iron.  Should  reflex  irritation  be  found  to  exist,  it  should  be 
corrected  at  once.  Of  the  therapeutics  of  the  disease  not  much  can  be  said. 
We  have  no  specific,  but  the  two  most  useful  drugs  are  arsenic  and  cimici- 
fuga,  the  former  as  Fowler's  solution  and  the  latter  as  the  fluidextract. 
Fowler's  solution  should  be  given  in  3-  to  5-drop  doses  three  times  a  day 
for  a  few  days,  and  then  increased  1  drop  per  diem  until  the  point  of  toler- 
ance is  reached  or  the  physiologic  action  is  manifest.  The  remedy  is  now 
to  be  continued,  but  in  reduced  dosage.  The  late  Hiram  Corson  first 
warmly  recommended  cimicifuga  in  the  treatment  of  chorea,  and  I  have 
found  the  combined  use  of  this  drug  and  arsenic  to  be  more  prompt  and 
efficient  than  the  latter  alone,  particularly  in  protracted  cases.  If  rheu- 
matic symptoms  appear,  the  salicylates  should  be  administered  in  full 
doses,  aspirin  being  particularly  well  taken.  Between  the  attacks  of 
chorea,  syrup  of  the  iodid  of  iron  may  be  given  with  advantage. 


HUNTINGDON'S  CHOREA. 

[Chronic  Progressive  Chorea;  Hereditary  Chorea.) 

Definition. — An  hereditar}'-  disease  affecting  many  members  of  a 
family,  developing  in  early  adult  life,  and  characterized  bv  irregular 
muscular  contractions,  incoordination,  and  progressive  dementia.  The 
disease  was  first  definitely  described  by  Huntingdon  in  1872,  but  other 


1214  nrSFASES  OF  THE  NERVOUS  SYSTEM. 

■writers  had  alri'mly  alluded  to  it.  Sporadic  cases  are  reported  from  time 
to  time. 

Htiologfy. — The  disease  is  strictly  hereditary,  and  lias  been  traced 
through  five  generations.  The  offspring  of  parents  that  escape  are  for- 
ever immune.  It  occasionally  alternates  with  idiocy,  epilepsy,  and 
various  degenerative  conditions.  It  a))pears  to  be  endemic  in  certain 
localities,  and  still  exists  upon  the  southern  shore  of  Long  Island,  where 
Huntingdon  first  observed  it. 

Pathologfy. — The  changes  found  consist  of  chronic  pachy-  and 
leptonieningitis.  chronic  hemorrhagic  encephalitis,  characterized  by 
round-cell  infiltration  of  the  cortex,  degeneration  of  the  ganglion-cells, 
proliferation  of  the  neuroglia,  sclerosis  of  the  blood-vessels  with  dilata- 
tion of  the  perivascular  and  lymph-spaces,  and  numerous  hemorrhagic 
foci  (Facklam).  There  are  also  atrophy  and  thinning  of  the  cortex, 
slight  irregular  changes  in  the  spinal  cord,  and  multiplication  of  the 
nuclei  in  the  muscles. 

Symptoniatologfy. — The  choreiform  movements  commence  insidi- 
ously and  only  in  the  rarest  cases  become  pronounced.  They  are 
usually  suscei)tible  to  voluntary  inhibition  and  disappear  during  sleep. 
They  usually  appear  first  in  one  extremity  and  then  gradually  invade  the 
other  parts  of  the  body.  There  is  considerable  incoordination  of  move- 
ment. The  mental  sumptoms  consist  of  progressive  dementia,  irrita- 
bility often  attaining  maniacal  violence,  delusions  of  persecution,  and 
rapid  diminution  of  intelligence.  In  some  cases  the  mental  changes  are 
very  slight. 

The  course  is  steadily  progressive,  but  the  patient  may  live  to  an 
advanced  age. 

Diagnosis. — The  only  condition  likely  to  cause  confusion  is  senile 
chorea  with  dementia.  In  this  the  mental  symptoms  are  usually  slight 
and  the  motor  symptoms  more  violent.  The  family  character  of  the 
disease  is  also  lacking.  By  many,  however,  this  is  supposed  to  be  a 
type  of  Huntingdon's  chorea. 

Treatment  is  entirely  symptomatic. 


PARAMYOCLONUS  MULTIPLEX. 

(^Myoclonus  Multiplex.) 

Definition. — This  is  a  disease  of  unknown  pathology,  first  described 
by  Friedreich,  and,  as  its  name  implies,  characterized  by  clonic  contrac- 
tions in  various  groups  of  muscles. 

Its  etiology  is  obscure.  Heredity  unquestionably  plays  an  import- 
ant part,  nearly  all  the  patients  having  among  their  ancestry  cases  of 
one  or  more  forms  of  nervous  disease.  Emotional  disturbance,  as  fright, 
is  often  the  exciting  cause.  It  usually  develops  in  early  adult  life,  and 
is  probably  more  common  in  males.  In  one  case  that  I  observed  it  was 
associated  with  idiocy. 

The  symptoms  of  the  disease  consist  of  cloiiic  contractions  of  indi- 
vidual muscles,  which  cause  either  no  or  very  little  movement  of  the 
parts  controlled  by  them,  occurring  chiefly  in  the  muscles  of  the  extrem- 


ELECTRIC  CHOREA   OF  DUBINl.  121  5 

ities  and  the  trunk,  and  only  occasionally  involvin;^;  the  muscles  of  the 
face.  These  contractions  are  very  sudden  ;  so  much  so  that  they  have 
been  described  as  lightninj^-like.  Voluntary  movement  diniitiislies  them 
somewhat,  emotional  disturbance  increases  them  considerably,  wbile 
during  sleep  they  disappear.  The  power  of  the  muscles,  their  si/.e  and 
nutrition,  remain  unimpaired.  The  electric  reactions  are  normal,  but 
electric  stimuli  and  any  cutaneous  irritation  are  apt  to  precipitate  an 
attack.  The  tendon-reflexes  are  increased.  Sometimes  the  patient  gives 
vent  to  a  peculiar  grunt,  which  is  probably  due  to  involvement  of  the 
larynx  and  diaphragm.  In  some  of  the  cases  sensitive  points  have  been 
found  over  the  spinal  column,  and  not  a  few  have  presented  other 
stigmata  of  hysteria. 

Varieties  of  this  disease  are  myokymia  or  persistent  quivering  of  the 
muscles  (fibrillary  chorea  of  Morvan),  and  fibrillary  or  fascicular  twitch- 
ings  (myoclonus  fibrillaris  multiplex  of  Kny).  In  these  cases  organic 
disease  of  the  peripheral  motor  neuron,  tuberculosis,  and  neurasthenia  must 
be  excluded  (pp.  1142,  1144,  1235).  All  of  these  symptoms  may  co- 
exist in  the  same  case. 

Pathology. — Friedreich  believed  that  it  was  due  to  irritation  of  the 
anterior  horn  cells.  In  the  case  studied  by  Hunt  nothing  was  found  but 
hypertrophy  of  the  muscle-fibers. 

Diagnosis. — The  essential  features  are  sudden,  quick,  spontaneous, 
multiple  contractions  of  individual  muscles,  which  do  not  cause  move- 
ment of  the  parts  supplied  by  the  aflFected  muscles.  This  is  sufficient  to 
distinguish  it  from  chorea.  The  so-called  electric  choreas  of  Bergeron 
and  Henoch  are  probably  varieties  of  the  same  disease.  A  similar  type 
of  movement  may  also  be  due  to  hysteria ;  when  so  caused,  other  mani- 
festations of  this  disease  will  be  found  (p.  1227).  It  may  be  mistaken 
for  one  of  the  forms  of  tic.  These  are  discussed  below,  where  the 
differential  points  are  given.  Myoclonus  may  also  occur  in  associa- 
tion with  other  diseases,  as  tuberculosis,  epilepsy,  and  the  muscular 
dystrophies  (p.  1270).  A  family  type  has  also  been  described  by  Un- 
verricht. 

In  the  non-hysteric  form  the  prognosis  is  serious,  very  few  of  the 
cases  ever  showing  permanent  improvement. 

The  treatment  consists  of  rest,  isolation,  full  feeding,  hypodermic 
injections  of  hyoscine,  arsenic,  bromids  and  valerian  internally,  and  the 
application  of  electricity.  The  latter  seems  most  effective  when  applied 
to  the  spinal  column,  a  constant  galvanic  stream  being  employed  and 
the  anode  being,  placed  over  the  sensitive  vertebrse.  It  is  not  unlikely, 
however,  that  these  cases  are  of  an  hysteric  nature. 

ELECTRIC    CHOREA   OP   DUBINl. 

A  disease  closely  allied  by  its  symptoms  with  the  preceding,  but 
probably  of  very  different  etiology,  is  the  chorea  electrica  of  Duhini, 
a  disease  endemic  in  Northern  Italy.  It  occurs  at  all  ages,  affects  both 
sexes,  and  appears  to  be  of  an  infectious  nature.  Occasionally  congestion 
of  the  meninges  has  been  found  ;  in  other  cases  there  are  inflammatory 
lesions  in  other  parts  of  the  body,  and  particularly  in  the  lungs. 

Symptoms. — The  disease  commences  with  severe  pains  in  the  head, 
the  neck,  and  the  lumbar  region.     After  a  brief  interval  contractions 


1216  DISEASES  OF  THE  NERVOUS  SYSTEiV. 

occur  in  the  niusclos,  usually  a})peariug  iirst  in  the  upper  extremities,  but 
rapidly  becoming  general,  xhey  are  almost  continuous,  and  are  separated 
by  approximately  eijual  intervals,  so  that  they  are  distinctly  rhythmic  in 
character.  From  time  to  time  there  are  attacks  of  general  convulsions, 
that  may  occur  as  often  as  four  times  per  day,  and  are  usually  followed 
by  paresis  of  the  limbs.  There  is  slight  hyperesthesia  of  the  skin,  and 
usually  more  or  less  fever. 

The  prot/nosia  is  extremely  unfavorable,  death  occurring  in  90  per 
cent,  of  the  cases.  The  duration  of  the  disease  varies  from  two  or  three 
days  to  four  or  five  months,  death  usually  occurring  from  heart-failure 
while  the  patient  is  comatose. 

No  satisfactory  treatment  has  been  suggested. 


DYSBASIA   LORDOTICA  PROGRESSIVA. 

This  affection,  also  termed  dystonia  mnscnlorum  deformans  and  torti- 
pelvis,  has  been  recently  described  by  Oppenheim.^  It  occurs  in  children 
and  young  adults  of  the  Jewish  race.  The  symptoms  consist  of  tonic 
and  clonic  spasms  of  the  muscles  around  the  pelvis,  associated  sometimes 
with  similar  twitchings  of  other  muscles.  These  cause  a  deformity  around 
the  pelvis.  Excepting  the  deformity  the  symptoms  disappear  when  the 
patient  is  recumbent.  Attempts  to  either  stand  or  walk  develop  them. 
There  is  marked  lordosis  in  the  lower  dorsal  and  upper  lumbar  regions, 
with  prominence  of  the  buttocks  and  a  peculiar  gait  which  has  been 
termed  "the  monkey  or  dromedary  gait."  Symptoms  of  organic  disease 
of  the  nervous  system  are  absent. 


TIC. 

{Habit  Chorea;  Habit  Spasm;  Tic  Convulsif ;  Motor  Tic;  Pahnus.) 

Definition. — ^Ieige2  has  defined  a  tic  to  be '-a  coordinated  pur- 
posive act,  provoked  in  the  first  instance  by  some  external  cause  or  by 
an  idea;  repetition  leads  to  its  becoming  habitual,  and,  finally,  to  its  in- 
voluntary production  without  cause  and  for  no  purpose,  at  the  same  time 
as  its  form,  intensity,  and  frequency  are  exaggerated  ;  it  thus  assumes 
the  characters  of  a  convulsive  movement,  inopportune  and  excessive  ;  its 
executicm  is  often  preceded  by  an  irresistible  impulse,  its  suppression 
associated  with  discomfort.  The  effect  of  distraction  or  of  volitional  effort 
is  to  diminish  its  activity ;  in  sleep  it  disappears.  It  occurs  in  predis- 
posed individuals,  who  usually  show  other  indications  of  mental  insta- 
bility." 

'  Fraenkel,  Joxr.  Xerv.  and  Ment.  Dis.,  .Jnne,  1912,  p.  361. 

'  Tics  and  their  Treatment,  Meige  and  Feindel,  translated  by  Wilson,  p.  260 


Tia  1217 

l^tiology  and  Symptoms. — '^rhese  have  been  pnictically  described 
in  the  detinition  given  above.  A  few  points  sliouhl  be  enipJiiiHized.  The 
disease  is  especially  apt  to  develop  in  those  who  possess  a  neuroi)at}iie 
ancestry,  and  who  tbcmselves  show  other  evidences  of  a  neurotic  diathesis, 
as  neurasthenia,  hysteria,  etc.  Most  cases  are  originally  excited  by  an 
effort  to  relieve  some  peripheral  irritation.  Thus,  a  man  who  had  a  sore 
spot  on  the  upper  lip  which  he  was  constantly  moistening  with  his  tongue 
found  that  after  tlie  sore  had  healed  he  continued  to  protrude  the  tongue 
involuntarily.  This  protrusion  has  occurred  more  or  less  frefjuently  since, 
until  it  has  become  an  unconscious  act,  and  at  the  same  time  the  tongue 
is  protruded  much  further  than  would  occur  in  a  normal  protrusion.  By 
concentrating  his  attention  upon  himself  he  could  prevent  this^  but  a 
marked  feeling  of  discomfort  was  caused  by  so  doing.  He  had  had  sev- 
eral attacks  of  "nervous  breakdown." 

Tics  may  develop  at  any  age.  Any  group  of  muscles  may  be  involved. 
Thus,  we  have  facial  or  mimic  tics,  tics  of  the  nose  or  sniffing  tics,  of  the 
lips  or  sucking  tics,  of  the  jaws  or  biting  ticks,  of  the  tongue  or  licking 
tics,  of  the  neck  or  nodding  tics,  of  the  trunk-muscles,  of  tTie  arms, 
of  the  hands,  or  scratching  tics,  of  the  legs  or  leaping  tics,  of  respiration 
or  snoring,  sniffing,  blowing,  whistling,  coughing,  and  sobbing  tics,  etc. 
Any  voluntary  and  purposive  act  may  be  so  simulated.  The  move- 
ments are  usually  quick,  and,  as  has  been  said,  are  imitations  and  ex- 
aggerations of  normal  acts.  The  predisposed  may  acquire  the  condition 
by  imitation  of  one  who  has  the  disease. 

Diagnosis. — In  the  first  place,  this  must  be  made  from  a  true  spasm. 
A  spasm,  as  defined  by  Meige  [loo.  cit),  is  the  motor  reaction  consequent 
on  stimulation  of  some  point  in  a  reflex  spinal  or  bulbospinal  arc.  In 
other  words,  it  is  due  to  some  irritative  lesion.  Patrick  ^  has  well  sum- 
marized the  points  of  difference,  part  of  which  are  here  given :  Tic  is 
more  common  than  spasm,  and  invariably  develops  in  a  nervous  or  neuro- 
pathic individual.  Disposition  or  temperament  appears  to  have  nothing 
to  do  with  spasm. 

Spasm  is  absolutely  devoid  of  voluntary  or  involuntary  control,  while 
tic,  to  some  extent,  is  always  under  the  control  of  the  will,  and  always 
subject  to  involuntary  control  by  strong  emotional  or  intellectual  pre-occu- 
pation.  Spasm  is  an  anatomical,  tic  a  physiological,  disorder.  Voluntary 
simulation  of  a  true  spasm  is  practically  impossible.  The  patient  himself  can 
always  repeat  or  imitate  his  tic  movement,  and  another  person  can  nearly 
always  do  so.  A  spasm  in  its  incipiency  may  be  confined  to  part  of  a 
muscle  or  of  the  muscles  taking  part  in  a  movement  (fascicular  contrac- 
tions). A  tic  always  involves  all  of  the  muscles  taking  part  in  any  one 
physiological  movement.  From  chorea  tic  is  readily  distinguished  by  the 
coordinate  and  purposive  character  of  the  movements ;  from  tic  doulou- 
reux (p.  1079),  by  the  absence  of  pain.  In  the  so-called  general  tic,  or 
Tourette's  disease,  there  are  mental  symptoms  (p.  1218)  which  do  not 
occur  in  the  form  just  described. 

Prognosis  and  Treatment. — The  prognosis  is  doubtful  as  regards 

cure.     Of  course,  it  does  not  cause  death.     The  treatment  is  educational 

— that  is,  training  the  patient  to  perform  movements  the  opposite  to  those 

involved  in  the  tic ;  this  he  can  do  before  a  mirror  several  times  daily. 

^  Journal  Nervous  and  Ifental  Diseases,  January,  1909,  p.  1. 

77 


1218  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  lulilition.  measures  to  improve  the  neuropathic  state — viz.,  fresh  air, 
easily  digested,  plain  food,  etc. 

GENERAL   TIC. 
{Maladic  des  Ti<!S  convithif;  Maladie  de  G tiles  de  la   I'onrettc.) 

Definition. — A  disease  apparently  psychic  in  nature  and  character- 
ized by  coordinated  spasmodic  movements,  explosive  sounds  or  Avords,  and 
imperative  ideas,  -without  intellectual  disturbance. 

The  pathology  of  the  disease  is  unknoAvn.  It  occurs  in  those  suf- 
fering from  neuropathic  heredity,  and  usually  indirectly.  It  most  fre- 
quently commences  in  childhood — that  is,  before  puberty — and  affects 
either  sex. 

Symptoms. — The  disease  generally  commences  in  the  orbicularia 
palpehrariun.,  the  first  movement  being  an  uncontrollable  ■winking.  This, 
as  a  rule,  is  rapidly  associated  with  movements  of  the  muscles  of  the  face, 
causing  the  patient  to  exhibit  various  grimaces  ;  finally,  other  muscles  of 
the  body  may  be  involved,  and  the  patient  is  compelled  to  repeat  many 
times  some  apparently  purposeful  and  coordinated  movement,  as  the 
brushing  away  of  insects  or  the  stroking  of  the  beard.  From  time  to 
time  he  emits  sounds  that  may  be  either  inarticulate  cries  or  imitation 
of  some  animal,  as  the  crowing  of  the  cock  or  the  barking  of  the  dog, 
or  the  repetition  of  some  obscene  word  {coprolalia).  These  movements 
are  partially  under  the  conti'ol  of  the  will,  and  are  diminished  by  occu- 
pation, but  increased  by  emotion.  At  other  times  the  patient  is  com- 
pelled to  imitate  sounds  that  he  has  just  heard,  no  matter  how  unusual  or 
unexpected  {ccliolaJla).  A  more  curious  symptom  is  the  imitation  of 
movements  that  he  has  observed  {echokinesis),  which  may  lead  to  most 
absurd  or  painful  results.  Still  another  psychic  symptom  is  the  occasional 
development  of  imperative  ideas.  These  usually  take  the  form  of  a  desire 
to  recall  some  unimportant  word  or  syllable  {onomatomania)  or  the  per- 
formance of  difficult  problems  in  mental  aritlimetic  {arithmomania).  One 
of  my  patients,  a  boy  of  fourteen  years,  before  undertaking  a  definite  act, 
would  repeat  the  words  "ten,  ten,  ten,"  three  times,  followed  by  a  rapid 
count  of  figures  from  one  to  ten.  If  riding  in  a  public  conveyance,  he 
would  do  the  same,  endeavoring  to  finish  before  reaching  a  definite  place, 
as  a  street-corner,  or  before  hearing  the  sound  of  the  voice  or  whistle  of 
the  conductor  if  in  a  trolley-car.  A  failure  to  accomplish  the  task  was 
cause  for  intense  mental  worry.  These  patients  are  usually  affected  at  the 
same  time  with  a  certain  degree  of  melancholia  or  anxiety  that  interferes 
to  some  extent  with  their  normal  life.  The  disease  is,  as  a  rule,  very 
obstinate,  and  ordinarily  continues  throughout  life. 

The  differential  diagnosis  is  not  difficult,  the  presence  of  motor 
tic,  associated  with  the  peculiar  mental  symptoms,  being  characteristic. 

The  prognosis  is  unfavorable  for  cure ;  death,  however,  almost  never 
occurs  as  the  result  of  the  disease. 

The  treatment  is  symptomatic,  and  consists  in  putting  the  patient 
in  the  most  favorable  physical  condition  possible ;  also  hydrotherapy, 
change  of  climate,  tonics,  and  the  correction  of  any  atonic  condition,  are 
all  useful  measures.  Potassium  bromid  to  a  certain  extent  controls  the 
paroxysms  when  they  become  very  severe. 


PARALYSIS  AOITANS.  1219 

SALTATORIC   SPASM. 
(Jumper H  ;  Latah. ) 

Definition. — This  is  a  term  applied  to  a  peculiar  clonic  contraction 
occurring  in  the  lower  logs  of  a  patient  on  attempting  to  stand  upright. 
The  disease  was  first  described  by  Bamberger.  It  appears  to  occur  more 
frequently  in  men  than  in  women,  and  usually  in  individuals  who  have 
suffered  from  other  functional  diseases.  Occasionally  it  appears  in  those 
who  exhibit  hysteric  phenomena.  The  condition  may  develop  after  severe 
exertion,  and  sometimes  appears  during  convalesence  from  an  acute  dis- 
ease. In  one  of  my  own  cases  the  condition  suddenly  arose  in  the  course 
of  habit-chorea.     Saltatoric  spasm  is  not  a  clinical  variety  of  true  chorea. 

Symptoms. — This  condition  is  probably  related  to  the  tics  (p. 
1216).  When  the  patient  attempts  to  stand,  violent  clonic  convulsions 
take  place  in  the  muscles  of  the  legs,  particularly  of  the  calves.  Tliese 
may  cause  the  patient  simply  to  rise  on  his  toes,  or  they  may  be  so 
severe  as  to  cause  him  to  spring  from  the  ground,  in  which  case  he  usually 
falls.  As  soon  as  he  lies  down  the  spasms  disappear,  but  they  may  be 
produced  in  patients  lying  in  bed  by  pressing  against  the  feet. 

The  prognosis  is  generally  favorable.  The  attacks  usually  last  for 
a  period  of  from  two  days  (Gowers)  to  a  few  weeks,  but  a  few  cases  have 
been  recorded  that  persisted  throughout  life.  Gowers  recommends  dia- 
phoretic treatment.  Antispasmodics  may  also  be  employed,  and  in  those 
cases  with  hysteric  stigmata  suggestion  is  useful. 


PARALYSIS  AGITANS. 

(Shaking  Palsy ;  Parkinson's  Disease.) 

Definition. — A  chronic  disease  characterized  by  a  tremor ;  by  rig- 
idity of  the  muscles ;  by  the  peculiar  character  of  the  speech  and  gait, 
and  by  a  progressive,  but  very  seldom  complete,  loss  of  power. 

Pathology. — Lesions  that  are  probably  only  senile  in  type  have 
been  frequently  described.  There  are  peri-  and  endarteritis,  irregular 
degenerations  in  the  posterior  columns,  and  numerous  amyloid  bodies. 
Other  observers  have  noted  changes  in  the  motor  cells  of  the  cerebral 
cortex.  Camp  has  called  attention  to  the  constancy  of  changes  in  the 
muscles,  and  disturbance  of  the  function  of  the  parathyroids  has  been 
thought  by  some  to  be  the  cause  of  the  trouble. 

Ktiology. — Paralysis  agitans  is  a  disease  of  adult  life,  developing  in 
the  large  majority  of  cases  between  the  fortieth  and  forty-fifth  years  ;  it 
is  met  with  more  often  in  men  than  in  women.  No  definite  etiologic 
factor  is  known,  though,  as  with  most,  if  not  all,  nervous  diseases  it  is 
predisposed  to  by  mental  strain,  worry,  or  trouble  of  any  kind.  Some 
cases  seem  to  be  excited  by  traumatism. 

Symptoms. — Usually  the  first  evidence  of  the  disease  is  tremor. 
slight  at  first,  and  in  the  extremities,  the  hand  usually  being  the  first  to 
betray  it.  The  movement  is  very  characteristic,  the  thumb  and  forefinger 
being  approximated  as  in  the  act  of  making  a  pill.    At  the  same  time  the 


1220  DISEASES  OF  THE  ^'ERVOUS  SYSTEM. 

liiiml  is  somi-rotared  ami  tlic  forearm  trembles  more  or  less  as  a  -whole. 
The  upper  arm  is  either  but  slightly  or.not  at  all  aftected.  The  legs  are  also 
but  slightly  implicated.  The  tremor  is  most  noticeable  when  the  patient 
is  sitting  Avith  one  leg  crossed  over  the  other,  the  foot  then  being  sure  to 
be  in  more  or  less  constant  motion.  AVhen  the  head  is  involved  (rather 
the  e.xception  than  the  rule)  the  motion  is  a  nodding  one.  The  tremors 
cease  when  the  patient  sleeps,  l)ut  are  continuous  during  waking  liours, 
tJiough  it  is  not  rare  to  meet  with  cases  in  which,  during  purposeful  acts 
necessitating  the  use  of  the  affected  parts,  the  tremors  diminish  or  even 
cease  temporarily,  to  return  as  soon  as  the  voluntary  mot'on  is  completed. 
The  latter  movements,  it  will  be  noticed,  are  awkward,  and  as  the  disease 
advances  they  become  more  and  more  stiff".  This  rigidity,  with  its  conse- 
quent impairment  of  activity,  is  another  cardinal  feature  of  the  disease. 
The  patients  movements  are  slow  and  apparently  measured.  There  is 
some  impairment  of  power  also,  but  it  is  slight,  and  may  be  rather  from 
disease  than  from  a  direct  nerve-  or  muscle-involvement.  Turning  in 
bed  unaided  is  difficult  or  impossible.  The  skin  is  often  thickened,  and 
to  this  change  the  rigidity  has  been  in  part  ascribed,  but  I  believe  incor- 
rectly, because,  particularly  in  young  patients,  it  may  be  delicate  in  texture. 

Two  of  the  most  striking  symptoms  of  the  disorder  are  the  gait  and 
attitude  of  the  patient.  He  walks  with  head  and  body  bent  forward, 
eyes  directed  toward  the  ground  a  short  distance  ahead,  and  takes  short, 
mincing,  and  somewhat  hurried  steps  (festination),  giving  one  the  im- 
pression that  he  is  about  to  fall,  which  he  would  do  but  for  each  successive 
step,  which,  as  it  were,  gives  him  a  fresh  center  of  gravity.  His  station 
is  equally  striking.  The  head  and  back  are  bent  forward,  the  feet  are 
kept  some  little  distance  apart,  and  one  in  front  of  the  other,  while  the 
arms  are  slightly  flexed  and  pendulous.  From  time  to  time  the  patient 
will  make  a  slight  forward  movement  {propulsion),  or  else,  if  walking, 
bend  or  fall  backward  {retropuhion).  The  facial  muscles  are  set, 
the  eyebi'ows  arched,  and  the  whole  expression  is  "mask-like."  The 
general  sIoav  character  of  all  movements,  except  walking,  which  is  neces- 
sarily quicker,  is  imparted  to  the  speech,  though  after  a  sentence  is  begun 
the  balance  may  be  rendered  normally  or  even  hurriedly.  The  voice  may 
be  high-pitched.  The  pulse  is  usually  rapid ;  the  skin  flushes  easily, 
and  the  patients  are  sensitive  to  cold.  There  are  no  trophic  or  sensory 
symptoms,  and  the  reflexes  are  normal.  Apart  from  the  diffidence, 
amounting  in  some  cases  to  a  positive  dislike  for  meeting  people,  and  the 
melancholia  occasionally  induced  by  brooding  over  the  affliction,  there 
are  no  mental  changes. 

Cases  occur  in  Avhich  the  tremor  is  very  slight  or  absent,  the  diagnosis 
then  being  based  on  the  rigidity,  attitude,  and  facial  expression. 

Course. — The  disease  is  almost  always  of  slow  onset  and  of  insidious 
progress.  Often  one  side  is  involved  before  the  other,  or  the  two  sides 
are  unequally  aff"ected.  Very  rarely  the  earlier  symptoms  may  develoj) 
somewhat  rapidly,  but  in  every^  case  their  further  progress  is  slow.  Dis- 
appearance of  tremor,  usually  transient,  has  been  observed  in  the  side 
affected  by  a  subsequent  hemiplegia.  The  course  may  be  interrupted 
from  time  to  time ;  even  seeming  improvement  may  take  place,  but  it  is 
not  maintained.  The  disease  lasts  for  years,  and  the  patient  usually 
dies  of  some  intercurrent  disease. 


TETANY.  1221 

Tlie  diagnosis  i.s  not  ut  all  difficult  when  the  tremor,  attitude,  gait, 
and  rigidity  have  developed.  During  tlie  earlier  stages  it  may  he  con- 
founded with  multiple  sclerosis,  though  this  condition  develops  earlier  in 
life,  and  the  volitional  character  of  the  tremor,  the  nystagmus,  and  the 
scanning  speech  should  sei-ve  to  differentiate  it.  The  musculai-  rigidity, 
peculiar  gait,  and  temporary  cessation  of  the  tremor  after  some  muscular 
effort  distinguishes  it  from  senile  tremor.  That  the  rigidity  is  not  due 
to  disease  of  the  central  motor  neuron  is  shown  by  the  absence  of  the 
Babinski  reflex,  and,  in  most  cases,  absence  of  increased  tendon  reflexes. 

Treatment. — The  medical  management  of  the  disease  is  unsatisfac- 
tory. Graduated  exercise,  tepid  baths,  and  massage  should  be  employed 
to  keep  up  the  tone  of  the  muscles.  The  patient  should  avoid  excitement 
and  overfatigue,  both  mental  and  physical.  The  long-continued  use  of 
arsenic  may  be  of  service,  and  hyoscine  hydrobromate  (gr.  ^oimliT  ^-  '^-  ^^■) 
often  relieves  the  symptoms.  Electricity  in  the  form  of  dipolar  faradic 
baths  has  been  recommended.  Parathyroid  gland  (gr.  -^^  of  the  powdered 
gland)  three  or  four  times  daily  has  given  good  results. 


OTHER  FORMS  OF  TREMOR. 

1.  Hereditary  tremor  has  been  described  by  C.  L.  Dana,  who  has  also 
reported  interesting  cases.  It  may  commence  in  infancy  and  continue 
till  old  age,  unaccompanied  by  detectable  lesions. 

2.  Simple  tremor,  lasting  a  longer  or  shorter  period  (oftener  it  is  com- 
paratively brief),  is  a  rare  condition  and  without  serious  possibilities.  Its 
etiology  is  unknown,  though  it  is  sometimes  aggravated  by  nervous  shocks 
and  other  debilitating  conditions. 

3.  Senile  Tremor. — This  is  common  in  old  persons,  and  rarely  appears 
before  three-score-and-ten  years.  It  is  excited  by  muscular  motions,  is 
always  fine,  and  affects  chiefly  the  hands  and  arms ;  more  rarely  the  neck 
is  also  involved,  and  the  head  may  then  be  seen  to  tremble. 

4.  Toxic  Tremor. — This  results  from  the  action  of  alcohol,  lead,  mer- 
cury, tobacco,  and  other  poisonous  substances.  It  is  usually  fine  and 
irregular  [vide  The  Intoxications). 

5.  Hysteric  tremor  (vide  Hysteria). 

6.  Tremor  may  also  be  a  symptom  of  neurasthenia,  exophthalmic  goiter, 
and  multiple  sclerosis. 

TETANY. 

Definition. — A  disease  of  unknown  cause,  characterized  by  parox- 
ysms of  tonic  cramp  that  usually  affect  the  flexor  muscles  of  the  extremi- 
ties, by  sensory  disturbances,  and  by  a  peculiar  alteration  of  the  electric 
reaction  of  the  muscles. 

Ktiology. — Tetany  may  occur  in  epidemics,  and  has,  therefore,  been 
supposed  to  be  infectious.  There  is  some  doubt,  however,  whether  these 
epidemics  are  cases  of  true  tetany  or  are  hysteric  in  nature.  There  is 
also  some  evidence  that  it  is  due  to  an  intoxication  occurring  in  the  course 
of  some  other  morbid  condition.  Tetany  is  frequently  associated  with 
infectious  diseases ;  it  also  occurs  in  connection  with  ^astro-intestinal  dis- 


1222  DISEASES  OF  THE  yERVOUS  SYSTEM. 

orders,  especially  dilatation  of  the  stomach,  diarrhea,  and  intestinal  para- 
sites, during  pregnancy  and  lactation,  and  it  is  associated  uith  the  myx- 
edema tliat  (levelops  after  the  removal  of  tiie  thyroid  gland,  in  which 
cases  it  is  due  to  the  parathyroids  also  being  removed.  Exposure  to 
cold  has  often  preceded  the  disease.  Occupation  seems  to  exert  a  remark- 
able intluence  upon  the  jiredisposition  to  it,  the  great  majority  of  those 
affected  being  shoemakers  or  tailors.  In  childhood  males  are  far  more 
fre(iueutly  attacked  than  females,  and  the  victims  are  freijuently  rachitic, 
but  in  adult  life  this  proportion  is  reversed.  Heredity  may  have  some 
influence,  since  tetany  often  occurs  in  several  members  of  the  same  family. 
It  is  much  more  common  in  the  spring  months,  and,  curiously  enough,  it 
appears  to  be  endemic  in  certain  localities,  particularly  Leipsic  and 
A'ienna.     Tt  is  rare  in  the  United  States. 

Pathology. — Distinct  morbid  lesions  of  the  nervous  system  have 
not  been  found  in  all  cases.  Slight  vascular  changes  in  the  brain  and 
cord  and  vacuolization  of  the  ganglion-cells  have  been  described,  but 
these  are  not  peculiar  to  this  disease.  It  has  been  supposed  that  changes 
ought  to  be  found  in  the  motor  nerves,  but  the  most  careful  observers 
have  failed  to  detect  them.  It  is  evidently  occasioned  by  a  toxemia 
which,  in  some  cases,  is  due  to  absence  or  disease  of  the  parathyroid 
glands.     Excessive  excretion  of  calcium  salts  is  found  in  the  urine. 

The  symptoms  fall  naturally  into  two  groups :  (1)  Those  of  the  par- 
oxysm, and  (2)  Those  of  the  interval.  (1)  The  first  symptoms  of  an  attack 
usually  consist  of  peculiar  sensory  disturbances  in  the  limbs,  either  ting- 
ling, formication,  pain,  or  numbness,  and  these  may  precede  the  attack  for 
some  hours  or  even  days.  Stiffness  of  the  muscles  usually  begins  in  the 
fingers.  There  may  be  slight  clonic  movements  at  first,  but  this  is  not 
frequent.  The  limbs  are  symmetrically  involved.  The  spasm  commences 
first  in  the  hand,  the  fingers  being  straightened  and  flexed  upon  the  hand, 
and  bunched  so  that  the  hand  has  been  likened  to  that  of  the  scrivener 
or  obstetrician.  The  spasm  then  extends  to  the  muscles  of  the  forearm 
and  arm,  and  usually  also  to  the  feet  and  lower  limbs.  If  the  cramp  is 
slight,  the  pain  may  be  insignificant,  but  ordinarily  it  is  severe,  and  is 
increased  by  attempts  to  overcome  the  contractures.  The  muscles  are 
hard,  painful  upon  pressure,  and  occasionally  fibrillary  twitchings  may  be 
observed.  There  is  sometimes  a  slight  edema,  and  often  sweating  of  the 
limbs.  The  paroxysms  may  last  for  several  minutes  or  for  several  hours 
or  even  days,  and  may  even  persist  during  sleep.  If,  however,  the  period 
is  very  long,  remissions  are  usually  observed.  Sometimes  a  series  of 
paroxysms  may  occur  with  considerable  regularity.  Attacks  are  more 
likely  to  occur  at  night,  and  they  may  also  be  brought  on  by  prolonged 
and  severe  muscular  effort,  or  by  emotional  shocks.  Besides  the  pares- 
thesiae  in  the  affected  extremities,  the  patient  may  suffer  from  severe 
headache  or  pain  in  the  back  and  neck. 

(2)  The  symptoms  of  the  interval  are — Trousseaus  sign — L  e.  the 
possibility  of  causing  an  attack  by  prolonged  pressure  upon  the  main 
nerve-trunks  or  vessels  of  the  limbs.  Frankl-IIochwart  has  shown  that 
pressure  upon  the  nerves  is  essential ;  pressure  upon  the  vessels  acting 
secondarily  if  at  all.  Chvostek's  sign  is  a  peculiar  excitability  of  the  mus- 
cles of  the  face,  so  that  spasms  are  produced  if  the  trunks  of  the  facial 
nerve  are  lightly  percussed  by  a  hammer.  Th'ys  occurs  in  other  condi- 
tions, particularly  the  cachexiae,  but  in  most  cases  of  tetany  the  spasm 


TETANY.  1223 

occurs  if  the  skin  of  the  face  is  lightly  stroked ;  and  this  reaction  appears 
to  be  pathognomonic.  Erb's  sign  consists  of  a  greatly  increased  electric 
excitability  of  the  muscles,  and,  occasionally,  of  an  alteration  of  the  electric 
reaction,  so  that  ACIC  may  be  greater  than  KCIC.  Moreover,  AOTe  is 
often  obtained,  and,  in  at  least  2  cases,  KOTe  has  also  been  noted.  The 
last  two  reactions  occur  in  no  other  condition.  Hoffman's  sign  consists 
of  an  increased  reaction  of  the  sensory  nerves  to  electric  stimuli.  The 
facies  of  the  patient  is  peculiar  and  characteristic.  The  face  is  slightly 
swollen,  dusky,  and  expressionless,  but  if  carefully  examined  usually  no 
edema  can  be  detected.  Often  this  swelling  is  also  found  in  the  hands 
and  feet,  and  may  be  associated  with  distinct  enlargement  of  the  veins. 
Even  during  the  interval  the  feet  when  at  rest  have  a  tendency,  particu- 
larly in  children,  to  assume  a  slightly  inverted  and  extended  position. 

The  sensory  disturbances  consist  of  cramp-like  pains  during  the  attack, 
some  diminution  of  sensation  in  the  aifected  parts,  and  increased  sensi- 
bility of  the  sensory  nerves.  The  contractures  are  not  invariably  limited 
to  the  extremities.  Sometimes  the  muscles  of  the  neck,  back,  and  larynx 
are  involved;  sometimes  also  the  diaphragm,  and  occasionally  the  com- 
pressor urethra.  Involvement  of  the  larynx  gives  rise  to  stridulous  res- 
piration ;  involvement  of  the  diaphragm  to  severe  dyspnea ;  when  the 
urethra  is  compressed  there  is  retention  of  the  urine.  Fever  occurs  in 
about  one-half  the  cases  ;  it  is  slight  and  generally  limited  to  the  paroxysm. 
The  urine  usually  contains  a  large  amount  of  phosphates,  and  less  fre- 
quently indican  is  present  in  excess.  Partial  tetany — that  is,  with  the 
absence  of  one  or  more  of  the  cardinal  signs — occurs  not  infrequently, 
especially  in  gastro-intestinal  conditions.  Pain,  cramp,  and  Trousseau's 
sign  are  usually  present. 

The  differential  diagnosis  is  very  easy,  as  a  rule,  if  the  patient  is 
seen  during  a  paroxysm.  The  severer  forms  may,  however,  be  con- 
founded with  tetanus  or  meningitis.  Tetany  can  be  distinguished  from 
the  former  by  the  fact  that  the  spasm  begins  at  the  periphery  and  rarely 
affects  the  muscles  of  the  jaw.  From  the  latter  it  may  be  diagnosed  by 
the  absence  of  coma  and  the  slighter  degree  of  fever.  The  diagnosis 
from  certain  forms  of  ergotism  is  more  difficult,  and  can  often  be  made 
only  by  careful  attention  to  the  etiology.  The  hysteric  forms  can  be 
differentiated  by  finding  various  hysteric  stigmata.  An  epidemic  occur- 
ring among  young  women  should  give  rise  to  a  suspicion  of  the  true 
nature  of  the  malady. 

Prognosis. — The  duration  varies  from  a  few  days  to  many  months, 
the  most  obstinate  forms  being  those  due  to  thyroidectomy,  in  which  the 
parathyroids  have  also  been  removed,  and  chronic  diarrhea.  The  disease 
cannot  be  said  to  have  disappeared  until  the  characteristic  symptoms  of 
the  interval  (Trousseau's,  Erb's,  and  Chvostek's  signs)  can  no  longer  be 
elicited.  The  prognosis  is  usually  favorable,  nearly  all  cases  tending  to 
spontaneous  cure.  Death,  however,  may  occur  from  chronic  diarrhea, 
from  respiratory  failure  when  the  diaphragm  is  involved,  and  from 
cachexia  strumipriva. 

The  treatment  is  purely  symptomatic.  The  patient  should  be  placed 
in  the  most  favorable  hygienic  conditions  and  given  plenty  of  nourishing 
food,  especially  that  containing  calcium  salts.  Full  doses  of  these  salts, 
as  calcium  chlorid  or  lactophosphate,  should  also  be  given.  During 
the  spasm  bromids   or   chloroform-inhalations    seem    to   give   the   best 


1224  DISEASES  OF  THE  XERVOUS  SYSTEM. 

results.  The  most  important  tlierapeutic  measure  is  the  correction 
of  the  underlying  cause.  Thus,  in  children  rachitis  is  almost  invari- 
ably associated  with  tetany,  and  the  most  efficient  remedies  are  iron  and 
cod-liver  oil.  Intestinal  disorders  should  he  treated  according  to  the 
principles  laid  down  in  the  discussion  of  these  diseases.  The  form  due 
to  removal  of  the  thyroid  gland  usually  disappears  under  a  course  of  para- 
thyroid medication,  while  that  occurring  during  pregnancy  usually  persists 
until  delivery. 


PERIODIC  PARALYSIS. 

{Family  Periodic  Paralysis,) 

Definition. — A  disease  characterized  by  paroxysmal  attacks  of  com- 
plete paralvsis,  and  alteration  in  the  electrical  reactions,  occurring  in 
many  members  of  a  family. 

Patholog^^. — In  excised  fragments  of  muscle  Goldflam  and  Oppen- 
heim  found  hypertrophy  of  the  fibers  and  slight  vacuolation,  Avithout 
multiplication  "of  the  nuclei  or  proliferation  of  the  connective  tissue.  In 
most  cases  no  changes  have  been  found,  and  the  condition  has  been  sup- 
posed to  be  an  auto-intoxication,  associated  with  a  lowered  condition  o£ 
metabolism.  In  a  case  observed  by  Mailhouse  there  was  a  diminished 
excretion  of  calcium  and  magnesium  salts  in  the  urine,  and  he  mentions 
the  possibility  of  the  paralysis  being  due  to  their  inhibitory  influence 
upon  nerve  and  muscle  when  retained  within  the  body. 

Ktiologfy. — The  disease  is  purely  hereditary.  Both  sexes  are  affected. 
The  attacks  appear  to  be  more  frequent  in  summer,  and  often  seem  to 
occur  after  overfilling  the  stomach. 

Symptoms. — The  attacks  are  preceded  b}''  prodromes  in  the  form  of 
vague  discomfort  or  parestliesia.  The  patient  then  usually  falls  asleep 
and  awakens  completely  paralyzed.  Speech,  deglutition,  and  the  sphinc- 
ters are  unaffected.  During  the  attack  there  is  often  transient  albumin- 
uria, with  blood-cells  in  the  urine.  The  reflexes  are  abolished,  and  the 
muscles  either  do  not  react  well  or  not  at  all  to  the  electric  current. 
The  paralysis  lasts  from  twelve  hours  to  three  days,  and  then  there  is 
an  outbreak  of  perspiration,  with  gradual  recovery,  the  muscles  of  the 
head  first  regaining  power.  During  the  interval  the  muscles  react  to 
electricity  and  the  reflexes  return.  Dilatation  of  the  heart  has  existed 
during  an  attack,  to  disappear  during  the  interval.  A  fcAv  cases  have 
been  associated  with  migraine. 

Prognosis. — The  disease  does  not  usually  kill ;  but  there  appears  to 
be  no  tendency  to  recover,  and  a  few  cases  have  died  during  the  attack. 

Treatment. — This  involves  only  caring  for  the  children  during  the 
attack.     Large  doses  of  potassium  citrate  have  been  beneficial. 


HYSTERIA. 


Definition. — A  condition  of  the  general  nervous  system  partaking 
of  the  natures  of  both  a  neurosis  and  a  psychosis,  and  characterized  by  a 
vast  multiplicity  of  clinical  manifestations,  all  indicative  of  a  loss  of 
voluntary  control  over  inhibitory  and  active  nervous  influence. 


HYSTERIA.  1225 

Pathology. — Hysteria  is  to  be  regarded  as  essentially  a  morbid 
entity,  without,  however,  any  tangible  pathologic  features.  The  most 
careful  postmortem  examinations  of  subjects  who  have  while  in  life  mani- 
fested pronounced  hysteric  symptoms  have  failed  to  reveal  any  organic 
nervous  alterations,  however  slight.  The  occurrence  of  the  affection  in 
men  as  well  as  in  women  excludes  the  former  theory  of  a  uterine  path- 
ology, which,  though  an  idle  fancy,  held  sway  for  so  many  centuries  and 
gave  origin  to  the  name  by  which  the  condition  is  generally  recognized. 

Ktiology. — There  are  a  large  number  of  predisposing  and  exciting 
factors,  all  of  which,  however,  may  be  grouped  under  a  few  dominant 
heads.  Thus  among  the  former  must  be  mentioned,  pre-eminently, 
heredity.  The  investigations  of  many  neurologists  and  alienists  of  divers 
lands  have  gone  far  to  demonstrate  that  at  the  foundation  of  the  vast 
majority,  if  not  of  all,  of  the  hysterias  is  to  be  discovered  an  inherited 
neurotic  tendency  or  temperament.  The  family  histories  of  these  patients 
generally  reveal  a  large  number  of  consanguineous,  neurotic,  or  hysteric 
individuals.  It  is  apparently  in  close  relationship  with  the  various 
psychoses  and  major  neuroses  (epilepsy,  chorea,  tetany) ;  and  with  the 
so-called  rheumatic  diathesis. 

In  the  process  of  transmission  one  generation  may  entirely  escape  the 
pernicious  influence,  and  successive  generations  may  manifest  strikingly 
different  evidences  of  the  disease,  in  one  the  neurotic  and  in  another  the 
psychic  element  predominating.  A  curious  phenomenon  that  is  worthy 
of  mention  is  the  apparent  contagiousness  of  hysteria ;  moreover,  the 
baleful  influence  one  neurotic  individual  exerts  over  the  unfortunates  of 
this  temperament  explains  the  so-called  "hysteric  epidemics"  that  have 
swept  over  communities,  and  even  over  vast  tracts  of  land  or  entire  coun- 
tries, at  different  periods  of  the  world's  history.  Similar,  though  limited, 
outbreaks  may  still  be  seen  in  the  nervous  wards  of  hospitals  or  in 
religious  and  political  conventions,  and  these  depend  largely  upon  the 
general  prevalence  of  the  neurotic  disposition  untempered  by  a  virile 
will-power. 

The  hysteric  temperament  may  be,  and  often  is,  fostered  by  improper 
and  pernicious  modes  of  life,  especially  by  luxurious  and  sensuous  living 
and  by  the  habit  of  gratifying  every  desire  of  the  will  during  early  life. 
It  is  manifested  at  this  early  stage  of  the  individual's  existence  by  hyper- 
sensitiveness,  brilliancy,  undue  enthusiasm,  and  a  more  or  less  erratic 
turn  of  mind. 

Contrary  to  the  prevailing  opinion,  hysteria  is  not  limited  to  the 
female  sex,  although  they  are  the  chief  sufferers  from  the  more  dramatic 
forms.  Instances  of  a  most  rebellious  nature  not  infrequently  occur  in 
the  opposite  sex. 

Age. — The  condition  is  generally  encountered  between  the  ages  of 
fifteen  and  thirty  years,  although  it  is  often  enough  observed  in  young 
children.  After  the  latter  age  the  frequency  of  the  disease  rapidly 
diminishes. 

A  very  influential  factor  in  the  production  of  the  disease  is  the  lack 
of  proper  mental  development.  It  stands  to  reason  that  those  who  are 
coarse  and  illiterate,  and  who  have  not  been  taught  the  lessons  of  self- 
control,  and  who  are  subject  to  the  various  and  multiplex  superstitions 
that  are  ever  prevalent  amgng  the  masses,  will  respond  more  quickly  and 


1226  DISEASES  OF  THE  yERVOUS  SYSTEM. 

more  ortnerally  to  the  causes  that  tend  to  destroy  mental  equilibrium. 
Hence,  hysteria  or  insanity  shows  its  rankest  development  among  those 
whose  education  and  culture  are  detective.  This  is,  however,  by  no 
means  an  inevitable  law,  for  over-stimulation  of  the  faculties  may  be  just 
as  deleterious  as  under-stimulation,  and  some  of  the  brightest  lights  of 
the  world  have  manifested  at  various  periods  of  their  lives  decided  hysteric 
symptoms. 

Improper  hygienic  surroundings,  tending  as  they  do  to  enervation 
and  physical  depression,  are  influential  predisposing  factors  in  the  evolu- 
tion of  hysteria.  In  addition  to  poor  and  insufficient  food,  lack  of  proper 
ventilation,  overcrowding  in  foul  habitations,  and  insufficient  bathing, 
must  be  mentioned  the  enervating  influence  of  hot  and  moist  climates. 
It  is  generally  conceded  that  more  cases  of  hysteria  occur  in  the  warm 
than  in  the  colder  portions  of  the  temperate  zones,  and  that  this  propor- 
tion mcvedises  pari  passu  with  the  height  of  the  temperature. 

Finally,  the  causal  influence  of  the  chronic  toxemias  (alcoholism, 
morphinism,  absinthism,  saturnism  and  intoxications  by  other  metals) 
is  to  be  mentioned.  In  systemic  poisoning  the  depraved  condition  of 
the  physical  reacts  upon  the  mental  organism,  and  sooner  or  later 
hysteric  manifestations  may  be  found  to  coexist  with  the  original  toxic 
phenomena. 

The  exciting  causes  of  hysteria  may  be  grouped  as  follows : 

(1)  Most  commonly  psycho-neurosis  follows  some  profound  emotion 
or  mental  or  moral  shock.  Thus,  in  neurotic  males  it  may  be  excited 
by  excessive  and  protracted  business-worry  or  excitement,  or  by  active 
competition  in  certain  lines  of  occupation,  or  by  some  heavy  and  unex- 
pected monetary  reversal.  In  females  it  is  not  uncommon  as  a  sequel 
to  the  establishment  of  puberty  and  the  menstrual  function,  or  to  the 
physiologic  arrest  of  menstruation  at  the  period  of  the  climacteric.  Espe- 
cially is  it  prone  to  develop  in  young  and  illegitimately  pregnant  women, 
or  during  the  first  pregnancy  in  newly-married  women  of  a  neurotic  tem- 
perament. Great  religious  excitement  during  the  progress  of  a  revival- 
wave  and  profound  political  upheavals  have  been  most  potent  in  estab- 
lishing the  disease  in  numerous  instances ;  and  other  profound  mental 
impressions,  of  fear,  grief,  or  great  and  unexpected  joy,  have  assumed 
the  exciting  role.  In  this  connection  the  theories  of  Breur  and  Freud, 
now  receiving  considerable  attention,  but  only  accepted  by  comparatively 
few,  should  be  mentioned,^  but  in  the  space  at  hand  it  is  impossible  to 
give  them  in  detail.  They  teach  that  hysteria  is  always  due  to  a  physi- 
cal or  psychical  trauma,  which  may  have  occurred  some  time  before  the 
symptoms  develop.  According  to  Freud,  the  trauma  practically  always 
is  sexual  in  nature.  Thus  there  develop  in  the  period  before  puberty 
definite  sexual  activities,  which  are  mostly  of  a  perverse  nature.  These 
activities  do  not,  as  a  rule,  lead  to  a  definite  neurosis  up  to  the  time 
of  puberty,  which,  in  the  psychic  sphere,  appears  earlier  than  in  the 
physical ;  but  sexual  fantasy  maintains  a  perverse  direction  by  reason 
of  the  infiintile  sexual  activities.  On  constitutional  (aff'ect)  grounds  the 
increased  fantasy  of  the  hysteric  leads  to  the  formation  of  com- 
plexes which  are  not  taken  up  by  the  personality,  and,  by  reason 
of  shame  or  disgust,  remain  buried  in  the  subconscious  mind.  There 
'  Psyckanalysis,  Brill,  W.  B.  Saunders  Co. 


HYSTERIA.  1227 

therefore  results  a  conflict  between  the  characteristic  normal  libido  and 
the  sexual  repressions  of  these  buried  infjintilc  perversions.  These  con- 
flicts give  rise  to  the  hysterical  symptoms.' 

(2)  Extreme  physical  prostration,  the  result  of  some  very  acute  or  much 
protracted  chronic  disease,  may  exert  an  etiologic  effect.  Thus,  some  of  the 
most  marked  and  intractable  forms  of  the  disease  have  resulted  from  the 
specific  fevers  (typhoid,  typhus,  and  the  other  exanthemata),  while  it  is 
not  rare  in  a  varying  degree  in  the  final  stages  of  tuberculosis,  chronic 
nephritis,  and  other  grave  censtitutional  aff'ections  of  long  standing. 

(3)  The  so-called  "traumatic  hysteria"  has  come  to  occupy  a  prom- 
inent place  in  the  etiologic  category  of  the  disease.  Especially  do  we 
find  the  incurable  varieties  of  hysteria  resulting  from  a  slight  or,  it  may 
be,  a  more  severe  traumatism.  It  must  be  remembered  that  a  considerable 
period  of  time  may  intervene  between  the  date  of  the  injury  and  the 
appearance  of  the  initial  hysteric  symptoms,  so  that  in  all  cases  it  becomes 
of  the  utmost  importance  to  make  a  careful  study  of  the  patient's  history 
for  signs  of  traumatism,  however  remote.  It  has  also  been  noted  that  oft- 
repeated  minor  traumatism  may  finally  result  in  some  hysteric  manifes- 
tations. 

(4)  Finally,  in  a  limited  number  of  cases  sexual  excesses  and  mastur- 
bation are  the  influential  factors  in  the  production  of  hysteria.  These 
sexual  cases,  though  few  in  number,  do  exist,  and  are  especially  to  be 
found  among  the  class  of*  so-called  sexual  perverts. 

Clinical  History. — Clinically,  hysteria  presents  three  well-marked 
stages,  known  respectively  as  the  prodromal,  the  convulsive,  and  the 
latent.  The  latter  is  also  designated  as  the  interconvulsive  stage  or  the 
period  of  the  stigmata,  and  during  this  period  the  number  of  the  symp- 
toms and  their  complexity  almost  baffle  attempts  at  classification  ;  they 
can,  however,  best  be  portrayed  by  presenting  them  under  the  heads  of 
the  various  systems  {vide  infra). 

(1)  The  Prodromal  Stage. — The  prodromes  are  invariably  present,  and 
at  times  they  are  more  marked  than  at  others.  They  are  evident  alike 
to  both  patient  and  physician,  and  are  largely  psychic  in  nature.  There 
may  be  noted  a  marked  mental  depression  associated  with  introspection, 
and,  it  may  be,  with  a  form  of  mild  mania  or  of  melancholia.  A  con- 
dition of  aprosexia  develops,  and  the  patient  becomes  irritable,  restless, 
and  discontented.  The  mental  derangement  may  manifest  itself  in  the 
form  of  delusions  or  nightmare,  and  there  is  a  characteristic  neglect  of 
the  toilet  and  attire.  There  may  also  be  disturbances  of  the  gastro- 
intestinal tract — viz.,  anorexia,  nausea,  vomiting,  constipation,  and  per- 
versions of  taste.  These  phenomena  persist  for  several  days  and  are 
followed  by  emotional  disturbances — spasms  of  hysteric  laughing  and 
crying — that  immediately  precede  the  aura,  which  is  as  marked  a  feature 
in  hysteria  as  in  epilepsy.  It  may  assume  one  of  a  number  of  forms, 
but  more  commonly  it  has  an  ovarian,  a  cervical,  a  cerebral,  or  a 
surface  or  cutaneous  origin  (unilateral).  Very  frequently  the  convulsion 
is  preceded  by  a  condition  of  extreme  sensitiveness  and  pain  in  one 
or  both  ovarian  regions,  so  that  the  lightest  touch  at  a  point  on  the 
abdominal  surface  one  inch  above  Poupart's  ligament,  and  midway 
between  the  pubis  and  the  anterior  superior  iliac  spine,  will  elicit  ex- 
1  Jellifle,  Oslei-'s  Modern  Medicine,  vol.  vii.,  p.  816. 


1228  DISEASES  OF  THE  SERVO  US  SYSTEM. 

quisite  tenderness.  This  is  so  constant  and  characteristic  that  many 
patients  can  invariably  predict  the  onset  of  the  convulsion.  Not  infre- 
quently the  aura  begins  in  the  neck,  the  patient  experiencing  a  sensation 
as  of  a  ball  lodging  in  the  throat  {(jlobus  Iii/stericus) :  this  is  due  to  a 
spasmodic  conti-action  of  the  muscles  of  the  pharynx  and  esophagus,  and 
is  accompanied  by  tachycardia  and  a  sense  of  suffocation.  If  the  aura 
originate  above  the  scalp,  it  is  characterized  by  the  sudden  appearance, 
generally  in  the  top  of  the  head,  of  a  severe  neuralgic  pain,  as  if  pro- 
duced by  the  entrance  of  a  nail  (clavus  hi/stericus:) ;  this  is  freciuently 
associated  with  vertigo  and  tinnitus  aurium.  The  aura,  finally,  may 
appear  in  the  form  of  spots  of  cutaneous  tenderness,  mainly  localized 
upon  the  trunk,  to  which  areas  has  been  given  the  name  of  hyster- 
ogenous  zones. 

(2)  The  Hysteric  Convulsion. — Closely  following  upon  the  footsteps  of 
these  prodromes,  and  immediately  following  the  aura,  the  hysteric  convul- 
sion may  appear.  Most  commonly  this  is  epileptoid  in  nature  ;  rarely  it 
assumes  a  less  common  type.  Hence  it  becomes  necessary  to  describe 
several  of  the  forms  of  the  convulsions — viz.  (a)  the  epileptoid  (hystero- 
epilepsy)  ;  (b)  the  gymnastic  (clownism) ;  (c)  the  enwtional  cataleptic,  or 
dramatic  ;  and  (c?)  the  delirious.  All  of  these  forms  may  be  present  in 
the  same  attack,  the  one  passing  quickly  into  the  other,  or,  as  in  the 
abortive  cases,  one  or  the  other  form  will  predominate.  Briefly  described, 
the  characteristic  features  are  as  follows  : 

(a)  Epileptoid  {Hystero-epilepsy). — Immediately  upon  the  appearance 
of  the  aura  the  patient  commonly  emits  a  shriek  and  falls  upon  the  floor 
or  in  some  convenient  place,  taking  special  care  to  do  herself  no  injury: 
this  is  in  strong  contradistinction  to  the  true  epileptic  spasm.  The  head 
and  limbs  are  thrown  about  by  more  or  less  violent  clonic  muscular 
spasms,  and  at  times  a  condition  of  opisthotonos  or  other  trunkal  contor- 
tion (emprosthotonos,  pleurosthotonos)  may  be  noticed  ;  these  muscular 
movements,  however,  are  more  or  less  volitional,  and  are  not  the  aimless 
movements  of  the  true  epileptic.  In  some  cases  there  is  merely  a  tonic 
spasm  or  muscular  rigidity.  The  patient  may  or  may  not  foam  at  the 
mouth.  There  is  a  constant  twitching  of  the  eyelids  and  the  eyes  are 
rolled  about,  but  apparently  retain  a  more  or  less  observant  expression. 
Consciousness,  as  a  rule,  is  not  fully  last.  The  facial  muscles  are  distorted, 
rapid  changes  of  expression  being  noted  (Jiysteric  trismus),  and  respira- 
tion is  somewhat  impeded.  As  the  convulsion  passes  ofi"  the  movements 
gradually  subside,  and  the  patient  generally  sinks  into  a  state  of  quies- 
cence or,  it  may  be,  into  a  light  sleep.  ^This  may  be  followed  by  complete 
temporary  recovery,  or  the  epileptoid  may  pass  into  one  of  the  other  forms 
of  the  convulsive  seizure.  The  duration  of  the  spasm  as  described  is  usu- 
ally longer  than  that  of  a  true  epileptic  seizure.  This  form,  more  or  less 
severe,  is  the  one  usually  seen  in  this  country. 

{}))  The  Gymnastic  Form  {Clowniali). — This  stage  is  characterized  by 
violent  and  grotesque  muscular  movements.  Here  are  to  be  grouped  all 
of  the  more  curious  manifestations  of  tlie  disease  recorded  in  the  history 
of  medicine.  The  most  difficult  feats  of  the  contortionist  are  performed 
with  apparent  ease ;  the  patient  may  suddenly  begin  to  dance  or  jump  at 
a  most  astonishing  rate,  persisting  in  the  movements  until  she  drops  from 
pure  physical  exhaustion.      The   so-called  religious   ceremonies  of  the 


HYSTERIA.  1229 

-Shakers  of  Lebanon,  Pennsylv;inia,  and  of"  the  Jumpers  of  the  Middle 
Ages  are  manifestations  of  this  form  of  hysteria.  In  children  the  attack 
may  appear  as  the  so-called  heaat-mimicry,  in  which  the  movements  or 
sounds  of  the  lower  animals  may  be  simulated;  such  is  also  the  explana- 
tion of  the  condition  known  as  spurious  liydrophohia.  Consciousness  is 
never  lost  during  this  period. 

(c)  The  Emotional  Catalei^tic^  or  Dramatic  Form. — In  this  form  the 
patient  seems  to  suffer  from  delusions  or  hallucinations  that  are  apparently 
the  outcome  of  the  preceding  condition.  The  emotion  that  is  most  devel- 
oped in  the  patient's  moral  constitution  now  dominates  his  spasmodic  ac- 
tions. As  Lloyd  aptly  expresses  it :  "  The  third  period  of  the  hysteric 
convulsion  is  one  of  dramatic  representation  of  emotional  images,  and  these 
are  of  countless  varieties,  according  to  time  and  person."  All  of  the  mani- 
festations of  the  cataleptic  state  are  present.  Sensation  is  largely  abolished, 
consciousness  is  retained,  and  the  patient  is  usually  able  to  recall  events 
that  have  transpired  during  the  period.  Especially  common  now  is  the 
assumption  of  dramatic  and  passionate  attitudes,  which,  as  described  by 
Richer,  include  "  the  attitude  of  the  cross,  of  defence,  of  menace,  of  ap- 
peal, of  lubricity,  of  ecstasy,  of  dread  of  animals  (as  rats),  of  scorn,"  and 
the  like.  The  body  of  the  patient  retains,  at  times  for  indefinite  periods, 
whatever  position  is  first  assumed  {hysteric  catalepsy).  In  some  cases  the 
patient  falls  into  a  condition  of  apparent  sleep  or  narcolepsy  {hysteric  sleej), 
hysteric  somnolence,  hysteric  trance)  of  varying  degrees  of  intensity  ;  this 
may  persist  for  any  period  of  time,  from  a  hour  or  two  up  to  weeks,  months, 
or  even  years.  In  these  extreme  cases,  while  the  patient  at  first  appears 
to  be  in  a  normal  sleep,  sooner  or  later  the  body  assumes  a  corpse-like 
appearance,  with  pale,  waxy  skin,  almost  imperceptible  respiration  and 
cardiac  action,  and  a  subnormal  temperature. 

{d)  The  Stage  of  Delirium. — The  final  stage  of  the  hysteric  convulsion 
is  but  a  continuation  of  the  preceding  period,  with,  however,  a  cessation 
of  the  muscular  movement  to  a  great  extent.  The  tendency  now  is  to 
delirium  of  a  mild  type,  tinged  with  more  or  less  melancholia.  Conscious- 
ness is  maintained  throughout  this  stage,  and  there  now  appear  some  curi- 
ous motor  phenomena  that  may  persist  for  days  or  weeks.  These  may 
consist  in  the  abolishment  of  muscular  power  in  various  portions  of  the 
body.  Very  often  associated  with  these  motor  phenomena  is  noted  a  con- 
dition of  mutism  that  lasts  for  indefinite  periods  of  time. 

Systeric  paralyses  occur,  and  may  simulate  any  form  of  the  organic 
paralyses  (monoplegia,  hemiplegia,  paraplegia).  In  many  cases  the  patient 
is  left  with  a  more  or  less  permanent  spasm  of  a  single  set  of  muscles  or 
of  associated  sets.  These  so-called  hysteric  contractures  may  aff"ect  any 
portion  of  the  body.  One  arm  may  be  bent  at  the  elbow  or  one  leg  at 
the  knee ;  in  the  former  case  the  fingers  are  rigidly  contracted  and  em- 
brace the  thumb,  which  is  crossed  upon  the  palm,  while  in  the  latter  the 
toes  are  strongly  flexed  upon  the  plantar  surface  and  the  foot  is  inverted. 
The  ankle-  and  knee-jerk  persist.  In  other  cases  a  curious  spastic  gait 
is  produced  that  closely  simulates  that  of  spinal  sclerosis.  The  muscles 
of  the  hips^  shoulder,  back,  and  neck  {hysteric  torticollis)  may  share  in  the 
process.  In  women  the  muscles  of  the  diaphragm  and  abdominal  walls 
may  be  involved  {liysteric  pseudo-cyesis).  Hysteric  rotary  sjyasju,  hys- 
teric athetosis,  and  hysteric  tremor  are  all  dependent  upon  a  spasmodic 


1230  DISEASES  OF  THE  NERVOUS  SYSTEM. 

action  of  the  muscles  affected.  The  convulsive  seizure  generally  is  of 
short  duration.,  lasting  but  fifteen  to  thirty  minutes.  Occasionally,  how- 
ever, there  is  developed  a  prolonged  convulsive  status,  during  which  time 
the  patient  continually  falls  from  one  convulsion  into  another,  until  one 
hundred  or  more  may  be  recorded  and  the  excess  of  nervous  power  is 
exhausted. 

(3)  The  Latent  or  Interconvulsive  Stage,  or  Period  of  the  Stigmata. — 
After  the  convulsive  attack  the  patient  enters  upon  a  more  or  less  pro- 
longed interval  of  comparative  quiet;  this  is  characterized,  however,  by 
numberless  and  varied  phenomena — the  hysteric  stigmata.  The  whole 
course  of  the  affection  may  be  comprised  in  this  period,  convulsions  being 
absent.  As  I  have  already  stated,  these  can  best  be  described  under  the 
heads  of  the  various  systems : 

(a)  The  Nervous  System. — This  presents  the  most  characteristic  hys- 
teric stigmata.  They  are  generally  grouped  into  the  three  classes  of 
motor,  sensory,  and  psychic. 

The  motor  symptoms  have  already  been  referred  to  in  part  in  the  de- 
scription of  the  hysteric  convulsion.  They  embrace  every  variety  of  mus- 
cular pathology,  from  obdurate  paralysis  to  and  including  tremor,  which 
may  be  cither  fine  or  coarse,  incoordination,  and  tonic  spasm  or  con- 
traction. The  hysteric  paralyses,  as  stated,  may  be  absolute  or  partial, 
and  either  general  or  limited  to  groups  or  to  individual  muscles,  and  may 
simulate  any  variety  of  true  paralysis  of  organic  origin.  There  is  usu- 
ally noted  an  exaggeration  of  the  reflexes  of  the  affected  side ;  muscular 
wasting,  if  present,  is  very  slight  and  due  to  disuse;  usually  it  is  absent. 
It  is  not  at  all  uncommon  to  find  associated  contractures  and  sensory 
phenomena.  The  paralyzed  limb  or  limbs  show  evidences  of  circulatory 
disturbances,  as  edema  and  bluish  discoloration.  In  the  paraplegic  cases 
it  is  unusual  for  trophic  disturbances  (bed-sores)  to  appear.  Paralysis 
of  muscles  supplied  by  motor  cranial  nerves,  especially  those  of  the 
larynx  and  pjharynx,  may  occur,  with  these  exceptions  it  is  usually  a 
pseudo-paralysis  due  to  spasm.  Hysteric  tremors  are  not  infrequent, 
and  are  usually  well  marked  and  persistent.  They  are  generally  asso- 
ciated with  contractures  and  other  hysteric  stigmata.  Choreiform  move- 
ments may  be  simulated,  but  they  are  usually  more  quick  and  rhythmical 
than  true  chorea.  It  is  important  to  remember  that  hysteria  may  co-exist 
with  chorea ;  also,  that  apparently  true  choreic  movements  may  arise  from 
imitation,  in  Avhich  event  it  is  justifiable  to  term  them  hysterical. 

Hysteric  incoordination  {hysteric  ataxia)  has  also  been  termed  astasia- 
ahasia;  it  is  one  of  the  rarest  of  the  motor  phenomena  of  hysteria.  The 
name  implies  an  inability  to  stand  or  walk,  although  muscular  power  in 
the  legs  and  trunk  is  retained,  and  they  can  be  moved  perfectly  w^ell 
when  the  patient  is  at  rest.  Hysteric  contractures  may  occur  as  distinct 
phenomena  or  may  be  associated  with  some  form  of  hysteric  paralysis. 
Usually  the  contractures  occur  Avith  startling  abruptness,  and  are  most 
intense  and  persistent.  They  may  persist  during  sleep,  but  disappear  under 
the  influence  of  an  anesthetic.  There  may  be  associated  sensory  phenomena. 
The  toes  and  the  fingers  are  most  frequently  the  seat  of  contracture,  but 
the  muscles  of  the  face  and  neck  may  likewise  share  in  the  affection. 

Sensory  Symptoms. — The  anesthetic,  hysteric,  and  paresthetic  varieties 
are  noted.     The  anesthesia  may  be  general  or  it  may  involve  but  half  of 


HYSTERIA.  1281 

the  body  or  scattered  areas  of  the  cutaneous  surface.  tSegmental  aneisthenia 
is  the  term  applied  to  that  condition  in  which  a  limb  or  a  portion  of  a 
limb  is  involved.  Not  only  is  the  skin  affected,  but  often  the  deeper 
tissues  as  well,  and  there  is  generally  some  vasomotor  involvement,  as  is 
shown  by  the  fact  that  punctures  by  a  needle  are  not  followed  by  bleed- 
ing. There  is  often  associated  an  anesthesia  of  one  or  more  of  the  special 
senses  (Jiysteric  amaurosis  or  blindness,  hysteric  deafness,  and  hysteric 
ayiosmia).  The  anesthesia  is  severe,  as  a  rule,  immediately  after  an 
hysteric  convulsion,  but  it  may  be  entirely  absent  throughout  a  given 
case  of  hysteria.  There  is  often  contraction  of  the  field  of  vision  or 
inversion  of  the  color  fields,  the  red  being  more  extensive  than  the  blue. 
This  may  also  be  due  to  brain  tumor. 

Hysteric  hyperesthesia  is  also  a  frequent  clinical  manifestation,  and  is 
generally  confined  to  limited  areas,  as  the  ovarian,  mammary,  or  spinal 
regions,  or  to  one  of  the  larger  joints  {hysteric  joint),  simulating  organic 
disease  of  the  part.  Pressure  upon  these  areas  may  precipitate  parox- 
ysmal attacks,  and  they  have  been  termed  hysterogenic  zones.  These 
conditions  can  be  recognized  by  etherizing  the  patient,  when  perfect 
mobility  of  the  affected  joint  is  noted.  When  one  of  the  mammae  is 
involved,  the  organ  becomes  exceedingly  painful  to  the  touch  and  slightly 
edematous  [hysteric  breast).  Hysteric  paresthesice  include  the  common 
varieties  of  formication,  dead  fingers,  and  the  like. 

Psychic  Symptoms. — These  form  some  of  the  most  interesting  and  re- 
markable of  the  manifestations  of  the  disease.  Lethargy  or  a  tendency 
to  sleep  may  exist,  the  periods  of  which  may  follow  or  alternate  with  the 
crises.  The  sleep  in  this  condition  is  peculiar  because  complete  muscular 
relaxation  does  not  exist,  as  is  the  case  in  ordinary  sleep.  There  may 
also  be  mental  depression  and  unrest,  melancholia,  and  a  notable  lack 
of  volitional  power  whereby  the  patient  becomes  especially  open  to  the 
suggestions  of  the  hypnotist.  Double  consciousness  or  somnambulism  is  a 
peculiar  state,  often  following  a  grand  crisis,  but  occasionally  arising 
independently.  The  morbid  period  may  last  for  a  few  minutes  or  hours 
or  may  extend  for  days  or  months.  During  its  continuance  the  patient 
may  be  excited  and  more  or  less  abnornal,  or  an  apparently  normal 
person  of  altered  character.  The  most  remarkable  feature  is  the  loss  of 
memory  for  the  normal  state,  and  the  recollection  of  what  transpired 
during  the  preceding  attacks,  and  loss  of  memory  for  all  that  happened 
during  the  attacks  in  the  normal  state,  so  that  the  subject  may  actually 
live  two  lives.  Analogous  to  these  are  the  states  of  ambulatory  autom- 
atism, in  which,  as  a  result  of  an  irresistible  impulse,  the  subjects 
may  wander  considerable  distances  from  home,  appearing  more  or  less 
normal  during  the  journey,  but  preserving  an  imperfect  recollection  of 
what  had  taken  place.  Somewhat  similar  attacks  occur  as  substitutes  for 
the  epileptic  attack. 

(5)  The  Digestive  System. — Among  the  usual  clinical  manifestations 
of  this  group  may  be  mentioned  anorexia  (which  may  be  complete),  a 
strange  and  persistent  perversion  of  taste,  occasional  uncontrollable  vomit- 
ing without  nausea  {hysteric  vomiting,  anorexia  nervosa),  marked  dyspep- 
sia, and  at  times  extreme  emaciation  with  dryness  and  a  parchment-like 
feel  of  the  skin.  Excessive  flatulence  and  the  peristaltic  unrest  of  Kiiss- 
maul  may  be  marked  symptoms,  as  may  also  either  diari'hea  or  constipa- 


1232  DISEASES  OF  THE  SER VOL'S  SYSTEM. 

tion.  ITi/stcni'  In- mat  erne  six:  is  the  rt'sulr  of  swallowing  blood  ;  this  is 
usually  drawn  from  the  guuis  or  tonsils,  or  it  may  be  taken  secretlv  by 
the  patient  from  other  external  sources. 

(c)  The  Respiratory  System. — Difficulty  of  respiration  (hi/.<iteric  dys- 
pnea) is  not  uneommon.  and  is  characterized  by  an  extreme  rapidity  and 
shallowness  of  the  respiratory  movements.  These  are  much  out  of  pro- 
portion to  the  heart-beats,  and  are  unassociated  with  cyanosis.  In  other 
cases  the  disturbance  assumes  the  form  of  uncontrollable  yawning,  sneez- 
ing, or  hiccoughing,  due  probably  to  a  spasmodic  action  of  the  involun- 
tary muscles  of  the  bronchial  tubes  and  diaphragm.  Hysteric  cough  is 
a  troublesome,  and  very  often  a  stubborn  symptom,  occurring  espe- 
cially in  young  females.  It  is  dry  and  barking,  and.  as  a  rule,  unaccom- 
panied by  expectoration.  At  times  it  may  be  followed  by  hysteric 
hemoptysis,  in  which  there  is  an  escape  of  light-red  fluid'  from  the 
pharyngeal  mucosa.  Hysteiic  aphonia  is  also  frequently  noted ;  in  this 
condition  the  patient  speaks  in  a  scarcely  audible  whisper.  In  such  cases 
restoration  of  the  voice  is  as  of  sudden  occurrence  as  is  its  loss.  In  one 
of  my  own  cases  aphonia  manifested  almost  true  intermittence  for  a  period 
of  five  years,  while  during  the  last  two  jears  or  over  it  has  stubbornly 
persisted  even  without  remission  (p.  1109). 

{d)  The  Vascular  System. — Hysteric  tachycardia  is  often  noted,  and 
much  less  frequently  hysteric  bradycardia  appears.  A  variety  oi pseudo- 
angina  is  not  of  rare  occurrence  {vide  Angina  Pectoris,  p.  713).  Very 
frequently  the  patient  exhibits  a  localized  flushing  of  the  skin  {hysteric 
erythema),  and  especially  of  the  face  and  neck,  or,  as  has  already  been 
noted,  there  may  be  an  apparent  bloodlessness  of  a  part.  Profuse  general 
or  localized  sweating  is  not  uncommon,  and  may  at  times  be  bloody. 

Hysteric  fever  may  be  mentioned  here  as  a  rare  manifestation,  the 
bodily  temperature  usually  being  normal  in  hysteria.  The  elevation  of 
temperature  may  be  moderate  or  there  may  be  an  extreme  hyperpyrexia 
(110°-120°  F."— 43.3°-48.8°  C),  without  grave  results.  *If  this  be 
associated  with  localized  neuralgia,  it  becomes  a  difficult  matter  to  diagnose 
between  the  neurotic  condition  and  organic  disease  of  the  apparently 
affected  part. 

{e)  The  Urinary  System. — An  excessive  flow  of  urine  {hysteric  poly7iria) 
is  of  very  common  occurrence,  while  the  opposite  condition  {anuria^  is 
much  rarer. 

Diagnosis. — The  diagnosis  of  hysteria  depends  entirely  upon  the 
discovery  and  recognition  of  the  hysteric  stigmata  ;  for  one  or  more  of 
them  is  always  present.  Of  these  the  most  frequent  are  areas  of 
anesthesia,  concentric  narrowing  of  the  visual  field  and  inversion  of  the 
color  fields,  and  hysterical  aphonia,  although  any  of  the  others  that 
have  been  described  may  occur.  If,  in  addition,  hysterical  crises  are 
present  or  have  been  observed,  the  diagnosis  becomes  certain.  A 
valuable  feature  is  the  inability  to  explain  the  symptoms  by  reference 
to  the  anatomy  of  the  nervous  system.  It  must  not  be  forgotten  that 
hysteria  and  organic  disease  may  coexist. 

Differential  Diagnosis. — A  ery  important  is  it  to  distinguish  between 
hysteric  and  true  paralyses,  and  between  hysteric  and  organic  abdominal 
tumors.  In  the  following  tables  the  most  striking  points  of  difterence 
between  these  conditions  have  been  set  down : 


IIYSTKRIA. 


1233 


Hysteric  Palsies. 

Occur  without  a  previous  hJKtory  of  or- 
ganic disease,  but  witli  a  neurotic  liis- 
tory.     Traumatism  may  be  tlie  cause. 

Are  accompanied  by  otJier  hysteric  stig- 
mata or  perversions  of  sensation. 

Are  not  accompanied  by  wasting  of  tlie 
muscles  involved. 

Reactions  of  degeneration  are  absent. 


Tlie  power  of  motion  returns  before  sen- 
sation. 

In  hysteric  hemiplegia  the  facial  muscles 
are  not  involved. 

Anesthesia  generally  causes  relaxation  of 

hysteric  contractions. 
The  sphincters  are  never  involved. 
Babinski  reflex  not  present. 


Hysteric  Abdominal  Tumors  (Psetjdo- 

CYESIS). 

Almost  invariably  occur  in  neurotic  women 
near  the  menopause. 

The  percussion-note  is  invariably  tympan- 
itic. 

Anesthesia  causes  a  disappearance  of  the 
tumor. 

Is  variable  as  to  size  and  tonicity. 

Is  accompanied  by  tympany  and  flatu- 
lence. 


Organic  PALSifcs. 

Are  always  secondary  to  organic  disease 
of  the  neuromuscular  system. 

Hysteric  stigmata  are  absent. 

If  due  to  a  lesion  of  the  jieriplieral  neuron, 
atrophy  is  present.  In  cential  neuron 
lesions  it  is  usually  not  mar-ked. 

Reactions  of  degeiicnition  are  more  or  lesj 
marked  in  [)eripheral  palsies.  In  central, 
the  electrical  reactions  are  normal. 

Sensation  if  absent  first  reappears. 

The  facial  muscles  of  the  same  oi-  f)ppf>- 
site  side  are  often  involved  in  true  hemi- 
plegia. 

Organic  pai"alytic  contractions  are  not 
aflected  by  anesthesia. 

Often  are  in  paraplegias. 

In  central  palsies  (pyramidal  tract)  it  is 
present. 


Organic  Abdominal  Tumors. 

Occur  irrespective  of  sex. 

The  percussion-note  over  the  swelling   is 

dull,  or  a  dull  tympany. 
Anesthesia  has  no  effect  upon  the  tumor. 

Slowly  but  steadily  progresses  in  size. 
The  bowels  are  not  always  distended  by 
gas. 


Hysterical  hemianesthesia  differs  from  that  due  to  organic  disease  in 
that  the  special  senses  and  mucous  membranes  are  affected.  The  line  of 
demarcation  is  sharp  and  in  the  middle  line.  Tickling  the  anesthetic 
mucous  membrane  of  the  nose  will  cause  tears  to  flow,  which  will  not 
happen  if  of  organic  origin,  and  lateral  homonymous  hemianopsia  is  never 
present.  If  either  the  segmented  form  or  scattered  areas  of  sensory  paral- 
ysis are  present,  they  often  have  no  connection  with  any  known  area  of 
nerve  distribution.  They  all  may  be  transient,  reappearing  and  disap- 
pearing, and  changing  their  location. 

The  differential  diagnosis  between  hysteria  and  true  neurasthenia, 
psychasthenia,  and  epilepsy  will  be  found  in  the  discussion  of  these 
affections. 

Prognosis. — As  regards  death,  the  prognosis  in  hysteria  is  good ; 
true  hysteric  patients  never  die  of  the  disease,  nor  does  the  hysteric 
spasm  ever  result  fatally.  As  to  an  ultimate  cure,  however,  the  prognosis 
is  very  doubtful.  If  the  disease  occur  early  in  life  and  if  there  is  a 
marked  congenital  neurotic  tendency  manifested  in  the  patient,  there  is 
almost  no  hope  of  effecting  a  permanent  cure.  In  the  acquired  cases, 
under  proper  moral  and  hygienic  control  great  benefit  may  be  effected  or 
even  an  absolute  cure  recorded. 

Treatment. — Of  the  Temperament. — Accurately  speaking,  the  treat- 
ment of  hysteria  should  be  begun  before  birth.     Neurotic  women  bearing 

78 


1234  DISEASES  OF  THE  yERVOUS  SYSTEM. 

children  slioulil  be  subjected  to  a  course  of  rest-cure  and  mental  and 
moral  suasion,  and  the  condition  of  their  nervous  systems  should  receive 
the  careful  attention  of  the  attending  ])hysician.  Neurotic  children  re- 
quire the  greatest  care  during  the  developmental  period.  A  strong  }>hy- 
sique  must  be  secured  by  proper  attention  to  out-of-door  exercise,  and, 
for  the  time  being,  even  at  the  expense  of  mental  culture.  Such  children 
should  not  be  subjected  to  the  ''cramming"  process  so  common  in  our 
modern  courses  of  education,  but  should  be  trained,  if  possible,  at  home, 
■\vhere  the  element  of  com})etition  may  be  eliminated.  Systematic  hours 
of  study  and  of  recreation  (with  absolute  rest  from  study  during  the 
summer  months),  and  opportunities  of  travel  and  change  of  air  and  scene, 
will  work  wonders  in  these  hyperesthetie  little  individuals.  Especially  at 
the  time  of  puberty  is  the  greatest  of  care  required  in  order  to  avoid  an 
additional  strain  upon  the  already  seriously  taxed  nervous  system.  In 
addition  to  the  foregoing  a  strict  watch  must  be  kept  over  the  moral 
nature  of  the  child.  The  satisfaction  of  every  whim  and  the  lack  of 
moral  suasion  are  the  surest  ways  to  develop  the  hysteric  temperament. 
When  possible  the  child  should  be  taken  away  from  the  enervating  in- 
fluences of  city  life.  The  diet  should  be  plain,  but  nutritious,  and  all 
over-indulgence  is  to  be  absolutely  prohibited.  Frequent  bathing  and 
friction  of  the  skin  are  very  beneficial,  as  well  as  careful  regulation  of  the 
emunctories  generally. 

The  Hysteric  Convulsion. — As  hysteric  patients  almost  never  injure 
themselves  during  a  paroxysm,  protective  measures  are  not  necessary. 
Indeed,  the  attack  is  usually  prolonged  by  attention  and  observation. 
Extreme  measures  to  cut  short  an  attack  are  only  justifiable  if  the  friends 
and  relatives  become  unduly  anxious.  Cold  plunge-bathing,  dashing 
cold  water  into  the  face,  or  the  hypodermic  injection  of  apormorphin, 
thereby  producing  a  profound  mental  shock,  may  have  a  beneficial 
effect.  Pressure  over  the  ovary  or  upon  one  of  the  large  vessels  (as  the 
carotid)  will  sometimes  promptly  induce  a  termination  of  the  attack. 

Internal  Treatment. — In  the  latent  period  of  the  disease  it  is  probable 
that  most  can  be  done  to  improve  the  condition  of  the  patient.  In  addi- 
tion to  the  general  laws  of  mental  and  physical  regimen  already  advanced, 
she  should  be  taught,  so  far  as  possible,  the  undignified  condition  into 
which  she  is  sinking,  and  advised  and  encouraged  to  exert  powerful 
efforts  to  control  her  nervous  organism.  All  harsh  methods  are  to  be 
deprecated,  nor  should  she,  after  the  first  admonition,  be  reminded  too 
constantly  of  her  condition.  Full  doses  of  the  nerve-sedatives  and  anti- 
spasmodics (valerian,  asafctida,  sumbul,  musk,  and  camphor),  together  with 
the  general  tonics  (iron,  arsenic,  strychnin),  are  often  useful.  Change  of 
environment,  and  particularly  of  associates,  is  often  of  the  greatest  value. 
I  have  repeatedly  found  the  rest-cure  of  Weir  Mitchell  especially  benefi- 
cial at  this  time ;  it  is  fully  described  under  Neurasthenia  (vide  p.  1239). 

Hypnotism  has  commanded  considerable  attention  during  this  stage  of 
the  disease,  and  it  is  claimed  that  under  the  suggestion  of  the  hypnotist 
an  absolute  cure  very  frequently  follows.  This  is  not  altogether  true, 
however,  for  while  many  patients  are  undoubtedly  benefited  by  this  pro- 
cedure, the  good  result  must  be  attributed  not  alone  to  the  suggestion  of 
the  operator,  but  also  to  the  profound  mental  effect  produced  upon  the 
patient  by  the  mysterious  process.    Hysterical  symptoms  can  be  relieved, 


NEURASTHENIA.  1235 

however,  by  suggestion  and  persuasion,  without  putting  the  patient  in 
the  hypnotic  state,  and  this  constitutes  a  vahiable  procedure!. 

In  the  treatment  of  the  organic  manifestations,  which,  it  must  be  re- 
membered, are  dependent  entirely  upon  the  general  nervoiis  condition, 
the  physician  is  called  upon  to  exercise  the  greatest  amount  of  tact.  Aa 
far  as  is  possible  the  mind  of  the  patient  must  be  directed  away  from  the 
affected  part.  The  irritable  bladder  must  be  treated  by  internal  remedies, 
as  boric  or  benzoic  acid,  salol,  or  the  compound  infusion  of  buchu,  and  not 
by  local  irrigation  and  catheterization. 

Hysteric  vomiting  may  not  require  any  special  medication.  Occasion- 
ally, however,  it  may  be  relieved  by  rectal  alimentation  or  gastric  lavage. 
Cocain  hydrochlorate  in  the  form  of  a  10  per  cent,  solution  (3  to  f)  drops 
internally),  and  the  application  of  mild  counter-irritation  or  of  a  small 
fly-blister  over  the  epigastrium  will  be  useful.  Cannabis  indica,  acctanilid, 
phenacetin,  and  antipyrin,  in  small  doses  and  only  when  absolutely  needful, 
will  relieve  hysteric  neuralgias,  especially  the  cephalalgia.  For  the  pseudo- 
angina  pectoris,  digitalis,  strophanthus,  caffein,  amyl  nitrite,  or  nitrogly- 
cerin, or  a  combination  of  these  drugs  in  suitable  doses,  may  be  exhibited. 

For  the  pelvic  hyperesthesia  of  hysteric  females  local  applications  (tinc- 
ture of  iodin,  croton  oil,  or  a  small  fly-blister)  over  the  ovarian  region  may 
prove  very  beneficial. 

Hysteric  palsies,  either  general  or  local,  and  hysteric  disturbances  of 
the  special  senses,  must  be  treated  on  general  principles.  As  far  as  is 
possible  the  patient's  attention  must  be  directed  from  the  affected  part  or 
parts,  and  an  occasional  local  blistering,  the  use  of  galvanism  and  massage, 
with  daily  friction,  will  be  of  service,  especially  when  they  are  supple- 
mented by  an  appropriate  course  of  internal  medication. 

Electricity  is  a  very  valuable  adjunct.  The  static  current  is  most 
effective,  and  it  may  be  applied  in  various  forms.  Perhaps  the  most 
useful  of  these  is  the  spark,  which  should  be  drav^^n  from  the  anesthetic 
area  or  the  paralyzed  limb,  thus  producing  a  profound  mental  effect. 

Analytical  or  Cathartic  Method. — Based  upon  the  theories  of  Breur 
and  Freud  (p.  1226),  this  method  has  been  evolved.  Briefly,  it  consists 
in  getting  the  patient  "to  tell  the  story  of  his  life."  In  other  words, 
while  in  a  relaxed  condition  (reclining  on  a  couch)  he  is  encouraged  to 
make  a  confession  of  all  the  disagreeable  happenings  of  his  life.  This- 
may  require  some  time  and  a  number  of  stances.  Clues  to  these  may 
be  obtained  from  the  description  of  the  patient's  dreams.  Gaps  may  have 
to  be  filled  in  by  the  physician  by  some  method  of  psycho-analysis.  After 
the  so-called  mental  catharsis  has  occurred,  the  cause  of  the  trouble  being 
so  determined,  the  patient  usually  recovers.^ 


NEURASTHENIA. 


Definition. — Functional  exhaustion  and  irritability  of  the  nerve- 
centers.  Neurasthenia  is  the  expression  of  an  abnormal  sensitiveness 
(irritability)  in  response  to  stimuli,  and  of  weakness  of  the  nerve-centers 
presiding  over  the  organic  functions.  Several  varieties — cerebral,  spinal, 
cardiac,  and  gastric — have  been  distinguished,  owing  to  the  fact  that  the 
predominating  features  may  be  manifested  by  single  organs  or  systems  of 

^  Psyehanalysis,  Brill,  W.  B.  Saunders  Co. 


1236  DISEASES  OF  THE  yERVOUS  SYSTEM. 

the  l)0(ly.  That  the  disease  is  essentially  <ionerali7.ed  in  all  instances, 
however.   T  do  not  doubt.     It  is  not  a  psychosis. 

Pathology. — A  variable  degree  of  weakness  of  the  sympathetic  cen- 
ters, permitting  congestions  on  trivial  provocation,  is  obvious,  but  there 
are  no  discoverable  lasions  (coarse)  in  the  nerve-centers  that  are  peculiar 
to  the  aflection.  C  Y.  Hodge'  has  invited  attention  to  certain  changes 
in  nerve-cells  during  the  active  exercise  of  their  function,  and  something 
of  pathologic  importance  has  been  added  to  our  previous  knowledge  by 
his  observations.  There  are  many  causes  and  associated  affections  that 
present  a  variety  of  morbid  lesions,  but  they  are  purely  incidental.  It 
should  be  pointed  out  here  that  neurasthenia  is  often  found  in  association 
with  other  functional  nervous  disorders — a  fact  that  has  not  only  caused 
mental  confusion  among  certain  authors,  but  has  also  led  to  the  belief 
among  others  that  as  a  distinct  affection  it  does  not  exist.  Glenard,  in 
1888,  called  attention  to  the  fre(iuent  association  of  profound  neuras- 
thenic symptoms  with  splanchnoptosis. 

Ktiology. — The  causes  are  divisible  into — 1,  predisposing ;  and  2, 
exciting.  Among  the  former  (a)  heredity  heads  the  list.  A  clear  history 
of  nervousness  or  morbid  irritability  in  one  or  both  pai-ents  (oftener  the 
father)  is  at  times  obtainable.  Ancestors  that  were  sufferers  from  gout, 
rheumatism,  syphilis,  tuberculosis,  and  chronic  alcoholism,  all  diseases 
that  exhaust  vitality,  may  have  transmitted  to  their  offspring  a  strong 
neurasthenic  disposition.  The  latter  have  inherited  a  small  stock  of  ner- 
vous energy  with  which  to  begin  life's  unceasing  struggle. 

Other  predisposing  factors  are — [h)  improper  training,  mental  and 
phvsical,  (c)  the  character  of  the  mental  pursuits,  those  entailing  strains 
being  especially  deleterious,  {d)  Age  and  sex  are  not  without  appreci- 
able effect,  most  cases  occurring  between  the  twentieth  and  fiftieth  years, 
when  the  work  and  worry  of  life  are  maximal ;  they  are  more  frecjuent 
in  men  than  in  women,  and  [e)  disturbances  of  metabolism  accompanied 
by  an  abnormally  low  output  of  endogenous  uric  acid  (Peck  and  Thomp- 
son). 

Exciting  Causes. — According  to  my  own  observations,  traumatism  has 
an  active  potency,  though  it  is  probably  not  the  most  frequent  cause. 
Overwork,  at  least  in  America,  is  responsible  for  a  greater  number  of 
cases  than  any  other  single  ftxctor,  and  in  estimating  its  effects  the  rela- 
tivity of  individual  nerve-capital  must  be  carefully  considered.  Asso- 
ciated causes  are  to  be  observed  in  unpleasurable  emotional  excitement, 
mental  worriment,  particularly  if  dependent  upon  love-affairs,  and  sexual 
excesses.  Abuse  of  the  sexual  organs,  excessive  venery,  masturbation, 
and  the  like  are  powerful  in  producing  neurasthenia.  Finally,  as  stated 
under  Pathology,  the  condition  may  be  induced  by  other  functional  and 
organic  affections  (symptomatic  neurasthenia). 

Sjrtnptoins. — The  subjective  symptoms  are  protean  and  varied,  and 
are  usually  described  with  great  detail,  for  the  patients  are,  as  a 
rule,  exceedingly  voluble.  Among  the  more  prominent  features  enter- 
ing into  the  symptom -complex  of  neurasthenia  are  great  irritability, 
physical  fatigue  without  adequate  reason,  even  to  a  feeling  of  utter 
exhaustion  on  rising  in  the  morning,  disturbed  sleep,  headache,  with  a 
sense  of  weight  and  constriction,  impairment  oj  mevwry,  anorexia,  and 
'  .Ji)iiiiiftl  of  Morplwlogy,  vol.  v.,  Xo.  11,  p.  95. 


NEURASTHENIA.  1237 

constipation;  the  patient  is  very  irritable,  dispirited,  \h  fciarful,  and  fre- 
quently sinks  into  a  state  of  absolute  dejection.  Female  sufferers — and 
less  frequently  males  also — may  manifest  strong  emotions,  and  in  such 
cases  the  condition  presents  many  points  of  resemblance  to  the  milder 
forms  of  hysteria.  The  external  appearances  may  be  indicative  of  sound, 
vigorous  health  ;  oftener,  however,  the  physiognomy  is  worn  and  anxious. 

The  motor  phenomena  include,  besides  readily  oncoming  exhaustion  of 
the  muscular  strength  under  exercise,  a  variable  condition  of  the  tendon- 
reactions.  On  the  whole,  however,  they  are  increased.  Muscular  tremors 
(fine)  are  sometimes  present,  when  neurasthenia  is  the  result  of  trauma  or 
fright  (Dercum),  and  spasmodic  contractions  of  small  isolated  groups  of 
muscular  fibers  of  the  face,  trunk,  or  extremities  are  observed. 

The  sensory  disturbances  are  varied  and  sometimes  striking.  The 
patient  makes  constant  complaint  of  feeling  "  tired  "  or  "  never  rested," 
and  indeed  sometimes  betakes  himself  to  bed  for  this  reason.  A  feeling 
of  "lightness,"  giddiness,  and  even  true  vertigo,  may  occur  and  recur, 
and  rarely  the  latter  symptom  is  v\^ellnigh  continuous.  The  headache  (pre- 
viously mentioned)  is  often  wholly  dependent  upon  mental  work,  since  it 
disappears  with  the  cessation  of  the  latter.  Another  form  of  pain  is  a 
dull  aching  that  may  be  generalized,  though  more  commonly  it  is  con- 
fined to  the  small  of  the  back  and  limbs.  tSpinal  tenderness,  when  sought 
for,  may  often  be  elicited  over  certain  circumscribed  areas  or  mere  points, 
and  it  may  be  combined  with  a  deep-seated  ache  or  an  exacerbating  pain 
("spinal  irritation").  Cutaneous  hyperesthesia  is  common,  but  anesthe- 
sia is  not  found  in  uncomplicated  neurasthenia.  Numbness,  either  spon- 
taneous or  as  the  result  of  slight  pressure,  is  a  conspicuous  feature  for  a 
variable  period  upon  or  near  the  nerve-trunks,  and  linked  with  it  there 
may  be  a  generalized  or  localized  feeling  of  coolness  of  the  body-surface, 
or  of  pricking  sensations  (formications)  and  circumscribed  subjective 
sensations  of  heat  and  burning. 

The  'psycldc  symptoms  grow  out  of  the  same  fundamental  conditions 
as  do  the  physical  symptoms — i.  e.  fatigue  of  the  nerve-centers.  As 
would  be  expected,  then,  the  capacity  for  sustained  mental  work  is  gener- 
ally lessened,  and  the  power  to  concentrate  or  rivet  the  attention  upon 
any  subject  as  well.  The  patient  is  self-centered,  sensitive  to  a  degree, 
easily  angered,  and  is  morbidly  suspicious.  His  emotional  nature  is 
unstable,  and  the  mental  depression  (before  mentioned)  deepens  until  it 
approaches  true  hypochondria. 

Insomnia  is  one  of  the  most  constant  and  troublesome  of  all  the 
symptoms  of  neurasthenia.  It  occurs  in  various  forms.  Usually  the 
patient  goes  to  sleep  readily,  but  awakens  in  a  few  hours  and  remains 
awake  either  for  the  rest  of  the  night  or  until  morning  is  approaching ; 
sometimes  there  is  difficulty  in  falling  asleep ;  sometimes  rest  is  fre- 
quently disturbed.  Agrypnia,  total  inability  to  sleep,  occurs  only  in 
the  most  severe  forms  of  the  disease.  Disturbances  of  the  organs  of 
special  sense  are  not  wanting.  The  eye  presents  the  most  important 
fatigue-symptoms.  Vision  may  be  imperfect  (blurred)  and  continuous  close 
use  of  the  eyes  may  be  impossible.  There  is  a  lack  of  power  of  accom- 
modation and  retinal  hyperesthesia  may  supervene.  The  pupils  may  be 
unnaturally  large.  All  forms  of  tinnitus  constantly  arise  in  neurasthenia, 
and  may  lend  so  vivid  a  coloring  to  the  clinical  picture  that  the  real  nature 
of  the  attack  is  liable  to  be  oveidooked.     I  have  recently  seen  a  case  of  the 


1238  DISEASES  OF  THE  yEEVOUS  SYSTEM. 

sort  occurring  in  a  clergyman  in  wliom  aural  disease  had  previously  been 
diagnosticated.  This  symptom,  like  all  others  due  to  neurasthenia,  may, 
however,  be  associated  with  genuine  organic  diseases  of  the  ear  {otoneu- 
rasthenia).  Disturbances  of  taste  sometimes  appear,  but  they  are  of 
minor  importance.  Vasomotor  disorders,  such  as  hot  flushes  and  pro- 
fuse sweats,  commonly  arise  in  consequence  of  the  diminished  tone  of  the 
arteries ;  these  form  ((uite  distressing  fatigue-symptoms.  Visible  throb- 
bing of  the  superficial  vessels  and  of  the  abdominal  aorta,  and  rarely  also 
of  the  veins  and  the  capillary  pulse,  occur.  The  urinar]!  phenomena 
may  excite  particular  attention  owing  to  their  prominence,  and  this  remark 
applies  especially  to  the  frequent  combination  of  neurasthenia  and  lith- 
emia  (lithemic  neurasthenia).  Oxaluria  and  transient  glycosuria  and 
albuminuria  may  also  be  present.  The  daily  amount  of  urine  is  often 
small,  and  less  frequently  it  is  large.  The  sexual  apparatus  is  weak  and 
irritable,  as  shown  by  seminal  emissions  and  incomplete  erections,  and  by 
premature  ejaculation.  The  fear  of  becoming  impotent  often  renders  the 
mental  attitude  of  those  really  potent  such  as  to  excite  the  keenest  com- 
passion. The  orgasm  in  the  female  and  the  emission  in  the  male  are  fol- 
lowed by  a  sense  of  prostration  and  mental  depi*ession. 

The  somatic  disturbances  referable  to  the  heart  (palpitation,  precordial 
pain)  have  been  considered  under  Neuroses  of  the  Heart,  and  the  various 
gastro-intestinal  features  in  the  discussion  of  Neuroses  of  the  Stomach. 
Reference  has  already  been  made  to  several  clinical  varieties  based  upon 
the  predominance  of  special  and  localized  groups  of  symptoms — e.  g.,  when 
the  reigning  features  are  spinal  the  variety  is  termed  spinal  neurasthenia  ; 
•when  these  are  presented  by  the  sexual  apparatus,  sexual  neurasthenia, 
and  so  on.  A  further  subdivision  has  recently  been  made  in  which  the 
predominant  symptoms  are  various  morbid  fears,  imperative  ideas,  impul- 
sive acts,  and  the  so-called  doubting  mania.  This  has  been  termed  jos?/- 
chasthenia  (p.  1242).  The  most  obstinate  type  of  neurasthenia  is  that 
associated  with  congenital  defects  of  structure,  particularly  splanchnop- 
tosis, the  so-called  Gl^nard's  disease.  It  does  not  diifer  essentially  from 
the  ordinary  forms,  but  the  gastro-intestinal  symptoms  predominate. 

Diagnosis. — That  cases  of  neurasthenia  are  misdiagnosed  as  other 
conditions,  and  the  reverse,  I  feel  convinced.  An  important  matter  at 
the  outset  is  to  avoid  confounding  the  neurasthenic  symptoms  (secondary) 
of  various  local  and  general  organic  diseases  with  the  primary  form  by  a 
careful  exclusion  of  the  latter.    From  hysteria  the  diagnosis  is  as  follows : 

IIvsTERiA.  Neurasthenia. 

By  nature  a  psycho-neurosis.  A    neurosis  ;    often    with    a    pronounced 

psychical  clement. 

Occurs  in  individuals  presenting  a  marked  Occurs  as  the  result  of  nerve-tire,  over- 
hereditary  taint.  work,  and  the  like  in  individuals  not 

necessarily  presentinii  hereditary  taint. 

The  onset  is  frequently  abrupt.  The  onset  is  always  gradual. 

The  clinical  features  are  dependent  upon  Is  characterized  by  a  notable  lack  or  in- 

an  excess  of  nervous  energy.  sufficiency  of  nerve-force. 

Presents  the  characteristic  stigmata,  as  These  are  absent, 
paralysis  and  anesthesia  in  most  cases. 

Is  sometimes  accompanied  by  violent  con-  Convulsive  seizures  never  occur, 
vulsive  seizures. 

NeuraJfjic  attacks  infrequent  nnd  absent.  Neuralgic  attacks  are  very  common. 

Insomnia  is  not  marked.  Insomnia  i.s  very  common. 


NEUBA  STIIKNfA .  1  239 

Hysteria,  it  is  to  be  remembered,  may  be  a  complication  of  neuras- 
thenia, and  this  association  must  b(!  distin.^uished  from  simple  hysteria. 
Neurasthenia  must  also  be  distinguished  from  psychastiienia  (p.  1242). 
It  should  also  be  remembered  that  neurasthenic  symptoms  m;iy  mark  the 
commencement  of  various  grave  physical  and  mental  disorders.  Tuber- 
culosis, diseases  of  the  blood,  dilated*  stomach,  gastric  cancer,  gastroptosis, 
movable  kidney,  chronic  uterine  and  ovarian  disease,  paresis,  dementia 
prsecox,  hypochondria,  pellagra '  (p.  1286),  and  melancholia  should  all 
be  considered  before  the  diagnosis  of  pure  neurasthenia  is  made. 

Prognosis. — Neurasthenia  is  a  curable  disease  if  appropr'iate  treat- 
ment be  commenced  before  secondary  structural  changes  set  in  and  render 
the  use  of  the  most  approved  measures  of  no  avail.  In  long-standing 
cases  deleterious  habits  (morphinism,  chloralism,  alcoholism)  are  some- 
times developed  and  prevent  the  possibility  of  a  cure.  Hysteria  (the 
complication)  tends  to  delay,  but  does  not  preclude,  recovery. 

Treatment. — The  first  step  should  be,  after  locating  the  major  cause 
or  causes,  to  remove  them,  or,  if  this  be  impossible,  to  minimize  their 
baneful  influence  so  far  as  may  be.  For  example,  if  the  conditions  have 
been  induced  by  overwork  of  the  brain,  rest  for  the  organ  must  be  pro- 
cured; if  sexual  excesses  have  been  the  obvious  responsible  factor,  rest 
for  the  sexual  apparatus  is  imperatively  demanded.  In  the  next  place, 
the  mental  and  moral  environment  must  be  conducive  to  contentment  and 
to  wholesome  forms  of  exercise  of  the  mind.  In  this  way  the  exhausted 
stock  of  nervous  energy  can  be  often  increased  by  the  natural  recuperative 
forces  alone.  Indeed,  successful  removal  of  the  essential  etiologic  influ- 
ences is  in  the  milder  forms  followed  by  prompt  recovery.  In  not  a  few 
instances  the  symptoms  disappear  as  the  result  of  a  prolonged  sojourn  in 
a  suitable  climate  or  by  travel  for  a  considerable  period  with  its  ever- 
accompanying  change  of  scene,  though  it  is  well  in  doing  so  to  avoid  the 
din  and  excitement  of  large  cities.  The  compulsory  rest  and  complete 
isolation,  combined  with  the  purity  of  atmosphere,  afforded  by  a  sea-voyage 
sometimes  work  admirable  results.  Being  occupied  by  easy  and  agree- 
able employment  under  supervision,  as  embroidery,  basket-making,  etc., 
has  been  successful.  Unfortunately,  many  subjects  suff'ering  with  neu- 
rasthenia, and  particularly  males,  are  either  unable  or  unwilling  to  ari-est 
the  loss  of  nervous  function  by  ceasing  their  excessive  activities.  In  the 
majority  of  instances,  for  the  reasons  above  stated,  certain  other  measures 
— hygienic  and  medicinal — are  to  be  advised. 

To  Dr.  S.  Weir  Mitchell  belongs  the  credit  of  having  systematized 
the  "  rest-cure  "  in  the  management  of  this  disease.  This  mode  of  treat- 
ment involves  (1)  physical  and  psychic  rest.  The  former  is  obtained 
by  strict  confinement  to  bed,  the  latter  by  isolation  from  all  business, 
professional,  household,  and  family  affairs ;  in  severe  cases,  to  the  com- 
plete exclusion  of  the  family.  (2)  Hypernutrition.  This  requires  the 
administration  of  a  quantity  of  food  in  excess  of  the  amount  required 
merely  to  maintain  life  and  repair  waste,  and  is  usually  secured  by  feed- 
ing at  frequent  intervals  and  using  nutritious  food.  (3)  The  stimulation 
of  the  metabolic  processes.  This  is  accomplished  by  massage,  passive 
movements,  and  electricity.  (4)  The  encouragement  and  education  of 
the  patient.  This  depends  largely  upon  the  tact  and  authority  of  the 
physician  and  nurse,  although  graduated  and  increasing  voluntary  mus- 

1  Tucker,  Amer.  Jour.  Med.  ScL,  March,  1912,  p.  332. 


1240  DISEASES   OF  THE  ySRVOUS  SYSTEM. 

cular  and  mental  exercises  are  of  some  value.  In  lon'f-standino;  cases 
rest  should  be  made  absolute  if  possible,  while  in  the  mihler  forms  merely 
lengthening  the  hours  for  sleep  or  rest  in  bed  often  suffices.  The  amount 
of  rest  must  be  accurately  proj)ortioiied  to  the  necessity  of  each  case. 

The  patient  is  to  be  put  in  eliarge  of  a  properly  selected  nurse,  who 
will  aftbrd  agreeable  entertainment  by  suitable  conversation  and  reading 
under  the  direction  of  the  physician.  In  desperate  cases  the  patient 
should  not  be  allowed  to  feed  himself,  must  not  rise  to  void  the  urine  or 
feces,  nor  even  turn  in  bed  without  the  help  of  the  nurse. 

Upon  the  careful  regulation  of  the  diet  depends,  to  a  large  extent, 
the  success  of  the  treatment.  This  must  be  modified  to  suit  each  indi- 
vidual patient,  and,  when  it  is  possible,  it  is  desirable  to  first  make  a 
careful  quantitative  and  tjualitative  examination  of  the  stomach  contents. 

The  two  commonest  derangements  are  excess  of  hydrochloric  acid, 
with  retention  of  stomach-contents  and  anacidity. 

In  the  former  condition  the  diet  must  consist  of  the  lighter  meats, 
the  more  readily  digested  vegetables,  particularly  the  legumes,  the  cereals, 
light  desserts,  toasted  bread,  crackers,  etc.,  a  liberal  amount  of  fat  and 
milk,  and  eggs  in  moderation.  I  have  rarely  found  it  necessary  to  com- 
mence with  a  very  restricted  diet  of,  say  milk,  but  as  a  rule,  the  patient 
can  begin  on  three  full  meals  a  day,  with  a  luncheon  consisting  of  milk 
and  toast  or  crackers,  malted  milk,  chocolate,  or  cocoa,  etc.,  in  the  mid- 
morning  and  mid-afternoon,  before  going  to  bed,  and,  in  severe  cases, 
also  once  during  the  nicrht.  These  cases  are  also  benefited  bv  the 
administration  of  moderate  quantities  of  soda  after  each  meal. 

In  the  achylic  form  the  total  quantity  in  each  meal  should  be  some- 
what less,  but  from  six  to  eight  meals  may  be  given  in  the  course  of 
twenty-four  hours.  The  diet  should  consist  of  meats,  eggs,  the  legumes, 
the  acid  vegetables,  the  cereals,  bread,  fruit,  light  desserts,  a  moderate 
amount  of  coffee,  and  a  liberal  amount  of  milk.  Hydrochloric  acid 
should  be  given  before  each  meal.  In  either  case  the  caloric  value  of  the 
diet  should  exceed  3000  in  the  course  of  twenty-four  hours. 

In  cases  in  which  the  gastric  analysis  is  not  possible,  it  is  of  advan- 
tage to  commence  with  small  quantities  of  food,  and  to  increase  them 
rapidly  until  a  very  liberal  diet  is  being  taken.  As  a  general  rule  the 
red  meats  should  not  be  given  too  freijuently,  the  coarser  vegetables 
should  be  excluded  entirely,  and  sweet  food  should  be  taken  sparingly. 
Most  cases  do  well  on  cream  taken  in  quantities  of  four  to  eight  ounces 
at  a  time,  sipped  slowly,  while,  at  the  same  time,  crackers  or  toast  are 
eaten. 

It  is,  of  course,  understood  that  the  patient  should  never  be  consulted 
about  the  diet.  The  nurse  brings  the  food  at  the  proper  time,  served  in 
the  most  attractive  manner  possible,  and  at  meal-time  always  in  courses, 
so  that  only  moderate  amounts  of  food  are  placed  before  the  patient  at 
one  time.  The  patient  should  lie  perfectly  flat  for  at  least  an  hour  after 
eating. 

Passive  exercise^  massage,  and  electricity  form  an  essential  part  of  the 
"rest  cure."  Massage  should  not  be  commenced  until  the  second  or 
third  day.  At  first  it  should  be  continued  for  a  few  minutes  only,  and 
consist  of  gentle  rubbing  or  light  strokes.  As  tolerance  becomes  estab- 
lished,  it  should    be    practised    for    a    longer   period  (about    an   hour). 


NEURASTIIENTA.  1241 

Deeper  rolling,  kneading,  and  spiral  manipulations  are  tlien  allowalde. 
TKe  direction  of  the  venous  "blood-current — toward  the  center  of  the  body 
from  the  periphery — is  to  be  borne  in  mind,  and  all  massage-motions  are 
to  be  made  in  the  same  direction.  This  measure  is  to  be  carried  out  by 
the  nurse,  who  should  be  a  well-trained  masseuse  and  thoroughly  ac- 
quainted with  the  details  of  her  work.  Electricity,  like  massage,  com- 
pensates for  the  lack  of  exercise.  The  slowly-interrupted  faradic  current 
is  to  be  selected,  and  the  aim  should  always  be  to  induce  satisfactory  con- 
tractions with  the  least  amount  of  pain.  The  current  should  be  applied 
to  the  individual  muscles,  one  of  the  extremities  being  selected,  and  the 
poles  applied  over  the  motor  points,  passing  from  muscle  to  muscle  until 
all  have  been  faradized.  The  time  of  each  sitting  should  not  exceed  half 
an  hour.  The  entire  body  should  also  receive  the  faradic  current  (rapidly 
interrupted).  A  large  sponge  moistened  with  salt  water  is  applied  at  the 
nape  of  the  neck,  and  another  to  the  soles  of  the  feet,  and  the  strongest 
current  tolerable  is  thus  used.  This  process  should  be  continued  from 
fifteen  to  twenty  minutes,  and,  like  the  faradization  of  the  single  muscles, 
it  is  to  be  repeated  at  intervals  of  twenty-four  hours.  Passive  move- 
ments should  be  employed  systematically,  slowly  increasing  in  duration 
and  extent.     They  promote  circulation  and  nutrition  and  are  soothing. 

Hydrotherapy  may  be  employed  in  the  form  of  the  shower,  spray, 
bath,  or  pack,  and  is  most  efficacious  when  quickly  applied  for  a  few 
moments  and  followed  by  vigorous  toweling  to  reinforce  the  action  of 
the  cold.  In  insomnia  with  difficulty  in  going  to  sleep,  the  dry  cold 
pack  applied  to  the  spine  for  an  hour  is  often  of  benefit.  Extreme  cau- 
tion is  necessary  at  the  beginning  of  the  application  of  cold  to  the  sur- 
face, since  there  are  neurasthenic  subjects  who  not  only  fail  to  receive 
benefit,  but  are  rendered  worse  in  consequence  of  a  highly  sensitive 
^organization. 

Although  the  administration  of  drugs  plays  a  minor  part  in  the 
management  of  the  rest-cure,  in  certain  cases  they  are  essential,  and 
must  not  be  excluded,  Musser  lauds  very  highly  ascending  doses  of  the 
tincture  of  nux  vomica,  taken  before  meals.  It  is  his  custom  to  begin 
with  10  or  15  minims  before  each  meal,  increasing  the  dose  every  second 
day  until  as  much  as  a  dram  of  the  tincture  is  taken  three  times  a  day 
before  meals,  providing  no  untoward  symptoms  arise.  This  method  of 
administration,  while  helpful,  has  not,  in  my  hands,  yielded  the  brilliant 
results  that  are  claimed  for  it.  Alkalies  or  acids  are  indicated,  accord- 
ing to  the  condition  of  the  stomach-contents.  If.  there  is  excess  of  acid 
the  alkalies  may  be  taken  after  meals ;  if  there  is  a  deficiency  of  acid, 
hydrochloric  acid  should  always  be  given  before  meals,  and  in  ample 
doses — from  10  to  20  minims  of  the  dilute  acid. 

The  most  important  drugs  are  the  laxatives.  In  the  beginning  calomel 
and  the  salines  are  often  of  great  value  in  flushing  out  the  intestines, 
but  during  the  course  of  the  disease  it  is  the  invariable  rule  never  to 
purge.  Of  the  vegetable  laxatives  cascara  is  probably  the  most  useful, 
but  aloin  and  rhubarb  are  often  of  service.  Of  the  saline  laxatives  the 
most  efiicient  are  certain  forms  of  magnesia  and  phosphate  of  soda.  In 
cases  where  there  is  considerable  alkalinity  from  5  to  10  grains  of  oxide 
of  magnesia  in  powder  form  may  advantageously  replace  the  soda  after 
meals.     Or,    1  or  2   drams  of  the  milk  of  magnesia  may  be  given  in 


1242  DISEASES  OF   TllK  SERVO  US  SYSTEM. 

milk,  two  or  three  times  a  day.  Small  doses  of  phosphate  of  soda  in  hot 
water  should  be  c;iveii  just  before  breakfast  in  the  morning,  being  care- 
fully regulated  so  that  only  a  laxative  effect  is  produced. 

If  there  is  pronounced  anemia,  moderate  doses  of  iron,  perhaps  com- 
bined with  arsenic  and  the  bichloride  of  mercury,  are  often  of  service, 
but  must  be  discontinued  if  they  interfere  with  the  appetite.  There  is 
considerable  dispute  regarding  the  value  of  phosphoric  acid,  or  its  salts. 
According  to  my  experience,  it  is  of  comparatively  little  value. 

The  rest-cure  in  all  of  its  details  should  be  continued  for  a  period 
ransjinnf  from  fi)ur  to  eifiht  weeks.  The  patient  should  leave  his  bed  in 
the  most  gradual  manner,  and  should  sit  up  for  a  few  minutes  only  at  first, 
the  time  being  gradually  lengthened ;  soon  exercise  may  be  commenced 
in  a  like  manner  and  be  cautiously  increased.  During  this  period  of 
convalescence  it  is  my  custom  to  omit  the  electric  treatment,  while  the 
massage  is  continued  at  intervals  of  two  or  three  days  for  some  weeks. 
After  the  patient  has  made  some  improvement,  as  evidenced  by  a  large 
appetite,  the  disappearance  of  the  most  pronounced  subjective  symptoms, 
and  especially  by  a  substantial  gain  of  weight  (tAventy  to  twenty-five 
pounds — 11.3  kgms.),  he  should  be  advised  to  make  a  change  of  resi- 
dence, preferably  to  the  country,  the  mountains,  or  the  seashore,  being 
guided  by  the  season  and  the  wishes  of  the  patient. 

We  must  increase  the  activity  of  the  metabolic  processes  in  cases  in 
which  the  endogenous  uric  acid  output  is  lowered  (400  gr.  or  less  daily). 
Peck  and  Thompson  ^  advocate  the  use  of  the  electric-light  baths.  Cases 
which  are  not  able  to  undergo  these  methods  (they  being  somewhat  ex- 
pensive) must  be  treated  symptomatically,  small  doses  of  the  bromids, 
combined  with  arsenic,  if  irritability  is  excessive.  Cold  douches  or 
baths,  with  vigorous  rubbing  in  the  mornings ;  tonics,  as  the  glycero- 
phosphates, iron,  etc.,  attention  to  the  gastro-intestinal  tract,  encourage-, 
ment,  regulation  of  the  employment,  as  much  fresh  air  as  possible,  elec- 
tricity in  the  form  of  high-frequency  currents,  etc. 

TRAUMATIC    NEUROSES. 

Owing  to  the  marked  influence  of  trauma  in  causing  both  neurasthenia 
and  hysteria,  such  cases  are  often  specially  classified  under  the  above 
title.  The  symptoms  are,  however,  essentially  those  of  either  hysteria 
or  neurasthenia,  or  both  combined.  The  general  rules  of  diagnosis  and 
prognosis  in  these  conditions  here  apply.  It  should  be  remembered  that 
the  strain  incident  to  litigation,  to  which  these  cases  are  often  subjected, 
may  retard  recovery. 

PSYCHASTHENIA. 

A  GROUP  of  symptoms,  until  recently  classified  under  neurasthenia, 
has  been  given  the  above  title.  They  consist  of  obsessions,  fears,  doubts, 
undue  anxiety,  uncontrollable  movements,  deficient  will-power,  combined 
with  more  or  less  of  the  physical  symptoms  of  neurasthenia.  As  ex- 
amples of  these  mental  symptoms  may  be  mentioned  dread  of  impending 
danger,  either  to  family  or  self,  fear  of  open  spaces  (agoraphobia),  fear 
of  closed  places  (claustrophobia),  of  being  alone  (monophobia),  fear  of 
I  Jour.   Amfr.  Med.  Assoc,  Feb.  29,  1908. 


OCGUPA  TION-NEUROSES.  ]  243 

crowds,  abnormn,!  fear  of  storniH,  of  wind,  etc.  ;  fear  of  personal  defile- 
ment (mysopliobia) ;  the  doubting  mania,  in  which  the  patient  is  never 
certain  that  he  has  performed  an  action  correctly;  irresistible  impulse  to 
touch  certain  objects  (delire  du  toucher);  irresistible  tendencies  to  repeat 
continually  certain  words  (onomatomaTiia),  to  count  a  certain  number  of 
times  before  performing  an  action  (arithmomania),  etc.  'J'he  patient  is 
conscious  of  the  absurdity  of  these  actions  and  feelings,  but  cannot  resist 
them.  Epileptiform  convulsions  may  also  occur.  The  prognosis  is 
doubtful,  but  treatment  similar  to  that  recommended  for  hysteria  may 
achieve  good  results. 

OCCUPATION-NEUROSES. 

Definition. — Conditions  in  which  the  performance  of  certain  haljitual 
coordinated  movements  is  prevented  by  the  development  of  cramp,  tremor, 
paralysis,  or  pain, 

The  pathology  of  this  condition  is  unknown.  It  is  probably  purely 
functional,  and  the  discovery  of  appreciable  lesions  is  not  to  be  expected, 
though  nodular  thickening  of  the  pei'ipheral  nerves  has  been  described 
in  a  few  cases. 

The  etiology  is  various.  Those  following  any  occupation  requiring 
the  continuous  repetition  of  fine,  coordinated,  muscular  movements,  as 
sewing,  type-writing,  playing  musical  instruments,  telegraphing,  and 
writing,  may  be  affected.  Writing  is  the  most  common  cause,  and  is 
known  as  scrivener's  palsy,  or  writer's  cramp.  It  is  the  form  here 
particularly  described,  although  the  symptoms  due  to  other  causes  are 
similar.  Males  are  far  more  frequently  affected  than  females,  the  condi- 
tion usually  occurring  in  early  adult  life,  although  children  are  not  ex- 
empt. Gowers  lays  great  stress  upon  improper  methods  of  holding  the 
pen,  particularly  those  in  which  most  of  the  writing  is  done  from  the 
wrist ;  that  is,  with  the  muscles  of  the  forearm  and  hand.  As  scrivener's 
palsy  occurs  sometimes  in  those  that  write  properly,  and  as  a  similar  con- 
dition is  not  uncommon  in  other  occupations,  it  seems  unlikely  that  this 
is  the  most  important  cause.  A  person  with  a  neurotic  temperament  is 
far  more  apt  to  be  affected  by  the  disease  than  one  with  a  normal  nervous 
system;  we,  therefore,  frequently  find  it  associated  with  hysteria,  neu- 
rasthenia, or  great  bashfulness,  and  not  infrequently  it  is  possible  to  elicit 
a  neuropathic  heredity  in  the  family  history.  It  is  also  met  with  in  cer- 
tain other  nervous  diseases  (epilepsy,  locomotor  ataxia — in  the  early 
stage).  Often  the  patients  admit  that  at  the  time  the  disease  developed 
they  were  suffering  from  severe  anxiety. 

Symptoms. — Motor. — When  the  patient  attempts  to  write  there  is 
usually  a  cramp  of  the  flexor  muscles  of  the  forearm,  so  that  the  pen  is 
held  more  or  less  rigidly,  and  it  is  almost  impossible  to  control  its  mo- 
tions. Less  frequently  there  is  a  cramp  of  the  extensor  muscles,  so  that 
the  fingers  are  spread  and  it  is  impossible  to  hold  the  pen  at  all.  Some- 
times there  is  a  sudden  twitching,  and  the  pen  may  be  thrown  altogether 
out  of  the  hand.  The  spasm  is  nearly  always  tonic  in  character,  but 
often  it  is  associated  with  a  fine  tremor,  and  at  times  there  are  clonic 
movements.  In  some  cases,  and  particularly  those  occurring  in  patients 
showing  hysteric  stigmata,  there   is   a   coarse,    irregular   tremor,    most 


1244  DISEASES  OF  THE  SERVO  US  SYSTEM. 

niavkt'il  wlien  tlio  patient  is  under  observation.  Paresis  is  frequently 
associated  with  the  cramp,  so  that  the  arm  soon  becomes  tired  and  it  is 
almost  impossible  to  write.  This  fatigue  may  in  a  few  moments  progress 
to  almost  complete  paralysis  of  the  arm,  but.  curiously  enough,  both 
fatigue  and  paralysis  disappear  as  soon  as  some  coordinated  movement 
other  than  writing  is  undertaken. 

Sensory. — Pain  is  very  common,  and  is  neuralgic  or  cramp-like  in 
character,  being  referred  either  to  the  muscles,  bones,  or  joints.  In 
intensity  it  varies  from  a  dull  ache  to  the  most  excruciating  burning,  and 
may  form  the  only  symptom,  the  muscles  performing  their  work  perfectly. 
At  times  it  is  sharply  localized  to  one  particular  joint,  affecting  either  the 
metacarpal  bones  or  the  fingers.  Quite  often  the  patient  complains  of  a 
tinsjlinir  or  burning  sensation  in  the  limb,  or  it  mav  be  numb  and  the 
hand  feels,  when  writing,  as  if  a  heavy  weight  were  attached  to  it.  Often 
there  is  tenderness  either  of  the  muscles  or  the  nerves,  which  may  be 
localized  in  certain  points.  In  very  severe  cases  vasomotor  disfurhanres 
occasionally  occur.  The  disease  ordinarily  commences  slowly.  At  first 
the  subject  notices  that  the  handwriting  is  not  quite  as  perfect  as  before, 
a  stroke  occasionally  going  astray ;  later  distinct  spasms  appear,  and 
these  are  finally  associated  with  pain. 

The  diagnosis  is  usually  easy.  Care  must,  however,  be  taken  not 
to  call  every  disturbance  of  writing  writer's  cramp:  thus  in  paralysis  agi- 
tans,  in  slowly  developing  hemiplegia,  in  multiple  sclerosis,  paresis,  and  in 
locomotor  ataxia  disturbances  of  writing  frequently — in  fact,  almost  in- 
variably— occur.  Moreover,  those  cases  in  which  hysteria  or  neuras- 
thenia seems  to  be  at  the  bottom  of  the  trouble  should  be  carefully  differ- 
entiated from  those  that  are  apparently  idiopathic. 

The  prognosis  is  rather  unfavorable,  though  complete  cure  is  some- 
times attained. 

The  treatment  consists  first  in  a  total  cessation  of  writing  ;  if  this 
is  impossible,  various  mechanical  devices  may  be  employed  to  use  another 
set  of  muscles  or  the  old  ones  rather  differently,  such  as  a  thick  penholder 
or  one  constructed  with  supports  for  the  fingers.  Local  treatment  of  the 
arm  in  the  form  of  electricity  should  be  advised  ;  the  anode  of  a  constant 
galvanic  current  of  medium  intensity  should  be  placed  over  the  sensitive 
points  on  the  nerves  and  over  the  bodies  of  the  muscles.  The  wire 
brush  employed,  with  the  rapidly  interrupted  faradic  current,  to  stroke 
the  painful  nerves  and  muscles,  affords  great  relief.  Massage,  and 
particularly  careful  and  sj^stematic  exercises,  are  also  of  great  value.  At 
the  same  time,  the  general  condition  of  the  patient  must  not  be  neglected. 
In  those  associated  with  neurasthenia  a  treatment  appropriate  to  this 
condition  should  be  emploN^ed. 


ACROMEGALY. 

{Gluniisiit.) 

Definition. — A  disease  first  recognized  and  described  by  Marie,  and 
characterized  by  a  jirogressive  and  peculiar  enlargement  of  the  face  and 
extiemities. 

Pathology. — Those  cases  that  have  been  examined  jjo.st7yiortein  have 
shown,  as  the  most  constant  change,  an  enlargement  of  the  pituitary  body, 


ACROMEGALY.  1245 

with  a  corresponding  dilatation  of  the  .sella  turcica,  and  a  persistonco  of 
the  thymus  gland.  Alterations  may  be  found  in  other  ductless  glands, 
especially  the  thyroid,  which  may  be  either  goitrous  or  atrophied,  fn 
some  cases  the  pituitary  may  not  be  enlarged  macroscopically.  The  lips, 
tongue,  and  trachea  are  usually  considerably  enlarged,  and  the  sexual 
organs  may  either  be  hypertrophied  or  atrophied,  the  latter  condition 
being  more  common  in  the  uterus  and  testicles.  The  bones  of  the  ex- 
tremities and  face  are  thickened,  apparently  chiefly  as  a  result  of  hyper- 
plasia of  the  spongy  portion,  and  Klebs  has  shown  that  the  peripheral 
vessels,  particularly  those  in  the  aifected  bones,  are  also  larger.  Occa- 
sionally there  are  hypertrophy  of  the  heart  and  enlargement  of  the  spleen 
and  liver. 

Acromegaly  is  due  to  an  increased  activity  of  the  anterior  lobes  of  the 
pituitary  body  occurring  after  epiphyseal  union  has  taken  place.  If  it 
occurs  before  this  (in  childhood)  gigantism  is  the  result.  In  this  changes 
in  the  pituitary  will  be  found  similar  to  those  occurring  in  acromegaly 
(p.  1244). 

Cashing  ^  has  described  cases  in  which  with  overgrowth  are  associated 
symptoms  of  posterior  lobe  insufficiency,  ^.  e.,  adiposis,  increased  sugar 
tolerance,  polyuria,  polydipsia,  subnormal  temperature,  dry  skin,  loss  of 
hair,  epileptiform  disturbances,  etc.  He  believes  such  cases  are  due  to 
anterior  lobe  hyperplasia  associated  with  posterior  lobe  hypoplasia. 

Both  sexes  are  about  equally  affected,  and  the  disease  ordinarily  com- 
mences in  adolescence. 

The  earliest  Symptom  is  usually  an  increase  in  the  thickness  of  the 
fingers  and  toes,  so  that  rings,  gloves,  and  shoes  are  too  small  and  can  no 
longer  be  worn.  This  enlargement  is  chiefly  in  thickness,  although  there 
is  also  a  certain  amount  of  increase  in  length.  Both  the  soft  and  hard 
parts  are  affected.  The  nails  are  flattened,  longitudinally  ridged,  and 
more  friable  {spade-like  hand).  The  face  becomes  considerably  enlarged ; 
the  supraorbital  ridges  project,  giving  rise  to  a  rather  simian  aspect;  the 
nose  becomes  broader  and  longer;  the  cheek-bones  project ;  but  the  most 
positive  characteristic  is  the  enormous  enlargement  of  the  lower  jaw,  so 
that  it  becomes  broader  and  prognathous,  and  the  lower  teeth  can  no 
longer  be  brought  in  apposition  with  the  upper.  The  spinal  columyi  is 
ordinarily  kyphotic,  the  change  affecting  the  upper  dorsal  and  cervical 
regions.  Frequently  there  is  also  an  associated  scoliosis.  The  rest  of  the 
skeleton  remains  unaffected  for  a  long  time  ;  finally,  changes  may  be  ob- 
served in  the  clavicles,  sternum,  ribs,  pelvis,  and  particularly  in  the  pa- 
tellae. The  skin  sometimes  shows  slight  pigmentation ;  the  hair  is  rough 
and  may  become  thinner ;  the  muscles  occasionally  exhibit  increased 
electric  excitability,  and  less  frequently  there  is  muscular  atrophy  with 
reactions  of  degeneration.  The  lips,  tongue,  and  tonsils  are  usually  en- 
larged, and  the  larynx  is  increased  in  dimensions,  so  that  the  voice  be- 
comes deep  and  rough ;  this  is  a  very  characteristic  symptom  in  women. 
Ordinarily,  an  area  of  dulness  can  be  detected  in  the  upper  part  of  the 
sternum  that  has  been  ascribed  to  the  persistence  of  the  thymus  gland. 
The  tendon-reflexes  may  either  be  normal,  diminished,  or  abolished.  They 
are  never  exaggerated.  The  urine  is  increased  in  amount,  and  glycosuria 
is  often  present.  The  secretion  of  siveat  is  also  greatly  increased.  The 
subjective  symptoms  consist  of  severe  intermittent  or  continuous  head- 
1  Amer.  Jour.  Med.  ScL,  Mar.,  1913,  p.  313. 


1246  DIi>EAi;t':S  OF  THE  yERVOVS  SYSTEM. 

ache  and  of  a  diimniition  of  the  I'isual  power.  There  may  be  paresis 
of  the  third  nerve,  giving  rise  to  external  strabismus,  and  soiuetiiues  to 
temporal  hcniiano/isiix  as  a  result  of  pressure  upon  the  central  part  of 
the  chiasm  by  an  enlarged  pituitary  body.  Sometimes  late  in  the  dis- 
ease there  are  occasional  momentary  general  tremors.  The  patients  often 
present  polyphagia  and  polydipsia.  Neuro-retiuitis  and  subsequent 
atrophy  of  the  optic  nerve  may  also  occur.  The  mental  condition  is 
affected,  and  there  are  usually  great  a})athy  and  diffidence  (perhaps  ex- 
plicable by  their  changed  appearance),  loss  of  memory,  and  somnolence. 
Symptoms  of  either  myxedema,  exophthalmic  goiter,  syringomyelia,  and 
epilepsy  may  co-exist. 

Diagnosis. — In  the  later  stages  the  appearance  is  characteristic,  and 
acromegaly  can  then  hardly  be  confounded  with  other  diseases.  The  pe- 
culiar enlargement  of  the  extremities,  the  oval,  prognathous,  and  distorted 
face,  the  deep,  rough  voice,  the  more  or  less  pronounced  pigmentation  of 
the  skin,  the  wasting  of  the  muscles,  and  the  profound  cachexia  give  a  per- 
fect clinical  picture.  In  those  cases  in  Avhich  the  cachexia  has  become 
extreme  there  are  from  time  to  time  peculiar  tremors  or  spasms  of  the 
body. 

Differential  Diagnosis. — In  the  earlier  stages  the  disease  is  most  easily 
confounded  with  the  Ju/pertropMc  pulmo7iary  osteo-artliropathy  of  Marie. 
In  this  both  hands  and  feet  are  greatly  enlarged  ;  but  the  fingers  are  club- 
shaped,  the  face  is  not  involved,  and  there  usually  exists  some  chronic  pul- 
monary complication.  In  a  case  that  I  observed  there  were  bronchiectasis 
and  bronchorrhea.  From  osteitis  deformans  it  may  be  distinguished  by  the 
fact  that  in  this  condition  chiefly  the  long  bones  of  the  limbs  and  the  flat 
bones  of  the  skull  are  hypertrophied  and  very  painful.  Elephantiasis 
may  be  distinguished  by  the  fact  that  it  attacks  the  lower  limbs,  does  not 
involve  the  bones,  and  the  skin  presents  a  granular  or  a  nodular  appear- 
ance. From  arthritis  deformans  acromegaly  may  be  distinguished  by  the 
fact  that  the  disease  is  painful,  and  is  associated  with  great  deformity  of 
the  joints,  the  face  ordinarily  escaping.  The  following  table  (after 
Dercum)  will  serve  to  distinguish  two  diseases  that  are  apt  to  be  con- 
founded with  one  another : 

Acromegaly.  Myxedema. 

Occurs  most  commonly  in  early  adult  life.      A  disease  of  mature  life — forty  to  fifty 

years. 
In  males  and  females  equally.  Five  times  as  frequent  in  females  as  in 

males. 
Enlargement  of  the  bones  characteristic.      No  enlargement  of  the  bones. 
Marked  prognathism  of  jaw  and  flatten-      Face  full-moon-shaped. 

ing  of  cheeks. 
Skin   brownish-yellow  ;   hair   coarse  and       Skin  pale,  waxy,  shiny,  and  boggy ;  hair 

unwieldy;  nails  short  and  striated.  falls  out;  nails  not  affected. 

Fingers  symmetric  and  sausage-shaped.         Fingers  clubbed  at  the  end. 
Administration  of  thyroid  extract  is  of       Thyroid  treatment  of  the  greatest  benefit. 

the  smallest  benefit. 

A  skiagraphic  examination  is  of  great  value  in  doubtful  cases,  as  en- 
largement of  the  sella  turcica  will  usually  be  found. 

The  prognosis  is  hopeless  for  cure  and  doubtful  for  duration.  The 
disease  is  progressive,  although  it  remains  stationary  for  a  longer  or 
shorter  period.      Retrogression  never  occurs.      Ordinarily,  the  patient 


ADIPOSIS  DOLOROSA.  1247 

dies  of  some  intercurrent  condition  ;  altliou^^h  deiith  may  be  due  to  the 
cachexia  of  acromegaly  itself.  Life,  however,  may  last  for  twenty  years 
after  the  appearance  of  the  first  symptoms. 

Medical  treatment  of  the  condition  has  proved  unavailing.  Extracts 
of  both  thyroid  and  pituitary  glands  have  been  used  with  not  encourag- 
ing results.  Removal  of  the  pituitary  gland,  if  the  seat  of  tumor,  has 
been  done  with  good  results  in  some  cases.  The  cephalalgia  can  be  more 
or  less  completely  controlled  by  antipyrin  or  caffein.  Phosphorus,  mer- 
cury, the  iodids,  and  arsenic  have  been  useful  in  some  cases. 


ADIPOSIS   DOLOROSA. 

This  disease  was  first  described  by  Dercum,  of  Philadelphia,  in  1888. 
It  may  be  defined  as  a  condition  in  which  masses  of  fat  are  deposited 
irregularly  in  the  subcutaneous  tissue  of  the  body,  with  tenderness  and 
spontaneous  pain  in  these  masses,  and  derangement  of  the  menstrual 
functions.  Several  cases,  including  the  one  first  described  by  Dercum, 
have  been  examined  postmortem,  and  a  variety  of  changes  have  been 
found.  The  fat  is  usually  denser  than  ordinary  fat,  due  to  the  presence 
of  a  considerable  amount  of  fibrous  connective-tissue  trabeculse.  The 
thyroid  glands  are  sometimes  small  and  sclerotic,  and,  in  the  case  re- 
corded by  Burr,  there  was  a  tumor  of  the  pituitary  body.  The  cutaneous 
nerves  show  a  moderate  amount  of  degeneration,  sometimes  associated 
with  interstitial  neuritis.  The  main  nerve-trunks  are  usually  normal. 
Hemolymph-glands  have  been  found  in  the  fatty  tissue. 

The  etiology  of  the  condition  is  unknown.  It  has  been  ascribed  to 
an  early  climacteric,  and  to  the  changes  in  the  thyroid  gland,  but  it  is  not 
understood  how  either  condition  could  give  rise  to  the  clinical  feature  of 
adiposis  dolorosa.     It  occurs  almost  exclusively  in  women. 

Symptomatology. — Some  time  in  adult  life  the  patient  begins  to 
grow  stout.  This  condition  gradually  progresses,  and  the  patient  notices 
that  the  fat  is  more  or  less  irregularly  distributed,  appearing  first  in  one 
and  then  in  another  part  of  the  body,  and  that  in  the  places  in  w^hich  it 
appears  there  are  severe  pains  of  a  burning,  shooting  character.  Finally, 
the  masses  of  fat  become  huge ;  as  a  result  of  their  weight  they  become 
pendulous ;  they  are  elastic,  give  an  indistinct  sense  of  fluctuation,  but 
do  not  pit  on  pressure.  The  skin  remains  soft  and  flexible  as  normal. 
There  are  no  distinct  evidences  of  muscular  degeneration,  but  the  patient 
becomes  weak  and  indisposed  to  physical  exertion.  There  is  no  dis- 
turbance of  the  psychic  functions,  but  the  mental  processes  are  sluggish. 
The  cutaneous  sensibility  may  be  slightly  altered,  areas  of  anesthesia,  or 
particularly  of  hypesthesia,  being  found  in  various  parts  of  the  body. 
The  knee-jerks  are  usually  lost,  but  Romberg's  symptom  is  not  present. 
Death  occurs  as  a  result  of  some  intercurrent  afiection. 

The  differential  diagnosis  is  to  be  made  from  simple  obesity  and 
from  myxedema.  From  simple  obesity  it  differs  by  the  fact  that  the  fat 
is  firmer ;  it  is  irregularly  distributed  ;  nodules  appear  and  disappear  in 
the  skin ;  and  particularly  by  the  sharp  pains  in  the  fatty  masses.  From 
myxedema,  by  the  absence  of  mental  changes,  and  of  tetany,  and  by  the 
presence  of  the  pains  in  the  fatty  masses.  The  distinguishing  test  is  the 
failure  to  respond  to  thyroid  medication.     (See  also  pp.  1186  and  1245.) 


1248  DISEASES  OF  TllK  yERVOUS  SYSTEM. 

The  progrnosis  is  hopeless  for  cure,  but  the  duration  of  the  disease 
is  often  irreatly  prolonged.  Dercum's  original  case  ^Yas  under  observa- 
tion for  eleven  years,  and  then  died  of  fatty  degeneration  of  the  heart. 

Treatment  is  unavailing.  The  administration  of  thyroid  substance 
ajipears  to  be  of  no  benefit.  The  pains  must  be  controlled  \vith  anodynes, 
employing  at  first  the  coal-tar  analgesics,  particularly  phenacetin,  which 
must  be  used  in  small  doses  on  account  of  the  chronic  nature  of  the  case, 
and  if  this  is  insufficient,  morphin  must  be  administered. 


AMAUROTIC    FAMILY   IDIOCY. 

Tay  and  Sachs  have  described,  independently,  a  most  extraordinary 
disease  of  the  central  nervous  system  'which  is  characterized  by  the 
occurrence,  a  few  months  or  a  few  years  after  birth,  of  marked  impair- 
ment of  intelligence,  and  gradually  progressive  loss  of  vision.  The 
pathology  of  the  disease  is  not  known.  Degeneration  of  the  cells,  peri- 
vascular accumulation  of  round  cells,  and  some  degeneration  of  the  fibers 
in  the  central  nervous  system  have  been  found.  The  etiology  of  the  dis- 
ease is  not  understood.  It  is  usually  hereditary  or  familiar,  that  is  to 
say,  several  children  in  one  family  are  sure  to  be  affected.  As  it  occurs 
in  early  life  direct  inheritance  is,  of  course,  impossible,  but  children  of  the 
ancestors  have  sometimes  suffered  from  the  same  condition.  It  is  also 
racial ;  all  the  cases  hitherto  recorded,  with  one  doubtful  exception, 
having  occurred  among  Jews. 

The  symptomatology  is  as  follows :  The  child  at  first  develops 
normally,  appears  healthy  and  intelligent.  Usually  in  the  latter  por- 
tion of  the  first  year  or  in  the  early  part  of  the  second,  its  mother 
observes  that  it  does  not  notice  as  well  as  formerly ;  that  it  appears 
to  be  weaker  and  less  intelligent.  It  gradually  becomes  more  and 
more  idiotic  until  it  is  a  complete  imbecile,  uncleanly  in  its  habits, 
and  at  the  same  time  the  blindness  progressively  increases.  This  blind- 
ness appears  to  be  due  to  a  degeneration  of  the  retina,  the  earliest  sign 
being  a  bluish  discoloration  or  spot  in  the  region  of  the  macula.  The 
reflexes  are  usually  greatly  increased  and  sensation  becomes  generally 
blunted. 

The  diflFerential  diagnosis  is  to  be  made  from  other  forms  of 
idiocy  occurring  early  in  life.  The  race,  the  familiar  type  of  the  dis- 
ease, and  particularly  the  progressive  blindness,  with  the  peculiar  changes 
in  the  eye-ground,  usually  suffice  to  determine  the  character  of  tbe  dis- 
ease. 

The  prognosis  is  hopeless.  The  children  die  in  the  course  of  from 
three  to  five  years. 

Treatment  is  of  no  avail.  Prophylaxis  has  been  attempted,  par- 
ticularly by  keeping  the  mother  in  good  condition  before  and  during 
pregnancy,  and  by  careful  attention  to  the  health  of  the  child  during 
early  infancy.  As  only  a  certain  number  of  children  in  each  family 
are  affected,  it  is  impossible  to  determine  how  effective  these  measures 
are.  They  should  at  least  be  employed  in  all  cases  in  Avhich  one 
member  of  the  family  has  had  the  disease.  Antisyphilitic  remedies 
are  injurious. 


ANGIONEUROTIC  EDEMA.  1249 

VII.  VASOMOTOR  AND  TROPHIC  DISORDERS. 
ANGIONEUROTIC  EDEMA. 

( A  cute  Circumscribed  Edema  of  the  Skin  ;  Intermittent  Angioneurotic  Edenm  ;  Giant  Urticaria. } 

Definition. — A  disease  characterized  by  the  appearance  of  an 
edematous  swelling  of  the  skin  or  mucous  membranes.  In  general  it  is 
not  accompanied  by  constitutional  symptoms. 

The  pathology  of  the  disease  is  obscure.  It  is  supposed  to  be  due 
either  to  venous  stasis  or  to  some  nervous  influence  upon  the  lymph- 
channels,  causing  them  to  exude  liquid.  No  lesions  have  as  yet  been 
described. 

l^tiology. — Neuropathic  heredity  appears  to  have  some  influence 
upon  the  disease,  but  nervous  manifestations  in  the  patient  himself  are 
more  important.  Occasionally  the  condition  follows  infectious  diseases  or 
severe  hemorrhage.  The  most  important  exciting  causes  are  cold  and 
emotional  disturbances.  The  disease  occurs  most  frequently  in  males, 
and  almost  exclusively  in  early  adult  life. 

Symptoms. — The  edema  usually  appears  suddenly,  is  sharply  cir- 
cumscribed, and  the  skin  of  the  affected  area  is  slightly  elevated  and 
reddened,  or  else  somewhat  paler  than  the  surrounding  tissue.  It  does 
not  pit  on  pressure.  Ordinarily,  subjective  symptoms  are  absent;  occa- 
sionally there  are  slight  paresthesice.  The  edema  may  appear  in  any 
part  of  the  body,  but  usually  it  is  most  common  on  the  backs  of  the 
hands  or  legs  and  in  the  face,  especially  the  eyelid.  Occasionally  it 
may  appear  upon  the  mucous  membranes  either  of  the  lips,  tongue,  or 
glottis ;  in  the  latter  situation  it  sometimes  produces  severe  dyspnea,  and 
at  least  in  one  case  it  has  caused  death.  Its  presence  has  also  been 
suspected  in  the  mucous  membrane  of  the  gastro-intestinal  tract.  Ordi- 
narily the  patient  has  no  symptoms  whatever  of  disease ;  occasionally,  how- 
ever, there  are  severe  colicky  pains  and  sometimes  vomiting.  In  one  case 
hematuria  was  observed,  and  in  another  hemorrhage  from  the  swollen 
gums  ;  of  course,  in  the  latter  case  the  diagnosis  was  doubtful.  Certain 
writers  have  noted  eosinophilia  with,  or  without,  leukocytosis.  The 
patient  may  exhibit  a  certain  degree  of  anxiety  during  the  attack.  Ordi- 
narily the  swelling  persists  a  few  days,  and  then  disappears,  but  relapses 
are  exceedingly  common,  and  may  recur  very  frequently  for  many  vears. 

The  differential  diagnosis  has  to  be  made  from  urticaria,  to  which 
it  bears  a  great  similarity.  According  to  Osier,  giant  urticaria  is  the 
same  disease. 

The  prognosis  is  of  course  favorable  for  life;  fcr  cure  it  is  more 
doubtful,  as  the  disease  is  sometimes  exceedingly  obstinate. 

The  treatment  consists  of  rest,  the  use  of  tonics  particularly  directed 
to  the  nervous  system,  and  the  correction  of  any  gastrorintestinal  dis- 
order. Strychnin  has  proved  very  valuable.  xA.tropin  during  the  attack 
is  also  of  service.  If  the  larynx  is  affected,  scarification  of  the  edematous 
areas  and  even  tracheotomy  may  be  required. 


79 


1250  DISEASES   OE  THE  yERVOCS  SYSTEM. 


RAYNAUD'S   DISEASE. 

{Symmeiric  Gangrene.)  . 

Definition. — A  condition  apparently  of  vasomotor  nature,  affecting 
symuK'tric  p:nt.s  of  the  body,  and  cliieHy  the  tips  of  the  extremities. 

Pathology''. — Clinical  and  pathologic  studies  seem  to  show  that  this 
condition,  as  well  as  others  to  be  mentioned  under  diagnosis  and  which 
are  closely  related,  are  dependent  upon  disease  of  the  peripheral  blood- 
vessels, causing  deficiency  of  the  blood-supply.  This  may  be  a  vasomotor 
spasm  or  some  form  of  endarteritis.  The}'  may  also  be  associated  with 
organic  disease  of  the  spinal  cord,  especially  tabes  dorsalis  and  peripheral 
neuritis. • 

The  etiology  of  the  condition  is  obscure  and  complex,  largely,  no 
daubt,  because  a  number  of  different  conditions  have  been  confounded 
under  this  designation.  The  disease  occurs  in  children  and  in  neurotic 
women,  less  often  in  men.  A  neuropathic  heredity  seems  to  predispose 
to  it,  and  occasionally  it  exists  in  connection  with  other  nervous  dis- 
eases, as  epilepsy,  migrain,  hysteria,  and  mental  disorders.  The  occur- 
rence of  paroxysmal  hemoglobinuria  has  led  to  the  suspicion  that  malaria 
is  an  etiologic  fiictor.  I  am  not  aware,  however,  that  plasmodia  have 
been  found  in  any  case,  and  the  asserted  good  results  following  the  ad- 
ministration of  ((uinin  are  insufficient  to  establish  the  contention.  Syph- 
ilis and  various  other  infectious  diseases  have  also  been  mentioned  as 
etiologic  factors.  The  most  itnportant  exciting  cause  is  exposure  to  cold, 
although  attacks  may  also  be  brought  on  by  severe  emotional  disturbances. 
Symptoms. — The  disease  presents  three  grades  of  severity :  first, 
anemia  or  local  syncope ;  second,  cyanosis  or  local  asphyxia ;  and  third, 
gangrene.  Local  syncope  consists  in  a  vasomotor  spasm  in  one  or  more 
extremities,  the  fingers  being  most  frequently  aff'ected,  and  rarely  more 
than  one  at  a  time.  They  become  white,  almost  waxy  in  appearance, 
cold,  and  hard  to  the  touch,  and  they  may  be  either  dry  or  covered  with 
a  cold  perspiration.  The  finger  is  perfectly  numb,  but  severe  neuralgic 
pains  may  be  felt  in  the  arm  ;  if  the  skin  be  pricked  with  a  pin,  no  blood 
flows.  Ordinarily  this  syncope  disappears  gradually,  the  reaction  being 
accompanied  by  tingling  and  formication  in  the  aff'ected  digit,  which  ulti- 
mately returns  to  a  normal  condition.  Local  asphyxia  is  a  further  stage 
of  this  condition :  in  this  the  finger  is  blue  and  swollen,  and  there  is  a 
sense  of  discomfort  that  is  apparently  due  to  the  stretching  produced  by 
the  engorged  veins.  This  cyanotic  condition  may  also  aff'ect  the  ears, 
toes,  and  the  tip  of  the  nose,  and,  like  the  preceding  stage,  it  may  dis- 
appear without  leaving  any  trace  of  its  existence.  Patients  that  have 
reached  this  stage  seem  to  be  more  liable  to  a  recurrence  upon  slight  ex- 
posure than  those  who  only  present  local  syncope.  The  attacks  are  more 
likely  to  recur  constantly  in  the  same  digit,  and  not  to  appear  first  in  one 
and  then  in  another.  During  the  existence  of  this  stage  a  not  infrequent 
associated  symptom  is  hemofilohinnria  :  this  is  especially  apt  to  occur  in 
children,  and  has  led  to  the  suspicion  of  malarial  influence.  In  some 
cases,  when  hemoglobinuria  is  not  found,  the  urine  contains  an  excess 

^  Barker  and  Sladen,  Jour.  Nerv.  and  Ment.  Dis.,  Dec,  1907,  p.  745:  Sachs,  Amo", 
Jour.  Med.  Sci.,  Oct.,  1908,  p.  560. 


RAYNAUD'S   DISEASE.  1251 

of  urates.  If  the  attack  lasts  for  several  days,  tropJac  changen  take 
place  in  the  finger-nail,  giving  rise  to  a  transverse  ridge,  which  per- 
sists until  that  portion  of  the  nail  has  grown  beyond  tlio  end  of  the  fin- 
ger. If  local  cyanosis,  however,  continues  sufficiently  long,  f/arujrenovs 
changes  take  place.  These  appear  first  as  small  black  spots  or  vesicles 
filled  with  serum  upon  the  end  of  the  fingers  or  about  the  root  of  the 
nail ;  these  gradually  slough  oflF,  leaving  a  small  ulcer  that  may  slowly 
cicatrize.  Often  patients  subject  to  recurrences  of  the  disease  show  a 
number  of  cicatrices  on  the  ends  of  the  fingers,  or  if  the  ears  are  affected 
there  may  be  slight  shrivelling  of  their  edges.  The  gangrene,  however, 
may  be  more  severe,  in  which  case  the  distal  phalanges  of  the  affected 
fingers  may  become  black  or  dark  red,  covered  with  blebs,  and  finally 
mummified.  The  line  of  demarkation  then  forms,  and  ultimately  the 
gangrenous  portion  falls  off,  leaving  an  ulcerated  stump  that  slowly 
cicatrizes.  This  form  may  not  be  limited  exclusively  to  the  hands  and 
feet  or  ears,  but  symmetric  patches  sometimes  appear  in  the  skin  of  the 
breast.  During  the  time  that  the  gangrene  is  present  the  patients  suffer 
from  excruciating  pains  in  the  limbs  that  interfere  with  sleep,  often  causing 
transient  melancholia,  and  seeming,  more  than  the  gangrene  itself,  to 
depress  the  general  condition.  Fever  is  rarely  present ;  sugar  is  some- 
times found  in  the  urine,   but  not  constantly. 

Diagnosis  must  be  made  from  erythromelalgia ;  acroparesthesia 
(p.  1253);  acrocyanosis,  in  which  condition  we  have  cyanosis  of  the 
extremities,  often  associated  with  gangrene  and  ulceration,  but  which 
differs  from  Raynaud's  disease  in  not  being  paroxysmal ;  and  intermittent 
claudication,  w^hich  is  characterized  by  muscular  cramps,  numbness,  and 
transient  loss  of  motor  power  dependent  upon  exertion  (p.  1145).  As 
has  been  said,  all  of  these  symptom  groups  are  closely  related,  and  a  sharp 
line  of  demarcation  cannot  always  be  maintained.  The  condition  of  the 
posterior  tibial  and  dorsalis  pedis  arteries  should  always  be  determined, 
an  absent  or  diminished  pulsation  being  frequently  found.  Cases  of  this 
type  are  especially  prevalent  among  the  Russian  Jews,  and  the  feet  are 
mostly  affected.  They  are  characterized  by  more  or  less  constant  pain, 
constant  coldness  of  the  feet  with  local  syncope,  tenderness  of  the  calves, 
diminution  of  sensibility  in  the  feet,  followed  by  local  asphyxia  and 
gangrene.  The  pain  is  usually  relieved  by  allowing  the  feet  to  hang 
down.  Buerger  has  applied  the  name  thrombo-angiitis  obliterans  to 
them.^  Diabetic  gangrene  with  neuritis  may  be  confounded,  but  exami- 
nation of  the  urine  should  make  the  diagnosis  clear. 

Senile  gangrene  differs  in  its  mode  of  onset  and  by  its  occurring  in 
old  age.  Tabes  dorsalis,  in  which  these  symptoms  may  occur,  can  be 
distinguished  by  the  occurrence  of  other  characteristic  symptoms  of  that 
disease.  The  same  may  be  said  of  syringomyelia.  Peripheral  neuritis 
may  be  sometimes  difficult  to  exclude,  especially  the  form  known  as  senile 
neuritis,  due  to  arteriosclerosis.  If  tenderness  over  the  nerve-trunks 
and  muscular  veeakness  and  atrophy  are  present,  neuritis  undoubtedly 
exists. 

Leprosy  may  also  have  to  be  considered.  Scleroderma  (p.  1254)  is 
also  related  to  the  vasomotor  neuroses  above  mentioned,  and  may  be 
mistaken  for  them. 

1  Amer.  Jour.  Med.  Sci,  Jan.,  1910,  p.  105. 


1252  DISEASES  OF  THE  yERVOUS  SYSTEM. 

Tlio  prognosis  is  fiivorable  unless  there  is  some  arterial  disease. 
Ovdiiianly  thvy  ItrcDme  in  time  loss  frequent  and  ultimately  disappear, 
but  in  a  tew  cases  the  tcndi-ncy  to  recurrence  is  obstinate. 

The  treatment  consists  of  improvement  in  the  general  condition 
durinix  the  intervals.  Durinii  the  attack  the  most  eft'ectual  measures  are 
a  mild  massage,  the  use  of  local  lukewarm  baths,  and  electricity  very 
cautiously  applied,  by  the  application  of  the  anode  to  the  spine  and  the 
cathode  placed  in  a  vessel  containing  water  into  which  the  affected  part 
is  put.  Nitroglycerin  is  sometimes  beneficial.  For  the  relief  of  the  local 
syncope  Gushing  has  devised  a  plan  of  treatment  which  has  been  success- 
ful. It  consists  in  applying  an  elastic  bandage  to  the  limb,  tight  enough 
to  stop  the  arterial  circulation  for  several  minutes ;  it  is  then  loosened, 
when  the  circulation  will  usually  return.  In  obstinate  cases  it  may  have 
to  be  repeated.  Pilocarpin  also  has  been  employed  with  good  results. 
If  the  pains  are  very  severe,  they  must  be  combated  by  morphin — although 
gangrene  may  occur  at  the  site  of  the  injection — administered  hypo- 
dermically,  if  necessary.  Sleep  should  be  obtained  by  means  of  narcotics. 
The  gangrenous  parts  should  always  be  carefully  protected  by  a  local 
dressing,  and  surgical  intervention  in  the  form  of  amputation  may  be 
required.     If  so,  it  must  be  done  high  or  a  return  of  symptoms  may  occur. 


ERYTHROMELALGIA  (  Weir  Mifchell). 

{I'aral^/tic  Vam-nioior  Neurosis  of  the  Ertremitien.) 

Definition. — A  disease  characterized  by  paresthesia,  redness  of  the 
skin,  and  by  pain,  usually  in  tlie  toes  and  heels,  associated  with  more  or 
less  severe  general  disturbances. 

The  pathology  is  doubtful — arteriosclerosis  of  the  blood-vessels  in 
the  affected  limb  has  been  found,  but  the  disease  appears  to  be  due  to 
some  disturbance  of  the  vasomotor  centers  or  nerves. 

etiology. — It  may  occur  in  association  with  various  forms  of  spinal 
cord  disease  (see  Raynaud's  disease). 

Symptoms. — The  earliest  symptom,  as  a  rule,  is  the  occurrence  of 
severe  pn/'ns  in  the  feet.  Objectively,  there  are  swelling  and  reddening 
of  the  skin,  and  the  sensitiveness  is  so  severe  that  the  patient  is  unable 
to  walk.  The  attacks  occur  more  frefjuently  during  the  summer  months, 
and  are  always  aggravated  by  exposure  to  heat  or  a  vertical  position  of 
the  limbs,      riceration  may  occur. 

The  diagnosis  is  often  difficult,  the  condition  being  confused  Avith 
inflammation  of  the  foot.  Operations  have  frequently  been  performed 
upon  these  cases.  A  characteristic  feature  of  the  condition  is  that  the 
redness  and  pain  arc  excited,  by  allowing  the  feet  to  hang  down,  and  dis- 
appear when  they  are  elevated  (see  also  Raynaud's  disease).  It  may 
occur  in  the  course  of  hemiplegia  and  in  some  organic  diseases  of  the 
spine,  and  those  should  be  excluded. 

The  prognosis  as  to  relief  is  bad ;  often  the  disease  will  recur  at 
irregular  periods  for  a  number  of  years.  The  attack  can  usually  be  cut 
short  by  plunging  the  limb  into  ice-cold  water. 


ACROPARESTHESIA.  12.53 

Treatment. — This  sliould  always  be  tonic,  and  employed  during  the 
intervals  ;  massage,  hot  and  cold  douches,  and  the  faradic  current  may 
be  used  upon  the  affected  extremities.  The  pain  may  call  for  anodynes. 
Resection  of  the  long  saphenous  and  musculocutaneous  nerves  and 
stretching  of  the  plantar  nerves  have  been  done  with  success.  It  has 
also  caused  gangrene. 


ACROPARESTHESIA. 

{Spastic  Vasomotor  Neurosis  of  the  Extremities.) 

Definition. — A  disease  characterized  by  abnormal  sensations  in  the 
hands,  slight  vasomotor  disturbances,  and  slight  stiffness  of  the  fingers. 

The  pathology  and  etiology  are  not  understood.  Possibly  the 
condition  is  due  to  some  disturbance  of  the  peripheral  nervous  system. 
It  occasionally  occurs  after  injury  or  as  a  result  of  prolonged  exposure 
to  cold,  hence  is  common  among  laundresses.  It  is  more  frequent  among 
women  than  men,  and  usually  develops  in  middle  life. 

The  symptoms  consist  in  the  more  or  less  sudden  development  of 
formication  and  tingling  or  numbness  in  the  fingers  and  finger-tips,  usu- 
ally bilateral,  but  sometimes  occurring  only  on  one  side.  Less  frequently 
the  toes  are  affected.  These  pains  are  more  severe  in  the  night  and  early 
morning,  and  worse  in  summer  or  after  exposure  to  heat.  The  vaso- 
motor disturbances  are  variable.  Sometimes  nothing  can  be  observed, 
and  sometimes  the  extremities  are  bluish  and  cold,  sometimes  pink  and 
warm.  Sensibility  is  rarely  affected.  In  some  cases,  however,  there  is 
considerable  hyperesthesia ;  in  others  moderate  anesthesia.  In  a  few 
cases  there  is  stiffness  of  the  hands.  Slight  trophic  disturbances  have 
been  reported  in  a  few  cases.  The  attacks  may  last  from  a  few  minutes 
to  several  hours,  and  may  recur  frequently  or  only  at  considerable  inter- 
vals. Usually  during  the  attack  the  abnormal  sensations  are  continuous, 
but  occasionally  they  are  intermittent  in  character.  The  conditioa 
known  as  tender  toes,  that  occasionally  occurs  after  an  attack  of  typhoid 
fever,  is  probably  a  form  of  this  disease.  It  is  ascribed  to  the  Brand 
treatment,  but  incorrectly. 

The  diagnosis  is  usually  easy.  Care  should  be  taken,  however,  not 
to  confuse  these  acroparesthesise  with  commencing  locomotor  ataxia, 
tetany,  or  hysteria.  In  Raynaud's  disease  cold  increases  the  intensity 
of  the  symptoms. 

The  prognosis  is,  in  general,  favorable,  the  disease  usually  disap- 
pearing after  some  months  ;  sometimes,  however,  the  condition  is  ob- 
stinate. 

The  treatment  is  rather  unsatisfactory.  Laundresses  should  be 
advised  to  adopt  some  other  vocation.  Local  stimulation  with  the  faradic 
brush  has  sometimes  been  of  value,  and  hydrotherapy  may  also  be  em- 
ployed. At  the  same  time,  the  patient  should  be  given  tonics,  particu- 
larly if  anemia  is  present.  Salicylates  seem  to  be  of  service  in  some 
cases.  Alkaline  washes  are  almost  a  specific  for  the  tender  toes.  Satu- 
rated solutions  of  sodium  bicarbonate  should  be  employed. 


1254  DISEASES  OF  THE  NERVOUS  SYSTEM. 

MERALGIA  PARESTHETICA. 

[Bernhardt' s  Disturbance  of  Sensation.) 

Definition. — A  disease  characterized  by  paresthesia  and  disturb- 
ance of  sensation  on  the  outer  side  of  the  thigh,  in  the  region  supplied 
by  the  external  cutaneous  femoral  nerve. 

Pathology. — Nawretsky  has  examined  one  case,  and  found  chronic 
interstitial  neuritis.  There  is  reason  to  believe  that  this  is  not  always 
present. 

Ktiology. — This  is  very  various  ;  some  of  the  cases  have  been  pre- 
cedotl  by  injury,  excessive  exercise,  or  infectious  disease.  Alcoholism, 
constipation,  and  pregnancy  are  also  common  predisposing  causes  ;  cold 
douches  have  been  blamed  in  several  instances.  Sometimes  the  disease 
is  hereditary.  The  exposed  situation  of  the  nerve  is  supposed  to  render 
it  more  liable  to  this  peculiar  disturbance. 

Symptoms. — These  are  of  two  varieties :  First,  the  j) are sthesioe.  There 
may  be  burning,  tingling,  or  stabbing  pains  that  are  severe  enough  to 
disable  the  patient ;  or  there  may  be  only  a  feeling  of  cold  or  numbness. 
Second,  the  sensory  disturbances.  These  vary  from  slight  hyperesthesia 
to  total  anesthesia.  The  different  senses  are  not  always  equally  involved ; 
pain,  temperature,  and  electro-cutaneous  sensibility  being  usually  more 
profoundly  affected  than  the  others.  Frequently  both  thighs  are  affected. 
There  is  often  a  tender  point  just  inside  the  anterior  superior  spine  of 
the  ilium. 

The  diagnosis  is  easy. 

The  prognosis  is  doubtful.  Some  of  the  cases  recover  rapidly, 
but  the  majority  become  chronic. 

Treatment. — But  little  can  be  done.  Locally,  the  dry  brush  seems 
to  do  good  in  some  cases,  and  the  general  health  should  be  improved  if 
possible.     In  aggravated  cases  a  portion  of  the  nerve  may  be  excised. 


SCLERODERMA  DIFFUSUM. 

Definition. — A  peculiar  hardening  of  the  skin,  with  areas  of  pig- 
mentation and  depigmentation,  associated  in  the  more  advanced  stages 
with  trophic  lesions,  muscular  atrophies,  and  affections  of  the  bones. 

Pathology. — The  affected  skin  is  characterized  by  an  increase  of  the 
connective  tissue  and  of  the  elastic  fibers,  and  by  a  narrowing  of  the  ves- 
sels as  a  result  of  perivascular  infiltration. 

The  etiology  is  not  clear.  Some  of  the  cases  are  associated  "with 
joint-affections  that  resemble  those  of  chronic  rheumatism  ;  others  follow 
exposure  to  a  very  low  temperature.  The  presence  of  trophic  lesions  in 
the  skin  and  the  development  of  myopathies  lead  to  the  supposition  that 
it  is  properly  classed  with   the  trophic   neuroses.     The   disease  usually 


SCLERODERMA   DIFFUSUM.  1255 

occurs  in  middle  life,  although  cases  have  been  observed  among  children. 
Women  are  more  frequently  aifected  than  men. 

Symptoms. — Three  stages  are  recognized  :  First,  a  ratlier  dense 
edema.  Second,  a  true  sclerosis,  in  which  the  skin  appears  thicker,  with 
an  absence  of  the  normal  folds  ;  it  becomes  firm  and  hard,  so  that  it  can- 
not be  pinched  between  the  fingers  and  lifted  from  the  flesh.  Moreover, 
there  are  always  pigmentary  changes,  certain  parts  being  darker  than 
normal,  while  others  become  a  dead  white,  appearing  almost  as  if  com- 
posed of  alabaster.  The  disease,  as  a  rule,  attacks  first  the  upper  por- 
tion of  the  body — i.  e.  the  face,  neck,  hands,  and  ar-ms,  or  the  surface 
of  the  thorax,  and  is  most  pronounced  in  those  regions  where  the  bones 
are  subcutaneous.  The  diminished  elasticity  considerably  interferes  with 
the  movements  of  the  body.  If  the  neck  is  aifected,  it  is  difficult  to  turn 
the  head  ;  if  the  skin  over  the  joints  is  involved,  their  normal  flexion  and 
extension  cannot  be  perfectly  performed.  The  subjective  sensations  are 
those  of  tension,  the  patient  complaining  that  the  skin  has  become  "  too 
small  "  for  him.  If  any  forcible  action  is  attempted,  there  is  severe  pain, 
accompanied  by  slight  tears  in  the  skin.  The  skin  is  paler  and  cooler 
than  normal,  and  the  slightest  exposure  to  cold  causes  great  discomfort 
and  cyanosis.  The  secretion  of  sweat  may  be  normal,  but  is  usually  di- 
minished. Tactile  sensibility  is  unimpaired.  The  third  stage  is  that  of 
atrophy  ;  the  skin  becomes  thin  as  paper  ;  the  other  symptoms,  however, 
remain  as  before,  except  that  the  secretion  of  sweat  is  abolished  and 
ulcerations  appear  that  either  heal  slowly  or  not  at  all.  In  addition,  there 
are  muscular  atrophies  associated  with  contractures.  Often  there  is  con- 
siderable atrophy  of  the  bones,  or  there  may  be  a  development  of  exos- 
toses from  the  periosteum  (sclerodactylia).  Occasionally  the  end-pha- 
langes of  the  fingers  undergo  a  process  of  gangrene  that  is  similar,  in 
some  respects,  to  that  of  Raynaud's  disease.  Chronic  joint-affections 
may  also  be  observed  in  this  stage,  particularly  of  the  fingers  (see  Mor- 
phea). 

The  course  of  the  disease  is  variable.  Usually  it  develops  slowly 
and  lasts  for  many  years. 

The  diagnosis  is  usually  easy,  though  occasionally  it  has  been  con- 
fused with  Addison  s  disease  on  account  of  the  excessive  pigmentation. 
There  is,  of  course,  some  resemblance  to  Raynaud's  disease,  although 
the  condition  of  the  skin  itself  is  very  difierent.  In  the  atrophic  stages 
it  may  be  confounded  with  xeroderma  pigmentosum. 

The  prognosis  is  always  doubtful.  In  the  later  stages  the  patients 
become  emaciated,  and  pass  into  a  cachectic  state,  in  which  death  may 
occur.  Pulmonary  complications  may  develop.  Complete  cure  may, 
however,  occur,  and  particularly  in  cases  that  have  a  rapid  course. 

The  treatment  is  unsatisfactory.  The  unpleasant  tension  of  the 
skin  may  be  somewhat  diminished  by  ointments  and  massage ;  warm 
water  or  steam  baths  may  also  give  considerable  relief.  The  most  im- 
portant thing  is  to  maintain  the  general  condition  of  the  patient  by  tonics 
and  a  change  of  climate.  Sodium  salicylate  has  been  recommended,  but 
is  probably  valueless.  Thiosinamin  hypodcrmically  may  prove  to  be 
of  service. 


1256  DISEASES   OF   THE  yERVOUS  SYSTEM. 

MORPHEA. 

(Scler(i(l(  rina    ( 'ircuinscrijAum. ) 

Tins  disease  consists  of  tlie  development  of  small  areas  of  sclerosis 
that  are  distinctly  related  to  the  distribution  of  tlie  nerves.  These  areas 
are  round  or  oval,  broAvnish  or  violet  in  color,  and  as  they  increase  in 
size  there  develops  in  their  centers  more  or  less  sclerosis.  In  these  scle- 
rotic areas  there  are  often  punctiform  collections  of  piiiment,  the  hairs  fall 
out,  and  superficial  ulcerations  may  be  present  Occasionally  they  may 
go  on  to  atropliy  of  the  skin.     There  are  no  constitutional  symptoms. 

The  diagnosis  is  usually  easy. 

The  prog^nosis  as  regards  life  is  favorable ;  as  regards  cure  it  is 
doubtful. 

The  local  treatment  is  the  same  as  for  the  diffuse  form  of  sclero- 
derma. 


AINHUM. 


This  is  a  disease  characterized  by  an  enlargement  of  the  little  toe 
and  the  formation  of  a  line  of  demarkation  at  its  base. 

The  pathology  is  not  known,  but  it  appears  from  a  Rbntgen-ray 
picture  that  the  bones  are  absorbed.  There  is  some  dispute  as  to  whether 
it  is  one  of  the  manifestations  of  leprosy  or  not.  At  any  rate,  it  does  not 
appear  that  typical  lepra  bacilli  have  been  found. 

Ktiology. — The  disease  may  occur  in  childhood  or  early  adult  life, 
and  is  most  common  in  negroes.  It  occurs  almost  exclusively  in  tropical 
regions — e.  g.  Brazil  and  Syria. 

The  symptoms  of  the  condition  consist  in  the  formation  of  sl  furrow 
at  the  base  of  the  little  toe  of  one  of  the  feet.  This  grows  deeper  and 
deeper  until  spontaneous  amputation  has  occurred.  Rarely  the  other 
toes  on  the  same  foot  become  progressively  involved.  Certain  vasomotor 
disturbances  may  be  observed ;  the  foot  is  usually  swollen,  bluish-red, 
and  cold  ;  sometimes  the  other  foot  may  exhibit  similar  changes  without 
the  formation  of  furroAvs  at  the  base  of  the  toes.  There  is  some  diminu- 
tion of  sensation  to  touch,  temperature,  and  electricity,  and  ordinarily 
the  patient  complains  of  vague  pains  in  the  limbs. 

The  diagnosis  is  to  be  made  from  leprosy,  with  which,  indeed,  it 
may  be  identical,  and  congenital  amputation :  the  latter  only  occasions 
difficulty  when  the  disease  commences  in  early  life. 

The  prognosis  is  favorable  to  life,  but  the  disease  is  usually  slowly 
progressive. 

No  effective  treatment  has  been  discovered,  but  the  parts  should  be 
protected  against  injury,  and  the  patients  may  be  given  tonics  and  ano- 
dynes as  required. 

PROGRESSIVE  HEMIATROPHY  OF  THE  PACE. 

{I'rixjrcKxive  Facial  Atrophy.) 

Definition. — A  rare  disease,  characterized,  as  its  name  would  indi- 
cate, by  a  progressive  atrophy  of  one-half  of  the  face,  stopping  sharply  at 
the  middle  line,  and  in  the  severer  forms  involving  the  skin,  muscles,  and 
bones. 


PROGRESSIVE  HEMIATROPHY  OF  THE  FACE.  1257 

The  pathology  of  the  condition  is  unknown.  Rarely  symptoms 
indicating  inflammation  of  the  cervical  sympathetic,  such  as  dilatation 
of  the  pupil  or  flushing,  have  been  present,  and  symptoms  indicating 
inflammation  of  the  trigeminus  have  been  equally  infrequent.  Mendel, 
however,  has  reported  a  case  in  which  he  found  chronic  interstitial  neuri- 
tis of  the  branches  of  the  trifacial,  and  other  cases  have  been  reported  in 
which  the  Gasserian  ganglion  was  diseased.  Microscopic  examination 
has  shown  a  disappearance  of  the  subcutaneous  fatty  tissue  and  a  general 
atrophy  of  the  elements  of  the  skin  itself,  often  associated  with  the  pres- 
ence of  an  abnormal  quantity  of  pigment.  As  a  rule,  the  vessels  are 
relatively  enlarged. 

The  etiologfy  is  unknown.  The  condition  usually  commences  early 
in  life  and  shows  no  predilection  for  either  sex.  An  hereditary  tendency 
does  not  appear  to  exist,  but  the  disease  occurs  frequently  as  a  complica- 
tion of,  or  rather  in  connection  with,  other  neurotic  conditions.  Of  these 
the  most  frequent  are  neuralgia,  migrain,  epilepsy,  and  mental  disorders ; 
less  frequently,  tic  convulsif  and  chorea,  particularly  if  the  latter  affects 
the  muscles  of  the  jaw  and  tongue.  Occasionally  it  has  been  recorded  as 
occurring  in  patients  suffering  from  locomotor  ataxia  or  multiple  sclerosis. 
It  does  not  appear,  however,  that  progressive  facial  atrophy  has  any  ana- 
tomic connection  with  these  conditions.  In  a  few  cases  the  disease  has 
been  preceded  by  an  injury  to  the  skull  or  face,  and  in  others  it  has  fol- 
lowed an  acute  infectious  disease.  Ordinarily  it  occurs  in  early  life — i.  e. 
between  the  tenth  and  fifteenth  years — and  in  these  cases  it  usually  pro- 
gresses to  the  most  severe  type. 

The  earliest  symptom  is  a  flattening  of  the  skin  on  the  affected  side, 
constituting  the  lightest  form  of  the  disease,  which  may  remain  station- 
ary at  this  point ;  if,  however,  it  progresses,  the  muscles  and  bones  also 
become  involved,  so  that  the  affected  half  of  the  face  is  distinctly  smaller 
than  the  healthy  side.  The  objective  changes  that  take  place  in  the  skin 
are  the  development  of  white  spots  in  which  the  pigment  has  disappeared, 
and  which  have  the  appearance  almost  of  scar-tissue,  or,  what  is  more 
commonly  the  case,  of  an  increase  in  pigme7itation  with  a  formation  of 
yellowish  or  brownish  blotches,  the  skin  being  depressed  in  these  areas, 
which  usually  lie  along  the  course  of  the  nerve-trunks,  especially  the 
infraorbital.  The  hair  becomes  thinner,  dryer,  and  often  falls  out.  The 
secretion  of  the  sebaceous  glands  is  diminished  and  the  skin  dryer.  Rarer 
phenomena  are  the  disturbance  of  blushing,  so  that  the  affected  side  of  the 
face  remains  unchanged  in  color  when,  as  a  result  of  some  emotional  dis- 
turbance, the  other  is  distinctly  reddened.  Disturbances  of  sensation  are 
aot  common.  In  some  cases  electric  and  tactile  sensibility  have  been 
diminished ;  in  others  the  patients  have  complained  of  slight  paresthesias. 
The  special  senses  remain  unaffected,  and  even  when  the  atrophy  extends 
to  the  tongue,  taste  remains  perfect  on  the  affected  side.  In  one  case 
there  were  a  slight  disturbance  of  hearing  and  occasional  tinnitus. 

The  diagnosis  of  the  condition  is  easy  both  when  it  is  suspected  and 
when  it  is  far  advanced.  The  only  condition  with  which  it  could  be  con- 
founded is  congenital  facial  asymmetry.  In  facial  hemiatrophy,  however, 
the  skin  is  shrunken  and  wrinkled,  and  the  hair  is  dryer  and  thinner, 
contrasting  markedly  with  the  healthy  side,  and  there  is  usually  a  history 
of  commencement  some  years  after  birth.     In  congenital  asymmetry  the 


1258  DISEASES  OF  THE  yEEVOUS  SYSTEM. 

difference  between  the  two  sitles  is  slight,  and  the  skin  over  the  smaller 
side  is  normal  in  every  respect.  Commonly  in  this  condition  we  also 
find  differences  in  the  development  of  the  extreuiities.  In  a  case  that  I 
recently  observed  with  marked  facial  asymmetry,  the  left  side  being 
smaller,  the  hand  and  foot  on  the  same  side  were  distinctly  smaller  than 
the  corresponding  members. 

The  prognosis  is  unfavorable  as  regards  cure.  The  disease  itself  is 
not  in  the  least  dangerous,  and  cases  have  been  recorded  that  have  been 
under  observation  for  thirty  years  or  more. 

Treatment  is  unsatisfactory.  The  prolonged  use  of  electricity  has 
been  said  to  arrest  the  process,  and  sometimes  this  arrest  occurs  sponta- 
neously ;  it  is  not  certain  that  the  treatment  is  of  any  use. 

An  allied  condition  is  hemihypertrophy  of  the  face.  This  is  an  ex- 
ceedingly rare  condition,  and  is  apparently  always  congenital.  It  involves 
chiefly  the  soft  parts,  the  ear,  skin,  tongue,  and  tonsils  being  all  enlarged. 
There  is  an  increased  secretion  from  the  sebaceous  glands,  which  may 
appear  as  small  elevations  upon  the  skin.  Usually,  as  in  congenital 
asymmetry,  there  is  enlargement  of  the  extremities  on  the  same  side. 
The  only  case  that  has  come  to  autopsy  presented  no  lesions. 

Treatment  is  of  course  unavailing. 


PART  X. 

DISEASES  OF  THE  MUSCLES. 


MYOSITIS. 


Rheumatic  myositis  and  the  suppurative  form  observed  in  pyemia, 
and  rarely  in  other  acute  infectious  diseases,  have  been  appropriately 
described  in  connection  with  the  diseases  to  which  they  are  secondary 
manifestations.  There  remain  to  be  discussed  two  rare  forms  of  the 
disorder. 

INFECTIOUS    MYOSITIS. 

{Acute  Polymyositis). 

Definition. — A  primary  acute  or  a  subacute  inflammation  of  the 
voluntary  muscles  due  to  an  unknown  microbic  agent. 

Pathology. — The  disease  is  a  true  inflammation  of  all  the  volun- 
tary muscles,  involving  chiefly  the  muscular  fibers,  and  to  some  extent, 
also,  the  interstitial  connective  tissue.  Beginning  with  marked  hyper- 
emia,  there  next  occurs  an  exudation  of  leukocytes.  The  muscles  are 
hard,  fragile,  and  later  undergo  fatty  degeneration.  Serous  infiltration 
occurs  and  there  is  a  slight  hyperplasia  of  the  intermuscular  connective 
tissues.  Hueppe  records  a  case  that  showed  nothing  definite  beyond  a 
hyaline  degeneration  of  the  muscular  fasciculi. 

Etiology. — We  are  no  less  ignorant  of  the  predisposing  influences 
than  of  the  specific  exciting  agency,  though,  perhaps,  young  males  are 
most  often  the  victims  of  this  malady. 

Symptoms. — As  a  rule,  first  the  muscles  of  the  extremities,  and 
later  of  the  trunk  also,  become  swollen,  firmer  than  normally,  and  stifi", 
rendering  locomotion  somewhat  difiicult  and  painful. 

The  involved  parts  may  also  be  tender  to  the  pressing  finger,  and  a 
slight  edema  may  be  noticed  that  is  at  first  more  or  less  localized,  but 
finally  becomes  generalized,  and  extends  even  to  the  face.  An  erythem- 
atous eruption  then  appears,  which  is  irregularly  disseminated  over  the 
skin-surface,  and  may  tend  to  more  or  less  pigmentation.  Moderate 
pyrexia  and  splenic  enlargement  are  among  the  early  ^nd  constant 
symptoms.  In  the  advanced  stage  the  muscles  of  deglutition  and  of 
respiration  become  involved,  rendering  the  act  of  swallowing  difficult, 
and  inducing  marked  dyspnea. 

Among  the  complications  may  be  enumerated  bronchitis  and  broncho- 
pneumonia, the  latter  often  being  a  terminal  condition. 

Diagnosis. — Taken  in  the  aggregate,  the  symptoms  are  of  little 
diagnostic  importance  and  the  previous  history  is  invariably  negative. 

1259 


12G0  Di:SEASES  OF  THE  MUSCLES. 

Triclinia  sis  must  be  discriminatoil,  since  this  disease  produces  an  iden- 
tical clinical  picture.  The  distinction  may  rest  upon  the  examination 
of  an  excised  piece  of  aft'ected  nniscle.  which  will  not  only  discover  the 
trichinic,  if  present  but  also  enable  the  microscopist  to  detect  the  posi- 
tive evidences  of  polymyositis.  Multiple  neuritis  presents  neither  swell- 
ing nor  edema. 

Course  and  Prognosis. — The  course  of  the  disease  may  either  be 
comparatively  rapid  (two  or  three  months),  or  it  may  be  slow  (chronic) 
and  continue  over  two  or  three  years.  It  usually  terminates  in  death, 
which  is  caused,  in  the  immense  majority  of  cases,  by  paralysis  of  respira- 
tion. Occasionally,  since  the  heart-muscle  has  been  sometimes  found  to 
be  implicated,  the  end  may  be  preceded  by  cardiac  failure. 

The  treatment  is  simply  palliative  and  supportive. 

PROGRESSIVE    OSSIFYING   MYOSITIS. 

Definition. — Myositis,  either  general  or  local,  in  which  the  aifected 
muscles  undergo  progressive  ossification. 

Pathology. — Following  the  changes  that  ordinarily  characterize 
myositis  (swelling,  leukocytic  exudation,  etc.),  a  calcification  that  is 
often  complete  takes  place.  The  process  may  extend  to  and  involve 
the  heart. 

The  etiology  is  obscure,  though  males  are  especially  the  subjects 
of  the  complaint,  which  usually  begins  about  the  time  of  puberty. 

Diagnosis. — The  muscles  are  represented  by  plates  of  bony  hard- 
ness, leading  to  more  or  less  complete  ankylosis  of  the  joints  and 
vertebrae. 

The  course  of  myositis  ossificans  is  very  slow,  and  treatment 
has  afforded  only  negative  results. 


MUSCULAR   DYSTROPHIES. 

Definition. — These  are  hereditary  affections  characterized  by  pro- 
gressive muscular  wasting  beginning  in  certain  groups  of  muscles,  which 
is  sometimes  preceded  by  or  associated  with  apparent  hypertrophy  of 
other  muscles,  without  fibrillary  tremors  and  marked  change  in  the  elec- 
trical reactions.     They  are  also  known  as  myopathies. 

Ktiology. — The  only  factor  known  is  the  influence  of  heredity,  the 
disease  running  through  a  number  of  generations.  It  usually  appears 
before  puberty,  but  may  develop  later. 

Morbid  Anatomy. — In  the  early  stages  true  hypertrophy  of  mus- 
cle fibers  may  be  found.  Later  proliferation  of  the  muscle  nuclei  and 
longitudinal  splitting  of  the  fibers,  with  an  increase  of  connective  tissue 
which  takes  the  place  of  the  degenerated  muscle-fibers.  A  marked  de- 
posit of  fat  is  present  in  the  pseudohypertrophic  type.  The  nervous  sys- 
tem is  normal. 

Symptoms. — A  number  of  clinical  types  have  been  described,  de- 
pen<ling  upon  the  muscles  first  affected,  occurrence  or  not  of  apparent 
muscular  hypertrophy,  and  the  age  at  onset.  They  may  all  more  or  less 
overlap.     They  are : 


MUSCULAR  DYSTROI'IirEfi.  1201 

1.  Pseudomuscular  hypertrophy  of  Duchenne. 
(a)  Leyden-Moebius  or  hereditary  type. 

2.  Erb's  juvenile  or  scapulohumeral  type. 

3.  Landouzy-D()j(irine  type,  or  infantile  progressive  muscular  atrophy 
of  Duchenne  or  the  facioscapulohumeral  type. 

PSEUDOHYPERTROPHIC    MUSCULAR    PARALYSIS. 

Symptoms. — This  form  usually  appears  under  the  age  of  ten.  The 
enlargement  as  a  rule  affects  the  muscles  of  the  calves  of  the  legs, 
although  various  muscles  in  other  parts  of  the  body  may  be  involved, 
as  the  infraspinatus  and  masseter,  or  the  muscles  of  the  arms  and 
thighs,  giving  the  patient  the  appearance  of  an  unequally  developed 
athlete.  With  this  may  be  associated  atrophy  of  the  latissimus  dorsi, 
lower  part  of  the  pectorals,  and  muscles  of  the  upper  arm  and  thigh. 
The  electric  reactions  show  no  qualitative  alteration,  but  are  quan- 
titatively diminished  in  proportion  to  the  loss  of  power.  This 
loss  of  power  is  manifested  first  in  the  gait,  which  is  uncertain  and 
waddling ;  next,  by  the  difficulty  the  patient  has  in  arising  from  the 
ground.  He  first  gets  on  his  hands  and  knees,  then  lifts  his  knees 
from  the  floor  and,  placing  his  hands  first  on  his  ankles,  climbs  up  his 
legs  until  he  assumes  a  more  or  less  upright  position  (Fig.  80).      In 


FiQ.  80.— Mode  of  rising  from  the  ground  in  pseudo-hypertrophic  paralysis  (Gowere). 

the  later  stages  of  the  disease  the  volume  of  the  muscles  becomes  less 
than  normal.  At  this  period  contractures  may  occur  leading  to  the  de- 
velopment of  club-foot  or  of  feteral  deviation  of  the  spine.  Lordosis  may 
also  be  produced  by  weakness  of  the  muscles  of  the  back,  and  the  spinal 
column,  being  no  longer  properly  supported,  may  topple  to  one  side  or 
the  other.  Ultimately  the  patient  may  lose  all  power  in  the  affected 
limbs  and  pass  into  a  cachectic  state,  in  which  he  dies.  Few  ever  reach 
adult  life.  Some  of  the  cases,  however,  seem  to  be  milder  in  character, 
and  may  amount  to  nothing  more  than  a  slight  Aveakness,  which  persists 
throughout  life  but  does  not  seriously  inconvenience  the  patient.  Often 
signs  of  intellectual  disturbance  are  present,  the  patient  learning  more 
slowly  and  showing  an  impaired  intellectual  coordination.  At  other  times 
epilepsy  may  be  present.  A  peculiar  variety  is  known  bj  the  French  as 
forme  fruste;  this  is  characterized  by  a  rapid  atrophy  of  the  hypertro- 
phied  muscles,  and  consequently  the  course  of  the  disease  is  more  severe. 

HEREDITARY  MUSCULAR  PARALYSIS  {Leyden-3Ioehius). 

This  commences  in  children,  and  usually  between  eight  and  ten  years 
of  age.     It  affects  the  muscles  very  much  as  they  are  affected  in  the 


1262  DJSEASEi)   OF  THE  MUSCLES. 

pseudohypertrophic  form,  except  that  there  is  no  increase  in  size.     The 
disease  is  markedly  hereditary  in  type. 

SCAPULOIIUMEKAL    OR    JUVENILE    TYPE  (Ufb). 

Symptoms. — This  type  may  appear  as  late  as  twenty  years  of  age. 
The  muscles  first  aftected  are  usually  the  pectorals  and  the  latissimus 
dorsi.  From  these  the  process  rapidly  extends  to  the  muscles  in  the 
neighborhood — i.  e.,  the  serrati  and  the  muscles  of  the  back.  The 
muscles  of  the  upper  arm  and  thigh  are  usually  most  involved.  Those 
that  are  most  likely  to  escape  are  the  sternomastoid,  the  spinati,  deltoid, 
and  those  of  the  forearm  and  leg  below  the  knee.  The  extensors  of  the 
wrist  and  fingers,  and  the  tibialis  anticus  and  peroneal  group,  may,  how- 
ever, eventually  become  affected.  The  muscles  gradually  waste,  and  the 
■wasting  is  accompanied  by  a  corresponding  loss  of  power,  a  diminution 
in  the  reflexes  and  of  the  electric  reactions.  Reactions  of  degeneration 
are  not  present.  Certain  peculiar  appearances  are  produced  by  the 
atrophy  of  certain  of  the  groups  of  muscles.  As  the  shoulder-blades  are 
no  longer  supported,  they  stand  out  from  the  back,  giving  rise  to  the  so- 
called  "winged"'  appearance,  and  as  the  result  of  the  weakness  of  the 
muscles  of  the  back  lordosis  is  exceedingly  common.  Weakness  of  the 
muscles  of  the  back,  and  particularly  of  the  glutei,  causes  the  patient, 
when  he  rises  from  the  stooping  posture,  to  go  through  the  same  actions 
that  are  carried  out  by  children  suffering  from  pseudomuscnlar  hyper- 
trophy— i.  e.,  climbing  up  his  own  legs.  Motion  is  affected  proportion- 
ately with  the  degree  of  atrophy.  The  gait  is  disturbed  and  becomes 
waddling,  due  to  the  alternate  lifting  of  the  sides  of  the  pelvis  in  order 
to  clear  the  foot  of  the  ground.  Sensation  is  never  disturbed.  The 
sphincters  are  not  involved  and  bulbar  symptoms  do  not  appear,  even  late 
in  the  disease. 

FACIOSCAPULOHUMERAL  TYPE  [Dejerine-Landouzy). 

Symptoms. — This  type  usually  develops  about  the  third  or  fourth 
year.  The  disease  usually  begins  in  the  muscles  of  the  face.  Of  these 
the  muscles  about  the  angle  of  the  mouth  first  undergo  degeneration, 
giving  rise  to  a  peculiar  expression,  caused  by  the  lips  protruding  (tapir 
mouth);  the  under  lip  drops  forward  and  downward:  the  upper  lip  is 
wasted  and  expressionless  ;  all  wrinkles  disappear,  and  the  patient  has  a 
peculiar  and  strikingly  stupid  expression.  The  ordinary  movements  of 
the  face  are  considerably  affected.  Whistling  cannot  be  accomplished 
and  speech  is  imperfect.  Otherwise  the  course  of  the  disease  is  that  of 
the  scapulohumeral  type. 

The  diagnosis  is  to  be  made  from  the  spinal  and  neural  formB  of 
muscular  atrophy  and  from  the  congenital  absence  of  certain  groups  of 
muscles.  From  the  two  first-mentioned  forms  it  can  readily  be  distin- 
guished by  the  fact  that  the  hand  becomes  involved,  if  at  all,  in  the  last 
stages  of  the  disease ;  also  by  the  absence  of  the  reactions  of  degenera- 
tion and  of  muscular  twitching.  It  is  also  diagnosed  from  the  neural 
type  by  the  absence  of  disturbances  of  sensation.  From  the  congenital 
absence  of  certain  groups  of  muscles  the  diagnosis  is  sometimes  difficult, 
for,  curiously  enough,  the  groups  of  muscles  affected  are  usually  the  same 


ARTHRITIC  MUSCULAR  ATROPHY.  1263 

as  those  affected  by  tlie  myopathy.  A  distinction  can  he  made  partly  by 
the  history,  partly  by  the  more  efficient  and  perfect  compensatory  hyper- 
trophy of  the  muscles  that  remain. 

The  course  of  the  disease  is  slowly  progressive,  only  occasionally  ex- 
hibiting a  temporary  arrest. 

The  duration  is  variable,  but  patients  may  live  thirty  or  forty  years 
after  the  first  symptoms  appear. 

The  prognosis  is  of  course  hopeless  as  regards  cure  or  improvement. 
As  regards  existence,  however,  it  is  the  most  favorable  of  all  the  forms 
of  progressive  muscular  atrophy — a  fact  that  is  probably  due  to  the  ability 
of  the  patients  to  walk  until  the  very  last  stages  of  the  disease,  so  that 
they  are  able  to  maintain  a  better  physical  condition. 

The  treatment  is  the  same  as  that  for  other  forms,  and  consists  of 
electricity,  massage,  and  especially  of  systematic  gymnastics.  Children 
born  of  dystrophic  parents  should  be  guarded  carefully,  their  nutrition 
being  maintained  at  the  highest  possible  point  and  physical  strain 
avoided.     Mothers  so  affected  should  not  suckle  their  children. 


MYOTONIA  ATROPHICA. 

This  rare  condition  is  characterized  by  weakness  and  atrophy  of  the 
facial  muscles  resembling  that  found  in  the  facioscapulohumeral  type  of 
dystrophy.  The  sternomastoids,  vasti  of  the  thighs  and  dorsal  flexors 
of  the  feet  are  also  usually  affected,  as  may  also  other  muscles.  With 
this  there  is  a  slow  relaxation"  of  certain  muscles  after  contraction,  the 
stronger  the  contraction  the  slower  being  the  relaxation.  In  some  in- 
stances cataract  developing  early  in  life  has  been  a  symptom.  It  may  be 
a  familial  disease. 


ARTHRITIC  MUSCULAR  ATROPHY. 

Pathology. — It  has  frequently  been  observed  that  after  inflamma- 
tion of  a  joint  the  muscles  that  move  it  have  undergone  a  certain  degree 
of  atrophy.  This  usually  occurs  in  the  extensors,  and  is  severe  in  pro- 
portion to  the  duration  of  the  inflammation.  Microscopic  examination 
of  the  muscles  shows  a  rather  uniform  diminution  in  the  breadth  of  the 
fibers,  as  well  as  a  slight  proliferation  of  the  nuclei  and  occasionally  an 
indistinctness  of  the  striation.  The  nerve-trunks  and  cord  have  been  re- 
ported to  be  normal. 

The  etiology  of  the  condition  is  not  clearly  determined.  It  has 
been  supposed  to  be  due  to  disuse,  but  if  such  were  the  case  all  the  mus- 
cles moving  the  joint  would  be  equally  affected.  Moreover,  it  sometimes 
occurs  too  rapidly  to  render  this  explanation  acceptable.  It  has  also 
been  supposed  to  be  due  to  the  extension  of  the  inflammation  either  to 
the  nerves  or  directly  to  the  muscles,  but  the  other  symptoms  of  neuritis 
are  rarely  present.  Finally,  Vulpian  has  suggested  that  it  is  of  reflex 
origin,  and  this  hypothesis  is  most  generally  accepted. 


1264  DISEASES  OF  THE  MUSCLES. 

Symptoms. — The  wasting  usually  occurs  very  rapidly  after  the 
onset  of  the  joint-affection.  The  muscles  show  a  'diminished  contrac- 
tility to  faradism  and  galvanism,  but  the  reactions  of  degeneration  do 
not  occur.  Occasionally  there  is  fibrillary  twitching.  The  mechanic 
irritability  of  the  muscles  is  greatly  increased,  and  the  reflexes  show 
a  corresponding  exaggeration,  ankle-clonus  being  frequently  observed 
when  the  knee-  or  ankle-joints  are  affected. 

The  diagnosis  may  be  readily  made  upon  the  existence  of  the  joint 
affection,  the  local  character  of  the  muscular  atrophy,  and  the  absence  of 
degenerative  reactions  with  increased  mechanical  irritability. 

Prognosis. — Ordinarily,  as  soon  as  the  joint  has  recovered,  improve- 
ment commences  in  the  muscles  and  progresses  rapidly  to  complete  resto- 
ration of  function.  In  some  cases,  however,  atrophy  persists,  and  in  a 
few  instances  secondary  contractures  take  place. 

The  treatment  consists,  first,  in  the  removal  of  the  cause  by  the  cure 
of  the  articular  condition  ;  secondly,  in  gentle  massage  and  electric  stimu- 
lation of  the  muscles.  As  a  rule  this  should  not  be  commenced  until  the 
joint  is  well. 

MUSCULAR    ATROPHIES. 

These  may  also  occur  as  a  result  of  other  conditions,  such  as  direct 
injury,  fracture  of  the  bones,  or  prolonged  Avork  with  a  single  group  of 
muscles,  but  they  scarcely  demand  separate  description.  On  tne  other 
hand,  muscular  hypertrophy  may  occur,  though  rarely. 


THOMSEN'S  DISEASE. 

[Myotonia  Congenita.) 

Definition. — An  hereditary  disease  of  the  muscles  in  which  the 
groujDS  that  have  been  contracted  by  a  voluntary  influence  remain  for 
a  short  time  in  a  state  of  contraction,  and  then  relax  slowly. 

Pathology. — Certain  authors  have  described  alterations  in  the  ter- 
minal nerve-plates  in  the  muscles,  but  it  is  difficult  to  determine  whether 
these  alterations  are  artificial  or  an  actual  part  of  the  disease.  The  pe- 
ripheral nerves  are  normal.  The  muscles  themselves  exhibit  the  follow- 
ing alterations :  The  muscle-fibers  are,  on  the  average,  of  an  increased 
transverse  diameter — i.  e.  the  smallest  are  the  size  of  ordinary  muscle- 
fibers  and  the  largest  about  twice  the  size.  There  is  also  a  distinct  and 
considerable  increase  in  the  number  of  nuclei.  The  protoplasm  is  not 
so  clear  as  in  normal  muscles,  but  shows  a  fine  granular  cloudiness, 
rendering  the  striation  less  distinct.  Occasionally,  the  muscle-fibers  are 
vacuolated.     The  connective  tissue  between  the  muscle-fibers  is  normal. 

Htiology. — Hereditary  influence  is  the  most  important  factor  in  the 
causation  of  the  disease.  Thomsen,  who  was  himself  a  victim,  has  been 
able  to  trace  the  disease  for  five  generations  in  his  own  family.  Occa- 
sionally a  generation  is  skipped.  Other  factors  that  have  been  supposed 
to  act  as  predisposing  or  exciting  causes  are  prolonged  exertion  (1  case 
having  developed  in  a  man  without  myotonic  antecedents  after  two  years 
of  severe  exertion)  and  emotional  disturbance  of  the  mother  during  preg- 


TlfOMSEN'S  J>fSKASK.  1265 

nancy.  Exposure  to  cold,  aiid  fViglit,  iiiid  :i,  neurotic  tornporamcnt  liave 
also  been  accused  of  exerting  a  predisposing  or  exciting  influence.  The 
disease  is  somewhat  more  frequent  in  males  than  in  females,  usually  de- 
velops in  early  life,  is  often  associated  with  manifestations  of  mental  dis- 
turbance, and  occasionally  occurs  in  those  whose  ancestors  have  exhib- 
ited lesions  of  the  nervous  system  other  than  myotonia. 

Sj^mptoms. — The  chief  symptom  of  the  disease  is  the  so-called  myo- 
tonic contraction.  If  the  patient,  after  a  period  of  rest,  attempts  to  set  a 
certain  group  of  muscles  in  action,  the  first  contraction  is  made,  but  is  not 
followed  by  relaxation  for  a  considerable  interval — sometimes  as  much  as 
a  half  minute ;  during  this  period  the  muscles  remain  in  a  state  of  tonic 
contraction.  Thus,  if  the  patient  attempts  to  shake  hands,  he  clasps  the 
other  hand  strongly,  and  the  clasp  persists.  When  he  lets  go,  it  is  seen 
that  a  slight  degree  of  tonic  contraction  still  exists,  for  it  is  impossible 
for  him  to  straighten  out  his  fingers  immediately.  Upon  a  repetition  of 
the  movement  the  tonic  contraction  recurs,  but  not  so  strongly,  and  if  the 
repetition  is  continued,  it  disappears  entirely,  so  that  the  muscular  system 
of  the  patient  behaves  in  all  respects  like  that  of  a  normal  person,  and 
long  walks  or  other  severe  muscular  exertion  may  be  undertaken.  In 
some  cases  practically  the  whole  muscular  system  is  affected,  although, 
excepting  the  muscles  of  mastication,  the  muscles  of  the  face  usually 
escape.  In  others  the  disease  is  limited  perhaps  to  the  upper,  perhaps  to 
the  lower,  extremities.  In  the  former  condition  the  patient  may,  upon  an 
attempt  to  make  a  vigorous  motion  after  resting,  suddenly  become  rigid 
and  fall  to  the  earth  with  considerable  force,  often  injuring  himself  se- 
verely. He  w411  then  lie  upon  the  ground  perfectly  conscious,  but  in- 
capable of  relaxing  his  muscles.  When  the  disease,  as  is  more  frequently 
the  case,  is  limited  to  the  lower  extremities,  the  chief  disturbances  ob- 
served are  in  walking.  The  first  step  is  accomplished,  whereupon  the 
patient  halts,  both  legs  having  become  fixed ;  after  a  time  they  relax  and 
another  step  is  taken.  The  period  of  delay  is  now  much  shorter,  and 
after  a  few  more  steps  disappears  entirely.  The  severity  of  the  contrac- 
tion is  diminished  by  moderate  exercise,  heat,  and  tranquillity  of  the 
spirits,  and  is  increased  by  excitement,  cold,  and  fatigue.  The  muscles 
of  deglutition  and  the  sphincters  and  the  muscles  belonging  to  the  non- 
striated  muscular  system  are  never  involved.  Pain  is  not  present,  except 
perhaps  a  slight  sensation  of  cramp,  nor  are  there  disturbances  of  sensa- 
tion. Mental  disturbances  are  frequent,  and  have  been  ascribed  to  the 
anxiety  occasioned  the  patient  by  the  disease.  They  consist  of  irrita- 
bility, the  avoidance  of  society,  and  sometimes  of  melancholia.  The 
reflexes  show  various  modifications;  the  knee-jerks  may  be  either  nor- 
mal, increased,  diminished,  or  absent.  The  most  important  pathogno- 
monic symptoms  are  the  alterations  in  the  electric  reactions  of  the 
muscles.  The  changes  are  as  folloAvs :  Mechanical  irritability  of  the 
motor  nerves  is  normal  or  diminished ;  but  of  the  muscles  it  is  increased, 
and  so  modified  that  the  contraction  instead  of  being  sudden  is  slow,  with 
a  long  tonic  after-contraction.  The  fiiradic  irritability  of  the  nerves 
is  normal,  and  faradic  excitation  of  the  muscles  produces  a  tonic 
contraction  of  long  duration.  The  galvanic  irritability  is  quantita- 
tively increased  and  qualitatively  altered ;  that  is  to  say,  ACC  is  equal 
to  and  sometimes  even  greater  than  KCC.    All  the  contractions  are  slow, 

80 


12il6  DISEASES   OF  THE  MUSCLES. 

tonic.  an<l  of  louir  duration.  Finally,  the  ajiplication  of  the  constant  sial- 
vanic  stream  gives  rise  to  rhythuiic  contractions  that  pass  along  the  body 
of  the  muscles  in  slowly  moving  waves  at  the  rate  of  about  one  to  three  per 
second.  Occasionally  (jualitative  galvanic  alterations  have  been  observed 
in  the  nerves.  Finally,  the  appearance  of  the  patient  is  of  some  value. 
The  muscles  are  developed  almost  as  much  as  those  of  an  athlete,  with- 
out a  corresponding  increase  of  power. 

The  diagnosis  is  usually  easy,  and  particularly  if  it  be  possible  to 
examine  the  electric  reactions.  The  condition  might  possibly  be  con- 
founded with  pscitdo-hjipertrophic  muscular  pat-aJj/sis,  in  which  the  mus- 
cles are  also  considerably  developed ;  but  instead  of  being  normal  they 
manifest  greatly  diminished  power  and  fail  to  give  a  myotonic  reaction. 
From  tetani/  the  condition  may  be  distinguished  by  the  absence  of  Trous- 
seau's sign,  by  a  briefer  period  of  tonic  contracture,  and  an  absence  of 
severe  pains.  From  spastic  paraplegia  and  Little's  disease  it  may  be 
distinguished  by  the  fact  that  in  these  diseases  the  spastic  conditions  are 
permanent  and  do  not  disappear  after  exercise.  From  occupation-neur- 
oses it  may  be  distinguished  by  the  fact  that  the  cramps  only  appear 
upon  the  performance  of  a  certain  peculiarly  coordinated  movement. 
From  hysteria  it  is  differentiated  by  the  absence  of  stigmata  and  the  care 
an  hysteric  patient  exhibits  to  avoid  injury  to  himself,  and  by  the  pecu- 
liar electric  reaction.     Myotonia  atrophica  resembles  it  (p.  1263). 

The  prognosis  is  hopeless.  The  disease  commences  in  early  life  and 
continues  until  death,  with  more  or  less  frequent  remissions  and  exacer- 
bations. It  is  possible  that  these  remissions  may  be  permanent,  and  one 
case  has  been  reported  of  a  young  woman  whom  marriage  greatly  bene- 
fited. The  disease  is  rarely  dangerous  to  life,  excepting  in  so  far  that 
those  who  suffer  from  it  are  much  more  liable  to  injury. 

Treatment  is  exceedingly  unsatisfactory.  Practically  nothing  can 
be  done,  although  in  a  few  cases  systematic  stimulation  of  the  muscles 
has  produced  some  mitigation.  The  patients  often  learn  methods  by 
which  they  can  at  least  diminish  the  unpleasant  symptoms.  Certain 
movements  seem  to  prevent  or  shorten  the  period  of  tonic  contraction. 
Of  course  exposure  to  cold  or  emotional  disturbance  should  be  avoided  as 
far  as  possible. 


MYATONIA  CONGENITA. 

{Amyotonia  Congenita.) 

This  disease,  first  described  by  Oppenheim  in  1900,  occurs  in  early 
childhood,  and  is  characterized  by  a  more  or  less  general  hypotonia  of 
the  muscles.  There  is  flaccidity  of  the  limbs,  es])ecially  the  lower,  and 
all  of  the  joints  are  abnormally  movable.  Muscular  power  is  much 
diminished.  Tiie  deep  reflexes  are  either  diminished  or  lost.  The 
electrical  reactions  are  either  quantitatively  diminished  or  lost.  The 
mental  faculties  are  not  impaired.  The  fact  that  it  is  congenital  but  not 
an  hereditary  disease  distinguishes  it  from  the  dystrophies.  It  differs  from 
amaurotic  family  idiocy  in  the  absence  of  blindness  and  mental  impair- 
ment.   In  Spiller's'  case  disease  of  the  muscles  was  found,  and  there  was 

^  University  of  Penna.  Med.  Bull.,  .Jan.,  1905. 


MYASTHENIA   GRAVIS.  Vli^l 

also  a  lesion  of  the  thymus  gland.      Oppenhcim   believed  it  to  he  due  to 
an  arrested  development  of  the  muscle. 

The  disease  is  not  necessarily  fatal,  and  measures  to  improve  the 
nutrition  of  the  muscles  (massage,  electricity,  etc.)  may  be  of  service. 


MYASTHENIA  GRAVIS. 

{Asthenic  Bulbar  Paralysis.) 

The  exact  classification  of  this  disease  is  still  a  matter  of  dispute. 
The  only  definite  changes  that  have  been  found  are  the  electrical  reac- 
tions in  the  muscles.  It  is  characterized  by  progressive  weakness  in  the 
muscles,  an  increased  susceptibility  to  fatigue,  and  the  occurrence  of  the 
myasthenic  reaction.  The  etiology  is  unknown.  Possibly  infectious 
processes  may  have  something  to  do  with  it ;  but  it  bears  no  definite 
relation  to  syphilis.  Pathologic  changes  have  not  been  found.  Pem- 
berton  has  suggested  that  it  is  a  derangement  of  metabolism  evidenced 
by  an  increased  calcium  and  reduced  creatinin  output.  The  mus- 
cles of  deglutition,  mastication,  and  speech,  and  the  group  of  muscles 
controlling  the  eyes  are  particularly  affected ;  sometimes  one  group, 
sometimes  another,  being  first  involved.  The  muscles  of  the  body  also 
become  weaker.  There  may  be  dyspnea,  and  even  difficulty  in  walking. 
The  most  peculiar  feature  is  the  rapidly  developing  fatigue  in  the  muscles 
when  they  have  been  used.  Thus,  if  the  patient  attempts  to  lift  the  arm  a 
number  of  times,  each  successive  motion  will  be  weaker  than  the  previous, 
until  finally  complete  paralysis  ensues.  If  the  eyes  have  been  held  open 
for  any  length  of  time  the  upper  lid  will  droop  until  thei'e  is  a  transient, 
but  complete,  ptosis.  The  muscles  also  exhibit  the  so-called  myasthenic 
reaction.  Upon  repeated  application  of  the  faradic  current  the  muscles 
contract  less  and  less  vigorously,  until  finally  the  capacity  for  contraction 
appears  to  be  exhausted,  to  return  after  a  period  of  rest. 

The  course  of  the  disease  is  variable.  There  are  remissions  more  or 
less  complete  and  prolonged,  but  ultimately  the  patient  dies  of  pro- 
gressive exhaustion  or  of  increasing  dyspnea.  Occasionally  patients 
have  strangled  while  attempting  to  swallow.  It  has  been  noticed  in 
women  that  the  symptoms  are  always  increased  during  menstruation. 

The  diagnosis  is  to  be  made  from  bulbar  paralysis.  The  symptoms 
resemble  each  other  very  closely.  In  bulbar  paralysis  there  is  usually 
complete  reaction  of  degeneration  in  the  affected  muscles.  The  myas- 
thenic reaction  is  absent,  and  in  the  unaffected  muscles  the  susceptibility 
to  fatigue  is  not  particularly  increased.  If  the  patient  has  been  observed 
for  any  length  of  time,  the  remissions  in  the  course  are  in  favor  of  myas- 
thenia. In  polioencephalitis  superior  or  acute  lesion  of  the  oculomotor 
nuclei,  the  sudden  onset  and  permanent  weakness  also  serve  to  make 
the  distinction. 

Treatment  appears  to  be  entirely  without  avail.  Strychnin  hypo- 
dermically  appears  to  be  useless ;  electricity  is  harmful.  Full  doses  of 
calcium  salts  may  be  tried.  The  patient  should  be  put  absolutely  at  rest, 
and  all  sources  of  worry  should  be  avoided.  If  there  is  difficulty  in 
swallowing,  the  stomach-tube  may  be  employed  with  advantage. 


PART  XI. 

THE  INTOXICATIONS;   OBESITY;    HEAT- 
STROKE. 


THE  INTOXICATIONS. 

ALCOHOLISM. 
{Alcoholic  Inebriety.) 

Definition. — An  acute  or  chronic  intoxication  due  to  the  abuse  of 
alcohol.  It  is  a  general  degenerative  condition,  particularly  of  the 
brain  and  nervous  system,  characterized  by  a  moderate  (often  progress- 
ively increasing)  or  excessive,  continuous  or  periodic,  craving  for  alcohol, 
leading  to  drunkenness.  Alcoholism  is  often  simply  a  variety  of  in- 
ebriety or  narcomania,  a  congenital  or  acquired  brain-  and  nervous  dis- 
ease, characterized  by  a  resistless,  permanent  desire  for  alcohol  {alco- 
Jiolic  inebriety).  3Ia7iia-a-potu,  or  "crazy  drunkenness,"  is  an  acute 
maniacal  condition  occurring  in  an  alcoholic  drinker  of  a  neurotic  con- 
stitution. Delirium  tremens  is  an  hallucinatory  manifestation  that 
occurs  in  habitual  drinkers  of  alcohol,  either  as  the  direct  consequence 
of  the  long-continued  action  of  alcohol  on  the  brain,  or  because  of  its 
sudden  withdra'sval  in  an  inebriate.  Dipsomania  is  an  alcoholic  insanity 
in  which  an  intense  maniacal  "drink-impulse"  occurs  in  a  periodic 
drinker  (usually  of  spirits). 

Pathology. — In  cases  of  death  from  acute  alcoholism  the  brain  and 
kidneys  are  found  to  be  greatly  engorged  with  blood.  The  gastro- 
duodenal  mucous  membrane  is  also  markedly  congested,  injected,  and 
covered  with  a  thick,  sticky,  blood-tinged  mucus. 

Chronic  Alcoholism. — Since  alcohol  is  physiologically  a  poison,  and 
not  a  food,  and  essentially  a  drug,  and  not  a  drink,  the  effects  of  its 
habitual  ingestion  are  directly  to  produce  degeneration  of  nearly  all  of 
the  bodily  tissues,  and  indirectly  to  increase  the  liability  to  many  dis- 
eases by  lessening  the  systemic  powers  of  resistance,  thus  favoring 
fatality  from  such  disease.  The  degree  of  pathologic  change  depends 
upon  the  innate  vigor  of  the  tissues,  the  age  at  which  indulgence  in 
alcohol  is  commenced,  and  upon  the  kind,  degree  of  concentration,  and 
the  quantity  of  alcohol  habitually  taken.  Ethylic  alcohol  is  less  dele- 
terious than  the  "  fusel  oil  "  that  is  sometimes  used  as  an  adulterant  in 
spirits. 

The  chief  effects  of  chronic  alcohol-poisoning  are  seen  in  the  ner- 
vous and  digestive  systems,  and  in  the  kidneys.  Fatty  changes  are  prom- 
1268 


ALCOHOLISM.  1269. 

inent  in  tlic  malt-liquor  intemperates,  while  a  connective-tissue  over- 
growth predominates  in  spirit-drinkers.  The  mucosa  of  tlie  stoiiiacii 
presents  the  a})})earance  of  chronic  gastric  catarrh.  Dihitation  of  the 
stomach  is  common  in  free  drinkers  of  beer,  iile,  ;ind  j)Oftei-.  The  liver 
shows  the  changes  of  chronic  congestion,  of  futty  infiltration  or  degen- 
eration, or  of  cirrhosis  and  contraction.  The  renal  changes  are  analo- 
gous to  those  of  the  liver,  the  chronic  o<mgested  ("  pig-backed  ")  and 
fatty  kidneys  occurring  mostly  in  cases  due  to  malt  lifjuors,  wjiile 
the  sclerosed  and  fibrous  kidneys  are  seen  in  spirit  liabitue.s.  The 
heart  is  often  loaded  with  fat,  and  tlie  musculai-  structure  may  reveal 
fatty  degeneration,  being  pale,  flabby,  friable,  and  dilated.  The  blood- 
vessels are  atheromatous,  thickened,  tortuous,  and  sometimes  varicose, 
and  sudden  death  has  been  caused  in  inebriates  by  the  rupture  of  small 
aneurysms  of  the  middle  cerebral  artery.  In  the  brain  the  various  stages 
of  sclerosis,  with  shrunken,  narrow,  and  flattened  convolutions  often 
appear.  Chronic  pachymeningitis,  with  slight  hemorrhages,  is  not  in- 
frequent. The  pia-arachnoid  membrane  also  may  be  oj)a((ue  and  thick- 
ened, and  serous  effusions  into  the  subarachnoid  space  and  into  the  ven- 
tricles have  been  noted.  The  nerve-cells,  nerve-centers,  and  nerve-fibres 
show  degeneration,  hardening,  and  atrophy.  Alcoholic  neuritis  is  espe- 
cially prominent  in  many  cases. 

il^tiology. — An  impaired  personal  health  and  vigor,  as  well  as  the 
"personal  equation"  and  a  deficiency  of  will-power,  self-control,  con- 
science, and  conviction,  are  predisposing  causes.  Drunken  or  inebriate 
parents  frequently  transmit  to  their  offspring  a  morbid  desire  for  alcohol, 
and  an  environment  of  depraved  morality  and  of  depressing  and  corrupt- 
ing social  influences  are  usually  potent  disposing  influences,  particularly 
in  those  who  ai-e  ill  prepared,  by  heredity  or  training,  to  resist  the  tempta- 
tion and  insidious  activities  of  such  evil  surroundings.  Some  assert  that 
poverty  predisposes  to  intemperance :  it  is  more  likely  to  be  the  cause 
rather  than  the  consequence  of  poverty.  The  exciting  cause  is  the 
persistent  misuse  of  alcohol  as  a  beverage  in  the  form  of  distilled 
liquors  or  spirits,  wines,  and  fermented  or  malt  liquors.  "  In  this 
country  there  is  a  little  appreciated  but  not  uncommon  cause  of  alco- 
holism in  the  use  of  patent  medicines  and  nostrums  as  tonics  and  cure- 
alls  "  (Lambert). 

Symptoms. — The  symptoms  of  acute  alcoholism  range  from  mild 
intoxication  to  an  acute  delirium  or  a  profound  stupor  and  coma.  It 
begins  with  the  stage  of  vascular  relaxation  and  of  feelings  of 
warmth  and  exhilaration,  due  to  the  depressing  and  paralyzing  effects 
of  the  alcohol  upon  the  vasomotor  tone.  The  second  stage  is  one  of 
partial  functional  paralysis  of  the  nerve-centers,  marked  disturbance  of 
the  faculties,  muscular  incoordination,  and  delirious  speech.  In  the 
third  stage,  of  "  dead- drunkenness,"  there  are  acute  coma,  stertorous 
breathing,  a  bloated  and  congested  face,  a  slow  and  full,  but  weak, 
pulse,  a  cold  and  clammy  skin,  a  heavy  alcoholic  odor  of  the  breath, 
and,  sometimes,  incontinence  of  urine  and  feces.  It  frequently  hap- 
pens that  unconsciousness  is  not  so  profound  but  that  the  patient  may 
be  aroused,  though  replies  to  questioning  are  stupid  and  incoherent. 
Ordinary  acute  alcoholism  seldom  passes  beyond  a  stage  of  exhilaration, 
ending  in  mild  narcosis.     Sometimes,  however,  the  irritant  action  of  the 


1270  THE  IXTOXTCATIONS;    OBESITY;   HEAT-STROKE. 

alcohol  predominates  over  its  narcotic  action,  giving  rise  to  acute  alco- 
holic gastritis  or  nephritis. 

Acute  mental  disorders  [''acute  alcoholic  insanity")  are  not  infre- 
quently met  with.  Mania-a-potu  may  come  on  quite  suddenly  in  de- 
bauchees, or  in  those  who  have  drunk  hard  during  a  short  time,  as  in  a 
night's  carousal.  The  mental  excitability  increases  until  a  violent  mani- 
acal storm  not  unlike  the  mania  of  epilepsy  possesses  the  drinker.  While 
in  this  state  of  infuriated  delirium  homicide  may  be  committed.  Tremors 
are  absent.  Acute  alcoholic  melancholia  develops  suddenly  in  some 
cases,  with  a  suicidal  tendency.  Delirium  tremens  is  more  common 
in  alcoholic  inebriates,  and  is  also  seen  at  times  in  those  who  drink 
greatly  to  excess,  but  are  not  habituds.  Convulsive  seizures  have 
been  noted  in  some  cases,  interrupting  the  coma  ("  acute  alcoholic 
epilepsy");  these  may  or  may  not  be  accompanied  by  mania.  An 
acute  alcoholic  paralysis  from  multiple  neuritis  (occasionally  with  ataxic 
symptoms)  may  attack  hard  drinkers,  and  may  last  for  several  weeks  or 
months. 

Chronic  alcoholism  (alcoholic  inebriety)  I  consider  a  true  disease. 
While  acute  alcoholism  may  also  be  an  occasional  manifestation  of  the 
chronic  affection,  it  is  often  a  vice  which,  if  indulged  in  to  an  excessive 
degree,  or  if  too  frequently  repeated,  becomes  a  disease,  though  it  is 
difficult  to  determine  at  what  point  the  transition  occurs.  Again,  it  is 
not  always  easy  to  learn  whether  the  early  acute  alcoholic  excesses  are 
really  vices  or  morbid,  diseased  cravings  for  alcohol  in  hereditary  narco- 
maniacs. The  disease  of  inebriety  (alcoholic)  is  a  condition  in  which,  as 
some  one  has  said,  it  is  not  whether  one  "cannot"  or  ''will  not;"  but 
in  which  one  "  cannot  will  "  to  resist  the  desire  for  alcohol. 

The  steady,  so-called  "moderate  drinker"  who  saturates  his  blood 
and  tissues  every  day  for  years  is  much  more  apt  to  suffer  from  chronic 
alcoholic  poisoning  with  its  attendant  degenerations  than  one  who  goes 
on  a  "  spree  "  once  a  month  for  a  day  or  two,  and  during  the  intervals 
is  free  from  the  toxic  influence  of  alcohol.  The  symptonis  develop  very 
gradually,  and  are  usually  marked  for  some  time  by  the  deceptive  sensa- 
tion of  stimulation,  warmth,  and  well-being,  due  to  the  vasomotor  pare- 
sis and  the  anesthetic  effects  of  the  alcohol.  Impairment  of  digestion 
is  early  noted.  There  are  a  coated  tongue,  foul  breath,  vomiting  before 
breakfast,  and  gastric  distress  after  eating.  Constipation  alternating 
with  diarrhea  is  common.  Muscular  tremors  gradually  develop  and  often 
progress  into  an  ataxic  gait.  Insomnia,  mental  impairment,  and  blunt- 
ing of  the  moral  sense  come  on.  "Alcohol  dims  the  perception,  con- 
fuses the  judgment,  paralyzes  the  will,  and  deadens  the  conscience  " 
(Kerr).  In  his  distress  and  degradation  the  inebriate  seeks  to  relieve 
himself  by  taking  more  of  the  alcohol,  only  to  find,  on  awakening  from 
his  narcosis,  that  body,  intellect,  will,  and  emotion  are  still  more  de- 
praved. In  fact,  the  brain-  and  nerve-disorders  are  more  grave,  perma- 
nent, and  extensive  in  the  majority  of  instances  than  those  of  the  viscera. 
This  is  owing  to  the  delicacy  of  the  nervous  mechanism  and  to  the  ready 
degeneration  under  the  influence  of  the  altered  Ijlood,  and  the  conse- 
quent impaired  cellular  nutrition,  directly  due  to  the  toxic  action  and 
deficient  normal  pabulum,  and  indirectly  to  the  lessened  elimination  of 
waste-products. 


ALCOHOLISM.  1271 

Dementia  is  often  the  terminal  state  of  the  chronic  inebriate.  Delusions 
of  persecution  are  frequent,  especially  those  of  marital  infidelity,  in  alco- 
holic insanity.  The  depurativc  organs  manifest  various  symptoms  due  to  the 
long-continued  irritating  action  of  alcohol.  The  liver  is  either  fatty  and  en- 
larged, or  cirrhotic  and  contracted,  and  jaundice,  dropsy,  and  hemorrhoids, 
along  with  physical  hepatic  signs,  are  correspondingly  oljserved.  The 
watery  eye,  the  injected  conjunctivae,  the  swollen  eyelids,  the  bloated  and 
flabby  or  pallid  and  shrunken  face,  the  dilated  capillaries  of  the  nose 
(acne  rosacea)  and  cheeks,  may  now  be  seen.  The  urinary  examination 
will  show  in  many  cases  the  deranged  function  of  the  kidneys  and  point 
to  the  nature  of  structural  impairment.  On  account  of  the  weak  and 
flabby  heart  there  are  palpitations,  dyspnea,  and  precordial  distress,  and 
occasionally  sharp  pains.  Chronic  valvular  endocarditis  may  be  discov- 
ered. The  pulse  is  soft  and  weak  in  beginning  fatty  degeneration  of 
the  vessels.  Thickened  arteries  are  common  in  old  cases,  and  the  pul- 
sations are  often  increased  in  tension  and  usually  rapid.  Muscular 
capacity  and  endurance  are  greatly  diminished. 

Delirium  tremens  occurs  in  the  majority  of  cases  in  inebriates  or 
chronic  drinkers  during  or  after  a  debauch,  and  particularly  from  the 
use  of  spirituous  liquors.  It  may  occur,  also,  during  abstinence  from 
alcohol,  on  account  of  some  mental  perturbation,  or  fright,  acci- 
dental shock,  or  acute  inflammatory  illness.  It  may  either  come  on 
suddenly,  or  be  preceded  (often  for  a  day)  by  some  slight  premonitory 
symptom,  as  anorexia,  restlessness,  or  depression  of  spirits.  The 
patient  usually  awakens  at  night  with  a  tremor,  becomes  sleepless, 
wants  to  get  out  of  bed  to  do  some  imaginary  thing,  talks  constantly 
and  incoherently,  looks  about  uneasily  and  fearfully,  and  breaks  gradu- 
ally into  a  cool  perspiration.  Hallucinations  of  sight,  hearing,  and 
smell  develop.  The  patient  sees  terrifying  and  loathsome  reptiles,  and 
tries  to  escape  from  them,  or  to  clutch  them  in  order  to  cast  them  away. 
The  "  horrors  "  may  become  so  great  that  suicide  may  be  attempted,  as 
by  falling  out  of  the  window.  Auditory  hallucinations  may  take  the 
form  of  enemies,  policemen,  or  the  roar  of  wild  animals.  The  mus- 
cular tremors  increase,  the  pulse  becomes  frequent  and  weak,  and  the 
tongue  coated  with  a  thick  white  fur.  There  is  moderate  fever,  which, 
if  the  delirium  is  prolonged,  takes  on  a  typhoid  character,  the  tongue 
becoming  tremulous,  dry,  brown,  and  fissured,  with  the  onset  of  sub- 
sultus  tendinum,  carphologia,  coma-vigil,  and  muttering  delirium.  In 
favorable  cases  improvement  begins  on  the  third  or  fourth  day,  from 
which  time  the  symptoms  gradually  subside.  Convalescence  may  be 
said  to  be  established  when  restful  sleep  can  be  obtained ;  this  is  fol- 
lowed by  a  desire  for  food.  In  unfavorable  cases  the  patient  may  pass 
from  a  typhoid  state  into  exhaustion  and  death,  or  may  die  suddenly 
either  during  a  paroxysm  of  cardiac  failure  or  from  some  complication, 
as  cerebral  hemorrhage  or  pneumonia. 

Korsakow's  psychosis,  or  the  mental  symptoms  that  may  occur  in 
connection  with  alcoholic  neuritis,  is  described  on  page  1085. 

Diagnosis. — The  condition  of  persons  found  dead-drunk  is  seldom 
mistaken  for  any  other.  The  reverse  more  often  happens,  and  in  this 
way  apojjlectic  and  uremic  comas  may  be  diagnosed  as  alcoholic  coma. 
Cases  picked  up  in  the  street  in  a  state   of  apparent   unconsciousness 


1272         Tin:  lyroxiCATioNS;  obesity ,-  heat-stroke. 

should  be  carefully  tested  in  this  regard.  Instances  in  which,  as  the 
postmortem  examination  subsetjuently  has  shown,  cerebral  hemorrhage 
has  followed  a  drinking-bout,  render  the  diagnosis  more  difficult ;  in 
such  the  patient  should  be  given  the  beuetit  of  the  doubt  and  handled 
as  though  the  case  were  one  of  apoplexy.  An  important  early  step  is 
to  ascertain  whether  the  coma  is  complete,  or  whether  the  patient  can 
be  roused  by  shouting  in  the  ear,  by  applying  ammonia  to  the  nostrils, 
or,  better  still,  by  pressing,  with  gradually  increasing  firmness,  over 
a  sensitive  spot,  as  the  supraorbital  notch  ;  if  the  unconsciousness 
is  alcoholic,  he  will  come  to  his  senses,  if  only  for  a  moment.  Ab- 
stemious apoplectics  have  been  known  to  stagger  and  talk  thickly, 
like  drunken  men  (Kerr),  and  have  been  arrested  and  taken  to  a  police- 
station  instead  of  to  a  hospital.  Congestion  and  lobar  pneumonia 
affecting  the  bases  of  the  lungs  should  be  looked  for,  as  they  are  com- 
mon causes  of  death  in  drunkards.  A  table  giving  the  principal  points 
in  the  differential  diagnosis  will  be  found  under  Uremia  {vide  p.  1011). 

The  diagnosis  of  chronic  alcoholism  is  made  from  the  histor}^,  and 
from  the  muscular  tremors  (worse  in  the  morning),  vomiting,  mental 
restlessness,  "mendacity,"  and  involuntary  "lying"  (Kerr).  The  con- 
dition may  resemble  general  paralysis,  and  if  the  habits  of  the  patient  are 
kept  secret  it  may  be  very  difficult  to  differentiate  these  affections.  A 
prominence  of  disorder  of  the  digestive  tract  usually  points  to  alcohol- 
ism. Nervous  excitement,  tremors,  fear,  wakefulness,  and  the  distinctive 
physiognomy  are  more  evident  in  chronic  alcoholism,  even  when  general 
paralysis  has  been  caused  by  alcohol,  which  is  apparently  the  case. 
Paralysis  agitans,  locomotor  ataxia,  epilepsy,  and  nervous  dyspepsia  may 
also  be  mistaken  for  chronic  alcoholism  by  the  unwary. 

Delirium  tremens  is  distinguished  by  the  history,  by  the  restlessness, 
delirium,  hallucinations,  tremors,  and  terrors.  Mania-a-potii  differs  from 
the  preceding  mainly  in  its  usual  association  with  acute  alcoholism  in 
neurotics,  in  the  muscular  contractions,  the  furious  mania,  and  convul- 
sive movements.  The  delirium  of  apical  pneumonia  that  obtains  in 
some  cases  (as  well  as  in  meningitis)  must  be  thought  of  in  the  diag- 
nosis of  delirium  tremens.  The  diagnosis  of  alcoholic  neuritis  from 
other  conditions  simulating  it  will  be  found  elsewhere  {vide  p.  1085). 

Prognosis. — In  acute  alcoholism  the  prognosis  is  favorable  in  pri- 
vate, manageable  cases.  Many  of  the  cases  brought  into  hospitals  are 
affected  also  with  pneumonia,  and  usually  die.  The  tissue-changes  in 
chronic  alcoholism  are  so  profound,  and  they  affect  such  delicate  and 
vital  tissues,  that  when  the  alcohol-habit  thus  becomes  fixed  permanent 
recovery  never  takes  place.  The  treatment  appropriate  for  the  inebriate 
and  forced  abstinence  from  alcohol  relieve  many  of  the  symptoms  and 
some  of  the  debility,  but  relapses  are  all  too  common  and  are  almost 
certain  to  occur.  Insanity  and  paresis  are  not  infrequent  terminations 
of  chronic  alcoholism.  Many  complications  are  apt  to  supervene,  as 
Bright's  disease,  epilepsy,  melancholia,  fatty  heart,  pneumonia,  and 
thrombosis.  Alcoholic  neuritis  often  clears  up  upon  withholding  alco- 
hol and  stimulating  the  peripheral  nerves  both  by  appropriate  drugs 
and  external  remedial  measures.  Recovery  from  delirium  tremens  is 
dubious  in  cases  of  severe  injury,  inflammatory  troubles,  or  infections. 

Treatment. — In  cases  of  acute  drunkenness,  which  are  only  too 


ALCOHOLISM.  V27S 

commonly  met  with,  nothing  special  is  required  except  to  prevent  the 
ingestion  of  any  more  alcohol  and  to  allow  the  patient  to  sleep  until  the 
elimination  of  the  poison  is  more  or  less  complete.  The  effects  of  the 
intoxication,  in  the  general  depression,  headache,  anxious  and  irritable 
stomach,  and  various  functional  visceral  and  nervous  disorders,  may  need 
careful  corrective  and  sustaining  treatment  for  a  week  or  more.  The 
diet  should  be  light  and  nutritious.  Aperient  waters,  hot  baths,  with 
li(luor  ammonii  acetatis  frequently  repeated,  and  a  combination  of  dilute 
mineral  acid  and  bitter  tonics  (nux  vomica,  gentian),  are  also  indicated. 
In  profound  cases  of  alcoholic  coma,  convulsions,  or  mania-a-potu 
no  alcohol  should  be  given.  Trite  though  this  injunction  may  seem,  it 
is  important  to  emphasize  this  statement,  so  that  the  physician  may  be 
sure  to  counteract  a  popular  impression  that  the  giving  of  more  alcohol 
will  cause  a  mania  to  subside  'permanently,  and  to  guard  against  the 
smuggling  of  liquor  to  the  patient  by  his  misguided  friends.  It  is  often 
necessary  to  empty  the  stomach  at  once  when  collapse  is  imminent  by 
the  use  of  the  stomach-tube  or  -pump,  washing  out  the  organ  with  hot 
water,  to  which  ginger  or  cinnamon  has  been  added.  To  this  end 
emetics  may  be  used — viz.  ipecac  or  apomorphin,  hypodermically  (gr.  \ 
to  -^ — 0.008-0.0108).  The  external  application  of  warmth,  friction, 
artificial  respiration,  faradism  to  the  phrenic  nerve,  ammonia-  or  amyl- 
nitrite-inhalations,  and  hypodermics  of  atropin,  strychnin,  and  digitalis, 
may  all  be  tried.  Hot  rectal  enemata  or  a  calomel  purge  if  the  stomach 
Avill  tolerate  the  drug  should  be  used  early.  The  maniacal  attacks  may 
be  treated  by  hypodermics  of  morphin  and  hyoscin,  and  by  such  seda- 
tives as  chloral,  bromids  in  large  (,5j — 4.0)  doses,  and  rarely  such  hyp- 
notics as  paraldehyde,  trional,  chloralamid,  and  the  like.  Indeed,  it  is 
very  important  to  secure  sleep  as  soon  as  possible.  An  excellent  for- 
mula in  cases  of  medium  severity  is : 

:^.  Sodii  bromid.,  gj    (32.0); 

Tr.  capsici,  3j    (4.0); 

Tr.  digitalis,  3ss  (2.0) ; 

Elix.  simplicis,  q.  s.  ad  |ij  (64.0). — M. 

Sig.  3J  (4.0)  every  two  or  three  hours,  in  water. 

As  soon  as  some  quietude  and  sleep  have  been  obtained,  it  is  in  order 
to  administer  concentrated  food  in  an  easily  assimilable  form. 

The  treatment  of  chronic  alcoholism  is  more  often  best  conducted  in 
"homes"  for  inebriates,  in  hospitals,  and  similar  institutions.  At  the 
outset  there  must  be  an  "unconditional  surrender  "  in  the  use  of  alco- 
hol. Its  withdrawal  should  be  enforced  at  once  in  many  cases,  and  very 
rapidly  in  all  others,  according  to  the  judgment  of  the  physican  as  to 
the  psychic  and  physical  condition  of  the  patient.  Substitutes  for 
alcohol  are  the  strong  fruit-juices,  as  hot  lemonade  or  hot  ginger,  capsi- 
cum infusion,  and  cardamom  tea  often  is  useful.  Coffee,  milk,  cocoa,and 
hot  broths  are  also  to  be  recommended.  The  diet  should  be  carefully  in- 
creased in  nutritive  strength  as  the  gastric  irritability  diminishes.  Some- 
times such  sedatives  to  the  stomach  as  the  bismuth  preparations,  effer- 
vescent alkaline  drinks,  and  lime-water  may  be  indicated.  Peptonized 
food  is  often  well  borne  at  first  in  cases  in  which  gastric  distress  is 
marked.     Nutrient  enemata  are  seldom  required,  but  should  be  resorted 


1274  THE  lyTOXICATIONS ;    OBESITY;  HEAT-STROKE. 

to  in  the  gravest  cases,  particularly  during  the  states  of  alcoholic  dementia. 
The  general  health  must  be  looked  after  by  placing  the  patient  in  the  best 
of  fresh  air,  exercise,  cold  and  warm  bathing,  by  mental  and  social  occu- 
pation, and  by  diversion.  When  the  craving  for  alcohol  is  hereditary  and 
intense,  seclusion  in  an  inebriate-house  or  some  similar  institution  is  often 
necessary  for  a  long  time  to  lessen  the  danger  of  lapsing  into  the  former 
drink-habit. 

The  insomnia  of  chronic  alcoholism  may  be  met  temporarily  by  the 
use  of  large  doses  of  bromids,  chloral,  hyoscin,  or  sulfonal.  Morphin 
maybe  indicated  at  times,  but  should  be  used  Avith  great  caution  in  order 
to  avoid  adding  the  morphiu-habit  to  that  of  alcohol.  Perhaps  the  best 
single  agent  to  use  in  counteracting  the  symptoms  of  chronic  alcoholism  is 
strychnin,  either  as  the  nitrate  or  sulphate,  hypoderniically  and  by  the 
mouth  ;  iron,  arsenic,  the  hypophosphites,  dilute  phosphoric  acid,  quinin, 
gold  and  sodium  chloride,  avena  sativa,  and  the  like  are  often  useful  ad- 
juvants in  the  tonic  treatment.  Atropin,  hypodermically,  may  also  be 
recommended  when  vascular  dilatation  and  -weakness  are  prominent. 
Sweating  and  purging  the  patient,  and  the  administration  of  bromids, 
chloral,  and  gelsemium  for  a  day  or  two  in  advance  may  avert  a  "  drink- 
storm  "  or  the  periodic  cravings  for  alcohol  that  may  be  expected  by  pro- 
dromal manifestations.  Sometimes,  however,  as  in  the  sudden  outbursts  of 
dipsomaniacs,  there  is  no  time  to  institute  their  treatment.  It  is  claimed 
that  hypnotic  suggestion  will  abolish  eftectually  the  ardent  desire  for  al- 
cohol in  a  certain  number  of  neurotic  cases  of  alcoholic  inebriety.  Tem- 
perance revivals  may  be  said  to  do  permanent  good  only  in  those  similar 
neurotic  cases  that  are  fortunately  impressionable  to  appeals  by  total- 
abstinence  orators,  but,  in  order  to  maintain  the  reformed  drunkard's 
pledge,  it  is  often  necessary  that  interested  persons  continue  to  watch, 
guide,  and  inspire  him,  in  order  that  a  weakened  will  may  not  precipitate 
a  cyclic  lapse  into  his  old  habits. 

All  the  influence  of  culture,  music,  and  the  fine  arts,  of  high-toned 
morality  and  pure,  undefiled  religion,  should  be  enlisted  to  strengthen 
self-repect  and  to  fortify  volition  and  inhibition.  Moral  regeneration 
may  thus  in  certain  cases  check  the  physical  and  mental  degeneration, 
but  it  cannot  eff'ace  the  consequences  of  the  alcoholic  poisoning  Avhich  it 
represents. 

McBride  recommends  the  following  methoil  of  treatment :  Hypodermic 
injections  of  strychnin  three  times  daily,  at  first  -^-^^  of  a  grain,  increased 
to  ^  by  the  end  of  the  first  week,  and  at  the  same  time  hypodermic  in- 
jections of  atropin  are  given,  which  arc  rapidly  increased  until  the  patient's 
tongue  is  made  dry  and  the  pupils  dilated.  A  bitter  mixture  containing 
cinchona,  gentian,  rheum,  capsicum,  and  more  atropin  and  strychnin  is 
also  given  six  times  a  day.  During  the  first  week,  usually  during  the 
first  few  days,  all  taste  for  alcohol  is  lost.  During  the  second  week  this 
treatment  is  continued,  but  during  the  third  the  injections  of  atropin  are 
gradually  diminished,  and,  finally,  stopped,  and  the  capsicum  is  with- 
drawn from  the  mixture  taken  by  the  mouth.  Thus  modified,  the  treat- 
ment is  continued  during  the  fourth  week.  At  the  end  of  tliat  time  the 
atropin  is  withdrawn  from  tlie  mixture  and  the  latter  is  given  four  instead 
of  six  times  daily.  During  the  sixth  week  the  injections  of  stryclmin  are 
reduced   and  stopped.     At  the  beginning  of   the  week  the  cinchona  is 


MORPHINISM.  12.1  T) 

also  withdrawn.     The  author  necessarily  varies  this  treatment  with  the 
requirements  of"  individuals. 

Delirium  tremens  requires  firm  but  tactful  isolation  and  vif^ilant 
nursing.  All  alcohol  should  be  withheld.  If  stimulation  is  necd(;d, 
aromatic  spirits  of  ammonia;  stryclmin,  and  atropin,  with  bland  hot 
drinks  and  broths,  may  be  administered.  Easily  digested  and  nutritious 
food  should  be  given  to  support  the  strength.  Sleep  must  be  procured 
by  such  means  as  are  mentioned  above  in  the  treatment  for  mania-a-ixjtu. 
The  dosage  required,  however,  is  usually  not  as  great,  but  must  be  kept 
up  longer  than  in  the  maniacal  condition.  Cardiac  weakness  may  need 
such  stimulants  as  digitalis  and  strophanthus.  After  the  attack  subsides, 
tonic  doses  of  strychnin,  gentian,  asafetida,  and  iron,  together  with  gra<l- 
uated  exercise  out-of-doors,  are  to  be  employed.  Turkish  baths,indust)i!il 
occupations,  and  the  like  are  indicated  to  fortify  the  patient  against  yield- 
ing to  a  morbid  appetite. 

GINGER   AND    COLOGNE- WATER   INEBRIETY. 

Habitual  drinkers  of  alcoholic  ginger,  capsicum,  and  lavender  prepa- 
rations, and  eau-de-Cologne  are  practically  alcohol-habituds  or  inebri- 
ates. They  drink  these  liquids  for  the  alcohol  that  is  in  them. 
The  so-called  essence  of  ginger  (Jamaica  ginger),  which  contains 
considerable  alcohol  in  some  of  its  preparations,  is  often  used  primarily 
for  relieving  an  attack  of  "cramps"  or  "colic,"  and  if  frequently  re- 
peated, can  readily  induce  a  morbid  habit  of  "ginger-drinking."  In 
other  cases  the  craving  for  alcoholic  indulgence  (often  hereditary),  may 
have  been  aroused  by  a  social  glass  of  wine,  but,  from  a  sense  of  shame 
the  desire  has  been  kept  secret,  and  gratified  by  drinking  eau-de-Cologne, 
lavender  essence,  or  even  tincture  of  capsicum.  Perhaps  many  more 
such  cases  exist,  and  especially  among  neurotic  women  in  good  circum- 
stances, than  are  usually  recognized. 

MORPHINISM. 

( Opium-inebriety. ) 

Definition. — A  chronic  intoxication,  due  to  the  habitual  use  of 
morphin  or  of  opium  in  some  other  form  (opiumism). 

Pathology. — In  cases  of  death  from  acute  or  chronic  opium-  or 
morphin-poisoning  there  is  nothing  distinctive  in  the  pathologic  appear- 
ances. In  acute  cases  vascular  congestion  of  the  brain  and  membranes 
has  been  noted ;  but  even  in  chronic  cases  the  tissue-degeneration  and 
fatty  and  connective-tissue  proliferations  that  are  characteristic  of 
alcoholism,  are  practically  absent.  Decided  lesions  are  usually  trace- 
able to  associated  affections.  The  principal  anatomic  changes  are  those 
due  simply  to  malnutrition.  Thus,  we  have  the  emaciation  and  the 
shrunken  appearance  of  cerebral  anemia,  and  pallor  and  atrophy  of  the 
cardiac  muscle  and  of  the  vascular  walls.  The  dried  and  wasted  struc- 
tures, due  to  tissue-starvation,  are  quite  a  contrast  to  the  fat-infiltrated 
or  degenerated,  cirrhotic,  and  inflamed  tissue  of  alcoholic  inebriety. 
Direct  destruction  of  parenchymatous  cells  is  more  evident  in  the  later. 

Ktiology. — The  climate,  country,  and  nationality  have  a  certain 
disposing  influence  in  the  development  of  opiumism  and  morphinism. 


1276  THE  IXTOXICATIOXS;    OBESITY;   HEAT-STROKE. 

In  the  opium-^rowiug  parts  of  Asia,  as  iii  Cliina,  India,  and  Persia, 
where  the  climate  is  warm,  enervating,  and  conducive  to  ph^'sical  and 
moral  abandonment  during  the  greater  part  of  the  year,  and  in  Turkey 
also,  upium-eating-and-smoking  habitu6s  arc  as  numerous  as  alcohol 
habitues  are  in  Europe  and  America  among  the  Cam-asians. 

Women  are  more  connnonly  the  victims  of  morphinism  than  men, 
except  physicians  and  druggists  as  a  class.  Mattison  has  found  TO  per 
cent,  of  his  opiate  patients  to  be  medical  practitioners.  Many  con- 
tracted the  habit  by  using  morphin  for  severe  chronic  neuralgia,  in- 
somnia, and  the  like.  Indeed,  pain  and  sleeplessness  have  been  the 
principal  source  of  this  drug-habit. 

Ennui  and  an  idle  spirit  of  irritation  and  adventure  among  the  sen- 
sation-loving and  luxurious  sometiuies  sow  the  seeds  of  an  indulgence 
in  narcotics  that  bring  forth  fruitage  in  the  form  of  a  fixed  habit. 

The  incautious  prescribing  of  morphin  and  the  too  ready  hypodermic 
use  of  the  alkaloid  by  physicians  in  treating  various  cases  of  pain  are 
not  infrequently  the  cause  of  morphinism.  Overwork  of  the  brain, 
great  business  or  social  strains,  prolonged  worry  and  anxiety  either 
with  or  without  work,  insomnia,  remorse,  idleness,  and  secret  vices,  are 
the  most  common  predisposing  agents  of  the  morpliin-habit. 

Paregoric,  laudanum,  chlorodyne,  and  "soothing-syrup"  are  drunk 
to  a  frightful  extent  in  large  cities  among  the  poor  and  miserable,  and 
cause  great  disturbance  of  the  health  of  the  habitues. 

Sj^tnptotns. — These  may  be  in  abeyance  for  some  time,  while  the 
habit  is  forming  and  the  doses  are  still  slight.  As  the  craving  increases, 
the  dose  and  its  frequency  increase  to  keep  pace  with  the  desire. 
Anemia  gradually  develops,  with  sallowness  of  the  skin,  wasting  of 
the  features  and  body,  languor,  weakness,  functional  deterioration, 
mental  depression,  anorexia,  restlessness,  insomnia,  tremors,  irritability, 
shyness,  dilatation  of  the  pupils  (except  when  under  the  influence  of 
the  drug),  and  a  characteristic  propensity  to  lying.  Cardialgia  is  often 
complained  of  by  those  Avho  use  opium  pretty  constantly.  The  asso- 
ciated vices  of  opiumism  are  less  violent  and  inflammatory  than  those 
of  alcoholism,  and  more  secretive  and  speculative,  such  as  gambling  and 
sexual  perversions.  Itching  is  frequent,  and  especially  after  taking  the 
opium  or  morphin.  Attacks  of  chills,  followed  by  pyrexia,  with  de- 
lirium and  transient  albuminuria  (renal  congestion)  occur  in  some  cases. 
Diarrhea  and  dysentery  have  been  observed  in  some  instances.  There 
may  be  also  disturbances  of  the  visual  muscular  apparatus.  Suff'erers 
from  painful  carcinoma  in  Avhom  opium  or  morphin  is  required  for  steady 
use  do  not  become,   except  in  rare  cases,  true  morphinomaniacs. 

The  course  of  morphinism  is  that  of  a  progressive  asthenia,  in  which 
cardiac  palpitation,  dyspnea,  abdominal  and  muscular  cramps,  trembling, 
fear,  sleeplessness,  mental  confusion,  melancholy,  slovenliness,  and  moral 
obtuseness  come  on.  Some  women,  known  to  be  kleptomaniacs,  have 
been  found  to  be  secret  opiumists.  Sexual  impotence  in  the  male,  and 
amenorrhea  and  abortion  in  the  female,  are  common  results.  The  skin 
is  wrinkled,  dry,  and  harsh,  and  may  show  numerous  needle-scars  and 
abscesses  in  those  addicted  to  the  hypodermic  use  of  the  drug.  The 
termination  is  the  direct  result  of  the  extreme  debility  or  marasmus  or 
of  some  intercurrent  affection. 


MORPHINISM.  1277 

The  diagnosis  must  be  made  from  the  history.  When  the  latter 
is  wanting  because  of  a  lack  of  veracity  or  deception,  chronic  alcohol- 
ism may  have  to  be  differentiated  from  opiumism.  The  more  open  and 
often  periodic  habits  of  the  alcoholic  habitu^,  and  the  general  aspect  of 
the  physical  and  mental  and  complicating  conditions,  usually  show 
marked  differences  between  the  two  drug-intoxications. 

Prognosis. — The  likelihood  of  a  cure  is  exceedingly  lemote.  On 
the  other  hand,  under  proper  conditions  much  relief  may  be  given  and 
life  prolonged  for  years.  Opium  smoking  produces  less  injurious  con- 
sequences, and  is  more  readily  cured  than  other  forms  of  the  addiction. 

The  treatment  is  manifestly  difficult  and  unpromising.  Institu- 
tional isolation,  rest,  diversion,  watchful  care,  regular  and  studied  feed- 
ing, baths,  and  graduated  exercise  in  the  open  air  as  far  as  possible,  but 
under  surveillance  in  order  to  prevent  the  smuggling  of  opium,  morphin, 
or  compound  preparations  containing  either,  are  the  most  efficient 
measures.  As  to  the  manner  of  withdrawing  the  narcotic,  much  care, 
judgment,  and  tact  form  a  sine  qud  non  in  the  treatment.  A  sudden 
and  absolute  stoppage  of  the  use  of  the  drug  sometimes  leads  to  great 
distress,  and  even  to  collapse  ("  abstinence  phenomena  ")  ;  it  is,  therefore, 
not  to  be  recommended,  as  in  chronic  alcoholism.  On  the  other  hand, 
the  too  gradual  withdrawal  is  torturing.  A  middle  course,  the  "  rapid- 
gradual  method  "  of  Erlenmeyer,  is  usually  resorted  to,  in  which  the 
reduction  of  the  quantity  of  morphin  or  opium  to  nothing  occupies  but 
a  week  or  ten  days.  Various  substitutes  have  been  recommended  that 
generally  prove  not  to  be  substitutes  at  all,  but  simply  act  in  a  symp- 
tomatic way,  and  may  lead  to  another  habit  as  bad  if  not  worse.  Such 
drugs  as  cocain,  hyoscyamus,  bromids,  and  chloral  have  thus  been  used. 
Hare  and  others  have  reported  good  results  from  the  method  of  treatment 
suggested  by  Lott,  namely,  by  the  use  of  hyoscin  hypodermically  in 
large  doses  (gr.  y^^  every  two  hours)  until  the  patient  is  rendered  calm 
or  even  unconscious,  after  which  this  state  is  to  be  maintained  for  several 
days  and  then  the  dose  is  to  be  gradually  diminished  so  as  to  permit  a 
return  to  the  normal  condition.  Cardiac  stimulants  may  be  needed.  The 
Towns-Lambert  method  of  treatment  is  now  widely  adopted,  and  the  re- 
sults which  have  been  recorded  in  literature  are  most  promising.^ 

In  the  symptomatic  treatment  of  the  morphin-habit  moderate  doses 
of  bromids,  with  cannabis  indica  and  some  such  vegetable  bitter  as  gen- 
tian, may  prove  useful  in  allaying  the  nervous  irritability  and  restless- 
ness at  night.  Sulfonal  is  a  good  hypnotic  in  these  cases.  Cathartics, 
stomach  sedatives  alternating  with  tonics,  concentrated  foods,  massage, 
hot  and  cold  bathing,  electricity  (general  galvanization),  and  "  complete 
control  over  the  patient "  are  usually  indispensable  adjuncts  in  the 
treatment  after  the  withdrawal  of  the  opium  or  morphin.  Cardiac 
stimulants,  strychnin  and  physostigmin  salicylate  (gr.  yro — 0-0006) 
hypodermically,  have  been  recommended  recently  as  important  in 
counteracting  the  functional  depression  of  these  habitues.  Industrial 
activity,  and  mental  and  social  diversion,  aid  in  maintaining  any  im- 
provement made  and  in  rendering  the  patient  less  liable  to  a  relapse. 
1  For  details,  see  The  Jour.  Amer.  Med.  Assoc.,  Feb.  18,  1911,  p.  503. 


1278  THE  ly TOXICA  TIONS;    OBESITY;   HEATSTROKE. 

PLUMBISM. 
(Chronic  Lead-poisoning :    Saturnism.) 

Definition. — A  chronic  intoxication  due  to  the  slow  absorption  of 
lead,  either  industrially  or  accidentally. 

Pathology. — The  principal  lesions  are  found  in  the  muscles,  periph- 
eral nervee,  liver,  kidneys,  and  mucous  membranes.  The  affected  mus- 
cles are  wasted,  pale-yellow  in  color,  and.  in  advanced  cases,  show  a 
marked  fibroid  growth.  The  vessels  in  the  muscles  also  reveal  arterio- 
sclerosis. The  peripheral  nerves  are  affected  with  a  parenchymatous 
neuritis,  and  are  especially  involved,  with  degenerative  changes  in 
the  nerve-endings  in  the  muscles.  The  nearer  we  approach  the  spi- 
nal cord  along  the  course  of  an  affected  motor  nerve,  the  less 
marked  are  the  changes,  although  in  some  cases  a  very  slight  in- 
volvement of  the  anterior  nerve-root  cells  has  been  noted.  The  cord  is 
usually  normal. 

In  the  brain,  slight  meningitis  and  arteriosclerosis  of  the  cerebral 
blood-vessels  here  and  there,  with  a  corresponding  connective-tissue 
growth  and  capillary  hemorrhages.  The  liver  and  kidneys  show  paren- 
chymatous atrophy  and  cirrhosis. 

Ktiology. — (a)  Personal  susceptibility  to  lead-poisoning  is  greater 
in  some  people  than  in  others,  all  other  things  being  equal,  (b)  Plumb- 
ism  is  more  common  in  adults  than  in  children,  because  of  greater  ex- 
posure, (c)  Sex. — Women  are  more  susceptible  than  men.  (d)  Occupa- 
tion is  the  most  frequent  cause  of  lead-intoxication.  AVorkei's  in  white 
lead  (plumbic  carbonate),  red  lead,  and  litharge,  all  of  which  substances 
are  used  as  paints,  are  especially  to  be  mentioned  as  liable  to  saturnism. 
Among  the  most  common  industrial  causes  are  the  following :  painting, 
plumbing,  lead-mining,  rolling  sheet-lead,  pottery-glazing,  type-found- 
ing and  setting,  shot-making,  dress-making  (in  which  lead-dyed  silk 
thread  is  used  and  the  ends  bitten  off),  lace-making,  glass-grinding,  and 
calico-printing,  (r)  Accidental  contamination  of  food  and  drink.  Men 
employed  in  the  manufacture  of  white  lead  and  eating  lunches  in  dusty 
work-rooms  suffer  from  plumbism.  Drinking  water  stored  in  lead-lined 
cisterns  and  passed  through  lead  pipes  is  frequently  contaminated,  espe- 
cially if  the  water  contains  a  slight  amount  of  acid.  Flour,  bread,  bis- 
cuit, candy,  butter,  and  milk  may  cause  poisoning  by  adulteration  with 
lead  chromate,  used  to  give  a  rich,  yellow  tint  to  these  articles ;  and 
tobacco  wrapped  in  lead-foil  has  resulted  in  saturnism.  (/)  Workers  in 
lead  suffer  more  frequently  during  the  warm  season,  [g)  Previous  attacks 
greatly  increases  susceptibility. 

The  ahsorption  of  the  lead  takes  place  mainly  through  the  gastro- 
intestinal tract  and  the  lungs,  and  much  less  through  the  skin.  It  may 
be  deposited  in  most  of  the  soft  tissues  and  viscera,  but  especially  in 
the  nerves,  muscles,  and  liver.  Elimination  takes  place  through  the 
kidneys,  and  probably,  though  in  very  slight  quantities,  with  the  bile 
and  saliva,  and  through  the  skin. 

Symptoms. — Depending  upon  individual  susceptibility,  it  may  be 
months  or  years  before  the  first  manifestations  appear.  Anemia  is  an 
early  and  marked  symptom.  The  red  cells  and  hemoglobin  are  reduced 
correlatively.     Boston,  in  the  study  of  24  cases,  found  the  leukocytes  to 


PLUMB  ISM.  3  279 

number  between  10,000  to  23,000  per  c.mra.  ;  and  average  of  12,000. 
The  erythrocytes  are  pale,  distortcid,  and  show  evi(h;nce  of  punctate  basic 
degeneration.  Grawitz  and  Frey  regard  polychromatophilia  as  an  im- 
portant blood  finding  (Need).     The  general  nutrition  is  poor. 

The  characteristic  blue  line  at  the  borders  of  the  gums  is  rarely 
absent,  especially  in  those  who  are  not  scrupulous  in  their  attention  to 
the  teeth.  It  is,  as  a  rule,  most  distinct  at  the  roots  of  the  lower 
canines  and  incisors,  and  is  formed  by  a  deposition  of  lead  suiphid. 
Bluish  patches  may  also  be  met  with.  Gowers  points  out  that  this  line 
is  black  instead  of  blue,  and  is  present  only  when  the  gums  are  slightly 
separated  from  the  teeth.      Slight  jaundice  may  at  times  be  noted. 

Colic  is  very  common  and  is  also  characteristic.  The  pains  center 
around  the  navel,  and  are  quite  severe  and  griping.  They  are  associated 
with  retraction  and  rigidity  of  the  abdominal  walls,  and  with  obstinate 
constipation.  The  pains  are  pai'oxysmal,  may  be  referred  at  times  to 
the  epigastrium,  and  may  be  accompanied  by  vomiting.  Between  the 
paroxysms  a  dull  pain  usually  exists  over  the  whole  abdomen.  During 
the  attacks  the  pulse-tension  is  increased  and  cardiac  action  lessened. 
The  stomach  contents  show  no  HCl  as  a  rule. 

Exaggerated  tendon  reflexes  may  be  present  early.  Paralyses  are 
common  symptoms,  and  may  either  be  acute,  subacute,  or  chronic  in 
nature.  Although  usually  localized  palsies,  they  are  sometimes  general- 
ized. The  most  characteristic  lead-palsy  is  that  known  as  wrist-drop  (see 
also  Multiple  Neuritis,  p.  1085).  Both  fine  and  coarse  tremors  occur. 
They  usually  begin  in  the  hands  and  arms,  are  rather  constant,  and  are 
aggravated  by  voluntary  effort  and  emotional  excitement. 

Cramps  in  the  affected  muscles  and  about  the  joints  ilead-arthralgioi) 
are  occasionally  noted.  Slight  anesthesia,  especially  in  cases  of  wrist- 
drop, is  sometimes  detected  here  and  there,  but  may  in  certain  instances 
be  due  to  saturnine  hysteria. 

The  cerebral  symptoms  are  important.  The  phrase  "  lead  encephal- 
opathy "  includes  such  manifestation  as  delirium  and  coma,  neuro-retini- 
tis,  aphasia,  convulsions,  hemiplegia,  amaurosis,  hysteria,  and  insanity. 
The  delirium  and  coma  are  the  commonest  brain-symptoms,  and  may 
come  on  suddenly  with  tremors  and  hallucination.  Epileptic  convul- 
sions are  often  severe.  Hemianopsia  has  been  observed.  Mania  and 
melancholia  occur  in  cases  of  mental  unbalancing,  and  hysteric  out- 
breaks are  seen  in  girls.  Intense  headache  is  not  uncommon.  "  Sat- 
urnine gout,"  so  called,  is  described  as  a  result  of  chronic  plumbism. 
The  kidneys  are  contracted,  the  heart  is  hypertrophied,  and  arterio- 
sclerosis is  marked,  with  a  diminution  in  the  excretion  of  urea  and  uric 
acid.  The  pulse-tension  is  increased.  These  evidences  show  a  simi- 
larity tc  gout,  and  favor  the  development  of  uratic  deposits  in  the  joints. 
Lead  may  be  discovered  in  the  urine  by  laying  a  strip  of  magnesium 
in  it  and  noting  the  deposit  of  metallic  lead  if  present  (Von  Jaksch). 
Abram  asserts  that  the  addition  of  a  solution  of  ammonium  oxalate 
(1  gm.  to  150  c.c.  of  water)  facilitates  the  test.  Hematoporphyrin  may 
be  found  in  the  urine. 

Diagnosis. — The  history  of  exposure  to  lead-poisoning  is  usually 
clear  in  those  working  the  metal  in  its  various  forms.  Accidental  origins 
of  saturnism  a^'e  often   obscure   and  very  difficult  to  trace,  although  if 


1280  THE  IXTOXICATIOyS;    OBESITY;   HEAT-STROKE. 

the  cliaracteri.stie  wrist-droj).  the  giiiirival  line,  colic,  and  cachexia  be 
present,  the  diairnosis  is  readily  made. 

Ah-'iholie  jMi rail/six  of  the  lower  extremities  may  he  difterentiated  by 
the  history,  the  jjreater  prominence  of  sensory  symptoms,  and  by  the 
absenri'  of  tiie  blue  line  on  the  gums,  and  of  punctate  basophilia. 

Prognosis.-^ In  the  absence  of  the  graver  nervous,  arterial,  and 
renal  symptoms,  the  prognosis  is  good.  AVhen  there  is  paralysis,  with 
reactions  of  degeneration,  and  especially  in  primary  atrophy  of  the  mus- 
cles, the  prognosis  is  generally  had.  In  encephalopathic  forms,  and  in 
cases  in  which  arteriosclerosis  and  renal  cirrhosis  are  manifested,  the 
prognosis  is  unfavorable,  but  depends  ujxtn  the  extent  of  damage  done. 
Pulmonary  tuberculosis  often  complicates  lead  intoxication. 

Treatment. — The  prevention  of  plumbism  is  diflScult  in  lead-work- 
ing establishments,  owing  to  the  carelessness"  and  indift'erence  of  both 
employers  and  employees,  and  to  the  lack  of  any  adequate  antidote 
during  exposure.  Rigid  cleanliness  is  absolutely  necessary,  especially 
of  the  hands  and  nails  and  before  eating.  Means  to  allay  dust  should 
be  regularly  and  constantly  employed.  Milk  and  sulphuric-acid  lemon- 
ade have  been  recommended  for  use  by  workers  in  lead,  for  their  sup- 
posed antidotal  effects.  As  perfect  ventilation  as  possible  should  be 
secured,  and  respirators  are  in  use  in  some  lead-works,  being  worn  as 
"snouts."  Potassium  iodid  should  be  given  in  chronic  plumbism, 
beginning  with  small  doses  (gr.  iii-v — 0.1944-0.324),  given  preferably 
in  milk,  after  meals. 

In  lead  colic  hot  applications  to  the  abdomen  and  hypodermic  injec- 
tions of  morphin  and  atropin  are  often  indicated.  Efficient  doses  of 
Epsom  or  Glauber's  salts  are  used  to  combat  the  constipation.  Given 
in  combination  with  dilute  sulphuric  acid  (in  order  to  form  an  insoluble 
lead  sulphate)  and  with  belladonna,  the  best  and  speediest  benefits  may 
be  obtained  thereby. 

Iron  for  the  anemia,  strychnin  and  galvanism  for  the  paralysis, 
lithia-water  for  the  renal  deterioration,  and  nitroglycerin  or  sodium 
nitrite  for  the  arteriosclerosis  (enough  to  relieve  increasing  tension)  are 
the  symptomatic  items  of  treatment  that  are  usually  indicated.  Rarely, 
hopeless  cases  of  saturnine  encephalopathy  need  to  be  sent  to  asylums 
for  the  insane. 

ARSENICISM. 
( Chronic  Arsenic-poisoning .) 

Definition. — A  chronic  intoxication  resulting  from  the  gradual 
absorption  of  arsenic. 

Pathology. — The  peripheral  nerves  show  a  degenerative  neuritis, 
and  the  anterior  horns  of  the  spinal  cord  may  be  similarly  affected. 

Ktiology. — The  causes  of  arsenicism  may  be  habitual,  industrial, 
medicinal  or  accidental,  and  individual  predisposition  varies.  A  neurotic 
diathesis  usually  underlies  the  habit  of  "arsenic-eating"  in  those  who 
crave  the  drug.  Not  a  few  Avomen  suiler  from  chronic  arsenicism  as 
the  result  of  the  ingestion  of  arsenic  "  to  improve  the  complexion  and 
brilliancy  of  the  eye."  Men  employed  in  arsenic  works  of  various  kinds 
often  suffer  from  the  chronic  poisoning.  For  example,  miners  and 
smelters  of  arsenic  pyrites,  dyers  and  wall-paper  workers  using  Scheele's 


ARSENICISM.  1281 

or  Schweinfurth's  <^rccn,  artificial-flower  makers,  sliot-innkcr.s,  glass- 
workers,  and  taxidermists,  are  all  liable  on  account  of  their  occupations. 
The  medicinal  use  of  arsenic,  even  for  a  short  time,  may  in  very  sus- 
ceptible persons  induce  arsenical  paralysis  (r*utnam ;  Osier).  Again, 
"  cancer  cures  "  containing  arsenic  may  cause  poisonous  effects.  Acci- 
dental arsenicism  may  come  from  living  in  rooms  where  wall-paper,  carpets, 
colored  paper  ornaments,  toys,  or  curtains  are  contaminated  with  arsenic 
anilin  dyes.  Drinkers  of  beer  may  suff'er,  the  arsenic  being  derived  from 
the  sulphuric  acid  used  in  manufacturing  the  glucose  that  is  employed 
in  its  manufacture. 

Symptoms. — There  are  anemia,  loss  of  flesh  and  strength,  dryness 
and  irritation  of  the  mucosae,  of  the  eyes,  nose,  throat,  and  upper 
respiratory  tract.  Anorexia,  nausea,  and  diarrhea  indicate  the  pres- 
ence of  a  gastro-intestinal  catarrh.  In  some  cases,  milder  than  others, 
the  fat  is  well  preserved.  Slight  puffiness  of  the  eyelids  or  eyebrows 
may  occur,  and  some  epigastric  distress  may  be  complained  of  Marked 
conjunctivitis,  occasional  dysenteric  attacks,  loss  of  the  hair,  and  numb- 
ness and  tingling  in  the  extremities  form  a  commonly  observed  symptom- 
group.  Cutaneous  symptoms  may  appear,  as  pigmentation  ("  arsenic- 
bronzing  "),  and  eczematous,  herpetic,  urticarial,  and  pemphigoid  mani- 
festations. Albuminuria  with  casts  and  blood  mark  the  renal  irritation 
that  sometimes  occurs. 

The  most  characteristic  evidence  of  chronic  arsenic-poisoning  is  seen 
in  the  gradual  increasing  diffuse  or  multiple  neuritis.  Differing  from 
lead-palsy,  the  leg-extensors  and  the  peroneal  group  of  muscles  are  in- 
volved first,  although  the  arms  may  also  become  aff"ected  later  {vide  Mul- 
tiple Neuritis,  (p.  1085).  Contractions  in  the  lower  and  a  fine  tremor  of 
the  upper  extremities  are  apt  to  occur.  Arsenic-poisoning  may  also 
cause  headache,  vertigo,  melancholia,  and  hysteria.  The  drug  is  elimi- 
nated by  the  kidneys  and  may  be  found  in  the  urine.  Sometimes  a 
great  toleration  of  arsenic  is  observed  in  workmen  and  habituds,  the 
only  evidences  being  a  clear,  sallow,  waxy  complexion,  a  gloomy  ex- 
pression, and  some  dyspepsia,  perhaps,  as  in  the  well-known  Styrians. 

Diagnosis. — This  is  not  difficult,  when  once  the  source  of  the  pois- 
oning is  determined.  The  clinical  appearances  are  distinct  from  lead- 
intoxication,  especially  in  the  mode  of  progress  of  the  paralysis,  and  in 
the  more  marked  sensory  symptoms  combined  with  the  motor-disturb- 
ances of  arsenicism.     Arsenic  should  be  sought  for  in  the  urine. 

The  prognosis  is  favorable  in  most  cases  in  which  removal  from 
the  exposure  to  the  influence  of  arsenic  is  possible.  A  few  cases  die 
from  the  great  general  debility. 

Treatment. — Abstention  from  the  use  of  arsenic  for  cosmetic  pur- 
poses, avoidance  of  its  influence  in  the  arts,  care  in  its  medicinal  ad- 
ministration, and  prophylaxis  as  regards  the  possible  or  discovered 
sources  of  contamination,  form  the  first  considerations  in  the  treatment. 
Elimination  of  the  arsenic  may  be  promoted  by  the  use  of  potassium 
iodid  and  purgatives.  Gastro-intestinal  and  other  irritations  must  be 
met  by  appropriate  sedative  remedies.  The  neuritis  and  palsies  require 
— as  soon  as  the  tenderness  and  pain  subside — massage  and  electricity. 
Judicious  and  wholesome  alimentation  and  tonics  are  indicated. 
81 


1282  THE  ISTOXICATIOSS;    OBESITY ;   HEAT-STROKE. 

MERCURIALISM. 
{Chronic  Mercurial  Poisoning.) 

Definition. — A  chronic  intoxication  caused  by  the  habitual  inges- 
tion, or  combined  industrial  absorption  of  mercury,  in  susceptible 
indiriduals. 

Pathology. — No  marked  pathologic  changes  have  been  noted  in 
human  beings,  aside  from  the  evidences  of  oral,  gastro-intestinal,  and 
renal  irritation  and  inflammation.  It  is  not  improbable  that  the  cerebral 
cortical  areas  suil'er  more  from  metallic  irritation  than  do  the  spinal  or 
peripheral  nerve-tis^sues. 

Ktiology. — Some  persons  are  much  more  easily  mercurialized  than 
others,  {a)  Salivation  and  stomatitis  from  the  therapeutic  use  of  mer- 
cury form  a  variety  that  is  less  frequent  than  formerly.  (6)  Indus- 
trial origin.  The  chief  cause  of  chronic  mercurialism  is  the  inhalation 
of  the  vapor  of  the  metal  by  artisans  in  the  industries  in  which  it  is 
used.  Thus  miners  and  smelters  and  those  engaged  in  making  mirrors, 
barometers,  thermometers,  amalgams,  felt  hats,  vermilion-pigment,  and 
artificial  teeth  sometimes  suffer  from  chronic  mercurial  poisoning.  It 
should  be  pointed  out  here  that  mercury  is  volatile  at  ordinary  tempera- 
tures, and  is  absorbed  into  the  blood  through  the  lungs,  digestive  tract, 
and  skin.  Calomel  vapor-baths  have  caused  poisoning  in  a  few  cases. 
((?)  Purely  accidental  mercurialization  also  occurs.  ((/)  Women  and  children 
are  more  susceptible  to  the  action  of  mercury  than  men.  In  all  cases 
the  mercury  exists  in  the  tissues  as  an  albuminate. 

Symptoms. — There  are  anemia,  emaciation,  gastro-intestinal  dis- 
orders, stomatitis,  salivation,  maxillary  necrosis,  ulceration  of  the  gums, 
loosening  of  the  teeth,  fetor  of  the  breath,  marked  tremors,  and  paraly- 
sis. The  oral  symptoms  are  not  as  prominent,  however,  as  in  acute 
mercurial  poisoning.  The  hair  falls  out,  the  nails  become  brittle,  and 
pigmentation  of  the  skin  is  seen. 

The  tremor  is  characteristic.  It  is  first  felt  or  noticed  in  the  tongue 
and  lips,  is  usually  fine,  later  coarse  and  choreiform,  and  spreads  grad- 
ually throughout  the  muscular  system.  It  is  aggravated  by  voluntary 
effort,  and  may  cease  during  sleep  in  mild  cases.  Speech  is  altered. 
Hysteric  tremors  may  also  exist.  Great  irritability  and  restlessness  are 
common.  Aphasia,  hemiplegia,  hemianesthesia,  and  peripheral  neuritis 
with  palsies,  occur.  There  is  no  atrophy,  nor  are  the  reactions  of  de- 
generation present  in  the  paralyzed  muscles.  Severe  pains  may  be 
present  in  the  extremities,  including  the  joints,  and  grave  cerebral 
symptoms  occasionally  develop  (stupidity,  headache,  loss  of  memory, 
insomnia,  hallucinations,  delirium,  coma,  convulsions,  and  confusional 
insanity).  Albuminuria  with  anasarca  may  occur.  The  effects  of 
chronic  hydrargyrism  in  women  upon  their  offspring  are  also  important, 
the  children  being  rachitic,  weak,  sickly,  and  prone  to  tuberculosis. 

Diagnosis. — The  history,  the  characteristic  tremors,  paresis,  and 
mental  irritability  are  significant.  In  the  absence  of  a  history  of  ex- 
posure to  mercury,  the  differentiation  from  progressive  general  jjaresis, 
disseminated  sclerosis,  or  paralysis  agitans  may  be  more  or  less  diflBcult. 

Prognosis. — Recovery  is  common  upon  the  removal  of  the  source 
or  on  removing  the  patient  from  the  source  of  the  poisoning.     Fatal 


FOOD-INFECTION  AND   PTOMAIN-POISONING.  1283 

terminations  rarely  ensue,   jhkI  tlien   in  cases  of  mercurial  encephalop- 
athy of  a  grave  type  and  with  a  tendency  to  idiocy. 

Treatment. — Prevention  of  further  poisoning  is  imperative,  and 
elimination  is  to  be  promoted.  Potassium  chlorate,  witli  the  tincture  of 
myrrh,  and  astringents  are  useful  for  the  occasional  stomatitis  and  sali- 
vation. Potassium  iodid  and  also  sulphur  haths  may  be  used  to  aid  in 
the  elimination  of  the  mercury.  Iron,  cod-liver  oil,  good  food  and  fresh 
air,  and  a  free  activity  of  the  emunctories  are  useful.  For  the  marked 
tremor,  sedatives  (e.  g.,  codeine,  chloral,  bromides,  belladonna)  are 
recommended.     Electricity  may  be  resorted  to  for  the  paresis. 

FOOD-INFECTION    AND    PTOMAIN-POISONING. 

In  recent  years  there  have  been  reported  an  increasing  number  of 
cases  of  serious  illness  that  have  been  traced  to  infected  and  contami- 
nated food.  Undoubtedly  many  such  instances  are  now  brought  to 
notice  that  in  former  times  were  attributed  to  other  causes,  or  that  were 
not  diagnosticated  because  of  a  lack  of  knowledge.  On  the  other  hand, 
the  increased  consumption  of  canned  and  preserved  meats  has  cer- 
tainly augmented  the  liability  to  poisoning  from  these  products,  as  the 
reports  of  cases  show.  Lack  of  care  in  the  inspection  and  selection  of  the 
meats,  uncleanliness,  and  sometimes  unscrupulousness,  in  their  handling 
and  preparation,  must  result  in  infection,  putrefaction,  and  toxicity. 
The  infection  of  the  food  may  be  due  to  (1)  disease  of  the  animal  or 
plant  from  which  the  food  is  derived ;  (2)  microbic  inoculation  of  the 
food  after  derivation  and  before  ingestion  by  human  beings;  (3)  infec- 
tion by  toxicogenic  bacteria,  and  the  presence  of  ptomains  or  toxalbu- 
moses.  The  transmission  to  man  of  such  affections  in  animals  as  tuber- 
culosis, anthrax,  glanders,  and  pleuro-pneumonia,  by  eating  the  infected 
meat,  has  been  sufficiently  proved.  Again,  meat  and  milk  may  become 
infected,  before  being  ingested  by  the  patient,  by  pathogenic  micro- 
organisms, as  of  typhoid  fever  and  diphtheria,  or  from  the  production 
of  toxins  owing  to  the  action  of  non-pathogenic  putrefactive  micro- 
organisms. A  great  many  instances  of  food-infection,  particularly  of 
meat  and  milk,  have  been  shown  to  be  due  to  the  presence  of  sapro- 
phytic germs,  this  happening  even  when  the  articles  of  food  have  been 
obtained  from  healthy  stock,  and  have  been  kept  free  from  specific  path- 
ogenic bacteria.  It  is  not,  however,  the  saprophytes  themselves  in  all 
cases,  but  the  poison  developed  in  the  food  before  it  is  eaten  or  formed 
in  the  body  afterward,  that  produce  the  symptoms  and  sometimes  death. 
According  to  Novy,  some  of  the  saprophytic  bacteria  with  which  food  is 
infected  outside  of  the  body,  under  certain  conditions,  are  capable  of 
living  in  the  body  as  parasites,  especially  on  dead  matter,  and  there 
become  toxicogenic. 

The  chronic  poisons  or  ptomains  resulting  from  the  action  of  the 
saprophytes  in  foods  are  called  "putrefactive  alkaloids;"  those  bacterial 
products  of  a  proteid  nature  are  called  "  toxalbumins  "  or  "  toxalbu- 
moses."  The  latter,  according  to  Vaughan,  are  more  frequently  present 
in  infected  foods.      They  are  all  absorbed  from  the  digestive  canal. 

Poisoning  by  Infected  Milk  and  Milk-products. — It  is  now  well  known 
that  the  cause  of  the  high  mortality-rate  among  infants  in  hot  weather 


1284  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

is  tracoiiMe  directly  or  indirectly  to  the  ''suuimer  diarrlieus  "  in  chil- 
dren fed  artificially,  wholly  or  partially,  with  milk  infected  b}"-  numerous 
varieties  of  saprophytic  germs  and  thus  poisoned  by  ptomains,  such  as 
tyrotoxicon.  This  special  chemical  poison  has  been  isolated  by 
Vaughan,  and  discovered  by  him  in  cheese.  It  has  also  been  found 
in  ice-cream,  frozen  custards,  and  cream-puffs,  and  has  caused  poison- 
ing-symptoms mainly  of  acute  gastro-intestinal  inflammation,  "con- 
striction of  the  fauces,"  nausea  and  vomiting,  sharp,  griping  intestinal 
pains,  headache,  thoracic  oppression,  chilliness,  dizziness,  and  sometimes 
purging,  followed  by  relief  in  mild  cases.  In  the  severe  and  long-con- 
tinued forms,  however,  exhaustion  may  supervene,  with  subnormal  tem- 
perature, coma,  collapse,  and  death  in  the  graver  cases.  No  chemical 
or  physiologic  antidote  is  known.  Elimination  may  be  assisted,  and 
stimulation  is  needed.  Irrigation  may  be  employed  for  the  former  in 
both  stomach  and  bowels.  Strychnin,  nitroglycerin,  atropin,  and  the 
aromatic  spirits  of  ammonia  are  most  effective  as  stimulants. 

Meat-poisoning. — Various  tainted  meats,  as  mince-meat  "  warmed 
over,"  veal  pie,  carelessly-kept  chicken  salad,  badly-preserved  and 
canned  meats,  partially-decayed  sausages  (botuUsmus)  have  caused 
violent  symptoms  of  poisoning.  Diseased  raw^  and  partially-cooked 
meat  has  also  been  eaten  Avith  disastrous  results.  Prolonged  cook  ins: 
may  fail  to  destroy  the  toxic  action  of  certain  ptomains  in  infected  meats  : 
also,  that  meat  that  has  been  cooked  and  kept  under  certain  conditions 
may  become  infected  with  bacteria  as  well  as  when  it  is  raw.  Putrid 
meat,  however,  has  been  known  not  to  cause  toxic  symptoms.  Gartners 
bacillus  [B.  enteritidis)  is  probably  the  exciting  cause  of  meat-poisoning. 

The  symptoms  caused  by  the  poisoning  are — "  (1)  those  due  to  a  true 
infection;  (2)  those  due  to  simple  poisoning"  (Mann).  Cases  of  the 
former  group  run  the  usual  course  of  an  infectious  disease,  often  simu- 
lating typhoid  fever.  Those  under  the  second  division  manifest  the 
symptoms  of  a  violent  gastro-enteritis,  with  vomiting,  intense  colicky 
pains,  purging,  fever,  accelerated  pulse,  nervous  prostration,  great  mus- 
cular weakness,  and  cramps  in  the  calves  of  the  legs.  Often  a  subse- 
quent subnormal  temperature,  extreme  depression,  convulsive  movement, 
vertigo,  dimness  of  vision,  dyspnea,  somnolence,  great  soreness  of  the 
mouth,  collapse,  and  sometimes  death  supervene.  The  mortality-rate 
varies  from  15  to  55  per  cent,  of  all  the  cases. 

Differential  Diagnosis. — Arsenic-poisoning  may  have  symptoms 
similar  to  those  of  ptomain-poisoning.  But,  as  Harrington^  points  out, 
there  are  three  chief  points  of  difference  :  in  arsenic-poisoning  there  is 
swallowing  because  of  pain  ;  in  ptomain-poisoning  the  pupils  are  us- 
ually dilated  and  the  muscular  prostration  is  almost  as  extreme  as  a  palsy. 

The  treatment  is  largely  eliminative,  symptomatic,  and  supportive. 
The  pro])liylactic  measures,  private  and  public,  are  generally  obvious. 

Poisoning  by  Fish  [la/tthyismus)  B^nd  Shell-fish. — Many  instances  of 
this  serious  form  of  intoxication  have  been  produced.  The  fish  may 
contain  certain  poison-glands,  ovaries,  etc.  Especially  is  this  true  of 
certain  species  known  in  Japan,  one  of  which  is  believed  to  cause  the 
disease  called  "  Kakke,"  which  prevails  during  the  summer  months  in 
Tokio.     A  certain  species  of  fish  (C'lupca  venenosa)  inhabiting  the  "West 

*  Boston  Medical  and  Surgical  Journal,  Dec.  14,  1899. 


GRATN-   AND    VEGETABLE-POISONING.  1285 

Indian  waters  is  supposed  to  be  always  poisonous,  although  the  source 
or  true  character  of  the  poison  is  doubtful.  In  Russia,  many  cases  of 
ichthyisraus  have  resulte(l  from  eating  both  the  fresh  and  preserved 
sturgeon  and  salmon  meat  that  are  affected  with  an  infectious  disease 
peculiar  to  the  fish.  In  Germany  and  other  parts  of  middle  Europe 
a  severe  form  of  gastritis  called  "  Barbencholera "  follows  the  eating 
of  sick  barbels. 

The  use  of  tainted  preserved  and  canned  fish,  eels,  oysters,  mussels, 
crabs,  lobsters,  and  the  like,  is  more  frequently  the  cause  of  symptoms  of 
poisoning,  however.  Brieger's  mytilotoxin,  the  active  poison  formed  in 
some  mussels,  and  the  eating  of  which  at  Wilhelmshaven  caused  several 
epidemics,  is  probably  developed  only  under  certain  favorable  conditions 
of  saprophytic  infection.  Devilled  crabs,  lobsters,  and  salad  have  also 
caused  severe  gastro-enteritis  because  of  contamination  with  germs  pro- 
ducing ptomains.  Oysters  have  been  accused  of  conveying  typhoid  in- 
fection {vide  p.  26).  The  si/mptoms  of  fish-  and  shellfish-poisoning  are 
variable.  Sometimes  marked  cerebro-spinal  manifestations  predominate, 
with  convulsions  and  paralysis.  Dryness  and  constriction  of  the  throat, 
dizziness,  labored  respiration,  disturbed  vision,  jerky  speech  or  aphonia, 
perhaps  rapid  pulse,  loss  of  coordination,  numbness,  coldness  of  the 
extremities,  dilated  pupils,  paresis,  collapse,  and  death  within  a  few 
hours,  may  ensue. 

Other  cases  have  a  pronounced  gastro-intestinal  or  choleraic  group 
of  symptoms,  with  nausea  and  vomiting,  pain,  tenesmus,  and  mucous  and 
bloody  stools.  In  some  of  them  marked  cutaneous  irritation  is  shown 
by  erythema,  great  heat  and  itching,  urticaria,  and  swelling.  Dyspnea, 
lividity,  and  sometimes  delirium,  have  also  been  noted.  The  progno- 
sis is  grave  in  many  instances.  The  treatment  is  similar  to  the 
above — namely,  emetics,  purgatives,  enemata,  and  lavage.  The  indica- 
tions are  to  be  provided  for  as  they  arise. 

GRAIN-   AND   VEGETABLE-POISONING. 

Ergotismus. — Epidemics  of  ergotism  have  resulted  from  the  con- 
tinued use  of  meal  made  from  contaminated  grains  grown  on  virgin  soil. 
The  parasite  (clavioeps  purpurea)  is  a  fungus  that  infests  rye  and  other 
grains ;  it  does  not,  however,  grow  readily  where  the  soil  is  well  culti- 
vated, and  epidemics  of  ergot-poisoning  are  much  less  frequent  than 
formerly,  if  we  except  certain  places  in  Spain  and  Russia.  According 
to  Robert,  three  poisonous  substances  are  found  in  the  ergot :  ergotinic 
acid,  sphacelinic  acid,  and  cornutin.  The  first  of  these  is  not  poisonous 
when  taken  into  the  stomach  ;  the  second  is  supposed  to  cause  gangrene ; 
and  the  last  produces  grave  effects  on  the  nervous  system,  and  is  found 
only  in  fresh  ergot,  hence  the  greater  prevalence  of  nervous  manifesta- 
tions in  sickness  that  breaks  out  soon  after  harvest. 

The  nervous  symptoms  are  remarkable  for  their  convulsive  character- 
istics (ergotismus  convulsivus).  Prodromes  of  Aveakness,  tingling  in  the 
extremities,  and  headache  may  exist  for  several  weeks  before  the  spasms 
come  on.  The  formication  increases,  and  cramps  and  contractures,  with 
flexed  wrists  and  extended  feet  and  toes,  seize  the  patient.  In  severe 
cases  epileptoid  convulsions  occur  and  may  prove  fatal.     Delirium  and, 


1286  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

in  very  chronic  cases,  dementia  may  supervene.  Recovery  is  slow,  and 
the  contractures  may  persist  for  some  time,  with  muscular  atrophy  and 
anesthesia.  In  some  interesting  instances  there  may  appear  nervous 
symptoms  resembling  locomotor  ataxia  (''  ergot  tabes  "),  owing  to  poste- 
rior spinal  sclerosis.     Abortion  results  in  pregnant  women. 

Gangrenous  ergotism  {t'njotisDius  c/a)i(j)'CP7iosi(><)  is  cliaracterized  by 
dry  gangrene  of  the  hands  and  feet,  usually  of  the  fingers  and  toes. 
Before  the  gradual  blackening  appears,  there  may  be  formication,  pain, 
spasm,  numbness,  and  coldness.  As  mortification  and  the  line  of  de- 
markation  progress,  the  parts  drop  off  bit  by  bit,  and  fever  may  attend 
the  sphacelation.  Pneumonia  (septic)  may  sometimes  complicate  this 
malady.  The  fatality  has  been  considerable  in  some  epidemics.  The 
treatment   of  ergotism   is  entirely  symptomatic. 

Maidismus  or  Pellagra. — This  is  a  chronic  nutritional  disturbance 
due  to  poisoning  from  eating  contaminated  corn-meal  bread.  The  dis- 
ease prevails  extensively  among  the  poorer  classes  in  Italy,  lloumania, 
JSpain,  France,  and  in  the  southern  portions  of  the  United  States. 

J-*(ifJi()h)(/i/. — Structural  changes  have  been  found  in  the  cord,  e.  g., 
degeneration  of  the  lateral  cokunns  in  the  dorsal  region  and  of  the  pos- 
terior columns  in  the  cervical  and  dorsal  regions,  and  fatty  degeneration 
and  ulceration  of  the  viscera. 

Etiology. — The  origin  of  the  infection  of  the  maize  is  said  to  be  bacil- 
lary,  the  latter  causing  putrefactive  or  fermentative  changes  in  the  fresh, 
moist  corn-meal,  with  the  ])roduction  of  ptomains.  A  second  theory  as- 
cribes the  disease  to  a  form  of  maize  intoxication.  Among  predisposivg 
caMScs  are  age,  most  cases  occurring  between  twenty  and  forty  years ; 
race,  negroes  being  more  susceptible  than  whites,  and  season,  the  spring 
furnishing  most  instances. 

The  symptoms  at  the  beginning  are  languor,  debility,  indigestion, 
anorexia,  vomiting,  and  occasionally  diarrhea.  This  is  soon  followed  by 
erythema,  pain,  and  roughness  of  the  skin.  Exfoliation  of  tlie  latter 
reveals  a  suppurating  surface.  The  erythema  aftects  usually  the  exposed 
parts,  beginning  on  the  backs  of  the  hands,  the  face,  neck,  and,  some- 
times, the  feet.  At  first  the  involved  areas  resemble  an  ordinary  sun- 
burn, later  becoming  darker  and  desquamating,  leaving  behind  some 
degree  of  pigmentation.  In  some  instances  bulht  and  vesicles  may  appear. 
Recurrences  are  common  and  lead  to  puffy  swelling  and  a  thickened,  in- 
durated condition  of  the  skin,  which  is  now  darker  in  color.  Finally, 
atrophy  of  the  skin  may  occur.  The  mucous  membrane  of  the  mouth 
and  throat  becomes  inflamed  with  shedding  of  epithelium,  leaving  behind 
a  raw  surface  so  that  mastication  is  painful.  In  severe  cases,  paresthesiae, 
spasms,  paraplegia  (p.  1153),  headache,  backache,  delirium,  and  a  suicidal 
mania  may  occur.  Idiocy  and  profound  cacliexia  may  result  from  numer- 
ous attacks. 

The  diagnosis  rests  on  the  association  of  the  cutaneous,  gastro-intes- 
tinal,  and  nervous,  as  well  as  other  general,  features. 

Course  and  Prognosis. — The  course  of  pellagra  is  slow  and  inter- 
rupted by  recurrences.  Generally,  the  prognosis  is  grave  in  the  severer 
forms  of  the  disease.  On  the  other  hand,  if  the  cause  be  removed,  and 
the  complaint  not  far  advanced,  amelioration  of  the  symptoms  and,  rarely, 
cure  is  prone  to  occur. 


OBESITY.  1287 

Treatment. — Prophylaxis  by  thorough  drying  and  careful  storing  of 
the  maize  is  to  be  aimed  at.  In  early  cases,  change  of  food  and  environ- 
ment may  prove  effective.  At  a  later  stage,  the  treatment  should  be 
directed  to  the  leading  symptomatic  indications.  No  methods  thus  far 
used  can  be  said  to  be  curative. 

Lathyrismus  is  an  intoxication  caused  by  the  seed  (used  in  the  form 
of  meal)  of  three  varieties  of  vetch  or  chicken-pea,  viz.  LathyruH  cicera, 
L.  sativus,  and  L.  clymenum,  or,  respectively,  red,  German,  and  Span- 
ish vetch.  The  meal  is  generally  mixed  with  that  obtained  from  other 
cereals.  Its  use  for  several  hundred  years  has  been  observed  to  cause 
leg-stiffness,  passing  into  a  transverse  myelitis,  with  sensory  and  motor 
paraplegia.  Spasticity  and  exaggerated  tendon-reflexes  may  remain 
for  some  time  after  the  paralysis  subsides.  Slight  fatty  degeneration 
was  noted  by  Cautain  in  excised  bits  of  muscle.  Very  chronic  cases 
may  die  in  paralysis,  from  the  toxic  eff"ects  of  the  poison,  which,  thus 
far,  has  not  been  separated. 

Mushroom-poisoning. — Though  not  so  common  as  formerly,  poisoning 
from  eating  non-edible  mushrooms  occurs  now  and  then,  owing  to  ignor- 
ance or  carelessness  in  gathering,  keeping,  and  cooking  them.  Fresh 
morels  are  poisonous,  while  those  that  have  been  dried  and  boiled  are 
not  so,  because  of  evaporation  or  solution  of  the  contained  poison. 

The  red  agaric  {amanita  muscaria),  on  account  of  the  poisonous 
alkaloid  muscarin  that  it  contains,  may  cause  very  severe  symptoms. 
These  are  nausea,  vomiting,  diarrhea,  hemoglobinemia,  hemoglobinuria, 
and  jaundice  {probably  hepatogenous)  in  the  case  of  fresh  morel-poisoning 
(Striimpell).  Tetanic  and  epileptiform  convulsions  give  a  slow  pulse, 
dilated  pupil,  disturbed  vision,  salivation,  coma,  and  death  in  the  gravest 
cases  of  red-agaric  intoxication,  in  addition  to  the  symptoms  of  gastro- 
intestinal irritation. 

The  treatment  is  symptomatic.  Emetics,  purgatives,  stimulants,  and, 
in  red-agaric  poisoning,  atropin,  for  its  physiologic  antidotal  eff"ect,  are 
usually  indicated. 


OBESITY. 

{Polysarcia  Adiposa  ;  Lipomatosis  Universalis.) 

Definition. — Corpulence,  or  the  presence  of  an  excessive  amount  of 
bodily  fat,  may  be  said  to  begin  to  take  the  form  of  a  disease  when  it 
becomes  an  inconvenience  or  impairs  the  bodily  functions.  Many  recent 
writers  regard  obesity  as  being  symptomatic  of  a  variety  of  underlying 
pathologic  conditions  rather  than  a  disease. 

Pathology. — The  chief  alteration  is  the  marked  and,  in  some  in- 
stances, colossal  increase  in  the  fat  deposit  throughout  the  body.  Not 
only  is  the  adipose  tissue  greatly  increased  in  localities  where  it  is  nor- 
mally found,  but  the  various  internal  organs  and  tissues  that  are  normally 
quite  or  nearly  free  from  fat  may  in  obesity  show  a  decided  fatty  infil- 
tration. The  round  fat  face,  "  double  chin,"  broad  and  deep  chest,  large 
waist,  thick  and  prominent,  sometimes  overhanging,  abdominal  panniculus 


1288  THE  IXTOXICATIOXS ;    OBESITY;   HEAT-STROKE. 

(uh'posus,  and  bulky,  cylindric,  and  apparently  shortened  extremities,  are 
familiar  appearances  /lostmorteni  as  -well  as  antet/iortoti. 

There  may  be  differences  in  the  number  and  size  of  the  fat-globules  in 
the  histoloiric  elements.  Thus,  in  the  plethoric  form  of  obesity  the  cel- 
lular fat-globules  are  larger  than  those  of  the  anemic  or  hydremic  form. 
The  heart  is  overlaid  with  fat.      Hypertrophic  dilatation  is  often  present. 

The  arteries  may  show  fatty  changes  and  chronic  endarteritis  with 
sclerosis.  The  veins  are  often  affected  Avith  varicosities.  In  nlethoric 
obesity  the  blood  shows  an  increase  in  specific  gravity  (1.062-1.070). 
The  erythrocyte  count  may  rise  to  6,000,000  per  c.mm.  Passive  con- 
gestion and  edema  of  the  luniks,  secondary  to  the  cardiac  weakness,  are 
common.  The  liver,  Jum/s,  and  kidneys  may  be  enlarged,  owing  to  fatty 
infiltration.      Chronic  interstitial  nephritis  may  form  a  complication. 

The  stomach  may  be  dilated,  and  often  shows  a  catarrh  of  the  mucosa. 

Pathogenesis. — Obesity  is  probably  dependent  on  a  disturbance 
of  cell-activity,  and  this  disturbance  of  metabolism  may  be  transmitted 
through  heredity  {vide  infra).  The  overuse  of  carbohydrates  leads  directly 
to  fat-increase.  The  consumption  of  proteins  may  also  result  in  a  fat- 
forming  non-nitrogenous  residue,  Avhich  if  not  oxidized  may  produce 
fatness  (see  also  Etiology). 

Ktiology. — Among  the  chief  predisposing  conditions  are  heredity, 
climate,  habit,  occupation,  temperament,  age,  and  sex.  Among  543  of 
my  cases,  in  which  the  family  history  was  noted,  heredity  was  distinctly 
traceable  in  60.7  per  cent.  Gout  was  either  in  association  or  occurred 
among  the  antecedents  in  43.2  per  cent,  of  these  cases  and  the  same  was 
true  of  "rheumatism"  in  35.5  per  cent.  The  condition  of  10  dates 
from  longer  or  shorter  periods  of  enforced  rest,  e.  g.,  following  accidents 
and  infective  diseases,  as  typhoid  fever  (in  4.7  per  cent,  of  543  cases). 
The  disease  dated  from  child-birth  in  16.2  per  cent,  of  the  cases  and 
from  marriage  (apart  from  child-birth)  in  4.8  per  cent,  among  437 
females.  The  menopause  has  little  if  any  influence.  Corpulence 
is  much  more  frequent  among  the  inhabitants  of  hot,  moist  climates, 
and  of  low  countries  of  the  temperate  and  arctic  regions.  Thus 
•it  is  commonly  observed  among  Orientals,  Dutchmen,  South  Pacific 
Islanders,  Southern  Italians,  and  certain  African  races.  Seden- 
tary habits  and  occupations  form  common  predisposing  factors.  The 
sluggish,  luxury-  and  rest-loving,  phlegmatic  temperament  also  favors 
an  abnormal  fat-deposition.  As  regards  the  age,  polysarcia  gen- 
erally makes  its  appearance  in  persons  of  advanced  middle  life,  between 
forty  and  fifty  years,  while  hereditary  obesity  dates  from  infancy  and 
early  childhood ;  in  women,  it  may  appear  at  puberty  and  between 
thirty  and  forty  years  of  age.  Women,  and  especially  Jewesses,  seem 
to  be  more  subject  to  corpulence  than  men.  Congenital  anomalies  and 
monstrosities  (idiots,  cretins,  acephali),  also  aneniics  and  hemiplegics, 
are  often  excessively  fat. 

The  exciting  causes  of  obesity  are  especially  the  ingestion  of  too  much 
fat-making  food,  the  intemperate  use  of  alcoholic  beverages,  especially 
beer,  ale,  and  porter,  with  or  without  deficient  exercise.  The  fat  may 
be  derived  from  an  excess  of  albumin,  fat,  or  carbohydrates.  An  ex- 
cessive diet  of  starches  and  sugars  acts  indirectly  as  a  fat-producer  by 


OBESITY.  1289 

lessening  the  oxidation  of  the  ingested  fat  and  of  the  fat  formed  from 
proteids,  because  the  carbohydrates  themselves  are  so  readily  oxidized. 

Symptoms. — Obesity  is  not  accompanied  by  any  bodily  symptoms 
at  first.  Except  some  inconvenience,  and  a  sense  of  burdensomeness 
during  walking  or  working,  nothing  may  be  complained  of  for  years. 
With  the  progressive  development  of  the  disease,  however,  and  particu- 
larly with  the  involvement  of  the  viscera,  subjective  manifestations 
increase  in  number  and  intensity.  Usually  the  earliest  troublesome 
symptom  is  hreatldessness  on  exertion,  due  to  a  weak  heart  and  to  the 
hampering  of  respiration  by  heavy  chest-walls  and  the  upward-crowded 
diaphragm.  In  plethoric  individuals  the  face  is  red  and  congested,  as 
are  also  the  mucous  membranes  (conjunctivae,  labiae).  In  anemic  subjects 
(usually  women)  the  skin  is  pale,  the  muscles  are  flabby  and  weak ;  the 
pulse  is  small  and  compressible,  and  dyspnea,  palpitation,  inclination  to 
rest  often  and  sleep  much,  and  dizziness  (symptoms  of  anemia  and  chloro- 
sis) are  manifested.  On  the  other  hand,  in  plethoric,  corpulent  subjects 
(usually  men)  the  muscles  are  firm  and  strong,  and  the  pulse  and  heart- 
beats vigorous ;  later,  however,  the  latter  becomes  weak  and  irregular. 
Brachycardia  is  not  infrequent.  The  signs  of  fatty  heart  {vide  p.  694) 
are  obtained  on  physical  examination.  Muscular  power  may  diminish 
and  irregular  fat  masses  (in  the  anemic  variety)  in  subcutaneous  tissue, 
are  obtained  on  physical  examination.  Muscular  power  may  diminish 
rapidly.  Intercurrent  acute  infections  (typhoid  fever,  pneumonia)  are 
badly  borne,  and  hyperpyrexia  is  usually  associated  with  them.  In  the 
anemic  form  the  blood-changes  are  of  the  chlorotic  type,  while  in  the 
plethoric  both  the  hemoglobin  percentage  and  erythrocytes  are  increased. 

The  liver  may  show  enlargement.  The  passive  congestion  of  the 
respiratory  mucous  membrane  is  often  signalled  by  cough  and  distressing 
dyspnea  and  attacks  of  asthma.  Profuse  sweating  is  common.  There 
may  be  polyuria  or  oliguria,  according  to  the  activity  of  the  skin  and 
kidneys  at  the  same  time.  Uric  acid  and  the  urates  are  usually  found 
to  be  increased. 

Symptoms  of  gastric  catarrh  and  gastrectasia  may  occur.  Great 
thirst  and  bulimia  are  noted  in  some  instances.  Constipation  may  be 
followed  by  chronic  diarrhea.  Sexual  desire  is  often  abated,  and  azo- 
ospermia is  not  rare.  Corpulent  women  often  suffer  from  uterine  dis- 
placement and  prolapse.  Amenorrhea,  sterility,  endometritis  (conges- 
tive), leukorrhea,  and  an  aggravated  climacteric  are  seen  in  obese  women 
also.  The  skin  is  often  irritated  (intertrigo)  by  the  excessive  sweating, 
and  by  the  friction  of  cutaneous  surfaces  in  the  folds  of  fat,  as  under  the 
breast,  at  the  abdominal  and  inguinal  folds,  and  around  the  scrotum  and 
labia.  This  may  be  followed  by  eczema.  Painful  excoriations,  pruritus, 
acne  rosacea,  and  alopecia  are  also  not  uncommon. 

There  are  types  of  adiposity  with  an  increased  assimilation  limit  for 
carbohydrates,  often  with  dry  skin,  subnormal  temperature  and  pulse, 
that  are  due  to  insufficiency  of  the  posterior  lobe  of  the  pituitary  body. 

Complications. — Hernia,  cardiac  asthma,  bronchitis,  pulmonary 
congestion,  edema,  arteriosclerosis,  albuminuria,  glycosuria,  anginal  at- 
tacks, Cheyne-Stokes  respiration,  cerebral  hemorrhage,  and  coma  may 
manifest  themselves  as  the  precursors  of  the  final  stage. 

Diagnosis. — This   is   not    difficult   in   most    cases.      Care    should 


1290  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

he  exercised  in  detecting  complications  and  sequela\  In  myx- 
edema the  skin  is  thick  and  inelastic,  and  the  physiognomy  mnch 
altered,  while  the  lips,  tongue,  nostrils,  and  mouth  are  all  thickened  by 
infiltration. 

The  prognosis  will  dei)end  upon  the  peculiar  features  of  each  indi- 
vidual case,  the  cause  and  its  removability,  and  upon  the  variety,  degree, 
symptoms,  and  prevailing  complications. 

Treatment. — Prophylaxis  is  important  in  the  earlier  years  of  those 
showing  an  hereditary  predisposition  to  corpulence.  The  fat-forming 
(farinaceous)  substances  must  be  diminished  in  the  dietary.  The  propor- 
tions of  fat  and  proteid  in  the  food  must  be  regulated  according  to  the 
amount  of  muscular  activity,  and  the  latter  should  be  encouraged  in 
fresh  air,  along  with  cool  bathing.  In  those  predisposed  to  poly- 
sarcia,  all  imprudences  in  eating  and  drinking  should  be  cautioned 
against,  and  the  quantities  of  various  articles  of  food  and  the  time  of 
eating  regulated.  Outdoor  sports  and  gymnastics  should  be  also  gauged 
accordingly. 

The  dietetic  treatment  of  confirmed  obesity  is  all-im))ortant.  In- 
separable from  this  is  the  stimulation  of  the  bodily  forces  that 
oxidize  and  destroy  the  fat.  These  two  means  are  utilized  in  the 
principal  methods  of  treating  obesity,  and  that  method  must  be  selected 
which  invigorates,  while  at  the  same  time  it  involves  no  weakening  of 
the  patient. 

The  principal  systems  of  dietary  are  those  known  by  the  names  of 
Banting,  Ebstein,  and  Oertel. 

In  "  Bantingism,"  sugars,  fats,  and  starches  are  greatly  reduced  in 
the  diet-list;  water,  however,  is  not  restricted,  and  vinous  and  spirituous 
liquors  are  permitted.  In  those  of  a  rheumatic  or  gouty  diathesis 
Banting's  heavy  proteid  and  alcohol  dietary  is  not  to  be  recommended. 
It  is  best,  I  think,  to  exclude  alcohol  in  most  cases,  owing  to  its  effect 
in  diminishing  tissue-oxidation  and  in  retarding  cell-metabolism.  This 
method  fails  to  secure  elimination  of  waste  products. 

In  Ebstein's  diet-list  more  than  double  the  amount  of  fat  and  car- 
bohydrates is  permitted  as  compared  with  Banting's  list,  whilst  the 
albuminous  substances  are  diminished.  Fat  is  freely  allowed,  as  this 
does  not  increase  stored  fat  (?),  but  tends  to  impair  the  appetite,  while 
sugar  and  potatoes  only  are  strictly  forbidden. 

Oertel  allows  more  fat  than  Banting,  but  less  fat  and  more  (about 
double  the  quantity)  proteids  and  carbohydrates  than  Ebstein.  The 
amount  of  free  water  permitted  daily  is  only  one  pint ;  about  one  pint 
additional  in  other  food  is  allowable.  This  method  is  adapted  to  cases 
of  obesity  with  feeble  hearts  and  of  the  anemic  form. 

OerteP  writes  :  "  The  body  stores  up  fat  if  more  than  118  grams  of 
albumin  and  259  grams  of  fat,  a  total  of  277  grams  (2894  calories),  are 
taken  in.  On  the  other  hand,  110  grams  of  albumin  and  600  grams 
of  starch,  a  total  of  710  grams  (2944  calories),  may  be  given  without 
producing  a  deposit  of  fat.  With  a  mixed  diet  the  limit  lies  near  118 
grams  of  albumin,  100  grams  of  fat,  and  368  grams  of  starch,  a  total 
of  586  grams  (2923  calories)."     His  diet-table  for  obesity  is  appended: 

1  Twentieth  Cent.  Pract.  of  Med.,  vol.  ii.,  pp.  698,  699. 


OBESITY.  1201 


Albumin.  Fat.  Carbohydrates.        Calorieu. 

Minimum 156  25  75  1180 

Maximum 170  45  120  1008 

Oertel  gives  a  special  diet-list  in  circulatory  disturbances. 

On  the  basis  of  Voit's  laws,  Striimpell  recommends  in  the  average 
cases  125  gm.  (4  oz.)  or  more  of  albumin,  40  gm.  (1{  oz.)  of  fat,  and 
150  gm.  (462  oz.)  of  starch.  Schwenniger's  rule  differs  from  Oertel's 
merely  in  the  forbidding  of  liquids  with  the  meals  and  in  permitting 
their  use  only  after  two  hours  have  elapsed.  Yeo's  diet-list  is  also  a 
useful  guide.  In  plethoric  obesity  a  judicious  rearrangement  of  the  food 
(some  increase  of  the  albuminoid  substances),  coupled  with  sufficient 
muscular  exercise  (walking,  horseback-riding,  bicycling,  rowing,  swim- 
ming, gymnastics),  accomplish  successful  reduction,  as  a  rule.  Moritz^ 
has  found  an  exclusive  milk  diet  extremely  effectual. 

Increasing  weakness  of  the  heart  with  an  impeded  circulation  natur- 
ally diminishes  the  excretion  of  water  by  the  cutaneous  and  renal  routes. 
In  such  cases  the  circulatory  system  must  receive  careful  attention  and 
the  consumption  of  fluid  must  be  limited.  If  evidences  of  anemia  be 
present,  the  amount  of  liquid  may  be  much  restricted  and  the  fat-forming 
dishes  rigidly  excluded.  "  The  hydremic  form  must  be  opposed  by  the 
ingestion  of  an  abundance  of  albuminoid  material,  of  fat-producing  sub- 
stance, and  the  hydrocarbons  "  (Oertel).  Sabbe  and  Furet^  recommend 
a  regimen  from  which  salt  is  entirely  eliminated,  in  connection  with  the 
ingestion  of  fluids  in  abundance.  The  organism,  in  order  to  maintain  its 
molecular  composition,  rejects  the  excess  of  fluid,  which  carries  off  excre- 
mentitious  products.  Under  any  system  of  dietetic  treatment  the  patient 
should  be  weighed  accurately  and  frequently,  and  the  food-limit  be  dim- 
inished or  modified  according  to  the  results.  The  food  may  be  weighed 
and  measured  at  first,  but  the  patient  soon  learns  to  estimate  by  bulk 
the  requisite  quantity  of  each  substance. 

The  following  dietary  illustrates  what  may  be  ordered  in  some  cases  : 

Morning  Meal. — Fine  wheat-bread,  1^  ounces  (40.0)  ;  a  soft-boiled 
egg ;  milk,  1  ounce  (32.0) ;  sugar,  77  grains  (4.9) ;  coffee,  4^  ounces  (136.0). 

Noon  Meal. — Soup,  3  ounces  (96.0);  fish,  3  ounces  (96.0);  roast  or 
boiled  beef,  veal,  or  game  or  poultry,  6  to  8  ounces  (192.0-256.0) ;  green 
vegetables,  1^  ounces  (48.0) ;  bread,  1  ounce  (32.0);  fruit,  3  or  4  ounces 
(96.0--128.0)l  no  liquid  (or  only  4  or  5  ounces— 120.0-148.0  c.c— of 
very  light  wine). 

Afternoon  Meal. — Sugar,  77  grains  (4.9);  coffee,  4  ounces  (128.0); 
milk,  1  ounce  (32.0);  occasionally  bread,  1  ounce  (32.0). 

Evening  Meal. — Caviare,  ^  ounce  (10.6) ;  one  or  two  soft-boiled 
eggs;  beefsteak,  fowl,  or  game,  5  ounces  (160.0) ;  salad,  1  ounce  (32.0); 
cheese,  1  dram  (4.0)  ;  bread,  rye  or  bran,  J  ounce  (16.0)  ;  fruit  or  water, 
4  to  5  ounces  (120.0-148.0). 

Galisch  recommends  the  simple  measure  of  reducing  the  amount  of 
food  taken  after  midday,  so  as  to  lessen  nourishment  at  night,  out  of 
which  to  build  fat. 

The  mechanical  treatment  (to  increase  oxidation),  by  exercise,  is  to  be 
used  in  conjunction  with  the  dietetic.     The  form  of* the  exercise,  and 

1  Miinch.  med.  Woch.,  1908,  xxx.,  p.  569. 

2  Revue  de  Medicine,  1905,  No.  9,  p.  674. 


1292  THE  ISTOXICATIOyS ;    OBESITY ;   HEAT-STROKE. 

also  the  time  and  frequency,  must  be  adjudged  for  each  case  {vide  supra). 
When  cardiac  dihitation  and  myocardial  degeneration  (fatty)  are  the 
cause  of  symptoms  of  precordial  distress,  dyspnea,  and  palpitation, 
resort  may  be  had  to  Oertel's  system  of  graduated  walking  on  the  level 
or  climbing  along  "health  paths"  {vide  Fatty  Overgrowth,  p.  694). 
Or.  the  well-known  Nauheim  or  Schott  treatment  may  be  used.  Great 
care  must  be  exercised  in  prescribing  the  mechanical  treatment  in  obese 
persons  who  have  atheromatous  vessels. 

Allavd  ^  recommends  the  employment  of  a  vibrating  ball  controlled 
by  an  electric  motor  in  circumscribed  obesity. 

The  medicinal  treatment  is  neither  satisfactory  nor  successful.  Caus- 
ative or  associated  conditions — e.  g.  gout — may  present  special  thera- 
peutic indications.  The  juice  of  the  phytolacca  berry  may  reduce  the 
weight,  but  is  harmful. 

Recently,  the  use  of  thyroid  extract  has  come  into  favor.  Leichten- 
stern,  Wendelstadt,  Ewald,  and  others  have  reported  success  in  a  number 
of  cases,  especially  in  those  exhibiting  the  anemic,  flabby,  "  myxede- 
matoid  "  form  of  obesity.  The  loss  of  weight  was  from  2  to  3  pounds 
(1-1.5  kgms.)  in  one  week,  and  as  high  as  20  pounds  in  two  to  four 
weeks.  In  two  of  my  own  cases  belonging  to  this  category  the  use  of 
thyroid  extract  (desiccated)  in  small  doses  (gr.  j — 0.0648,  t.  i.  d.)  caused 
a  progressive  loss  of  weight  at  the  rate  of  4  and  6  pounds  per  week  re- 
spectively, without  injury  to  the  general  health.  In  cases  in  which 
dietetic  measures  with  exercise  fail,  thyroid  insufiiciency  should  be  sus- 
pected, and  thyroid  treatment  instituted.  Thyroidin,  the  active  principle 
of  the  thyroid  gland,  as  shown  by  Baumann  and  Ross,  and  iodothyrin 
give  results  that  are  perhaps  as  good  as  those  of  thyroid-feeding.  Symp- 
toms of  thyroidism  are  the  signal  for  a  reduction  in  the  dosage  of  thyroid 
extract  {vide  Myxedema,  p.  502).  Hematinics  are  indicated  in  the 
anemic  variety  of  obesity.  Finally,  the  treatment  must  be  adapted  to 
the  special  case,  and  also  varied  from  time  to  time  to  meet  indications 
and  complications  as  they  arise. 

ADIPOSIS    TUBEROSA    SIMPLEX. 

The  writer  has  described  a  condition  which  resembles  adiposis  dolorosa 
(Dercum's  disease)  clinically,  but  differs  from  the  latter  in  that  it  is  depend- 
ent upon  general  obesity,  and  is,  therefore,  amenable  to  treatment. 

"  Circumscribed  fat  masses  appear  in  the  subcutaneous  tissues;  they 
form  distinct,  moderately  dense,  slightly  movable,  somewhat  flattened 
tumors,  ranging  in  size  from  a  bean  to  that  of  a  lien's  egg.  Their  number 
varies  all  the  way  from  one-half  dozen  to  two  dozen  or  more.  These 
moderately  firm  fat-nodules  are  not  distributed  over  the  entire  body,  but 
in  some  cases  are  confined  to  the  extremities,  particularly  the  lower,  and 
in  others  to  the  abdomen.  The  tumor  masses  show  no  tendency  to  fuse 
together,  and  are  not  elevated  above  the  surrounding  surface ;  the}'^  are 
sensitive  to  the  touch,  and  may  be  the  seat  of  pain,  which  varies  in  in- 
tensity within  rather  wide  extremes,  being  moderately  severe  and  dis- 
tressing in  rare  cases  and  trivial  or  even  absent  in  the  majority  of  in- 
stances. The  lymphatic  glands  are  not  involved,  and  the  skin  remains 
soft,  flexible,  and   non-adherent.      The  mental  processes  are  normally 

'  Bevm  de  Therapeutic,  1905,  No.  6,  p.  191. 


HEA  T-STROKE.  ]  293 

active,  and  also  the  muscles;  asthenia  is  not  present,  and  there  is  no 
more  indisposition  to  physical  exertion  than  is  observed  in  cfises  of" 
obesity,  as  a  rule.  The  knee-jerks  are  present,  and  the  cutaneous  sen- 
sibility is  unaltered,  in  some  cases  at  least.  TIk;  rnammje  and  abdominal 
panniculus  adiposis  may  be  overhanging  or  pendulous,  })ut  not  in  all 
cases.  It  is  an  uncommon  condition,  since  it  was  noted  in  only  4  out  of  • 
a  total  of  324  cases."  ^ 


HEAT-STROKE. 

( Sunstroke ;  Insolation ;   Thei'mic  Fever ;  Heat-exhaustion ;  Heat-prostration.) 

Definition. — A  diseased  condition  the  effect  of  exposure  to  exces- 
sive heat. 

Pathology. — Rigor  mortis  is  marked  and  comes  on  early.  The  high 
temperature  of  the  cadaver  accelerates  the  putrefactive  changes,  which 
also  appear  early.  There  is  considerable  venous  engorgement  of  the 
brain  and  of  the  cerebral  and  spinal  membranes ;  also  of  the  lungs, 
spleen,  and  conjunctiva.  The  blood  is  fluid  and  dark,  and  the  corpus- 
cles are  crenated  and  do  not  tend  to  form  rouleaux.  Parenchymatous 
changes  in  the  liver  and  kidneys  may  be  found.  Rigid  contraction  of 
the  left  ventricle  is  a  notable  feature,  while  the  right  ventricle  is  usually 
dilated  with  blood.  Van  Gieson's  recent  report  of  the  cellular  pathology 
of  the  cerebro-spinal  system  in  3  cases  of  sunstroke  in  New  York 
shows  an  acute  parenchymatous  degeneration  of  the  neurons  of  the 
whole  neural  axis  similar  to  that  of  "  a  species  of  auto-intoxication."' 

Ktiology. — Anything  that  lessens  bodily  resistance  to  external  high 
heat  predisposes  to  heat-stroke.  Thus,  privation,  unsanitary  surround- 
ings, fatigue  of  body  or  mind,  emotional  excitement,  worry,  and  exces- 
sive fretfulness,  overeating,  indulgence  in  alcoholics  (especially),  clothing 
suitable  for  cold  weather,  worn  on  hot  days,  and  previous  attacks  of  sun- 
stroke, are  all  conducive  to  heat-stroke  on  exposure  to  high  temperature. 
Males  are  affected  more  often  than  females,  and  the  condition  is  rare  in 
childhood.  The  colored  race  is  more  resistant  than  the  white  to  the  effect 
of  the  direct  solar  rays. 

Sunstroke  occurs  in  persons  (on  land)  working  hard  under  the  direct 
rays  of  the  sun,  in  an  atmosphere  that  is  very  hot  and  humid,  still,  and 
sultry.  Soldiers  on  the  march  and  heavily  accoutered,  masons,  brick- 
layers, hod-carriers,  roofers,  drivers,  farmers,  and  other  out-door  laborers 
are  particularly  subject  to  insolation. 

Heat-stroke  and  thermic  fever  are  terms  more  appropriately  applied 
to  those  similarly  aff"ected  in  midsummer  while  working  in  places  not 
exposed  to  the  sun,  but  yet  close,  confined,  and  excessively  hot,  such  as 
glass-works,  foundries,  ocean  steamers,  stoke-holes,  boiler-rooms,  steam 
laundries,  sugar-refineries,  kitchens,  and  the  like. 

Heat-exhaustion  (prostratio  thermica)  is  caused  under  similar  condi- 
tions as  the  preceding,  but  manifests  dissimilar  eflfects. 

The  majority  of  the  cases  of  sunstroke  occur  between  2  and  5  P.  M., 
although  heat-stroke  and  heat-exhaustion  may  occur  at  night  as  late  as 
10  or  11  p.  M.,  as  among  bakers,  night  engineers,  and  hotel  cooks. 
1  Amer.  Jour.  Med.  ScL,  March,  1908,  by  the  \7riter. 


1294  THE  ISTOXICATIONS ;    OBESITY ;   HEAT-STROKE. 

The  direct  cause  of  the  symptoms  of  sunstroke,  heat-stroke,  or  heat- 
prostration  is  the  action  of  the  excessive  heat  upon  the  lieat-centors,  or 
upon  the  vasomotor  center  or  nerves  (II.  C.  Wood),  the  former  of  wliicli, 
if  paralyzed,  produces  ^'thermic''  or  "■  heat-fever, '^  while  the  latter,  if 
paralyzed,  produces  heat-exhaustion.  Lambert  and  A^an  Gieson,^  after  a 
clinical  and  pathologic  study  of  805  cases,  hold  to  the  view  that  the  im- 
mediate basis  of  sunstroke  is  autotoxic,  with  heat  only  as  a  contributing 
cause.  Sambron  contends  for  the  infective  nature  of  heat-stroke  and 
thus  explains  its  endemic  and  epidemic  proclivities. 

Symptoms. — Two  forms  of  heat-  or  sunstroke  are  usually  met  with  : 
(1)  The  aspliyxial  or  apoplectic  form  ;  (2)  the  hyperpyrexial  form.  Flint 
believes  that  the  majority  of  the  cases  of  sunstroke  are  combinations  of 
apoplexy  and  exhaustion.  Tallin  puts  all  cases  of  insolation  into  two 
classes :  the  first,  sthenic  or  asphyxial,  corresponding  to  our  hyperpy- 
rexial or  congestive  variety ;  the  second,  asthenic  or  syncopal,  corre- 
sponding to  our  heat-exhaustion.  Mixed  forms  may  occur  quite  fre- 
quently, the  most  prominent  symptoms  being  referable  to  the  organs 
suffering  the  most,  as  the  cerebro-spinal  system,  heart,  lungs. 

Heat-apoplexy  [asphyxial  sunstroke)  is  probably  the  least  frequent 
form.  There  may  be  sudden  premonitions,  or  dizziness,  chromatopsia, 
throbbing  headache,  cessation  of  sweating,  or  dyspnea.  Sometimes 
the  patient,  while  at  work  in  the  sun,  suddenly  falls  unconscious,  a  few 
convulsions  may  occur,  and  in  this  state  he  may  die  with  symptoms  of 
cardiac  failure.  More  often,  insensibility  is  not  so  profound  as  complete 
coma,  there  is  much  restlessness,  epigastric  "  cramp"  may  be  complained 
of,  also  a  sense  of  thoracic  oppression,  and  occasionally  there  are  nausea 
and  vomiting.  The  headache  may  be  intense,  the  face  is  flushed,  the 
pulse  is  rapid  and  full,  the  temporal  and  carotid  arteries  are  bounding, 
the  breathing  may  be  labored  and  stertorous,  the  pupils  are  contracted. 
The  skin  is  hot  and  dry,  and  may  show  petechige.  The  tongue  is  coated. 
A  wild  delirium  has  been  observed  in  some  cases.  The  temperature  may 
be  subnormal,  and  is  not  higher  than  102°  F.  (-38.8°  C)  in  many  in- 
stances. In  others,  a  mild  degree  of  thermic  fever  may  be  associated 
with  the  apoplectic  condition,  the  thermometer  registering  104°-106°  F. 
(4U°-41.1°  C.).  In  fatal  cases  the  coma  becomes  deeper  and  deeper,  the 
pulse  more  rapid  and  feeble,  and  Cheyne-Stokes  respiration  may  precede 
the  termination.  A  "  mousey  "  odor  about  the  body  has  been  noted.  In 
favorable  cases  the  temperature  falls  to  normal  by  lysis  in  three  or  four 
days,  consciousness  being  rapidly  regained  at  the  same  time. 

The  liyperpyrexial  variety  comprises  the  numerous  cases  of  marked 
sunstroke  that  resemble  the  preceding  type,  with  the  addition  of  an 
intensely  high  temperature  {thermic  fever).  The  patient  may  suddenly 
become  comatose  and  die  in  an  asphyxiated  condition,  witli  a  temperature 
as  high  as  110°-115°  F.  (43.3°-46.1°  C.)  or  even  higher. 

Sometimes  prodromes,  as  an  anorexia,  progressively  increasing  phys- 
ical weakness,  cramp-like  abdominal  pains,  irritability  and  restlessness, 
vertigo,  colored  and  blurred  vision,  lack  of  sweating,  a  "bursting" 
headache,  and  an  irritable  bladder  may  exist  for  several  days.  A 
subconscious  (automatic)  state,  in  which  the  patient  may  be  unaware 
of  his  surroundings,  although  walkincr  or  even  Avorking,  may  be  noted 
^Med.  News,  July  24,  1897. 


HEAT-STROKE. 


129; 


for  hours  before  he  is  stricken  down.  The  onset  is  marked  by  hy- 
perpyrexia ;  the  skin  is  hot,  burning,  dry,  sometimes  flushed  and  red, 
and  sometimes  cyanotic  and  clammy;  the  eyes  are  suffused  or  "staring 
and  filling,"  with  pin-point  pupils.  There  is  a  full,  rapid,  and  non- 
compressible  pulse,  and  coma  may  be  present.  Clonic  spasms  may 
alternate  with  either  muscular  rigidity  or  flaccidity.  Delirium,  moan- 
ing, jactitation,  and  explosive  expiratory  sounds  may  occur.  There  is 
frequently  incontinence  of  both  feces  and  urine.  The  temperature  is 
very  high  in  most  of  the  cases,  varying  from  105°  to  112°  F.  (40. -S- 
44.4°  C.).^  The  pulse-rate  varies  with  the  temperature,  from  90  to 
160  beats  per  minute.  The  respirations  are  also  increased  to  24—50 
per  minute.     Many  of  the  alarming  symptoms,  including  the  high  fever 

C. 


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AUGUST 

Fig.  81.— Chart  of  a  case  of  sunstroke.    C.  B.,  aged  twenty-nine  years.    Recovery. 

unconsciousness,  cyanosis,  dyspnea,  and  convulsions,  may  greatly  subside 
during  and  after  the  use  of  the  cold  bath.  Secondary  exacerbations  occur 
for  a  few  days  before  convalescence  is  established  in  the  favorable  cases 
(vide  chart  Fig.  81).  Some  patients  never  rally  and  die  in  a  state  of 
asphyxia.  Retention  of  urine  (suppression)  is  observed  at  times,  and  par- 
ticularly in  those  accustomed  to  the  use  of  alcohol.  Leukocytosis  is  noted, 
besides  the  crenation  of  the  erythrocytes. 

1  Lambert  [loc.  cit.)  reports  a  case  in  the  N.  Y.  Hosp.  of  117.8°  F.  (47.6°  C). 


129(3  THE  ISTOXICATIOyS ;    OBESITY ;   HEAT-STROKE. 

Fatal  complirations  of  sunstroke  are  pneumonia,  meningitis,  uremia, 
and  cardio-respiratory  paralysis. 

Heat-prostration  or  /i('a(-i'.r/iausti<>tt  may  come  on  gradually  or  sud- 
denly, ^vltll  prodromal  symptoms  (dizziness,  faintness,  headache,  nausea, 
thirst,  drowsiness,  yawning,  epigastric  or  lumbar  pains,  numbness,  and 
tingling  of  the  hands  and  feet).  These  are  followed  l)y  coldness,  clam- 
miness, and  pallor  of  the  surface,  marked  muscular  weakness  and  pros- 
tration, a  small,  febrile,  rapid  pulse,  sighing  breathing,  syncope,  and  col- 
lapse in  the  iiraver  cases.  The  temperature  at  first  is  subnormal  (9.')°  to 
97°  F.— 3o°"to  86.1°  C),  though  mild  thermic  fever  of  from  100°  to 
102.5°  F.  (37.7°-39.1°  C.)  may  be  present.  Consciousness  is  rarely 
completely  absent.  Recovery  usually  takes  place  within  one  or  two  days, 
and  in  milder  cases,  under  prompt  and  appropriate  treatment,  within  a 
few  hours.  In  a  few  cases  of  extreme  prostration  in  weakly  persons  death 
may  ensue  from  cardiac  failure. 

Sun-trauhiatism  (Manson)  describes  a  condition  characterized  by  sud- 
den death  from  paralysis  of  the  heart  or  respiration  after  exposure  to  the 
sun.  Siriasis  occurs  only  in  high  temperatures,  and  is  characterized  by 
pulmonary  congestion,  coma,  and  hyperpyrexia. 

The  seciuela;  of  heat-stroke  are  quite  interesting.  Osier  relates  the 
case  of  a  patient  who  ''was  subse([uently  so  sensitive  to  temperatures  in 
the  neighborhood  of  7o°  F.  (23.8°  C.)  that  he  lived  comfortably  only  in 
the  cellar,  and  finally  sought  refuge  in  Alaska." 

Chromatopsia,  severe  headaches,  irritability  and  ugliness  of  temper, 
or  delirium  may  occur  in  some  patients  as  soon  as  Avarm  weather  sets  in, 
and  may  be  due  occasionally  to  chronic  meningitis  (Wood). 

Heat-cramps  may  develop  among  those  exposed  to  high  artificial  heat 
while  doing  muscular  work — e.  ^.,  stokers  on  steamships,  workers  in  iron 
foundries.  It  is  essentially  a  continuous  fibrillary  contraction  of  the 
muscles,  especially  those  of  the  calves.  The  condition  is  attributable  to 
an  acute  degenerative  process  in  the  muscles  (Edsall).  Painful,  tonic 
spasms  of  the  muscles,  more  particularly  of  the  forearms  and  legs,  occur 
in  paroxysms,  lasting  from  one-half  to  one  minute.  The  duration  of  an 
attack  of  heat-cramps  is  usually  less  than  24  hours,  and  it  is  followed  by 
muscular  soreness  and  slight  exhaustion. 

Diagnosis. — Bearing  in  mind  the  characteristic  differences  that  are 
outlined  above  between  sunstroke  (asphyxial  and  hyperpyrexial  forms) 
and  heat-exhaustion,  the  diagnosis  is  not  difficult.  The  history  and  cir- 
cumstances attending  the  seizure  are  also  important  factors.  From  other 
affections,  as  nmite  alcoholism,  meningitis,  urnnia,  and  cerebral  apoplexy/, 
the  differentiation  is  readily  made  by  noting  the  previous  history,  mode 
of  attack,  presence  or  absence  of  thermic  fever,  state  of  consciousness, 
urine,  skin,  pupils,  pulse,  respiration,  and  nervo-muscular  apparatus. 
Malaria  c:in  be  excluded  by  a  blood  examination. 

Prognosis. — This  is  usually  favorable  in  cases  of  heat-prostration 
and  heat-cramps.  It  is  less  so  in  sunstroke,  but  in  all  cases  it  depends 
on  the  severity  of  the  stroke,  the  previous  health  and  habits  of  the  patient, 
the  complications,  and  the  promptness  and  facility  of  the  treatment.  In 
general,  cases  in  which  unconsciousness  lasts  from  24  to  48  hours  termi- 
nate fatally.  The  mortality-rate  during  a  prolonged  period  of  hot  and 
humid  weather  may  be  very  high,  ranging  from  15  to  50  per  cent.     In. 


IlIUT-STROKE.  1297 

New  York  City,  during  tlio  week  ending  August  15,  1896,  out  of  a  total 
number  of  1810  deaths,  648  were  reported  as  due  to  sunstroke  (Lambert).' 

Treatment. — Prophylaxis. — Tliis  is  big}ily  imperative  in  hot,  sultiy 
weather,  i)i  whieh  persons  must  work  in  the  sun  or  in  poorly-ventilated 
and  highly-heated,  closed  places.  Workmen  should  be  taught  ;ind  warned 
privately  and  publicly,  as  through  the  medium  of  the  j)ress  and  Health 
Board  circulars,  to  take  extra  precautions  during  hot  weather,  to  woi-k 
and  sleep  in  as  well-ventilated  rooms  as  possible,  and  to  secure  artificial 
ventilation,  if  necessary.  They  should  live  regular  and  temperate  lives, 
avoiding  alcohol  and  heavy  eating ;  oat-meal  water  should  be  drunk, 
light-weight  and  light-colored  clothing  should  be  worn,  and  the  direct 
rays  of  the  sun  should  be  avoided  as  much  as  possible.  The  condition 
of  the  skin  should  be  watched  and  care  taken  that  sweating  continues 
freely.  Shelter  or  rest  should  be  sought  at  once  if  sweating  stops.  Cool 
wet  cloths  or  green  leaves  should  be  worn  inside  a  light  straw  hat,  and 
sometimes  it  may  be  necessary  for  employers  to  shorten  the  hours  of  labor 
during  the  hottest  part  of  the  day. 

Treatment  of  the  Attack. — Cases  of  ordinary  heat-prostration  seldom 
require  much  treatment  beyond  the  removal  of  the  patient  to  the  shade 
of  a  comparatively  cool  place,  loosening  all  constricting  clothing,  spray- 
ing with  cool  water,  the  use  of  ammonia-  or  amyl-nitrite-inhalations,  and 
of  the  aromatic  spirits  of  ammonia  or  spiritus  glonoini  by  the  mouth. 
If  the  temperature  is  subnormal  and  collapse  threatens,  a  hot  bath  is 
advisable.  Strychnin  and  digitalis  may  be  used  for  a  day  or  two  to 
combat  the  nervo-muscular  weakness. 

Heat-stroke,  especially  the  hyperpyrexial  cases,  must  be  promptly 
treated  by  the  application  of  the  ice-bath  (ice  floating  in  a  tub  of  water), 
temperature  about  40°  F.  (4,4°  C),  or  by  rubbing,  by  the  cold  pack, 
pr  by  the  needle-spray  with  iced  water  for  the  purpose  of  overcoming  the 
vasomotor  depreciation. 

In  the  aspJiyxial  cases  venesection  is  frequently  indicated.  The 
subcutaneous  or  intravenous  injection  of  physiologic  salt  solution  (F. 
A.  Packard)  may  be  a  valuable  procedure  in  many  cases.  External 
stimulation  should  be  applied  to  the  precordium  by  mustard  and  to 
the  feet  by  hot  bottles,  and  hypodermic  injections  of  nitroglycerin, 
strychnin,  atropin,  brandy,  camphor,  or  ether  are  useful.  Ice  should 
be  rubbed  over  the  head  constantly.  Care  should,  however,  be  taken 
to  see  that  the  temperature  is  not  reduced  too  far.  A  temperature  of 
about  102°  F.  (38.8°  C.)  should  be  the  signal  for  cessation  of  the  ice- 
bath,  and  for  the  removal  of  the  patient  to  a  cot,  where  he  is  to  be  rubbed 
dry  and  allowed  to  rest  until  an  exacerbation  of  fever  indicates  the 
reapplication  of  the  cooling  measures.  Ice-water  enemata,  with  or  with- 
out brandy,  are  often  useful  adjuvants.  The  needle-spray  of  cold  water 
is  an  excellent  nervous  stimulant  as  well  as  antipyretic  It  is  given 
while  the  patient  lies  on  a  Kibbee  or  netting  cot,  or  on  a  cot  covered 
with  a  rubber  sheet  so  arranged  as  to  drain  into  a  pail  or  trough.  Inter- 
nal antipyretics  are  seldom  well  absorbed,  and  their  depressant  action 
is  so  well  known  as  to  discom-age  their  use  in  place  of  hydrotherapy. 
Hutchinson,  Coplin,  and  Bevan  recommend  highly  the  use  of  morphin 
to  control  the  convulsions  of  heat-stroke.     Chloroform  has  also  been  ad- 

82  1  Loc.  cit. 


1298  THE  IXTOXICATIOXS ;    OBESITY;   HEAT-STROKE. 

vised.  Artificial  respiration  in  the  asphyxial  cases,  kept  up  until  other 
measures  and  stimulants  have  time  to  act,  may  be  the  means  of  saving 
life. 

After  the  reduction  of  the  hyperpyrexia  the  jiatient  should  be  lightly 
covered  on  a  cot  placed  in  a  cool  place.  An  ice-cap  should  be  applied 
to  his  head,  and  small  pieces  of  cracked  ice  may  be  given  to  allay  gas- 
tric irritability,  with  calomel  to  open  the  bowels  if  necessary.  Albumin- 
water,  skimmed  milk,  buttermilk,  unfermented  grape-juice,  junket,  and 
the  like  may  be  given  for  several  days  preparatory  to  the  ingestion  of 
heavier  food.  If,  as  sometimes  happens,  free  diaphoresis  does  not  come 
on  after  the  reduction  of  most  of  the  fever  and  the  stimulating  treatment, 
a  hot  bath  may  be  given,  and  perhaps  aided  by  the  hypodermic  injec- 
tion of  pilocarpin  in  urgent  cases.  Sequelce  must  be  treated  on  general 
principles. 

The  increased  susceptibility  to  repeated  attacks  of  insolation  (after  the 
first  attack)  makes  it  necessary  to  avoid  exposure  to  heat  ever  after, 
and,  if  possible,  to  seek  a  cooler  climate  during  the  hot  months. 


1 


NDEX 


Abdominal  aorta,  aneurysm  of,  732 
rheumatism,  323 
typhus,  17 
Abducens  nerve,  1097 
Abductor  paralysis,  1108 
Abiotrophy,  1151 
Abortive  pneumonia,  121 
Abscess,  atheromatous,  719 
in  lobar  pneumonia,  106 
of  brain,  1181 
of  liver,  922 

and  malaria,  differentiation,  926 
of  lungs,  573 
of  mediastinum,  611 
perinephric,  1046 
retropharyngeal,  765 
subphrenic,  920 
tonsillar,  755 
Absence  of  heart,  716 

of  interventricular  septum  of   heart, 
716 
Acardia,  716 
Acarus  scabiei,  385 
Acetic-acid    and    potassium-ferrocyanid 

test  for  albuminuria,  990 
Acetone  in  urine,  998 
Acetonuria,  998 
Achylia  gastrica,  825 
Acoria,  777 
Acromegaly,  1244 
Acroparesthesia,  1253 
Actinomycosis,  304 
bacteriology,  304 
clinical  history,  304 
course,  303 
cutaneous,  305 
diagnosis,  305 
historic  note,  304 
intestinal,  305 
modes  of  infection,  304 
oral,  304 
pathology,  304 
prognosis,  306 
pulmonary,  305 
treatment,  306 
Addison's  disease,  490 
diagnosis,  492 
etiology,  491 
pathology,  490 
prognosis,  493 
symptoms,  491 
treatment,  493 
Adductor  paralysis,  1109 
Adenitis,  tuberculous,  general,  245 


Adenitis,  tuberculous,  local,  243 

Adenoid  vegetations,  758 
Adenoma  of  kidney,  1049 

of  liver,  944 

of  pancreas,  957 
Adhesive  pericarditis,  624 

peritonitis,  967 

pleurisy,  601 
Adiposis  cerebralis,  1186 

dolorosa,  1247 

tuberosa  simplex,  1292 
Afebrile  typhoid  fever,  32,  45 
Agaraphobia,  1242 
Agnosia,  1179 

tactile,  1180 
Agraphia,  1168 
Ague,  fever  and,  342 
Ague-cake,  343 
Ainhum,  1256 
Air  in  pericardium,  627 
Albinism,  Virchow's,  565 
Albumin  in  urine,  987 
Albuminometer,  Esbach's,  990 
Albuminuria,  987 

forms  of,  987 

tests  for,  988 
Albuminuric  retinitis,  1091 
AJbumose  in  urine,  990 
Albumosuria,  990 

myelopathic,  991 
Alcohol  in  diphtheria,  162 
Alcoholic  cirrhosis  of  liver,  932 

inebriety,  1268,  1270 

insanity,  1270 

melancholia,  1270 

paralysis,  1270 
Alcoholism,  1268 

acute,  1268 

chronic,  1268,  1270 
Alexia,  1177,  1178 
Alimentary  glycosuria,  414,  421 

tract,  syphilis  of,  397 
tuberculosis  of,  276 
Alkapton  in  urine,  1005 
Alkaptonuria,  1005 
Allorrhji^hmia,  708 
Alveolar  ectasis,  564 
Amaurosis,  hysteric,  1231 

uremic,  1010 
Amaurotic  famity  idiocj',  1248 
Amblyopia,  toxic,  1092 
Amebiasis,  334 

Amebic  dj'sentery,  334.     See  also  Dys- 
entery, amebic. 

1299 


1300 


INDEX. 


Aniiinia,  117S 

Amnionienua  in  pyelitis,  1041 
Aiiurha  ilysonti'riiv,  334 
Ainphistonuun  hominis,  3G1 
Aimisia,  1178 

Ainvloid  ilogonoration  of  heart,  700 
"  (if  spleen,  94S    • 
disease  i)f  liver.  91. "i 
infiltratii)n  of  liver,  91o 
kidney.  101'2 

material,  tests  and  eharactoristics  of, 
910 
Amyotonia  congenita,  1260 
Aniyotroi)hia  siiinalis  progressiva,  1142 
Ainyolroiiliic  lateral  sclerosis,  1143 
AnadichroUc  venous  pulse,  659 
Anaemia     mfantum     pseudo-leukaemica, 

488 
Anemia,  459 
aplastic,  472 
Biennier's,  465 
brickniakers".  376 
chlorotie,  460.     See  also  Chlorosis. 
essential,  460 
idiopathic.  465 
mountain,  .376 
of  brain,  1160 
of  liver,  909 
of  spinal  cord,  1126 
pathology.  459 
primary,  460 

progressive  pernicious,  465 
blood-examination  in,  469 
diagnosis,  470 

differential.  470 
etiology,  466 
pathology.  465 
prognosis.  470 
sjinptoms,  467 

gastro-intestinal,  468 
nervous,  468 
respiratory,  468 
treatment,  471 
secondary,  472 
blood  in,  472 

from     excessiAe     albuminous     dis- 
charges. 474 
from  hemorrhage,  473 
from  inanition,  474 
from  toxic  agents,  474 
prognosis,  475 
symptoms,  474 
treatment,  475 
splenic,  488 
tunnel,  376 
Anemic  infarct,  695 

necrosis,  695 
Anesthesia,  olfactory,  1090 

segmental,  1231 
Aneurysm,  723 

arterio-venous,  723,  735 

cardiac,  700 
congenital,  735 
dissecting,  723 
false,  723 
miliary,  723 
mycotic,  724 


Aneurysm  of  abdominal  aorta,  732 

of  celiac  axis,  734 

of  coronarv  arteries,  734 

of  heart ,  700 

of  hepatic  arteries.  734.  914 

of  inferior  mesenterii-  artery,  734 

of  pulmonary  artery.  733 

of  renal  arteries,  734 

of  splenic  artery.  734 

of  .-superior  mesenteric  artery.  734 

of  thoracic  aorta,  724 

varicose.  723,  735 
Aneurysma  aorta\  724 
Aneurysmal  varix,,  723,  735 
Angina  abdominis,  714 

false,  714 

Ludovici,  751 

Ludwig's.  751 

major,  714 

maligna,  151 

minor,  714 

pectoris,  713 

scarlatinal.  205 

sine  dolore.  714 

vasomotoria.  714 

Vincent's,  ItiO 
Angioma  of  brain,  1174 

of  kidnev,  1049 

of  liver,  944 
Angioneurotic  edema,  1249 

intermittent,  1249 
Angiosclerosis,  720 
Angiospa.>^t ic  dilatation  of  heart,  687 
Anguillula  stercoralis,  384 
Anliydremia,  4.59 
Animal  para.«;itic  diseases,  334 
Ankylostomiasis,  375 

treatment,  379 
Ankylostomum  duodenale,  375 
Anomia,  1177 

Anopheles  maculipennis,  344 
Anorexia,  777,  829 

nervosa,  1231 
Anosmia,  1090 

hysteric,  1231 
Anthracosis,  575 
Anthrax,  306 

bacteriology-,  306 

diagnosis,  .308 

edema,  307 

etiology,  306 

external,  307 

internal.  307 

pathology,  306 

prognosis,  308 

treatment,  308 
Antipneumococcus  serum  in  pneumonia, 

128      ■ 
Antitoxin,  tetanus,  316 

treatment  of  diphtheria,  164 
Antityphoid  vaccination,  .53 
Anuria,  hysteric,  1232 
Aorta,  abdominal,  aneurj'sm  of,  732 

thoracic,  aneurysm  of,  724 
Aortic  incompetency,  639 

insufficiency,  639 

regurgitation,  639 


JNJ)EX. 


1 301 


Aortic  stenosis,  645 
Aortitis,  acute,  718 
Ape-hand,  1142 
Aphasia,  1175 

auditory,  1177 
cortical,  117S 
subcortical,  1178 

Bnx-a's,  1178 

conduction,  1178 

Marie's  theory,  1179 

motor,  1178 
cortical,  1178 
subcortical,  1178 

optic,  1177 

sensory,  1177 

visual,  1177 
cortical,  1178 
subcortical,  1178 

Wernicke's,  1179 
Aphemia,  1178 
Aphonia,  hysteric,  1232 
Aphoria,  spastic,  llOS 
Aphthae,  Bednar's,  739 

cachectica,  739 
Aphthongia,  1113 
Aphthous  fever,  332 

stomatitis,  738 
Aplasia  of  lung,  562 
Aplastic  anemia,  472 
Apoplexy,  1163 

delayed,  1164 

heat-,  1294 

meningeal,  1125 

pancreatic,  954 

pulmonary,  550 

serous,  1167 

spinal,  1126 
Appendicitis,  854 

bacteriology,  858 

chronic,  865 

diagnosis,  862 
differential,  863 

etiology,  858 

pathology,  855 

relapsing,  865 

symptoms,  859 

treatment,  868 
Appendix  dyspepsia,  866  ' 

Appetite,  777 

excessive,  830 

loss  of,  829 
Apraxia,  1178,  1179 
Aptyalism,  752 
Arachnida,  parasitic,  385 
Argyll-Robertson  pupil,  1096 
Arithmomania,  1218,  1243 
Arrhythmia,  708 
Arsenicism,  1280 
.Ai'senic-poisoning,  chronic,  1280 
Arterial  sclerosis,  718.     See  also  Arterio- 

sdeoris. 
Arteries,  diseases  of,  718 

in  typhoid  fever,  21 

syphilis  of,  400 

tuberculosis  of,  288 
Arteriocapillary  fibrosis,  718 
Arteriosclerosis,  718 


Arteriosclerosis,  circumscribed,  719 
clinical  histxjry,  721 
diagnosis,  722 
diffuse,  719 
et  iology,  720 
pathology,  718 
l)rognosi8,  722 
senile,  719 
treatment,  722 
varieties,  722 
Arteriovenous  aneurysm,  723,  735 
Arthritic  hemoptysis,  547 
muscular  atrophy,  1263 
purpura,  452 
Arthritis  deformans,  427 

and  gout,  differentiation,  438 
bacteriology,  428 
differential  diagnosis,  430 
etiology,  427 
pathology,  427 
predisposing  causes,  428 
prognosis,  431 
symptoms,  428 
treatment,  431 
varieties,  429 
gonorrheal,  185.     See  also  Gonorrheal 

arthritis. 
in  pneumonia,  119 
rheumatic,  427 
Articular  rheumatism,  acute,  174.     See 
also  Rheumatism,  acute  articular. 
chronic,  324 
Ascariasis,  372 
Ascaris  alata,  374 
lumbricoides,  372 
mystax,  374 
trechuria,  374 
vermicularis,  373 
Ascites,  970 
adiposus,  971 
chylous,  971 
Asiatic   cholera,   80.     See  also   Cholera, 

epidemic. 
Asphyxial  sunstroke,  1294 
Astasia-abasia,  1230 
Astereognosis,  1180 
Asthma,  533 
bronchial,  533 
cardiac,  534,  536 
clinical  historj',  534 
course,  536 
diagnosis,  536 
etiology,  533 
hay,  511 
Kopp's,  494 
Millar's,  494 
pathology,  533 
predisposing  causes,  534 
prognosis,  536 
thymic,  494 
treatment,  536 
AsjTnbolia,  1180 
Ataxia,  Friedreich's,  1151 
hereditary",  1151 

cerebellar,  1152 
hysteric,  1230 
locomotor,  1145 


1302 


INDEX. 


Ataxic  gait,  1 147 

paraplegia,  1152 
Atelectasis,  pulmonary,  561 
Atheroma,  7 IS 
Atheromatous  abscess,  719 

button,  719 
Athetosis,  1174 
hysteric,  1'229 
Atonic  dyspepsia,  827 
Atony  of  stomach,  827 
Atresia  of  pulnK)nary  orifice,  717 
Atrophic  cirrhosis  of  liver,  932 
nutmeg  liver,  910 
pharyngitis,  764 
spinal  paralysis,  1130 
Atrophy,  acute  yellow,  of  liver,  927 
arthritic  muscular,  1203 
brown,  of  heart,  700 
muscular,  1264 

facioscai)ulolunneral  type,  1262 
scapulohumeral    or    juvenile    iyvQ, 
1262 
of  liver  914 
of  thymus,  494 
optic,  1092 

progressive  facial,  1256 
neural  muscular,  1088 
neurotic  muscular,  1088 
spinal  muscular,  1142 
red,  of  liver,  927 
Auditory  aphasia,  1177 
cortical,  1178 
subcortical,  1178 
center,  1074 
nerve,  diseases  of,  1104 
Auricle,  left,  of  heart,  hypertrophy  of, 
682 
right,  of  heart,  h\Tier trophy  of,  682 
Auricles  of  heart,  h^T^ertrophy'  of,  679 
Auricular  fibrillation,  710 

flutter,  711 
Auto-intoxication,  intestinal,  884 
Autumnal  catarrh,  511 
Azotorrhoa,  953 


Baccelli's  sign  in  empyema,  599 
Bacillary  dysentery,  72 
Bacilluria,  typhoid,  1004 
Bacillus  anthracis,  306 
coli  communis,  78 
diphtheria^,  153 
dysenteriie,  S43 
influenza,  131 
lepra",  300 
mallei,  302 
mucosis  ozense,  509 
of  tetanus,  312 
of  tuberculosis,  234 
distribution,  236 
herditary  transmission,  239 
inhalation,  237 
inoculat  ion  with,  235,  239 
sources,  236 
sw^allow'ing,  238 
of  typhoid  fever,  22 

distribution  in  body,  23 


Bacillus  pertussis  eppendorfii,  225 

pseuilo-dipht  heria,  154 

tussis  convulsivu',  224 

xerosis,  154 
Bacony  infiltration  of  li\er,  915 
Bacteria  in  urine,  1004 
Bacteriuria,  1004 
Bagdad  boil,  340 
Balantidium  coli,  338 
Banti's  tlisease,  4S9 
Barbencholera,  1285 
Basedow's  <lisease,  498.     See  also  Gaiter, 

exophthalmic. 
Bastedo's   test  in   chronic  appendicitis, 

866 
Bast  ian's  center,  1176 
Beast-mimicry,  1229 
Bed-bug,  386 
Bcdnar's  aphtha*,  739 
Beer-heart,  679 
Belching,  826 
Bell's  mania,  1192 

palsy,  1101 
Bence-Joncs  protein,  991 
Beri-bcri,  316,  1086 

course,  319 

diagnosis,  318 
differential,  318 

distribution,  317 

etiology,  317 

historic  note,  317 

pathology,  317 

predisposing  caus(  s,  317 

prognosis,  319 

sjonptoms,  318 

treatment,  319 

varieties,  318 
Bernhart's    disturbances    of    sensation, 

1254 
Beta-oxybutyric  acid  in  urine,  998 
Biermier's  anemia,  465 
Bierniicki's  symptoms,  1200 
Big-jaw,  304 
Bile,  tests  for,  893 
Bile-ducts,  carcinoma  of,  906 

common,  inflammation  of,  892 

stenosis  of,  907 
Bile-pigment  in  urine,  994 

tests  for,  in  urine,  893 
Bilharzia  hematobia,  362 
Biliary  calculi,  898 

cirrhosis  of  liver,  932 
Bilious  pneumonia,  121 

tvi)hnid  fever,  410 
Birth-palsies,  1173 
Black  death,  141 

fever,  340 

small-pox,  193 
Blackwater  fever,  355 
Bladder,  diseases  of,  1051 

hemorrhage  of,  1057 

hemorrhoids  of,  1057 

irritability  of,  1058 

neoplasms  of,  1056 

neuroses  of,  1058 

tuberculosis  of,  285 
Bladder-worm  disease,  363 


INDEX. 


1303 


Bleeder's  disease,  455 

Nasse's  law  of,  455 
Blepharospasm,  1101 
Blindness,  day-,  1092 

hysteric,  1231 

mind-,  1095 

night-,  1092 

word-,  1177 
Blocked  pleurisy,  596 
Blood,  diseases  of,  459 

in  diabetes,  413 

in  diphtheria,  152 

in  leukemia,  479 

in  lobar  pneumonia,  114 

in  secondary  anemia,  472 

in  typhoid  fever,  22,  40 

in  urine,  984 

method  of  examining,  for  parasite,  357 
Blood-corpuscles  in  urine,  1006 
Blood-flukes,  362 
Blood-pigments  in  urine,  986 
Blood-test  for  diabetes,  421 

for  syphilis,  402 
Blood-vessels,  hepatic,  affections  of,  914 
Blow-fly,  387 

Boas'  resorcin  test  of  gastric  contents 
for  hydrochloric  acid,  779 

test  for  lactic  acid,  779 

for  motor  function  of  stomach,  781 
Bodo  urinarius,  338 
Boil,  Delhi,  340 

Boiling  test  for  albuminuria,  989 
Bones  in  typhoid  fever,  44 
Borborygmi,  836 

Boston's  test  for  albuminuria,  989 
Bot-flies,  387 

Bothriocephalus  latus,  368 
Bottger's  test  for  glycosuria,  991 
Botulismus,  1284 
Bovine  tuberculosis,  235 
Brachial  plexus,  diseases  of,  1114 

paralysis  of,  1115 
Brachycardia,  707 
Bradycardia,  707 

hysteric,  1232 
Brain,  abscess  of,  1181 

anemia  of,  1160 

angioma  of,  1184 

carcinoma  of,  1184 

cholesteatoma  of,  1184 

cysticercus  of,  1184 

cysts  of,  1184 

diseases  of,  1160 

disturbances  of  circulation,  1160 

dura  mater  of,  inflammation  of,  1118 

echinococcus  of,  366 

edema  of,  1162 

emboUsm  of,  1170 

enchondroma  of,  1184 

fibroma  of,  1184 

glioma  of,  1184  1 

gumma  of,  1184V 

hemorrhage  of,  1160 

hydatids  of,  1184 

hj^eremia  of,  1161 

inflammation  of,  1181 See  also  En- 
cephalitis. 


Brain,  lipoma  of,  1184 
myxoma  of,  1 184 
ost(!Oma  rjf ,  1 1 84 
sarcoma  of,  11 84 
softening  of,  acute,  1170 
syphilis  of,  ;5'J4 
tlirornbosis  (jf,  1 170 
tubercle  of,  1184 
tuberculosis  of,  286 
tumors  (jf,  1 1S3 
vascular  degcn(;ratiori  of,  1162 
wet,  1123 
Brand  method  in  typhoid  fever,  56 
Break-bone  fever,  139 
Breast,  hysteric,  1231 
Breast-pang,  713 
Brickmakcrs'  anemia,  376 
Bright's  disease,  acute,  1020 

chronic,  1027,  1032 
Broca's  aphasia,  1178 

convolution,  1176 
Bronchi,  diseases  of,  520 
Bronchial  asthma,    33 

glands,  tuberculosis  of,  244 
spirals,  535 
stenosis,  532 
Bronchiectasis,  529 
Bronchiolitis  exfoliativa,  533 
Bronchitis,  acute,  521 
diagnosis,  522 
etiology,  521 
pathology,  521 
prognosis,  523 
symptoms,  522 
treatment,  523 
capillary,  521,  554 
catarrhal,  520 
chronic,  525 
diagnosis,  527 
etiology,  525 
pathology,  525 
prognosis,  528 
sjTuptoms,  525 
treatment,  528 
varieties,  526 
croupous,  538 
fetid,  526 
fibrinous,  538 
in  lobar  pneumonia,  118 
mucous,  538 
plastic,  538 
Bronchocele,  496.     See  also  Goiter. 
Bronchopneumonia,  554 
bacteriology,  555 
diagnosis,  558 
duration,  556 
etiology,  555 
pathologj',  554 
prognosis,  559 
sjmiptoms,  556 
treatment,  559 
varieties,  558 
Bronchopneumonic    phthisis,    acute,    in 

children,  256 
Bronchopulmonary  hemorrhage,  544 
Bronchorrhagia,  544 
Bronchorrhea,  526 


1304 


JSDEX. 


Hronchoirhfa  serosa,  526 

lirtnizi'  tiiabctes,  4 IS 

lirown  atrophy  of  heart,  700 
induration  of  lungs,  ")41 

Brudzinski's  sign  in  cerebrospinal  men- 
ingitis, 100 

Bruit  de  galop,  709 

Bubo,  parotid,  752" 

Bubonie  plague,  141.     See  also  Flagiw. 

Buccal  psoriasis,  750 

Bulil's  disease,  45S 

Bulbar  i)aralysis,  1107,  1129 
asthenic,  12(57 

Bulimia,  S30 


Cachexia,  malarial,  354 

miners',  ;37(i 

strumipriva,  505  ' 

Cachexie  pachydermique,  502 
Caisson  disease,  1127 
Calcareous  degeneration  of  heart,  700 
Calcification  of  heart,  700 
Calcium  oxalate  in  urine,  1000 
Calculi,  biliary,  S9S 

intestinal,  870 

pancreatic,  958 

renal,  1014 

uric-acid,  1014 
Calculous  cholecystitis,  898 

pyelitis,  1014,  1040 
CaUphora  vomitoria,  387 
Calmette's  ophthalmic  reaction  in  chron- 
ic tuberculosis,  273 
Camp-fever,  67 
Cancerous  peritonitis,  968 

tumor  of  th^-roid,  496 
Cancrum  oris.  745 
Canter  rhj'thm,  688 
Cantering  rhythm,  709 
Cantlie's  sign  in  differentiation  of  peri- 
hepatitis from  acute  plastic  pleurisy, 

921 
Capillary  bronchitis,  521,  554 
Caput  medusa",  934 
Carcinoma,  green,  483 

intestinalis,  878 

of  bile-ducts,  906    . 

of  brain,  1184 

of  esophagus,  768 

of  intestine,  877 

(jf  kidney,  1049 

oi  liver,  939 

of  lung,  577 

of  mediastinum,  611 

of  pancreas,  955 

of  peritoneum,  975 

of  pleura,  610 

of  spleen,  949 

of  stomach,  813 
complications,  816 
course  and  duration,  817 
diagnosis,  817 

differential,  818 
etiology,  813 
predisposing  causes,  813 
symptoms,  814 


Carcinoma  of  stomach,  treatment,  S19 
Cardia,  insufficiency  of,  S27 
Cardiac  aneurysm,  700 

asthma,  534,  536 

clots  in  pneumonia,  119 

diseases,  combined  forms,  662 

thrombosis,  676 
Cardialgia,  S27 
Cardiohepatic  triangle,  620 
Cardiospasm,  826 

Carditis,  690.     See  also  M yocardiiis. 
Casts,  tube-,  in  urine,  1005 
Catalepsy,  hysteric,  1229 
Catarrh,  acute  gastric,  790 
gastro-interstinal,  843 
nasal,  507 

autiunnal,  511 

chronic  nasal,  508 

dry,  527 

duodenal,  S37 

intestinal,  835 
chronic,  839 

of  ileum,  837 

of  jejunum,  837 

of  stomach,  chronic,  796 
Catarrhal  bronchitis,  520 

cystitis,  1052 

dysentery,  73 

dyspepsia,  chronic,  796 

enteritis,  835 

fever,  epidemic,  130 

gastritis,  acute,  790 
chronic,  796 

jaundice,  892 

laryngitis,  acute,  513 

]jneumonia,  554 

stomatitis,  737 

tonsillitis,  acute,  754 

ulcer,  diffuse,  of  intestine,  854 
Cauda  equina,  lesions  of,  1159 
Celiac  axis,  aneurysm  of,  734 

disease,  846 
Cells,  giant,  in  tuberculosis,  233 

granular  fattj-  degenerated,  in  urine, 
1006 

heart-failure,  654 
Central  myelitis,  1134 

pneumonia,  120 
Cephalic  tetanus,  314 
Cephalodynia,  323 
Cercomonas  hominis,  338 

intestinalis,  338 
Cerebellar  ataxia,  hereditary,  1152 

softening,  1172 
Cerebral  leptomeningitis,   1121 

pachymeningitis,  1118 

pneumonia,  115 

rheumatism,  1122 
Cerebrospinal  meningitis,  95 
arthritis  in,  100 
bacteriology',  96 
Brudzinski's  sign  in,  100 
clinical  history,  97 
complications,  100 
differential  diagnosis,  102 
duration,  103 
etiology,  96 


INDEX. 


].'i05 


Cerebrospinal  iM(>iiinfi;itis,  forms  of,  101 
Kornig's  Kifi;n  in,  100 
lumbar  i)un(!turc  in,  101 
Maccwon's  sign  in,  100 
modes  of  conveyan(H',  97 
])al.hology,  !)() 
])retlisposinf);  causes,  97 
prognosis,  10;i 
prophylaxis,  103 
sequels,  102 
symptoms,  97 
cutaneous,  99 
gastro-intestinal,  100 
in  organs  of  special  sense,  99 
nervous,  98 
renal,  100 
treatment,  103 
syphilis,  1198 
Cervical  glands,  tuberculosis  of,  243 

plexus,  diseases  of,  1114 
Cervico-brachial  neuralgia,  1087 
Cervico-occii)ital  neuralgia,  1086 
Cestodes,  363 
Chalicosis,  576 
Charcot's  disease,  1143 

intermittent  fever,  901 
Chest  muscles  in  tuberculosis,  272 
Chicken-breast,  445 

in  chronic  tonsillitis,  760 
Chicken-pox,  202.     See  also  Varicella. 
Chills  and  fever,  342 
Chlorids  in  urine,  1003 
Chloroform  test  for  choluria,  994 
Chloroma,  4§3 
Chlorosis,  460 

blood-examination  in,  462 
diagnosis,  463 
Egyptian,  376 
etiology,  460 
masked,  463 
pathology,  460 
prognosis,  463 
rubra,  462 
symptoms,  461 
syphilitic,  474 
treatment,  463 
Choked  disk,  1092 
Cholecystitis,  acute  infectious,  896 
calculous,  898 
chronic,  897 
Cholelithiasis,  898 
Cholera  algida,  80 

Asiatic,  80.    See  also  Cholera,  epidemic. 
epidemic,  80 

asphyxic  form,  86 
brain  in,  82 

circulatory  system  in,  81 
clinical  history,  84 

types,  86 
complications,  86 
cramps  in  muscles,  85 
diagnosis,  differential,  86 
etiology,  82 
facies  in,  85 
foudroyant  form,  86 
historic  note,  80 
modes  of  infection  in,  83 


Cholera,  ei)idemif;,  pathology,  81 
predisposing  cuu.scs,  82 
prognosis,  86 
respiratory  organs  in,  82 
treatment,  87 
visc(!ral  lesions,  81 
infantum,  843,  844 
morbus,  848 
nostras,  848 
sporadic,  848 
Cholerine,  86 

Cholesteatoma  of  brain,  1184 
Cholesterin  in  urine  ■,  1005 
Cholesterinuria,  1005 
Choluria,  994 

Chondro-arthritis,  syphilitic,  401 
Chorea,  acute,  1211 

chronic  progressive,  1213 
electric,  1215 

of  Dubini,  1215 
fibrillary,  1215 
habit,  1216 
hereditary,  1213 
Huntingdon's,  1213 
posthemiplegic,  in  children,  1174 
Sydenham's,  1211 
Chvostek's  sign  in  tetany,  1222 
Chyle  in  urine,  993 
Chylo-pericardium,  627 
Chjdous  ascites,  971 
Chyluria,  993 
Cimex  lectularius,  386 
Circulation    of   brain,    disturbances    of, 

1160 
Circulatory  affections  of  liver,  909 
disturbances  in  lungs,  540 
system,  diseases  of,  615 
in  typhoid  fever,  39 
syphilis  of,  400 
Circumflex  nerve,  paralvsis  of,  1115 
Cu-cumpolarization,  998' 
Circumscribed  peritonitis,  963 

spinal  serous  meningitis,  1125,  1157 
Cirrhosis  of  liver,  931.     See  also  Liver, 
cirrhosis  of. 
of  lung,  552 

of  stomach,  benign,  820 
Cirrhotic  kidney,  1032 
Claustrophobia,  1242 
Clavus  hystericus,  1228 
Claw-hand,  1143 
Clergy-man's  sore  throat,  764 
Climatic  treatment  of  tuberculosis,  292 
Clownism,  1228 
Cnethocampa,  387 
Coin  sound  in  pneumothorax,  606 
Colic,  mucous,  886 

renal,  1014 
Colitis,  838 
cohca,  886 
ulcerative,  853 
Collapse  of  lungs,  561 
CoUes'  law  of  syphilis,  390 
Cologne-water  inebriety,  1275 
Colon,  dilatation  of,  883 
displacement  of,  884 
ectasia  of,  883 


1306 


INDEX. 


Colon  pneumonia,  130 

Coloptosis,  8S4 

Comedo  mite,  3S5 

Common  duct,  obstruction  of,  900 

Compensating  emphysema,  otM 

Compression  myelitis,  1134,  1138 

of  lungs,  561 

of  spinal  cord,  1138 
Compsom^-ia  macellaria,  387 
Conduction  aphasia,  1178 
Confusional  insanity,  1193 
Congestion,  active,  of  liver,  910 

of  kidneys,  982 

of  lungs,  540 

passive,  of  liver,  910 
Conjugate  deviation,  1097,  1165 
Conradi's  method  of  cultivating  typhoid 

baciUi,  48 
Const  ijxit  ion  889 

habitual,  880 
Const  it  utio  h-mphatica,  494 
Constitutional  diseases,  413 
Continued  fever,  simple,  329 

malarial  fever,  352 
Contracted  kidney,  1027 

priinary  or  genuine,  1032 
Contractions,  hysteric,  1229 
Contractures,  hysteric,  1230 
Conus  metlullaris,  lesions  of,  1159 
Convulsions,  hj'steric,  1228 

infantile,  1202 
Coprolalia,  1218 
Cor  biloculare,  716 

bo\dnum,  678,  1033 

triloculare,  716 
Coronary  arteries,  aneurysm  of,  734 

tliseases  of,  695 
Corradi's  treatment  of  aneurj''sm,  731 
Corrigan  pulse,  643 
Corrosive  esophagitis,  766 
Corset  liver,  891 
Corj'za,  acute,  507 
Costiveness,  880 
Cough,  hysteric,  1232 
Cow-pox,  200 
Crab-louse,  386 
Cramp,  writers',  1243 
Cramps,  heat-,  1296 
Cranial  nerv'es,  diseases  of,  1090 
Craniotabes,  444 
Crapulous  gastritis,  791 
Crazy  drurikermess,  1268 
Cretinism,  sporadic,  502.     See  also  Myx- 
edema. 
Crises,  Dietl's,  979 
Crisis,  laryngeal,  1107 
Croup,  151 

false,  517 

membranous,  158 
Croupous  bronchitis,  538 

enteritis,  847 

pharyngitis,  763 

pneumonia,  105.     See  also  Lobar  jmeu- 
monia. 

stomatitis,  760 
Crural  nerve,  anterior,  paralysis  of,  1117 

neuralgia,  1082 


Crutch-palsy,  1115 
Culex  auxifer,  387 
Culicitlu',  387 
Curschmann's  spirals,  535 
Cutaneous  act  inomycosis,  305 

psorospermiasis,  341 

system  in  tuberculosis,  271 
Cyanotic  induration  of  liver,  910 
Cyclaster  scarlatinalis,  206 
Cycloplegia,  10915 
Cynanche  gangra>nosa,  751 
Cyst,  hydatid,  of  lung,  579 

nephrydrotic,  1044 

of  brain,  1184 

of  liver,  944 

of  pancreas,  957 

renal,  1048 
Cystic  degeneration  of  kidneys,  1048 

duct,  obstruction  of,  902 

kidney,  1048 
Cysticercus  of  brain,  1184 
Cystin  in  urine,  1002 
Cystinuria,  1002 
Cystitis,  1051 

acute,  1052 

catarrhal,  1052 

chronic,  1055 

exfoliative,  1052 

febrile,  1052 

from  adjacent  inflammation,  1053 

gonorrheal,  1052 

gouty,  1052 

mycotic,  1053 

phlegmonous,  1052 

septic,  1052 

toxic,  1052 

traumatic,  1053 
Cj'torectes  Guarnicri,  200 
Cytozoa,  34 


Day-blindness,  1092 

Dead  finger  of  chronic  nephritis,  1036 

Deafness,  hj^steric,  1231 

uremic,  1010 

word-,  1104,  1168 
Decompression,  spinal,  in  chronic  mj^eli- 

tis,  1138 
Degeneration,  acute  fatty,  of  newborn, 
458 

amyloid,  of  heart,  700 
of  spleen,  948 

calcareous,  of  heart,  700 

cystic,  of  kidney,  1048 

diffuse,  of  spinal  cord,  1153 

fatty,  of  liver,  917,  918 

hyaline,  of  heart,  700 

of  heart,  696.     See  also  Heart,  degener- 
alion  of. 

of  liver,  915 

progressive  lenticular,  1180 

vascular,  of  brain,  1162 
Deglutition  murmur,  784 
Delayed  apoplexj',  1164 
Delhi  boil,  340 
Delire  du  toucher,  1243 
Delirious  mania,  acute,  1192 


INDEX. 


i:i07 


Delirium,  acute,  1192 
cordis,  709 
tremens,  1268,  1271 
Dementia  from  alcoholism,  1271 
paralytica,  1198 
senile,  1194 
Demodex  folliculorum,  385 
Dengue,  139 
clinical  history,  139 
complications,  140 
diagnosis,  140 

differential,  140 
etiology,  139 
treatment,  141 
Dermanyssus  avium  et  gallinse,  387 
Dermatobia,  387 
Dextrocardia,  716 
Diabetes,  413 
acute,  416 
blood  in,  415 
blood-test  for,  421 
bronze,  418 
chronic,  416 
clinical  history,  416 
diagnosis,  421 
etiology,  general,  415 

special,  416 
heart  in,  415 
infantile,  420 
insipidus,  425 
kidneys  in,  415 
lungs  in,  415 
mellitus,  413 
microbic  theory,  414 
nervous  system  in,  415 
pancreas  as  causative  factor  of,  413 
pancreatic,  421 
pathogenesis,  413 
pathology,  414 
phloridzin,  414 
prognosis,  421 
role  of  liver  in,  414 

of  suprarenal  glands  in,  413 
skin  in,  415 
stomach  in,  415 
symptoms,  417 

circulatory,  420 

constitutional,  420 

cutaneous,  418 

digestive,  418 

muscular,  420 

nervous,  418 

respiratory,  420 

sexual,  420 

special-sense,  420 

urinary,  417 
treatment,  422 

dietetic,  422 

hygienic,  423 

medicinal,  423 

symptomatic,  424 
varieties,  420 
Diacetone  in  urine,  998 
Diacetonuria,  998 
Diaphragmatic  pleurisy,  590 
Diarrhea,  acute  .dyspeptic,  843,  844 
hUl,  846 


Diarrhea,  lienteric,  839 

mycotic,  H4'.> 

nervous,  888 

of  childniu,  843 

premonitory,  84,  86 

summer,  843 
Diarrhoea  alba,  846 

chylosa,  846 
Diaschisis,  1176 
Diastolic  expiration,  729 
Diazo-rcaction    of    Ehrlich    in    tyjjlioid 

fever,  43 
Dietl's  crisis,  979 
Diffuse  myelitis,  1134 

nephritis,  acute,  1020 

sclerosis,  1198 
Digestive  system,  diseases  of,  737 

in  typhoid  fever,  33 
Dilatation  of  colon,  883 

of  esophagus,  771 

of  heart,  684.     See  also  Heart,  diluta- 
tion  of. 

of  hepatic  arteries,  914 

of  stomach,  786 
acute,  786 
Diphtheria,  151 

alcohol  in,  162 

and    follicular    tonsillitis,    differentia^ 
tion,  756 

antitoxin  treatment,  164 

associated  microbes,  154 

bacteriology,  153 

blood  in,  152 

carriers,  155 

complications,  158 

diagnosis,  159 
differential,  159 

etiology,  153 

heart  in,  152 

immunity  to,  155 

kidneys  in,  153 

laryngeal,  158 

lymphatic  glands  in,  153 

malignant,  156 

modes  of  infection,  154 

nasal,  157 

nerves  in,  153 

pathology,  151 

pharyngeal,  156 

predisposing  factors,  155 

prognosis,  159,  160 

pseudo-,  151 

sequels,  158 

serum-therapy,  164 

simple  tonsillar,  156 

site  of  infection,  154 

spleen  in,  152 

symptoms,  155 

toxins,  154 

treatment,  161 

wound-,  157 
Diphtheritic  dysentery,  74 
secondary,  76 
sequels,  76 
treatment,  76 

enteritis,  847 

gastritis,  794 


1308 


ISUKX. 


Diphtlu'ritis,  151 
Diplococ'i'us  pneunionia*,  107 

rlicuiuaticus.  175 

scarhitimi',  "JOG 
DislocaliHi  kidney,  978 
Dislocation  of  sploon,  945 
Displacement  of  colon,  884 
Dissecting  aneurysm,  723 
Disseniinatwl  myelitis,  1134 
Distoma  crassum,  361 

(Mideniii'inn,  361 

lieiiiatolMuni,  361,  362 

hei)aticum,  361 

lanceolatum,  361 

])ulnionale,  361 

Hingeri,  361 

sihricum,  361 

spatulatum,  361 
Distoniiasis,  361 
Ditt  rich's  i)lup;s,  526 
Diver's  ])aralysis,  1127 
Diverticulum,  esophageal,  772 
Dochmius  duodenalis,  375 
Dorsodyiiia,  323 
Dracontiasis,  383 
Dracunculus  medinensis,  383 

jMM-sarum,  383 
Dromedary  gait,  1216 
Droi)sy  of  pericardium,  626 

of  peritoneum,  970 

of  pleura,  608 

of  renal  disease,  1007 

thoracic,  608 
Driisenfieber,  333 
Dry  catarrh,  527 

mouth,  752 
Dubini's  electric  chorea,  1215 
Ductless  glands,  diseases  of,  409 
Dukes'  disease,  216 
Dumb  rabies,  310 
Dmii-<lum  fever,  340 
Duodenal  catarrh,  837 

stenosis,  877 

ulcer,  850 
latent,  852 
Duodenitis,  837 
Duodeno-cholangitis,  892 
Dura  mater  of  brain,  hemorrhage  into, 
1119 
inflammation  of,  1118 
spinal  hematoma  of,  1120 
tumors  of,  1156 
Dysacusis,  1104 

Dysbasia  lordotica  progressiva,  1216 
Dysentery',  72 

acute,  72 

amebic,  334 

clinical  history,  336 
complications,  336 
course,  337 
diagnosis,  336 
duration,  337 
])athology,  335 
prognosis,  337 
treatment,  337 

bacillary,  72 

catarrhal,  73 


Dysentery,  dironic,  78 
complicatit)ns,  79 
diagnosis,  79 

dilTerential,  79 
duration,  79 
pathology,  78 
symptoms,  79 
treatment,  79 
diphtheritic,  74 
secondary,  76 
secjuels,  76 
treatment,  76 
etiology,  72 
sporadic,  73 
tropical,  acute,  74 
varieties,  72 
Dyspepsia,  a])pendix,  866 
atonic,  827 

chronic  catarrhal,  796 
ner^'ous,  S21 
Dyspeptic  iliarrhea,  acute,  843,  844 
Dyspnea   as   symptom   of   tuberculosis, 
264 
hysteric,  1232 
Dystonia  musculorum  deformans,  1216 
Dystrophia  adiposogenitalis,  1186 
Dj'strophies,  nuiscular,  1260 


Eccentric  hypertrojihy  of  heart,  678 
Echinococcus  alveolaris,  363 
disease,  363 

of  brain,  366 

complications,  367 

diagnosis,  364 

of  lieart,  366 

of  kidneys,  367 

of  liver,  364 

of  mediastinum,  366 

of  jicritoneum,  367 

of  resjjiratory  organs,  366 

of  spinal  cord,  366 

of  spleen,  366 

sym])toms,  364 

treatment,  367 
hydatidosus,  363 
Echinorhynchus  moniliformis,  385 
Echokinesis,  1218 
Echolalia,  1218 
Eclampsia  infantilis,  1202 
Ectasia  of  colon,  883 
Ectasis,  alveolar,  564 
Ectopia  cordis,  716 

Edema,  acute  circumscribed,  of  skin,1249 
angioneurotic,  1249 

intermittent,  1249 
anthrax,  307 
of  brain,  1162 
pulmonary,  542 

collateral,  542 

general,  543 

hypostatic,  543 

recurrent  varietj^,  544 
Edematous  laryngitis,  519 
pygyptian  chlorosis,  376 
Elirlich-Hata  (606)  treatment  of  syphilis, 
405 


INDEX. 


]  '.'m 


Ehrlich's  diazo-rcatition  in  lyjihoid  fev(!r, 

4.3 
Eif^hth  nerve,  diseases  of,   1104 
Electric  chorea,  1215 
of  Dubini,  1215 
Elephantiasis  arabuni  from  filaria,  ;W.3 
Embolic  infarctions  of  kidney,  \)Ki 
Embolism  in  typhoid  fever,  40 
of  brain,  1170 
of  portal  vein,  911 
pulmonary,  550 
Embryocardia,  709 
Emphysema,  acute,  564 
compensating,  564 
hypertrophic,  565 
clinical  history,  566 
diagnosis,  569 

differential,  569 
etiology,  566 
pathology,  565 
prognosis,  569 
treatment,  570 
interlobular,  564 
senile,  570 
small-lunged,  570 
vesicular,  564 
Emprosthotonos,  314 
Empyema,  597 

Baccelli's  sign  in,  599 
clinical  history,  598 
diagnosis,  differential,  599 
etiology,  597 
necessitatis,  600 
of  pericardium,  623 
pathology,  597 
prognosis,  600 
pulsating,  599 
treatment,  600 
Emulsion-albuminuria,  1027 
Encephalitis,  1181 

acute  hemorrhagic,  1183 
suppurative,  1181 
Encephalopathy,  lead,  1279 
Enchondroma  of  brain,  1 184 
Encysted  pleurisy,  590 
Endarteritis  chronica  deformans,  718 

deformans,  1162 
Endocarditis,  628 
chronic,  636 

interstitial,  636 
fetal,  716 
infectious,  632 

in  lobar  pneumonia,  107,  118,  119 
malignant,  632 
mural,  633 
recurrent,  634 
simple  acute,  628 
ulcerative,  632 

and  typhoid  fever,   differentiation, 

635 
bacteriology,  633 
cerebral  variety,  634 
clinical  history,  634 
diagnosis,  635 

differential,  635 
etiology,  633 
pathology,  632 


Endocarditis,  ulcerative,  prognosis,  636 
treatm(;nt,  636 

varieties,  628 

verrucosa,  628 
Endolaryngitis,  acute,  513 

chronic,  515 
I*jnlargem(!nt  of  thymus,  494 
Entamceba  dysttuitcria;,  334 
Enteralgia,  887 
l<]nt,(Tic  fever,  17 
Enteritis,  catarrhal,  835 

croupous,  847 

diphtheritic,  847 

follicular,  835 

membranacea,  886 

phlegmonous,  847 
Enteroptosis,  834 
Enterospasm,  889 
Enuresis,  1060 

nocturnal,  1060 
Ephemeral  fever,  329 
Epiconus,  lesions  of,  1159 
Epilepsie  larve,  1201 
Epilepsy,  1204 

Jacksonian,  1207 

myoclonus,  1207 

nocturnal,  1207 

procursive,  1206 
Epileptoid  hysteria,  1228 
Epiplopexy  in  cirrhosis  of  liver,  939 
Epistaxis,  512 
Epithelium  in  urine,  1006 
Erb's  sign  in  tetany,  1223 

syphilitic  spinal  paralysis,  395 
Ergot  tabes,  1286 
Ergotismus,  1285 

convulsivus,  1285 

gangrsenosus,  1286 
Eructations,  826 
Erysipelas,  144 

bacteriology,  144 

clinical  history,  146 

complications,  147 

course,  148 

diagnosis,  148 
differential,  148 

duration,  148 

etiology,  144 

gangraenosum,  146 

in  typhoid  fever,  44 

migrans,  146 

neonatorum,  148 

pathology,  144 

phlegmonous,  148 

predisposing  causes,  145 

prognosis,  148 

pustulosum,  146 

relapsing,  148 

sequels,  148 

symptoms,  146 

treatment,  149 

varieties,  147 

vesiculosum,  146 
Erythema,  hysteric,  1232 
Erythrocytes  in  urine,  1006 
Erj^hrocj'tosis,  490 
Ervthromelalgia,  1252 


1310 


INDEX. 


Esbac'h's  albuminometer,  990 
Esophagismus,  770 
Esophagitis,  7G6 

acute,  706 

chronic,  767 

corrosive,  766 

pseudomembranous,  766 
Esophagomalacia,  770 
Esophagus,  carcinoma  of,  768 

dilatation  of,  771 

disejises  of,  766 

diverticulum  of,  772 

muscular  spasm  of,  770 

neuroses  of,  770 

paralysis  of,  771 

rupture  of,  769 

stricture  of,  774 

tuberculosis  of,  276 

ulcer  of,  767 
Essential  hematuria,  984 
Estivo-autumnal  fever,  352 

ha^mameba  causing,  346 
Estrida?,  387 
Ether-pneumonia,  121 
EustrongA'lus  gigas,  384 
Ewald-Boas  test-breakfast,  778 
Exanthematous  pharjTigitis,  762 
Exophthalmic     goiter,     498.     See     also 

Goiter,  exophthalmic. 
Expiration,  diastolic,  729 
Extrameningeal  hemorrhage,  1 125 
Extra-systole,  708 
Eye,  paralj'sis  of  muscles  of,  1097 
Eyeball,  motor   nerves   of,    diseases   of, 

1095 


Face,  hemihypertrophy  of,  1258 

progressive  hemiatrophy  of,  1256 
Facial  atrophj^  progressive,  1256 

ner\-e,  diseases  of,  1100 
paralysis  of,  1101 
spasm  of,  llOl 
Facies  leontina,  300 
Facioscapulohumeral  type  of  mus  ular 

atrophy, 1262 
Faget's  sign  in  yellow  fever,  93 
Falk  and  Tedesko's  test  in  tuberculosis, 

273 
Fallopian  tubes,  tuberculosis  of,  285 
False  aneurysm,  723 

angina,  714 

croup,  517 
Family  jaundice,  chronic,  896 

periodic  paralysis,  1224 
Farcy,  302 

acute,  303 

chronic,  303 
Farre's  tubercles,  940 
Fat  in  urine,  1004 
Fat -globules  in  urine,  1006 
Fatty  degeneration,  acute,  of  newborn, 
458 
of  heart,  696 
of  liver,  917,  918 

infiltration  of  heart,  699 
of  liver,  917 


Fattv  kidnev,  1027 

liver,  917' 

overgrowth  of  heart,  698 
Febricula,  329 
Febrile  cystitis,  1052 

tropical  splenomegaly,  340 
Febris  flava,  89 

recurrens,  407 
Feces,  examination,  830 
bacterial,  832 
chemical,  832 
macroscopic,  830 
microscopic,  831 
Fehling's  test  for  glycosuria,  996 
Femoral  neuralgia,  1082 
Fermentation  test  for  glycosuria,  99? 
Fetal  endocarditis,  716 

heart-rhjihm,  709 

heart-sounds,  688 
Fetid  bronchitis,  526 

stomatitis,  741 
Fever  and  ague,  342 
Fibrillary  chorea,  1215 
Fibrillation,  auricular,  710 
Fibrinous  bronchitis,  538 

pericarditis,  615 

pleurisy,  dry,  581 

pneumonia,  105.     See  also  Lobar  pneu 
tnonia. 
Fibrinuria,  1004 
Fibroid  induration,  552 

phthisis,  274.     See  also   Phthisis,  fi- 
broid. 
Fibro-lipoma  of  peritoneum,  977 
Fibroma  of  brain,  1184 

of  kidney,  1049 

of  peritoneum,  977 
Fibro-myoma  of  peritoneum,  977 
Fibrous  goiter,  496 

myocarditis,  691 
Fiedler's  disease,  328 
Fifth  nerve,  diseases  of,  1099 
Filaria  Bancrofti,  382 

bronchialis,  384 

dermaquai,  381 

hominis  oris,  384 

immitis,  384 

labialis,  384 

lent  is,  384 

loa,  382,  384 

mermus,  384 

perstans,  381 

philippinensis,  382 

sanguinis  hominis,  381 
diurna,  381 
nocturna,  381 

trachealis,  384 
Filariasis,  381 

symptoms,  382 

treatment,  383 
Finger,  dead,  of  chronic  nephritis,  1036 
Fish,  tape-worm,  368 
Fish-poisoning,  1284 
Flagellata,  338 
Flea,  386 
Flesh-fly,  387 
Flies,  387 


INDEX. 


1311 


Floating  h(>art,  703 

kidney,  978 

spleen,  945 
Florid  phthisis,  254 
Florida  complexion,  376 
Flukes,  blood-,  362 
Flutter,  auricular,  711 
Folic  Brightique,  1009 
Follicular  enteritis,  835 

pharyngitis,  764 

stomatitis,  738 

tonsillitis,  754 

and  diphtheria,  differentiation,  756 

ulcers,  853 
Food-infection,  1283 
Foot-and-mouth  disease,  332 
Foramen  of  Winslow,  871 

ovale,  incomplete  closure,  716 
Forme  fruste,  1196,  1261 
Fourth  disease,  209,  216 
treatment,  216 

nerve,  1097 
French  measles,  220 

Frerich's  method  of  inspection  of  stom- 
ach, 782 
Friedreich's  ataxia,  1151 

disease,  1151 
Frohlich's  syndrome,  1186 


Gait,  ataxic,  1147 
dromedary,  1216 
monkey,  1216 
steppage,  1117 
Galacturia,  993 

Gall-bladder  in  typhoid  fever,  20 
Galloping  consumption,  254 
Gall-stopes,  898 

chronic  obstruction  by,  900 
remote  effects,  902 
Gangrene  in  lobar  pheumonia,  106 
of  lungs,  571 
symmetric,  1250 
Gangrenous  pancreatitis,  952 

stomatitis,  745 
Gastralgia,  827 

ulcer  of  stomach  and,  differentiation, 
809  , 
Gastrectasis,  786 
Gastric  fever,  791 
Gastritis,  acute  catarrhal,  790 
suppurative,  794 
anacida,  798 
atrophicans,  798 
chronic  catarrhal,  796 
clinical  history,  797 
complications,  799  >' 
diagnosis,  800 
pathology,  796 
prognosis,  800 
symptoms,  797 
treatment,  800 
crapulous,  791 
diphtheritic,  794 
infectious,  791 
mucous,  798 
phlegmonous,  794 


Gastritis,  simple,  798 

toxic,  793 
Gastro-duodfiniti.s,  837 
Gastrodyiiia,  S27 

Gastro-enU'rif;  infection,  acute,  843 
Gastro-cntcritis,  843 
Gastro-intfwiinal  catarrh,  acute,  843 

tract  in  tuberculosis,  271 
Gastromyxorrhaia,  825 
Gastrophthisis,  796 
Gastroptosis,  784 
Gastro-succorrhcx-a,  824 

continua  (;hronir;a,  825 
Gastroxynsis,  824 
Gelfieber,  89 

Genitalia,  neuralgia  of,  1083 
Genito-urinary   organs    in   tuberculosis, 
271 

system,  tuberculosis  of,  283 
Gerhardt's  test  for  acetonuria,  998 
German  measles,  220 
Giant  cells  in  tuberculosis,  233 

urticaria,  1249 
Giantism,  1244,  1245 
Gin-drinkers'  liver,  931 
Ginger  inebriety,  1275 
Glanders,  302 

acute,  302 

bacteriology,  302 

chronic,  303 

clinical  history,  302 

diagnosis,  303 
differential,  303 

etiology,  302 

immunity  to,  302 

modes  of  infection,  302 

pathology,  302 

prognosis,  303 

treatment,  304 
Glandular  fever,  332 
Glassblowers'  mouth,  752 
Glioma  of  brain,  1184 
Gliomatosis,  1154 
Globus  hystericus,  1107,  1228 
Glomerulo-nephritis,  acute  syphilitic,  400 

chronic,  1027 

of  acute  course,  1020 
Glossina  palpalis,  339 
Glossitis,  748 

acute,  748 

chronic  superficial,  749 

desiccans,  750 
Glosso-labio-larjTigeal  paralysis,  1129 
Glosso-pharyngeal    nerve,    diseases    of, 

1106 
Glucose  in  urine,  995 
Gluteal  nerve,  superior,  paralysis  of,  1117 
Glycosuria,  995 

alimentary,  414,  421 

intermittent,  995 

lipogenic,  421 

paroxysmal,  995 
Gmelin's  test  for  bile-pigment  in  urine, 
893 
for  choluria,  994 
Gnats,  387 
Goiter,  496 


1312 


INDEX. 


GoitiT,  (liaiinosis,  497 
ctiolofiN',  49(i 
exophlhalmir,  49S 
course,  ")0() 
diagnosis,  oOO 
etiology,  49S 
prognosis,  iiOO 
symptoms,  499 
treatnu'nt,  oOl 
fibrous,  49G 
l)atlu)logy,  490 
prognosis,  497 
simple,  49() 
symptoms,  49(i 
treatment,  497 
varieties,  496 
Gonorrheal  arthritis,  l.S.o 
elinieal  symptoms,  185 
diagnosis,  lS(i 
pathology,  IS") 
treatment,  1S6 
eystitis,  1052 
Gout,  432 
acute,  434 

and   arthritis   deformans,    differentia- 
tion, 43S 
chronic,  435 
elinieal  history,  434 
diagnosis,  differential,  437 
etiology,  433 
heretlity  in,  433 
irregular,  435 

symptoms  of,  436 
kidneys  in,  433 
nature,  432 
pathology,  433 
retroeedent,  435 
rheumatic,  427 
saturnine,  1279 
treatment,  438 
dietetic,  438 
medicinal,  439 
prophylactic,  438 
uric-acid  theories,  432 
Goutv  cystitis,  1052 

kitfney,  1032 
Ciraham-8teel  murmur,  661 
Grain-poisoning,  1285 
Grand  mal,  1206 
Gravel,  1014 
Graves'   disease,   498.     See  also  Goiter, 

exophthalmic. 
Green  cancer,  483 

sickness,  460 
Grocco's  sign  in  sero-fibrinous  pleurisy, 

588 
Guinea-worm  disease,  383 
Gumma  of  brain,  1 184 

syphilitic,  of  spleen,  950 
Giinzburg's  test  of  gastric  contents  for 
hytlrochloric  acid,  778 


Habit  chorea,  1216 

spasm,  1216 
Habitual  constipation,  880 
Hadernkrankheit,  308 


HuMuameba,  345 

■    causing  estivo-autunnial  fever.  346 

quartan  fe\-er,  iUo 

tertian  intermittent    fever,  345 
HaMnatojJota  pluvialis,  387 
Harrison's  groove,  445 
Harvest  bug,  385 
Haut  mal,  1206 
Hay  asthma,  511 

fever,  511 
Havnes'  operation  for  cerebral  leptomen- 
ingitis, 1123 
Headache,  .sick,  1209 
Heart,  absence  of,  716 

interventricular  septum  of,  716 
aneurysm,  700 
arrested  development,  716 
beer,  679 

brown  atrophy,  700 
calcification,  700 
congenital  affections,  716 
degeneration,  696 

amyloid,  700 

calcareous,  700 

fatty,  696 

hyaline,  700 
dilatation,  684 

acute  primary,  686 

angioplastic,  687 

clinical  history,  687 

diagnosis,  689 

etiology,  686 

pathology,  685 

prognosis,  689 

treatment,  689 

varieties,  685 
diseases,  628 
echinococcus,  366 
fatty,  696 

infiltration,  699 

overgrowth,  698 
floating,  703 
hypertroijhy,  677 

circumscribed,  678 

concentric,  678 

course,  684 

diagnosis,  682 
differential,  682 

eccentric,  678 

etiology,  678 

general  and  partial,  678 

of  auricles,  679 

pathology,  67S 

primary  congenital,  679 
idiopathic,  679 

prognosis,  683 

simple,  678 

symptoms,  680 

treatment,  684 
in  diabetes,  415 
in  diphtheria,  152 
in  lobar  pneumonia,  107 
in  tuberculosis,  270 
in  typhoid  fever,  21 
irritable,  704 
misplacement,  703 
neuroses,  703 


INDEX. 


laia 


Heart,  new  growths,  702 

palpitation,  703 

parasites,  701 

patency,  716 

rapid,  705 

reptilian,  716 

rupture,  701 

transposition,  703 

tuben;ulosis,  287 

tumors,  702 
Heart-beat,  intermittent,  708 

irregular,  70S 
Heart-block,  712 
Heart-failure  cells,  654 
Heart-rhythm,  fetal,  709 
Heart-sounds,  fetal,  688 

in  lobar  pneumonia,  114 
Heat-apoplexy,  1294 
Heat-cramps,  1296 
Heat-exhaustion,  1293 
Heat-fever,  1294 
Heat-prostration,  1293 
Heat-stroke,  1293 
Heberden's  nodes,  430 
Heller's  test  for  albuminuria,  989 
Hematemesis,  820 

and  hemoptysis,  differentiation,  821 

hysteric,  1232 
Hematobia,  bilharzia,  362 
Hematoma  of  dura  mater,  1120 
Hematomyelia,  1126 
Hematoporphyrin  in  urine,  1004 
Hematoporphyrinuria,  1004 
Hematorachis,  1125 
Hematuria,  984 

endemic,  984 

essential,  984 

malarial,  355 
Hemeralopia,  1092 

Hemiatrophy,  progressive,  of  face,  1256 
Hemicrania,  1209 
Hemihypertrophy  of  face,  1258 
Hemochromatosis  in  cirrhosis  of  liver, 

935 
Hemoglobinuria,  985 

epidemic,  of  newborn,  458 

malarial,  355 

paroxysmal,  986 
Hemohepatogenous  jaundice,  896 
Hemolytic  jaundice,  896 
Hemopericardium,  627 
Hemophilia,  455 

Nasse's  law  of,  455 
Hemoptysis,  544 

and  hematemesis,  differentiation,  821 

arthritic,  547 

as  symptom  of  tuberculosis,  264 

^diagnosis,  differential,  548 

'etiology,  545 

'hysteric,  1232 

parasitic,  361,  548 

pathology,  545 

prognosis,  548 

symptoms,  546 

treatment,  548 

vicarious,  546    v 
Hemorrhage,  broncho-pulmonary,  544 
83 


Hemorrhage,  cerebellar,  1167 

ccsnibral,  1 164 

extraincriingeal,  1 125 

intestinal,  in  typhoid  fever,  34 

into  dura  mater  of  hrairi,  1119 

into  retina,  1091 

into  spinal  cord,  1120 
meninges,  1125 

intrameningeal,  1125 

mediastinal,  613 

of  bladder,  1057 

pancreatic,  954 

pontine,  1166 

ventricular,  1166 
Hemorrhagic  diseases  of  newborn,  458 

encephalitis,  acute,  1183 

infarction,  550 

myelitis,  1134 

pancreatitis,  949 

pericarditis,  624 

peritonitis,  chronic,  968 

pleurisy,  591 

purpura,  453 
Hemorrhoids,  vesical,  1057 
Henoch's  purpura,  453 
Hepatic  arteries,  affections  of,  914 
aneurysm  of,  734,  914 
hypertrophy  of,  914 

blood-vessels,  affections  of,  914 

facies,  934 

veins,  stenosis  of,  914 
Hepatitis,  interstitial,  931 

suppurative,  922 
Hepatogenous  jaundice,  892 
Hereditary  ataxia,  1151 

cerebellar  ataxia,  1152 

chorea,  1213 

spastic  spinal  paralysis,  1141 

tremor,  1221 
Hernia,  Treitz's  retro-peritoneal,  871 
Herpes  zoster,  1132 
Herpetic  laryngitis,  516 

pharyngitis,  762 
Hiccough,  777 
Hill  diarrhea,  845 
Hirudo,  387 
Hob-nailed  liver,  932 
Hodgkin's  disease,  483.     See  also  Pseu- 
doleukemia. 
Hoffmann's  sign  in  tetany,  1223 
Hookworm  disease,  375 
Hour-glass  stomach,  808 
House-fly,  387 
Huntingdon's  chorea,  1213 
Hutchinson's  face,  1099 

pupil,  1160 

teeth,  393 

triad,  393 
Hyaline  degeneration  of  heart,  700 

transformation  of  Zenker,  700 
Hydatid  cyst  of  lung,  579 

disease,    363.     See   also   Echinococcus 
disease. 

thrill,  365 
Hydatids  of  brain,  1184 
Hydoxerma,  387 
Hydrocephalus,  clironic,  1190 


LSlt 


INDEX. 


Hydroi'cphalus,  chronic,  external,  1100 

internal,  1190 
Hydronephrosis,  1043 

paraplegica,  1045 
Hydroperieardiuni,  026 
Hydrophobia,  309 
bacteriology,  309 
clinical  history,  310 
diagnosis,  310 
dumb,  310 
etiologj',  309 
intensive  treatment,  311 
pathology,  309 
prognosis,  311 
pseiido-,  311 
spiu'ious,  1229 
treatment,  311 
Hydrops  peritonaM,  970 
Hydrotherapy  in  lobar  pneumonia,  128 

in  typhoid  fever,  55 
Hydrothorax,  608 
HjTiienolepis  nana  fraterna,  371 
Hyperacitlity,  823 
Hyperacusis,  1105 
Hyperchlorhydria,  823 
Hyperemia  of  brain,  1161 
of  kidneys,  active,  982 

passive,  983 
of  hver,  910 
acute,  910 
passive,  910 
of  liuigs,  540 
active,  540 
hypostatic,  542 
mechanical.  541 
passive,  541 
of  spinal  cord,  1 126 
of  spleen,  946 
Hj'peresthesia,  hysteric,  1231 

of  stomach,  829 
H^^lergeusia,  1100 
Hyjierorexia,  830 
Hyperosmia,  1090 
Hyperplasia  of  thymus,  494 
Hj-persecretion  of  salivary  glands,  751 
HyperthjToidism,  498 
Hypertrophia  cordis,  677 
Hypertrophic  cirrhosis  of  liver,  932 
emphysema,    565.     See   also   Emphy- 
sema, hypertrophic. 
I)har3'ngitis,  chronic,  764 
stenosis  of  j)j-lorus,  819 
Hypertrophied  tonsils,  758 
Hypertrophy,  muscular,  1264 
of  auricles  of  heart,  679 
of  heart,  677.     See  also  Heart,  hyper- 
trophy of. 
of  hepatic  arteries,  914 
of  left  auricle  of  heart,  682 
of  liver,  914 

of  right  auricle  of  heart,  682 
ventricle  of  heart,  679,  681 
Hypogastric  neuralgia,  888 
Hypoglossal  nerve,  diseases  of,  1113 
paralysis  of,  1113 
spasm  of,  1113 
Hypo.static  hyperemia  of  lungs,  542 


H\-]Wthvroi(lism,  502 
Hysteria,  1224 

and  neurasthi>nia,  diflferentiation,  1238 

convulsions  of,  1228 

<leliriuin  stage  of,  1229 

diagnosis,  dilTerential,  1232 

dramatic  form,  1229 

emotional  cataleptic,  1229 

epileptoid,  1228 

etiology,  1225 

gymnastic  form,  1228 

latent  stage  of,  1230 

pathology,  1225 

prodromal  .><tage,  1227 

jH-ogiiosis,  1233 

symptoms  of,  jjsychic,  1231 
sensory,  1230 

traumatic,  1227 

treatment,  1232 
Hysteric  amaurosis,  1231 

anosmia,  1231 

anuria,  1232 

aphonia,  1232 

ataxia,  1230 

athetosis,  1229 

blindness,  1231 

bradycardia,  1232 

breast,  1231 

catalepsy,  1229 

contractures,  1229,  1230 

cough, 1232 

deafness,  1231 

dyspnea,  1232 

epidemics,  1225 

erj^hema,  1232 

fever,  1232 

hematemesis,  1232 

hemoptysis,  1232 

hyperesthesia,  1231 

joint,  1231 

paralyses,  1229 

j)aresthesia,  1231 

peritonitis,  964 

polyuria,  1059,  1232 

pseudo-angina,  1232 

pseudo-cyesis,  1229 

rotary  spasm,  1229 

sleep,  1229 

stigmata,  1230 

tachj'cardia,  1232 

torticollis,  1229 

trance,  1229 

tremor,  1221,  1229 

trismus,  1228 

vomiting,  1231 
Hystero-epilepsy,  1228 
Hysterogenous  zones,  1228 

ICHTHYISMUS,  1284 

Icterus,  892 

acute  febrile,  328 
catarrhal,  892 
chronic  family,  896 
gravis,  927 

hemohepatogenous,  896 
hemolytic,  896 


INDEX. 


n\^, 


Icterus,  hepatogenous,  892 

in  lobar  pnoumonia,  1 19 

malignant,  927 

neonatorum,  909 

obstructive,  892 

toxic,  896 
Idiocy,  amaurotic  family,  1248 
Idiopathic  anemia,  465 
Ileo-colitis,  845 
Ileo-typhoid,  17 
Ileum,  catarrh  of,  837 
Ileus,  871.     See  also  Intestinal  obstruc- 
tion. 
Immunity  to  diphtheria,  155 
Incompetency,  aortic,  639 

mitral,  647 

pulmonary,  661 

tricuspid,  657 
Incontinence  of  urine,  1060 
Indicanuria,  991 
Induration,  brown,  of  lungs,  541 

cyanotic,  of  liver,  910 

fibroid,  552 
Inebriety,  alcoholic,  1268,  1270 

cologne-water,  1275 

ginger-,  1275 

opium-,  1275 
Infantile  diabetes,  420 

paralysis,  1130 
Infarct,  anemic,  695 

white,  695 
Infarction,  embolic,  of  kidneys,  983 

hemorrhagic,  550 

intestinal,  850 
Infectious  diseases,  17 

associated  with  typhoid  fever,  44 
Infiltration,  fatty,  of  heart,  699 

of  liver,  915 
albuminoid,  915 
amyloid,  915 
bacony,  915 
fatty,  917 
lardaceous,  915 
waxy,  915 
Infianunation  of  brain,  1181.     See  also 
Encephalitis. 

of  common  bile-duct,  892 

of  dura  mater  of  brain,  1118 

of  mediastinum,  610 

of  meninges,  1118 

pseudo-membranous,  in  typhoid  fever, 
44 
Inflammatory  diseases  of  stomach,  790 

edema  of  lungs,  542 
Influenza,  130 

bacteriology,  131 

clinical  history,  132 
types,  133 

convalescence  in,  138 

diagnosis,  135 

duration,  136 

etiology,  131 

features  and  complications,  133 

historic  note,  131 

immunity  to,  132 

lobar  pneumonia  in,  134 

manner  of  invasion,  132 


Influenza,  inofles  of  convfiyance,  131 
nostras,  i;»5 
pathology,  131 
plastic  [)lcuriKy  in,  134 
predisposing  causrw,  132 
prognosis,  136 
sc(}uels,  136 

symptomatology  niul  fiourse,  132 
tn^atmcnl,,  136 
Inosituria,  1005 

Insane,  general  paralysis  of,  1198 
Insanity,  alcoholic,  1270 

confusionai,  1193 
Insolation,  1293 
Insufficiency,  aortic,  639 

mitral,  647 
Intercostal  nerve,  paralysis  of,  1 1 18 

neuralgia,  1081 
Intermittent  angioneurotic  edema,  1249 
claudication,  1145 

fever,  348.     See  also  Malarial  fever. 
Charcot's,  901 

tertian,  hemameba  causing,  345 
paraplegia,  1145  » 

Internal  language,  1166 
Interstitial  endocarditis,  chronic,  636 
hepatitis,  931 
nephritis,  acute  non-suppurative,  1026 

chronic,  1032 
pneumonia,  chronic,  552 
Intestinal  actinomycosis,  305 
auto-intoxication,  884 
calculi,  870 
catarrh,  835 

chronic,  839 
hemorrhage  in  typhoid  fever,  34 
infarction,  850 
obstruction,  871 
acute,  871 

symptoms,  873 
adynaniic,  873 
chronic,  872 
diagnosis,  874 
treatment,  876 
sensibility,  diminished,  888 
ulcers,  850 
Intestine,  carcinoma  of,  877 
diseases  of,  830 

methods  of  diagnosis,  830 
disturbances  of  mobility,  888 
secretory,  886 
sensory,  887 
examination  of,  physical  or  external, 

832 
neuralgia  of,  887 
neuroses  of,  886 

treatment,  890 
spasm  of,  889 
tuberculosis  of,  277 
diagnosis,  278 
symptoms,  277 
Intoxications,  1268 
Intrameningeal  hemorrhage,  1 125 
Intra-ocular  paralysis,  1096 
lodothyrin,  503 
Iridoplegia,  1096 
Irritability  of  bladder,  1058 


1316 


INDEX. 


Irritable  heart,  704 
Itch,  385 
Ixodes,  387 

albipictus,  387 

bovis,  387 

carapato,  3S7 

rieiuus,  387 


Jacksonian  epilepsy,  1207 

Jaffe's  test  for  iiuiicanuria,  U02 

Jail  fe\er,  07 

Jaundice,  892.     Se(>  also  Icterus. 

Jejunum,  catarrh  of,  S37 

Jigger,  387 

Johnson's  test  lor  albuminuria,  989 

Joint,  hysteric,  1231 

Joints  in  typhoid  fever,  44 

syphilis  of,  400 
Jumpers,  1219 
Juvenile  tyiu-  of  muscular  atrophy,  1262 


Iv.\H leu's  disease,  991 
Kakke,  316,  1284 
Kala-azar,  340 

Kelling's  test  in  cancer  of  stomach,  817 
Keratosis  follicularis,  341 
Kernig's  sign  in  cerebral  leptomeningitis, 
1121 
in  cerebrospinal  meningitis,  100 
in  tetanus,  314 
Keuchhusten,  223 
Kiilnev,  adenoma  of,  1049 

amyloid,  1012 

angioma  of,  1049 

carcinoma  of,  1049 

circulatory-  disorders  of,  982 

cirrhotic,  1032 

congestion  of,  982 

contracted,  1027 

])rimary  or  g(>nuine,  1032 

cystic,  1048 

degeneration,  1048 

diseases  of,  978 

dislocated,  978 

echinococcus  of,  367 

embolic  infarctions  of,  983 

fattv,  1027 

fibroma  of,  1049 

floating,  97S 

gouty,  1032 

hyperemia  of,  active,  982 
passive,  983 

in  diabetes,  415 

in  diphtheria,  153 

in  gout ,  433 

in  lf)bar  |)neumonia,  107 

in  tyjilioid  fever,  20 

large  red,  1028 
white,  1027 

lipoma  of,  1049 

lymjjhadenoma  of,  1049 

mobility  of,  978 

movable,  978 

new  growths  of,  1049 

of  pregnancy,  987 


Kidney,  palpable,  978 

red  granular,  1032 

rhabdomvoma  of,  1049 

Ro-si-lira'dford,  1039 

sarcoma  of,  1049 

secondar^•,  1027 

senile,  1()33 

small  white,  102S 

surgical,  1040 

syphilis  of,  400 

tuberculosis  of,  283 

v;iriegated,    of    chronic    hemorrhagic 
nepliritis,  1028 

wandering,  978 
Kleb.s-Loffler  bacillus,  153 
Koi)lik's  sign  of  measles,  523 
Kopp's  asthma,  494 
Korsakow's  psychosis,  1085,  1271 


La  ghippe,  130 
La  perleche,  745 
Lactic  acid,  test  for,  779 
Lactosuria,  1004 
Laennec's  cirrhosis,  932 

egophony    in  sero-fibrinous   i)leurisy, 
588 
Lamblia  intestinalis,  338 
Landry's  paralysis,  1133 
Language,  internal,  1176 
Lardaceous  infiltration  of  liver,  915 

spleen,  948 
Large  red  kindey,  1028 

white  kidney,  1027 
Larval  pneumonia,  120 

su])eracidity,  825 
Laryngeal  crisis,  1108 

diphtheria,  158 
Laryngitis,  acute  catarrhal,  513 

chronic,  515 

edematous,  519 

herpetic,  516 

.sicca,  513 

spasmodic,  517 

stridulus,  517 
Larynx,  diseases  of,  513 

in  typhoid  fever,  21 

])aralysis  of,  1108 

spasm  of,  1107 

tumors  of,  520 
Latah,  1219 
Latent  pneumonia,  120 
Lathyrismus,  1286 
Lead  en(;ei)halopathy,  1279 
Lead-poi.soning,  chronic,  1278 
Leber's  disease,  1093 
Leech,  387 
Legs,  weak,  316 
Lenticular    flegeneration,    progressive, 

1180 
Lepra,  299 

alba,  300 

mutilans,  301 
Leprosy,  299 

anesthetic  form,  301 

bacteriology,  300 

clinical  history,  300 


INDEX. 


1317 


Leprosy,  diagnosiK,  301 

(jtiology,  :S00 

historic  note,  299 

macular,  .'iOO 

iriodes  of  infection,  iiOO 

pathology,  299 

predisposing  causes,  300 

prognosis,  301 

treatment,  301 

tubercular  form,  300 
Leptomeningitis,  1121 

acute  spinal,  1123 

lumbar  puncture  in,  1124 

cerebral,  1121 

chronic,  1125 
Leptus  autumnalis,  385 
Leube-Riegel's  test-dinner,  778 
Leube's  test  for  motor  function  of  stom- 
ach, 781 
Leucinuria,  1002 
Leukanemia,  483 
Leukemia,  475 

acute,  symptoms,  478 

chronic,  symptoms,  478 

complications,  481 

diagnosis,  481 
differential,  481 

etiology,  477 

lymphoid,  476 

myeloid,  476 

pathology,  475 

prognosis,  481 

pseudo-,  483 

spleen  in,  479 

symptoms,  478 
general,  479 

treatment,  482 
Leukocytes,  diapedesis  of,  in  tuberculo- 
sis, 233 

in  urine,  1006 
Leukocythemia,  475.    See  also  Leukemia, 
Leukoplakia  oris,  750 
Lice,  385 

Lienteric  diarrhea,  839 
Lingua  geographica,  750 
Lingual  psoriasis,  750 
Lipaciduria,  1004 
Lipogenic  glycosuria,  421 
Lipoma  of  brain,  1184 

of  kidney,  1049 

of  peritoneum,  977 
Lipomatosis  universalis,  1287 
Lips,  tuberculosis  of,  276 
Lipuria,  993,  1004 
Lithemia,  440 
Lithic  acid  in  urine,  999 
Lithuria,  999 
Little's  disease,  1164 
Liver,  abscess  of,  922 

and  malaria,  differentiation,  926 

active  congestion  of,  910 

acute  yellow  strophy  of,  927 

adenoma  of,  944 

altered  shape  of,  891 

amyloid  degeneration  of,  915 

anemia  of,  909 

angioma  of,  944 


Liver,  anomalies  in  shape;  and  position, 

891 
atrophy  of,  914 
carcinoma  of,  939 
circulatory  aff(!c1  ions,  909 
(iirrhosis  of,  931 

alcoholic,  932 

atrophic,  932 

biliary,  932 

differential  diagnosis,  936-938 

hemochromatosis  in,  935 

hyp(!rtrophic,  932 
corset,  891 

cyanotic  induration,  910 
cysts  of,  944 
degeneration  of,  915 
diseases  of,  891 
echinococcus  of,  364 
fatty,  917 

degeneration  of,  917,  918 

infiltration  of,  917 
gin-drinkers',  931 
hob-nailed,  932 
hyj^eremia  of,  910 
hypertrophy  of,  914 
in  lobar  pneumonia,  107 
in  phosphorus-poisoning,  929 
in  typhoid  fever,  20,  36 
infiltration  of,  915 

albuminoid,  915 

amyloid,  915 

bacony,  915 

fatty,  917 

lardaceous,  915 

waxy,  915 
maKormations  of,  891 
nutmeg,  910,  931 

atrophic,  910 
pseudo-hypertrophy  of,  915 
red  atrophy  of,  927 
role  of,  in  diabetes,  414 
sarcoma  of,  944 
sclerosis  of,  931 
syphilis  of,  396 
tuberculosis  of,  283 
vascular  affections  of,  909 
Liver-fluke,  361 
Lobar  pneumonia,  105 

abscess  in,  106 

acute  nephritis  in,  120 

antipneumococcus  serum  in,  128 

arthritis  in,  119 

bacteriology,  107 

blood  in,  114 

bronchitis  in,  118 

cardiac  clots  in,  119 
stimulants  in,  126 

clinical  history,  110 

varieties    and    anomalous    types, 
120 

complications,  117 

congestion  stage,  116 

consolidation  stage,  116 

course  and  duration,  122 

diagnosis,  122 
differential,  123 

diet  in,  126 


131 S 


INDEX. 


Lobar  pneumonia,  endemic  influence  in, 
lOS 
endocarditis  in,  107,  118,  119 
engorgement  stage,  105 
epidemic  influence  in,  108 
etiolog}',  107 
gangrene  in,  106 

gastro-intestinal  complications,  119 
gray  hepatization  stage,  100,  117 
heart  in,  107 
heart -sounds  in,  114 
hydrot  iierapy  in,  128 
inununity  to,  110 
in  influenza,  134 
induration  in,  106 
jaimdice  in,  119 
kidneys  in,  107 
liver  in,  107 

micrococcus  lanceolatus  in,  107 
parotitis  in,  119 
pathology,  105 
pericarditis  in,  107,  118 
physical  signs,  116 
pleurisy  in,  117 
pncmnococcus  meningitis  in,  119 

septicemia  in,  117 
predisposing  causes,  108 
prognosis,  124 
pulse-rcsi)iration  in,  111 
l)urulent  infiltration,  106 
red  hepatization  stage,  105 
respiratory  stimulants  in,  127 
sequels,  122 
spleen  in,  107 
sputum  in,  111 
suppuration,  573 
symptoms.  111 
cerebral,  115 
circulatory,  112 
cutaneous,  115 
digestive,  115 
febrile,  112 
general,  112 
local,  111 
respiratory,  111 
thoracic,  110 
urinary,  115 
treatment,  126 

abortive  method,  128 
antiseptic,  128 
local,  129 

of  complications,  129 
of  special  s>Tnptoms,  128 
venesection  in,  128 
Lockjaw,  312.     See  also  Tetanus. 
Locomotor  ataxia,  1145 
Ludwig's  angina,  751 
Lumbago,  322 
Lumbar  plexus,  diseases  of,  1117 

puncture    in    acute    leptomeningitis, 
1124 
in  cerebrospinal  meningitis,  101 
Lumbo-abdominal  neuralgia,  1081 
Lumpy  jaw,  304 
Lung  fever,  105.     See  also  Lobar  pnew- 

monia. 
Lungs,  abscess  of^  573 


Lungs,  aplasia  of,  562 
brown  induration,  541 
circulatory  disturbances  in.  540 
cirrhosis  of,  552 
colla])se  of,  561 
compression  of,  561 
congestion  of,  540 
diseases  of,  540 
edema  of,  542 
collateral,  542 
general,  543 
hypostatic,  .543 
recurrent  variety,  544 
embolism  of,  550 
gangrene  of,  571 
hydatid  cyst  of,  .579 
hyjieremia  of,  540 
active,  540 
hypostatic,  542 
mechanical,  541 
passive,  541 
in  diabetes,  415 
in  typhoid  fcvc  r,  21 
new  growths  of,  577 
sarcoma  of,  579 
syphilis  of,  398 
LjTnph,  humanized,  for  vaccination,  201 
Lymphadenitis  of  mediastinum,  610 
LjTnphadenoma,  general,  483 

of  kidney,  1049 
Lymphatic  constitution,  494 

glands  in  diphtheria,  153 
LjTnph-glands,  tuberculosis  of,  243 
general  tuberculous  adenitis,  245 
local  tuberculous  adenitis,  243 
LjTiiphoid  leukemia,  476 
LjTiiphoma  of  pancreas,  957 
Ljonphomatous  nephritis,  1026 
LjTnph-scrotmn  from  filarise,  383 
Lymph-vuh'a  from  filarial,  383 
Lyssophobia,  311 

Macewen'h  sign  in  acute  tuberculosis, 
253 
in  cerebrospinal  meningitis,  100 
Macular  leprosy,  300 
Maidismus,  1286 
Main  en  griffe,  1088 
Malacia,  830 
Maladie  de  Gilles  de  la  Tourette,  1218 

des  tics  convulsif,  1218 
Malarial  complexion,  350 
fever,  342 

and  hepatic  abscess,  differentiation, 

925 
cachexia,  354 
complications,  356 
continued,  352 
diagnosis,  356 

differential,  356 
epidemiologj',  348 
etiologj',  343 

hematuria  and  hemoglobinuria,  355 
historic  note,  342 
immunity  from,  347 
in  typhoid  fever,  44 


INDEX. 


1319 


Malarial  fever,  intermittent,  348 
masked  intermitt(!nt,  '^^A 
mcithod  of  examining  blood  for  para- 

Hile,  .357 
parasitology,  348 
pathology,  342 
pernicious  intermittent,  351 
predisposing  causes,  346 
prognosis,  357 
remittent,  352 
treatment,  357 

pneunonia,  121 
Malformations  of  liver,  891 
Malignant  diphtheria,  156 

endocarditis,  632 
recurrent,  634 

jaundice,  927 

mural  endocarditis,  633 

pustule,  306 

scarlet  fever,  209 

syphilis,  392 
Malposition  of  stomach,  784 
Malta  fever,  319 
Mammary  glands  in  tuberculosis,  272, 

286 
Mania,  acute  delirious,  1192 

Bell's,  1192 

typho-,  1192 
Mania-a-potu,  1268,  1270 
Marechal-Rosin  test  for  choluria,  1004 
Marie's  theory  of  aphasia,  1179 
Martinet's  method  of  estimating  acidity 

of  urine,  999 
Masked  chlorosis,  463 
Massive  pneumonia,  116 
Masticatory  spasm  of  Romberg,  1100 
Mastigophora,  338 
Mastodynia,  1081 
Maw-worm,  373 
McBurney's  point,  860 
Measles,  216 

bacteriology,  217 

clinical  history,  217 

complications,  218 

diagnosis,  219 

etiology,  216 

French,  220.     See  also  Rubella. 

German,  220.     See  also  Rvbella. 

immunity  to,  217 

mortality,  219 

pathology,  218 

treatment j  219 
Meat-poisoning,  1284 
Median  nerve,  paralysis  of,  1116 
Mediastinal  hemorrhage,  613 
Mediastino-pericarditis,  617 
Mediastinum,  abscess  of,  611 

carcinoma  of,  611 

diseases  of,  610 

echinococcus  of,  366 

(inflammation  of,  610 

Ijmaphadenitis  of,  610 

sarcoma  of,  611 

tumors  of,  611 
Mediterranean  fever,  319 
Megalocytosis,  459 
Melaena  neonatorum,  458 


Melancholia,  alcoholic,  1270 
Melanuria,  1004 
M(;rnhni,rious  eroiip,  158 

pliaryngitiH,  H').'> 

sicjiiialiti.s,  740 
Menienj's  discsase,  1105 
Meningeal  apoplexy,  1125 
Meninges,  inflammation  of,  1118 

spinal,  hemorrhage  into,  1125 
Meningismus,  1123 
M(!ningitis,  acute  spinal.  1123 

cerobrospinal,   95.     See  also   Cerel/ro- 
spinal  meningitis. 

circumscribed  serous  spinal,  1125, 1157 

pneumococcus    in    lobar    pneumonia, 
119 

posterior  basic,  1122 

serous,  1123 

tuberculous,   249.     Sec;  also   Tubercu- 
lous meningitis. 
Meningo-encephalitis,     chronic     diffuse, 

1198 
Meningomyelitis,  1123 
Meralgia  paraesthetica,  1254 
Mercurial  poisoning,  chronic,  1282 

ptyalism,  747 

stomatitis,  747 
Mercurialism,  1282 
Merycism,  826 

Mesenteric  artery,  inferior,  aneiuysm  of, 
734 
superior,  aneurysm  of,  734 

glands  in  tjrphoid  fever,  19 
tuberculosis  of,  245 
Micrococcus  catarrhalis,  521 

lanceolatus,  107 

melitensis,  319 
Micromania,  442 
Micturition,  neuroses  of,  1060 
Migraine,  1209 

ophthalmique,  1096 
Migratory  pnemnonia,  120 
Miliary  aneurysm,  723 

fever,  331 

tuberculosis,    general,   247.     See   also 
Tuberculosis,  miliary,  general. 
Milk-poisoning,  1283 
Milk-sickness,  330 
Millar's  asthrna,  494 
Mimic  spasm,  1101 
Mind-blindness,  1095 
Miners'  cachexia,  376 
Mintz's  method  of  estimating  free  hydro- 
•  chloric  acid  in  gastric  contents,  780 
Misplacement  of  heart,  703 
Mitral  disease,  congenital,  717 

incompetency,  647 

insufficiency,  647 

regurgitation,  647 

stenosis,  653 
relative,  656 
Mobihty  of  kidney,  978 
Monarticular  rheiunatism,  176 
Monkey  gait,  1216 
Monophobia,  1242 
Morbus  maculosus  neonatorum,  458 
Morphea,  1256 


1320 


INDEX. 


Morphinism,  1275 
Morvan's  disejiso,  1155 
MDsquitoes,  3S7 

Motility  of  intestiiu-,  disturbances  of,  SSS 
Mt)tor  aphasia,  1178 
rortical,  II 7S 
subcortical,  1178 

nerves  of  ejoball,  diseases  of,  1095 

oculi,  1095 

tic,  1216 
Mountain  anemia,  376 

fever,  326 

sickness,  326 
Mouth,  diseases  of,  737 

dry,  752 

glassblowers',  752 
Movable  kidney,  978 
Muco-enteritis,  835 
Mucous  bronchitis,  538 

colic,  886 

f^astritis,  798 
Multiple  neuritis,  1085 

sclerosis,  1195 
Mumps,  249.     See  also  Parotitis. 
Musca  domestica,  387 
Muscidff,  387 
Muscles,  diseases  of,  1257 

in  tji^hoid  fever,  22,  44 

of  eye,  paralysis  of,  1097 
Muscular  atrophy,  1264 
arthritic,  1263 

facioscapulohiuneral  type,  1262 
progn'ssive  neural,  1088 
sjHnal,  1142 

scapulohumeral    or    juvenile    type, 
1262 

dystrophies,  1260 

hypertrophy,  1264 

paralysis,  hereditary,  1261 
pseudo-h}-pertrophic,  1261 

rheumatism,  321.     See  also  Myalgia. 

spasm  of  esophagus,  770 
Musculo-spLral  nerve,  paralysis  of,  1115 
Mushroom-poisoning,  1287 
Myalgia,  321 

cervicaUs,  323 

(Uagnosis,  323 

(>tiology,  322 

lumbahs,  322 

jxithology,  322 

prognosis,  323 

symptoms,  322 

treatment,  323 

varieties,  322 
Myasthenia  gravis,  1267 
Myatonia  congenita,  1266 
Mycotic  aneurysm,  724 

cystitis,  1053 

diarrhea,  843 
Mydriasis,  1096 
Myehtis,  1134 

acute,  1134 
diffuse,  1134 

central,  1134 

chronic,  1137 

compression,  1134,  1138 

diffuse,  1134 


Myelitis,  disseminatiHi,  1134,  1136 

hemorrhagic,  1134 

transverse,  1134 
Myeloid  leukemia,  476 
Myelomalacia,  1134 
Myelopathic  albumosuria,  991 
Myiasis  vulMcruin,  3S7 
Myocarditis,  690 

acute,  690 

chronic.  691 

fibrous,  691 
Myoclomis  epilepsy,  1207 

fibrillaris  multii)lex,  1215 

nuiltij)lex,  1214 
Myokjania,  1215 
Myomalacia  cordis,  695 
Myosis,  s})inal,  1096 
Myositis,  1259 

infectious,  1259 

progressive  ossifj'ing,  1260 

rheumatic,  323 
Myotonia  atrophica,  1263 

congenita,  1264 
Mysopholiia,  1243 
Mvtilotoxin,  12S5 
Myxedema,  502 

diagnosis,  504 

etiology,  503 

operati^-e,  505 

prognosis,  504 

sporadic  and  endemic,  505 

sym})toms,  503 

treatment,  504 
Myxoma  of  brain,  1184 
Myzomj'ia  ludlowi,  344 


Nasal  catarrh,  acute,  507 
chronic,  508 
diplitheria,  157 
Nasse's  law  of  hemoj)hilia,  455 
Necator  Americanus,  376 
Necrosis,  anemic,  695 
Necrotic  tonsillitis,  756 
Nematodes,  372 
Nephritic  retinitis,  1034 
Nephritides,  1005 
Nepliritis,  acute,  1020 
biologic  causes,  1021 
diffuse,  1020 
etiology,  1021 
in  lobar  pneumonia,  120 
interstitial  non-sup] lurative,  1026 
parenchj'matous,  1020 
patholog}-,  1020 
prognosis,  1024 
symptoms,  1022 
treatment,  1025 
clu"onic  desquamative,  1027 
diffuse,  1027 

with  exudation,  1027 
exudative,  1027 
diagnosis,  1030 
etiology,  1028 
pathology,  1027 
I^rognosis,  1031 
s3'mptoms,  1029 


INDEX. 


1321 


Nephritis,  chronic  exudative,  treatment, 
1031 

interstitial,  1032 
non-exudative,  1 032 
diagnosis,  1036 
etiology,  1033 
pathology,  1032 
prognosis,  1037 
shifting  paralysis  in,  1036 
symptoms,  1034 
treatment,  1037 
uremia  in,  1036 
urine  in,  1034 
parenchymatous,  1027 
productive,  without  exudation,  1032 
tubal,  1027 
in  scarlet  fever,  211 
lymphomatous,  1026 
Nephro-erysipelas,  148 
Nephrolithiasis,  1014 
Nephroptosis,  978 
Nephrydrosis,  1044 
Nephrydrotic  cyst,  1044 
Nerfs  radiculaires,  1146 
Nervenfieber,  17 

Nerve-pain,  1077.     See  also  Neuralgia. 
Nerves  in  diphtheria,  153 

tumors  of,  1089 
Nervous  complications  in  typhoid  fever, 
42 
diarrhea,  888 
diseases,  functional,  1074 

general  and  topical  diagnosis,  1074 
organic,  1074 
dyspepsia,  821 
system,  diseases  of,  1063 
in  diabetes,  415 
in  tuberculosis,  272 
in  typhoid  fever,  22,  41 
vomiting,  826 
Neural  muscular  atrophy,   progressive, 

1088 
Neuralgia,  1077 

cervico-brachial,  1081 
cervico-occipital,  1081 
crural,  1082 
femoral,  1082 
hypogastric,  888 
intercostal,  1081 
lumbo-abdominal,  1081 
obturator,  1082 
of  extremities,  1081 
of  genitalia,  1083 
of  intestine,  887 
of  neck  and  trunk,  1081 
of  rectum,  1083 
phrenic,  1081 
treatment,  1083 
visceral,  1083 
Neurasthenia,  1235 

and  hysteria,  differentiation,  1238 

etiology,  1236 

gastrica,  821 

pathology,  1236 

prognosis,  1239 

symptoms,  1236 

treatment,  1239 


Neuritic  muscular  atrophy,  progresHive, 

1088 
Neuritis,  1084 

endemic  multiple,  316 

in  pneumonia,  1 19 

interstitial,  10S4 

local,  1084 

multiple,  1085 

of  optic  nerve,  1092 

parenchymatous,  1084 

retrobulbar,  1092 
Neuroma,  1089 
Neuroses,  occupation-,  1243 

of  bladder,  1058 

of  esophagus,  770 

of    extr(!mities,    paralytic    vasomotor, 
1252 
spastic  vasomotor,  1253 

of  heart,  703 

of  intestine,  886 
treatment,  890 

of  micturition,  1060 

of  motility,  826 

of  secretion,  823 

of  sensation,  827 

of  stomach,  821 

traumatic,  1242 
Neurotic  tachycardia,  705 
Newborn,  acute  fatty  degeneration  of, 
458 

hemoglobinuria  of,  457 

hemorrhagic  diseases  of,  458 

melena  of,  458 

syphilis  hsemorrhagica  of,  458 
Night-bhndness,  1092 
Nitro-prussid  test  for  acetonuria,  998 
Nocturnal  enuresis,  1060 

epilepsy,  1207 
Nodes,  Heberden's,  430 
Noma,  745 

pudendse,  746 
Nose,  diseases  of,  507 
Nose-bleed,  512 
Nucleins,  1000 
Nutmeg  liver,  910,  931 

atrophic,  910 
Nyctalopia,  1092 

Nylander's  reagent  for  glycosuria,  997 
Nystagmus,  paralytic,  1097 


Obesity,  1287 

treatment,  1290 
Obstetric  paralysis,  1115 
Obstructive  jaundice,  892 

pyehtis,  1041 
Obturator  nerve,  paralysis  of,  1117 

neuralgia,  1082 
Occupation-neuroses,  1243 
Olfactory  anesthesia,  1090 

center,  1073 

hjTDeresthesia,  1090 

nerve,  diseases  of,  1090 
Oligemia,  459 
Oligochromemia,  459 
01igocji;hemia,  459 
Omodynia,  323 


i;i22 


INDEX. 


Onomatomania,  1218,  1243 
Ophthalmoplofliii.  1^98 

interna,  lOlH) 
Opis;thotonos,  312,  314 
Opium-inebriety,  1275 
Opiumism,  1275 
Ojisonin  test  in  disiignosis  of  chrome  tu- 

bereulosis,  273 
Optic  aphasia,  1177 

atrophy,  1092 

nerve,  diseases  of,  1092 
neuritis  of,  1092 

tract,  diseases  of,  1093 
Oral  actinomycosis,  304 
Oriental  sore,  340 
Orthostatic  purpura,  452 
Orthotonos,  314 
Oryzanin,  319 

Ossifj-ing  myositis,  progressive,  1260 
Osteoma  of  brain,  1184 
Otoneurastlienia,  1238 
Ovaries,  tuberculosis  of,  285 
Oxaluria,  1000 
Oxybutyria,  998 
Oxyiu"is  vermicularis,  373 

Pachymeningitis,  cerebral,  1118 
cervicales  hypertrophica,  1120 
externa,  1119 

ha?morrhagica  interna,  1120 
interna,  1119 
spinal,  1119 
Palate,  tuberculosis  of,  276 
Pahnus,  1216 
Palpable  kidney,  978 
Palpitation  of  heart,  703 
Pancreas,  adenoma  of,  957 
calculi  in,  958 
carcinoma  of,  955 
cysts  of,  957 
diseases  of,  949 
IjTnphoma  of,  957 
sarcoma  of,  957 
Pancreatic  apoplexy,  954 
diabetes,  421 
hemorrhage,  954 
Pancreatitis,  acute,  949 
chronic,  953 
gangrenous,  952 
hemorrhagic,  949 
suppurative,  951 
Papillitis,  1092 
Paracentesis  abdominis,  939 

spinal  leptomeningitis,  1124 
Paradoxical  pulse,  709 
Parageusia,  1100 
Paralysis,  acute  ascending,  1133 
agitans,  1219 
alcoholic,  1270 
atrophic  spinal,  1130 
Bell's,  1101 
birth-,  1164 
bulbar,  1107,  1129 

asthenic,  1267 
cerebral,  of  childhood,  1173 
crutch-,  1115 


Paralysis,  divers',  1127 

Erb's  syphilitic  spinal,  395 

essential,  of  chiklren,  1130 

family  periodic,  1223 

general,  of  iusnM(\  1198 

glosso-labio-laryngeal,  1 129 

hereditary  muscular,  1261 
spastic  spinal,  1141 

hysteric,  1229 

infantile,  1130 

intra-ocular,  1096 

Landry's,  1133 

obstetric,  1115 

of  abductors,  1108 

of  adductors,  1109 

of  anterior  crural  nerve,  1117 

of  brachial  plexus,  1115 

of  circumflex  nerve,  1115 

of  esophagus,  771 

of  external  poi)liteal  nerve,  1118 

of  facial  nerv'c,  1101 

of  hj'poglossal  nerve,  1113 

of  intercostal  nerve,  1118 

of  internal  popliteal  nerve,  1118 

of  larynx,  1108 

of  median  nerve,  1116 

of  muscles  of  eye,  1097 

of  musculo-spiral  nerve,  1115 

of  obturator  nerve,  1117 

of  peroneal  nerve,  1117 

of  sciatic  nerve,  1117 

of  spinal  accessory  nerve,  1112 

of  superior  gluteal  nerve,  1117 

of  supra-scapular  nerve,  1115 

of  third  nerve,  1095 

of  ulnar  nerve,  1116 

periodic,  1224 

pseudo-bulbar,  1166 

pseudo-hypertrophic,  muscular,  1261 

scriveners',  1243 

shaking,  1219 

shifting,  or  chronic  nephritic,  1036 

sleep-,  1115 

unilateral  ascending,  1144 
descending,  1144 
Paralytic  dementia,  1198 

nystagmus,  1097 

vasomotor  neurosis  of  extremities,  1252 
Parama^cium  culi,  338 
Paramyoclonus  multiplex,  1214 
Parai)hasia,  1168 
Paraplegia,  ataxic,  1152 

in  childhood,  1173 

intermittent,  1145 
Parasites  of  man,  334 
Parasitic  arachnida,  385 

diseases,  animal,  334 

hemoptysis,  548 

stomatitis,  743 
Parathyroid  glands,  diseases  of,  506 
Paratyphoid  carriers,  66 

fevers,  66 
Parenchymatous  nephritis,  acute,  1020 
chronic,  1027 
tonsUlitis,  acute,  755 
Paresis,  1198 
general,  1198 


INDEX. 


I;i23 


Paresthesia,  hysteric,  V1',M 
Parkinson's  disiiase,  1219 
Parorexia,  777 
Parosmia,  1090 
Parotid  bubo,  752 
Parotiditis,  229 

chronic,  7513 

clinical  history,  230 

complications,  231 

diagnosis,  230 

epidemic,  229 

etiology,  230 

in  pneumonia,  119 

pathology,  229 

sequels,  231 

symptomatic,  752 

treatment,  231 
Paroxysmal  glycosuria,  995 

hemoglobinuria,  986 

tachycardia,  705 
Pastia's  sign  in  scarlet  fever,  208 
Patheticus,  1097 
Pediculosis,  385 
Pediculus,  385 

capitis,  385 

corporis,  385,  386 

pubis,  385,  386 

vestimentorum,  386 
Peliosis  rheumatica,  452 
Pellagra,  1286 
Pelvic  peritonitis,  local,  964 
Pentastoma  tenioides,  385 
Penzoldt's  test  for  absorptive  power  of 

stomach,  781 
Pepsin,  test  for,  780 
Perforating  ulcer  of  stomach,  804 
Perforation  in  typhoid  fever,  35 
Periarteritis  nodosa,  735 

syphilitic,  400 
Pericarditis,  615 

acute  plastic,  615 

adhesive,  624 

bacteriology,  615 

callosa,  625 

chronic,  624 

tuberculous,  625 

external  pleural,  617 

fibrinous,  615 

hemorrhagic,  624 

in  lobar  pneumonia,  107,  118 

purulent,  623 

sero-fibrinous,  618 
clinical  history,  619 
course  and  duration,  621 
diagnosis,  621 

differential,  622 
etiology,  618 
pathology,  618 
prognosis,  621 
treatment,  622 

tubercululous,  acute,  279 
chronic,  280 

varieties,  615 
Pericardium,  air  in,  627 

diseases  of,  615 

dropsy  of,  626 

empyema  of,  623 


Pericardium,  tuberculosis  of,  279 
Periencepliaiitis,  acute,  1192 
Perihepatitis,  919 

acute,  91*^ 

chronic,  921 
Perimetritis,  964 
Perinepiiric  abscess,  1046 
Perinephritis,  1046 
Periodic  paralysis,  1223 
Peripheral  nerves,  diso^ases  of,  1077 
Peristalsis  of  stomacli,  dirriiiiished,  827 

increased,  826 
Peristaltic  unrest  of  stomach,  826 
Peritoneum,  carconoma  of,  975 

diseases  of,  959 

dropsy  of,  970 

echinoccoccus  of,  367 

fibroma  of,  977 

fibro-lipoma  of,  977 

fibro-myoma  of,  977 

lipoma  of,  977 

new  growths  in,  975 

sarcoma  of,  977 

tuberculosis  of,  280 
diagnosis,  282 
etiology,  281 
symptoms,  281 
Peritonitis,  acute,  959 

adhesive,  967 

cancerous,  968 

chronic,  967 

hemorrhagic,  968 
localized,  968 
tuberculous,  968 

circumscribed,  963 

hysteric,  964 

in  children,  963 

in  typhoid  fever,  21 

local  pelvic,  964 

localized  or  partial,  963 

proliferative,  968 

visceral,  963 
Pernicious  malarial  intermittent  fever, 

351 
Peroneal  nerve,  paralysis  of,  1117 
Pertussis,     223.     See     also     Whooping- 

cough. 
Pestis  ambulans,  143 
Petit  mal,  1206 

Pfuhl's  sign  in  acute  perihepatitis,  921 
Pharyngeal  diphtheria,  156 
Pharyngitis,  761 

acute,  761 
simplex,  761 

atrophic,  764 

chronic,  763 

hypertrophic,  764 

croupous,  763 

epidemic,  763 

exanthematous,  752 

follicular,  764 

herpetic,  762 

membranous,  763 

sicca,  763 
Pharyngocele,  772 
Pharyngo-typhoid,  21,  37 
PharjTix,  diseases  of,  761 


1324 


INDEX. 


Pharynx  in  typhoid  fever,  21,  30 

tuberculosis  of,  270 
Phlebo-sclerosis,  720 
Phlegmon,   acute  infectious,  of   throat, 

705 
Phlegmonous  cystitis,  10,52 
enteritis,  S47 
gastritis,  794 
Phloridzin  diabetes,  414 
Phosphaturia,  1001 
Phosj)horus-poisoning,  liver  in,  929 
Phrenic  nerve,  diseases  of,  1114 

neuralgia,  1081 
Phthiriasis,  3S5 

pubis,  380 
Phthisis,  acute,  254 

broncho-pneumonic,  in  cliildren,  250 
pneumonic,  254 

chnical  history,  255 
l)athology,  254 
ulcerative,   257.     See  also  Tvbercn- 
loaiti,  chroitic. 
fibroid,  274 

complications,  275 
course  and  duration,  275 
diflferential  diagnosis,  275 
pathology,  274 
symjjtoms,  274 
florid,  254 
galloping,  254 
Pica,  830 

Pigeon  breast,  445 
Pigmentary  retinitis,  1091 
Pin-worm,  373 
Piroplasmosis,  340 
Plague,  141 

bacteriology,  141 

clinical  history,  142 

diagnosis,  143 

etiology,  141 

historic  note,  141 

modes  of  transmission  and   entrance 

into  body,  142 
predisposing  causes,  141 
prognosis  and  mortality,  143 
sequels,  143 
treatment,  143 
varieties,  142 
Plaques  jaunes,  1170 

opalines,  752 
Plastic  bronchitis,  538 
pericarditis,  acute,  615 
pleurisy,  acute,  581 
in  influenza,  134 
Pleura,  carcinoma  of,  610 
diseases  of,  580 
dropsy  of,  608 
new  groAvths  of,  009 
sarcoma  of,  610 
Pleural  pericarditis,  external,  617 
Pleurisy,  580 

acute  plastic,  581 
adhesive,  601 
bacteriology,  580 
blocked,  596 
chronic,  601 
dry,  601 


Pleurisy,  chronic,  with  eflfusion,  601 
dia|)hragmatic,  .590 
thy  Hbrinous,  5S1 
hemorrhagic,  591 
in  lobar  pneumonia,  117 
in  typhoid  fever,  21 
interlobar,  590 
plastic,  in  iiiflvienza,  134 
pulsating,  599 
sero-iibrinous,  583 
diagnosis,  592 

differential,  592 
duration,  593 
etiology,  584 
Grocco's  sign  in,  588 
Laeimec's  egophony  in,  588 
jsathology,  583 
physical  signs,  587 
(prognosis,  593 
iSkoda's  resonance  in,  588 
special  forms,  589 
symptoms,  585 
treatment,  594 

Williams'  tracheal  tone  in,  588 
subacute,     583.     See     also     Pleurisy, 

xcrofihrinou.s. 
tuberculous,  279,  589 
varieties,  580 

with  effusion,  379.     See  also  Pleurisy, 
sero-fibrinou-s. 
Pleuritis,  580.     Sec  also  Pleurisy. 

purulent,  597.     See  also  Empyema. 
Pleurodynia,  322 
Pleuropneumonia,  117 
Pleurosthotonos,  314 
Pleuro-typhoid  fever,  45 
Plexus,  brachial,  diseases  of,  1114 
paralysis  of,  1115 
cer\-ical,  diseases  of,  1114 
lumbar,  diseases  of,  1117 
sacral,  diseases  of,  1117 
Plica  polonica,  386 
Plumbism,  1278 
Pneumatinuria,  1004 
Pneumococcus  meningitis  in  lobar  pneu- 
monia, 119 
septicemia  in  lobar  pneumonia,  117 
Pneumo-erysipelas,  148 
Pneumogastric  nerve,  diseases  of,  1 106 
Pneumonia,  abortive,  121 
bilious,  121 
catarrhal,  554 
central,  120 
cerebral,  115 
chronic  interstitial,  552 
colon-,  130 

croupous,  105.     See  also  Lobar  pneu- 
monia. 
epidemic,  120 
ether-,  121 

fibrinous,   105.     See  also  Lofiar  pneu- 
monia. 
interstitial,  in  chronic  tuberculosis,  259 
larval,  120 
latent,  120 

lobar,  105.     See  also  Lobar  pneumonia. 
malarial,  121 


INDEX. 


1325 


Pnoiumonia,  maaHive,  116 

migratory,  120 

neuritis  in,  119 

secondary,  130 

serous,  120 

streptococcus,  120 

terminal,  121 

typhoid,  120 

walking,  115 
Pneumonic  phthisis,  acute,  254 
Pneumonitis,  105.     See  also  Lobar  pneu- 
monia. 
Pneumonokoniosis,  575 

acute,  576 
Pneumopericardium,  627 
Pneumorrhagia,  550 
Pneumothorax,  603 

coin-sound  in,  606 

diagnosis,  606 

etiology,  604 

pathology,  603 

prognosis,  608 

symptoms,  604 

treatment,  608 

Wintrich's  sign  in,  607 
Pneumo-typhoid  fever,  38 
Podagra,  432.     See  also  Gout. 
Poikilocytosis,  459 
Points  douloureux,  1077 
Poisoning,  arsenic-,  chronic,  1280 

fish-,  1284 

grain-,  1285 

lead-,  chronic,  1278 

meat-,  1284 

mercurial,  chronic,  1282 

milk-,  1283 

mushroom-,  1287 

phosphorus-,  liver  in,  929 

ptomain-,  1283 

shell-fish-,  1284 

strychnin-,    and    tetanus,    differentia- 
tion, 314 

vegetable-,  1285 
Polioencephalitis,  inferior,  1129 

superior,  1098 
Poliomyelitis,  1134 

acute  anterior,  1130 
posterior,  1132 

chronic,  1132 
Polycythemia  hypertonica,  490 

with  splenic  tumor,  489 
Polymyositis,  acute,  1259 
Polyneuritis,  1084 
Polyphagia,  777,  830 
Polysarcia  adiposa,  1287 
Polyuria,  hysteric,  1059,  1232 
Popliteal  nerve,   external,   paralysis  of, 
1117 
internal,  paralysis  of,  1118 
Porencephalus  in  childhood,  1174 
Pork  tape-worm,  368 
Portal  vein,  diseases  of,  911 
embolism  of,  911 
stenosis  of,  914 
thrombosis  of,  911 
Posterolateral  sclerosis,  1152 
Posthemiplegic  chorea,  1174 


Pregnancy,  kidney  of,  987 
Pnimonitory  diarrhea.  84,  86 
Prend(!rgast's  typhoid  fever  test,  48 
Proctitis,  8;i9 
Proctospasin,  889 
Procursive;  epilepsy,  120() 
Proglottides,  368 

Progressiv(!  lenticular  degeneration,  1180 
Proliferative  i)eritonitis,  968 
Prostate,  tuberculosis  of,  285 
Protein,  B(!nce-Jones,  991 
Proteinuria,  990 
Pseudo-angina,  714,  715 

hysteric,  1232 

treatment,  715 
Pscudo-bulbar  palsy,  1166 
Pseudo-diphtheria,  151 

bacillus,  154 
Pseudo-hyrlrophobia,  311 
Pseudo-hypertrophic  muscular  paralysis, 

1261 
Pseudo-hypertrophy  of  liver,  915 
Pseudo-leukemia,  483 

diagnosis,  487 

etiology,  485 

pathology,  483 

prognosis,  487 

symptoms,  485 

treatment,  487 

varieties,  483 
Pseudo-membranous  esophagitis,  766 

infiammation  in  typhoid  fever,  44 
Pseudosclerosis,  1198 
Pseudo-tuberculosis,  274 
Psoriasis,  buccal,  750 

lingual,  750 
Psorospermiasis,  341 

cutaneous,  341 

external,  341 

internal,  341 
Psorosperms,  341 
Psychasthenia,  1238,  1242 
Psychic  centers,  1074 
Ptomain-poisoning,  1283 
Ptyalism,  751 

mercurial,  747 
Pulex  irritans,  386 

penetrans,  387 
Pulmonary  actinomycosis,  305 

apoplexy,  550 

artery,  aneurysm  of,  733 
sclerosis  of,  719 

atelectasis,  561 

edema,  542 
collateral,  542 
general,  543 
hypostatic,  543 
recurrent  variety,  544 

embolism,  550 

incompetency,  661 

orifice,  atresia  of,  717 
stenosis  of,  716 

regurgitation,  661 

stenosis,  662 

tuberculosis,    chronic,    257.     See   also 
Tuberculosis,  chronic. 
Pulmonic  constriction,  antenatal,  716 


1326 


INDEX. 


Pulsatiug  empyema,  599 

pleurisy,  599 
Pulse,  panuloxieal,  709 
Pulse-beat,  irrejiular,  708 
Pulsus  bigeniiims,  709 

quailrigeiniiius,  709 

trigeminus,  709 
Puncture,  lumbar,  in  acute  leptomenin- 
gitis, 1124 
in  cerebrospinal  meningitis,  102 
Pupil,  .Vrgyll-Robertson,  109ti 
Purpura,  4.")2 

arthritic,  452 

chronic,  455 

factitious,  453 

fulminans,  454 

lia'morrhagica,  453 

Henoch's,  453 

idiopathic,  452 

orthostatic,  452 

primary,  452 

secondary,  452 

simi)le,  452 

treatment,  455 
Purulent  j^ericarditis,  623 

jileuritis,  597.     See  also  Em'pyema. 
Pus  in  urine,  992 
Pustule,  malignant,  306 
Pyelitis,  1040 

ammoniemia  in,  1041 

calculosa,  1014,  1040 

infectious,  1041 

obstructive,  1041 
Pyelonephritis,  1040 
Pyemia,  170 

bacteriology,  171 

clinical  history,  171 

diagnosis,  differential,  173 

etiology,  171 

pathologj',  170 

predisposing  causes,  171 

prognosis,  173 

septico-,  173 

spontaneous,  171 

symptoms,  172 

treatment,  173 
Pylephlebitis,  suppurative,  912 
Pyloric  relaxation  of  stomach,  827 
Pyloroplasm,  827 

Pylorus,  hypertrophic  stenosis  of,  819 
Pyonephrosis,  1040 
Pyo-pneumopericardium,  627 
Pyo-pncumothorax,  603 

subphrenicus,  607,  919,  964 
P\Tosis,  777,  826 
Pj-uria,  992 

Quantitative  test  for  albvnninuria,  990 
Quartan  fever,  hemameba  causing,  345 
Quincke's  capillary  pulse,  643 

lumbar     puncture     in     cerebrospinal 
meningitis,  101 
Quinsy,  755 

Rabies,  309.     See  also  Hydrophobia. 
Rachitic  rosary,  444 


Rachitis,  442 

bacteriology,  443 
diagnosis,  445 
etiology,  442 
pathology,  442 
prognosis,  446 
symptoms,  443 
treatment,  446 
Rag-pickers'  disease,  308 
Rapid  heart,  705 
Raynaud's  disease,  1250 
Rectinn,  neuralgia  of,  1083 
Red  atr()])hy  of  liver,  927 

bldod-coiiniscles  in  urine,  1006 
granular  kidney,  1032 
kidney,  large,  1028 
Refractory  phase  of  heart-muscle,  708 
Regurgitation,  777 
aortic,  639 
mitral,  647 
pulmonary,  661 
tricuspid,  657 
Relapsing  appendicitis,  865 
fever,  407 

bacteriology,  408 
clinical  history,  408 
complications,  410 
diagnosis,  411 

differential,  411 
etiology,  408 
historic  note,  407 
mode  of  infection,  408 
pathology,  408 
predisposing  causes,  408 
prognosis,  411 
treatment,  412 
varieties,  410 
Relative  mitral  stenosis,  656 
Remittent  malarial  fever,  352 
Ren  mobilis,  978 

Renal  arteries,  aneurysm  of,  734 
calculi,  1014 
colic,  1014 
cyst,  1048 
dropsy,  1007 
sand,  1014 
Rennet  ferment,  780 

zymogen,  781 
Reptilian  heart,  716 

Respiratory  organs,  echinococcus  of,  366 
system,  diseases  of,  507 
in  typhoid  fever,  37 
Retention  of  urine,  1062 
Retina,  diseases  of,  1091 
hemorrhage  into,  1091 
Retinitis,  1091 
albuminuric,  1091 
nephritic,  1034 
pigmentary,  1091 
syphilitic,  1091 
Retrobulbar  neuritis,  1092 
Retroperitoneal  liernia,  Treitz's,  871 
Retropharyngeal  abscicss,  765 
Revaccination,  time  for,  202 
Rhabdomyoma  of  kidney,  1049 
Rheumatic  fever,  174 
gout,  427 


INDEX. 


1327 


Rheumatic  myositis,  323 
Rheumatism,  abdominal,  323 
acute  articulai',  174 
bacteriology,  174 
clinical  history,  175 
diagnosis,  180 

differential,  180 
etiology,  174 
in  children,  180 
pathology,  174 
predisposing  causes,  175 
prognosis,  181 

sjmaptoms  and  complications,  176 
cardiovascular,  177 
in  joints,  176 
in  skin,  178 
in  spleen,  180 
muscular  and  nervous,  179 
pulmonary,  180 
renal,  180 
treatment,  181 
cerebral,  1122 
chronic  articular,  324 
monarticular,  176 
muscular,  321.     See  also  Myalgia. 
subacute  articular,  184 
Rheumatoid  arthritis,  427 
Rhinitis,  acute,  507 
chronic,  508 
fibrinoiis,  157 
Rhizotomy  for  gastric   crises   of   tabes 

dorsaUs,  1150 
Rh5rthm,  cantering,  688,  709 
Rickets,  442.     See  also  Rachitis. 
Riga's  disease,  739 
Robert's  test  for  albuminuria,  989 

for  glycosuria,  998 
Rock  fever,  319 

Rocky  Mountain  spotted  fever,  326 
Romberg's  masticatory  spasm,  1100 

symptom,  1147 
Rose-Bradford  kidney,  1039 
Rosenbach's    test    for    bile-pigment    in 
urine,  893 
for  choluria,  994 
Rothehi,  220 
Round-worm,  372 
Rubella,  220 

clinical  history,  221 
complications,  222 
diagnosis,  222 

differential,  222 
etiology,  220 
prognosis,  222 
treatment,  222 
Rubeola  notha,  220 
Rumination,  826 
Runeberg's    method    of    inspection    of 

stomach,  782 
Rupture  of  esophagus,  769 
of  heart,  701 
of  spleen,  949 


Saccharomyces  albicans,  743 
Sacral  plexus,  diseases  of,  1117 
Saginata,  368 


Sago  sphicn,  948 

Salivary  glands,  diseases  of,  751 

hypcjrsecrcition  of,  751 
Saltatoric  Hpusm,  1219 
Salvarsan  in  syphilis,  405 

in  tabes  dorsalis,  1150 
Sanatorium    treatment    of    tuborculoBis, 

294 
Sand,  renal,  1014 
Sand-flea,  387 
Sarcocystis  Mi(;s(;h(;ri,  341 

oviforme,  341 
Sarcoma  of  brain,  1184 
of  kidney,  1049 
of  liver,  944 
of  lung,  579 
of  mediastinum,  Gil 
of  pancreas,  957 
of  peritoneum,  957 
of  pleura,  610 
Sarcophila  carnaria,  387 
Sarcoptes,  385 

scabiei  hominis,  385 
Saturnine  gout,  1279 
Saturnism,  1278 
Scabies,  385 
Scapulohumeral      type      of      muscular 

atrophy,  1262 
Scarlatina,  204.     See  also  Scarlet  fever. 
anginosa,  205 
sine  eruptione,  209 
Scarlatinal  angina,  205 
Scarlet  fever,  204 

bacteriology,  205 
clinical  types,  208 
complications,  210 
desquamation  in,  208,  210 
diagnosis,  212 

differential,  212 
eruption  in,  207 
etiology,  205 
immunity  to,  207 
malignant,  209 
mild,  208 
modes  of  conveyance,  206 

of  infection,  206 
nephritis  in,  211 
pathology,  205 
predisposing  causes,  207 
prognosis,  213 
traumatic,  209 
treatment,  213 
rash,  204 
Schlamnifieber,  328 
Schonlein's  disease,  452 
Sciatic  nerve,  paralvsis  of,  1117 
Sciatica,  1082 
Scleroderma  circmnscriptum,  1256 

diffusum,  1254 
Sclerosis,  amyotrophic  lateral,  1143 
arterial,  718.      See  also  Arteriosclero- 
sis. 
combined  system,  1153 
diffuse,  1198 
disseminated,  1195 
insular,  1195 
multiple,  1195 


1328 


INDEX. 


Sclerosis  of  liver,  %M- 

of  pulmonary  artery,  719 

of  veins,  720 

posterior,  114.5 

post  erol  at  era  1 ,  1152 

priniary  lateral,  1140 

subacute    combined,    of    spinal    coril, 
1153 
Sclerotic  thjToiditis,  495 
Soolex,  36S 

Scorbutic  stomatitis,  741 
Scorbutus,  447 

bacteriolofiy,  448 

diagnosis,  449 

etiology,  447 

infantile,  450 

pathology,  447 

predisposing  causes,  448 

prognosis,  449 

symptoms,  44S 

treatment,  449 
Screw-worm  fly,  387 
Scriveners'  palsv,  1243 
Scrofula,  243 

Scrotum,  lymph-,  from  filaria),  383 
Scur\y,  447.     S(>(>  also  Scorbutus. 
Seat-worm,  373 
Secondary  pneumonia,  130 
Secretion,  neuroses  of,  S24 
Secretory  disturbances  of  intestine,  886 
Segmental  anesthesia,  1231 
Senile  dementia,  1194 

em])hvsema,  570 

kidney,  1033 

neuritis,  lOSti 

tremor,  1221 
Sensation,  neuroses  of,  S27 
Sense,  stereognostic,  1179 
Sensory  aphasia,  1177 

cortical  area,  1072 

disturbances  of  intestine,  887 
Sepsis  intestinalis,  167 
Septic  cystitis,  1052 

sore  throat,  756 
Septicemia,  166 

bacteriology,  166 

clinical  historj',  168 

course,  169 

diagnosis,  169 

etiology,  166 

modes  of  infection  and   introduction, 
167 

pathology,  166 

pneumococcus    in    lobar    pneumonia, 
177 

prognosis,  169 

spontaneous,  167 

symptoms,  168 

treatment,  169 

typhoid,  27,  46 
Septicopyemia,  173 

Serofibrinous  peric^arditis,  618.     See  also 
Pericarditis,  serofihrino  us . 

pleurisy,  583.     See  also  Pleurisy,  sero- 
jihrinouH. 
Seroot-fly,  387 
Sero-pneumothorax,  603 


Serous  apoplexy,  1167 

membranes,  tuberculosis  of,  27S 

meningitis,  1123 

l)neinnonia,  120 
Scrum,   antipneinnococcus,    in   pneumo- 
nia, 128 
Serimi-diagnosis  of  typhoid   fe\-er,   47 
Serum-t herajiy  in  (lii)hth('ria,  164 

in  tuberculosis,  296 
Seventh   nerve,   diseases   of,    1100.     See 

also  Facidl  ncrrr. 
Shaking  palsy,  1219 

Shaven-beard  aj)pearance  in  t\ph()iil  fe- 
ver, IS 
Sheep  dung,  831 
Shell-fish,  jjoisoning  by,  1284 
Shifting  paralvses  in  chronic  nephritis, 

1036 
Ship-fever,  67 
Sick  headache,,  1209 
Siderosis,  576 
Simulium  reptans,  387 
Siriasis,  1296 
Sixth  nerve,  1097 
Skin,  acute  circumscribed  edema  of,  1249 

in  diabetes,  415 

in  typhoid  fever,  32 
Skoda's  resonance  in  serofibrinous  pleu- 
risy, 588 
Sleep,  hysteric,  1229 
Sleeping  sickness,  338 
Sleep-palsy,  1115 
Small  white  kidney,  1028 
Small-lunged  emphysema,  570 
Small-pox,  186.     See  also  Variola. 
Smell,  sense  of,  1090 
Softening,  cerebral,  acute,  1170 
Solitary  uIccts  of  intestine,  852 
Sore  throat,  septic,  756 
Spasm,  habit,  1216 

hysteric  rotary,  1229 

masticatory,  of  Romberg,  1100 

mimic,  1101 

nui.scular,  of  esojihagus,  770 

of  facial  nerve,  1101 

of  hy]5oglossal  nerve,  1113 

of  intestine,  889 

of  larynx,  1107 

of  stomach,  826 

of  third  nerve,  1095 

saltatoric,  1219 
Spasmodic  laryngitis,  517 
Spastic  aphoria,  llOS 

vasomotor     neurosis    of    extremities, 
12.52 
Speech  center,  1074 
location  of,  1 1 75 

genesis  of,  1 1 75 
Spinal  accessory  nerve,  diseases  of,  1110 
paralysis  of,  1112 

apoplexy,  1126 

cord,  anemia  of,  1126 

circulation  in,  disturbances  of,  1126 
compression  of,  1138 
diffuse  degeneration  of,  1125 
diseases  of,  1125 
echinococcus  of,  366 


INDEX. 


]  329 


Spinal  cord,  hemorrhage  into,  1126 
hyperemia  of,  1126 
locaUzation  of  functionn  of  segmentH, 

1071 
suba(;ut,(i  oombin(!(l  solerosis  of,  1 15:^ 
syphilis  of,  394 
tuberculosis  of,  2S7 
tumors  of,  1156 

decompression    in    (-hronic     myelitis, 
1138 

leptomeningitis,  acute,  1121 

meningitis,  acute,  1123 

circumscribed  serous,  1125 

muscular  atrophy,  progressive,  1142 

myosis,  1096 

nerves,  diseases  of,  1114 

pachjrmeningitis,  1119 

paracentesis  in  acute  leptomeningitis, 
11^4 

paralysis,  atrophic,  1130 
Erb's  syphilitic,  395 
hereditary  spastic,  1141 

serous  meningitis,  circumscribed,  1157 
Spine,  typhoid,  42 
Spirillosis,  407 
Spirillum  duttoni,  410 

Obermeieri,  407 
Spirochseta  refringens,  388 
Spleen,  amyloid  degeneration  of,  948 

carcinoma  of,  949 

diseases  of,  945 

dislocation  of,  945 

echinococcus  of,  366 

floating,  399 

hyperemia  of,  946 

in  diphtheria,  152 

in  leukemia,  479 

in  lobar  pnetunonia,  107 

in  tjTjhoid  fever,  20,  36 

lardaceous,  948 

morbid  growths  of,  949 

rupture  of,  949 

sago,  948 

syphilis  of,  399 

syphilitic  gumma  of,  949 

waxy,  948 
Splenic  anemia,  488 

artery,  aneurysm  of,  734 

fever,  306 
Splenitis,  946 
Splenization,  542,  543 
Splenomegaly,  febrile  tropical,  340 
Spleno-typhoid  fever,  45 
Splint-belly,  980 
Spondylitis  deformans,  429 
Spondylose  rhizom^lique,  429 
Spontaneous  pyemia,  171 

septicemia,  167 
Sporadic  cholera,  848 

cretinism,  502.     See  also  Myxedema. 

dysentery,  73 
Sporozoa,  341 

Spotted    fever,    95.     See    also    Cerebro- 
spinal meningitis. 
Sprue,  848 

Spurious  hydrophobia,  1229 
Sputum  in  lobar  pneumonia.  111 

84 


Sputum,  tuberculous,  tnftdod  of  examin- 
ing, 262 
St.  Anthony's  (huicc  I'^l  I 

fire,  144  ' 
St.  Vitus'  dance,  1211 
Staphylococcus  pyog(!n<«  aureus,  428 
Status  eclamfjticus,  1203 
epilepticus,  1207 
lymphati(;us,  494 
thymico-lymphaticus,  494 
Steatorrhea,  8)^0 
Stegomyia  fasciata,  91 
Stenocardia,  913 
Stenosis,  aortic,  645 
bronchial,  532 

hypertrophic,  of  pylorus,  819 
mitral,  653 
relative,  656 
of  bile-ducts,  907 
of  duodenum,  877 
of  hepatic  veins,^914 
of  portal  vein,  914 
of  pulmonary  orifice,  716 
pulmonary,  662 
tricuspid,  660,  717 
Steppage  gait,  1117 
Stercoral  typhlitis,  865 

ulcers,  853 
Stereognostic  sense,  1179 
Stern's  sign  in  tricuspid  incompetency, 

659 
Stigmata,  hysteric,  1230 
Stokes- Adams'  disease,  712 
Stomach,  abscess  of,  795 
acute  catarrh  of,  790 
atony  of,  827 

carcinoma  of,  813.     See  also  Carcino- 
ma of  stomach. 
chronic  catarrh  of, .  796 
cirrhosis  of,  benign,  820 
dilatation  of,  786 

acute,  786 
diminished  peristalsis  of,  827 
diseases  of,  776 

methods  of  diagnosis  in,  776 
examination  of,  external,  782 
for  absorptive  power,  781 
for  acetic  acid,  779 
for  fatty  or  volatile  acids,  779 
for  free  hydrochloric  acid,  780 
for  lactic  acid,  779 
physical,  782 

quantitative,   for   combined   hydro- 
chloric acid,  780 
for  lactic  acid,  780 
functions,  examination  of,  778 
hour-glass,  808 
hyperesthesia  of,  829 
in  diabetes,  415 
in  typhoid  fever,  36 
increased  peristalsis  of,  826 
inflammatory  diseases  of,  790 
malposition  of,  784 
motor  function,  tests  for.  781 
neuroses  of,  821,  823 
of  motility,  826 
of  secretion,  823 


1330 


INDEX. 


Stomach,  peristaltic  unrest  of,^826 
pyloric  incompetency  of,  827 
ticrectory  function,  examination  of,  778 
spasm  of,  82G 
tuberculosis  of,  276 
ulcer  of,  804.     See  also  I'lctr  of  stom- 
ach. 
Stomatitis,  737 
aphthous,  738 
catarrhal,  737 
crouposa,  740 
epidemic,  332 
erythematosa,  737 
fetid,  741 
foUicular,  738 
gangrenous,  745 
membranous,  740 
mercurial,  747 
mycosa,  743 
neurotica  chronica,  742 
pariisitic,  743 
scorbutic,  741 
ulcerative,  741 
Streptococcus  erysipelatis,  144 
pneumonia,  120 
tonsiillitis,  75G 
Strict  lu-e  of  esophagus,  774 
Strongyloides  intestinalis,  384 
Struma,  496 
Strumitis,  494 
Strychnin-poisoning  and  tetanus,  drffer- 

entiation,  314 
Subpericardial  overfatness,  698 
Subphrenic  abscess,^920 
Succussion-sounds,  784 
Succussion-splash  in  pneumothorax,  606 
Sugar  in  urine,  995 
Summer  diarrhea,  843 
Sunstroke,  1293 

asphyxial,  1294 
Sun-traumatism,  1296 
Superacidity,  larval,  825 
Suppurative  encephalitis,  1181 
gastritis,  acute,  794 
hepatitis,  922 
jxincreatitis,  951 
pneumonitis,  573 
pylephlebitis,  912 
Suprarenal  capsules,  diseases  of,  490 

glands,  role  of,  in  diabetes,  413 
Supra-scapular  nerve,  paralysis  of,  1115 
Surgical  kidney,  1040 
Swamp  fever,  342 
Sweating  sickness,  331 
Sydenham's  chorea,  1211 
Symmetric  gangrene,  1250 
Symptomatic  parotitis,  752 

tachycardia,  705 
Synchopexia,  705 
Syndrome,  Frohlich's,  1186 

Weber's,  1186 
Syphilis,  388 

acquired,  clinical  history,  390 

treatment,  404 
cerebrospinal,  1198 
Colics'  law,  390 
contagion,  389 


Syphilis,  diagnosis,  401 
differential,  403 
Ehrlich-Hata  (606)  treatment,  405 
etiology,  general,  388 
hiemorrhagica  neonatorum,  458 
hereditaria  tarda,  402 
hereditary,  clinical  syn.ptoms,  392 

nuHlicinal  treatment,  404 
Justus'  blood-test  for,  402 
malignant,  392 
modes  of  infection,  389 
of  alimentary  tract,  397 
of  arteries,  400 
of  brain,  394 

of  circulatory  system,  400 
of  joints,  400 
of  kidneys,  400 
of  liver,  396 

and  cancer,  differentiation,  397 
of  lung,  398 
of  si>inal  cord,  394 
of  spleen,  399 
of  testicles,  401 
parasitology,  388 
pathology,  general,  388 
predisposing  causes,  389 
tertiary,  treatment  of,  407 
treatment,  403 

by  fumigation,  405 
by  inunctions,  404 
hyi)odermic,  405 
prophylactic,  403 
visceral,  388,  391,  394 
Wassermann  reaction  in,  402 
SjTJhilitic  chlorosis,  474 
chondro-arthritis,  401 
glomcrulo-nephritis,  acute,  400 
gununa  of  sj^leen,  749 
periarteritis,  400 
retinitis,  1091 
spinal  paralysis,  Erb's,  395 
SjTingoniyelia,  1154 


Tabes  dorsalis,  1145 

mesenterica,  245 
Tachycardia,  705 

hysteric,  1232 

neurotic,  705 

paroxysmahs,  705 

symptomatic,  705 
Tactile  agnosia,  1180 
Taenia,  367 

diagnosis,  369 

echinococcus,  363 

flavopunctata,  371 

lata,  368 

Madagascariensis,^  372 

mediocanellata,  368 

nana,  371 

natural  historj^  367 

prognosis,  370 

serrata,  372 

solium,  368 

sjTnptoms,  369 

treatment,  370 

varieties,  368 


INDEX. 


1331 


Tape-worms,  367.     Soe  also  Tmnia. 
Tapir  mouth,  1262 
Taste,  777 

center,  1074 
Terlesko  and  Falk's  test  in  tuberculosis, 

273 
Teeth,  Hutchinson's,  393 
Tender  toes,  1253 
Terminal  pneumonia,  121 
Tertian   intermittent    fever,    hemameba 

causing,  345 
Testes,  syphilis  of,  401 
tuberculosis  of,  285 
Test-meals,  778 
Tetanin,  313 
Tetano-toxin,  313 
Tetanus,  312 
acute,  314 

and    strychnin-poisoning,    differentia- 
tion, 314 
bacteriology,  313 
cephalic,  314 
chronic,  314 
clinical  history,  314 
course,  315 
diagnosis,  315 
etiology,  313 
immunity  to,  314 
modes  of  infection,  313 
neonatorum,  312 
pathology,  312 
prognosis,  315 
treatment,  315 
Tetanus-antitoxin,  316 
Tetany,  1221 
Thermic  fever,  1293 
Third  nerve,  1095 
paralysis  of,  1095 
spasm  of,  1095 
Thiroloix  Achalmii,  174 
Thirst,  777 

Thomsen's  disease,  1264 
Thoracic  aorta,  aneurysm  of,  724 

dropsy,  604 
Thread-worm,  373 
Thrill,  hydatid,  365 
Throat,  acute  infectious  phlegmon  of,  765 

sore,  septic,  756 
Thrombo-angiitis  obliterans,  1251 
Thrombosis,  cardiac,  676 
in  typhoid  fever,  39 
of  brain,  1170 
of  portal  vein,  911 
Thrush,  743 
Thymic  asthma,  494 
Thymus  gland,  atrophy  of,  494 
diseases  of,  494 
enlargement  of,  494 
hyperplasia  of,  494 
Thyroid  gland,  diseases  of,  494 
Thyroiditis,  494 
sclerotic,  495 
Tic,  1216 

convulsif,  1216 
douloureux,  1079 
facialis,  1101 
general,  1218 


Tic,  motor,  1216 
Tinnitus  auriurn,  1104 
'i'oes,  lender,  \2r)'.', 
Tongue,  (liseasfs  of,  748 

tuberculosis  of,  276 
I'onsillar  absf-css,  755 

diphtheria,  sirr]i)le,  156 
Tonsillitis,  aeuf.e,  753 
catarrhal,  754 
lacunar,  754 
parenchymatous,  755 
chronic,  758 
follicular,  754 

and  diphtheria,  differentiation,  756 
necrotic,  756 
streptococcus,  756 
superficial,  754 
Tonsillo-typhoid  f(!ver,  21,  37 
Tonsils,  diseases  of,  753 
hypertrophied,  758 
in  typhoid  fever,  21,  37 
tuberculosis  of,  276 
Topfer's  quantitative  estimation  of  free 
hydrochloric  acid  in  gastric  contents, 
780 
test    of   gastric    contents    for    hydro- 
chloric acid,  779 
Torticollis,  323,  1110 

hysteric,  1229 
Tortipelvis,  1216 
Toxic  amblyopia,  1092 
cystitis,  1052 
gastritis,  793 
jaundice,  896 
tremor,  1221 
Toxins  of  diphtheria,  154 
Tracheo-bronchitis,  520 
Transposition  of  heart.,  703 
Transverse  myelitis,  1134 
Traube's  theory  of  uremia,  1008 
Traumatic  cystitis,  1053 
hysteria,  1227 
neuroses,  1242 
scarlatina,  209 
Treitz's  retro-peritoneal  hernia,  871 
Trematodiasis,  361 
Trembles,  330 
Tremor,  hereditary,  1221 
hysteric,  1221,  1229 
senile,  1221 
simple,  1221 
toxic,  1221 
Treponema  pallidum,  388 
Trichina,  som-ces  of,  378 
Trichiniasis,  377 
diagnosis,  380 

differential,  380 
pathology,  378 
prognosis,  380 
sjTnptoms,  379 
treatment,  380 
Trichinosis,  377 
Trichloracetic-acid  test  for  albuminuria, 

989 
Trichocephalus  dispar,  374 
Trichomonas  intestinaUs,  338 
pulmonalis,  338 


1332 


INDEX. 


Trichomonas  vaginalis,  338 
Tricuspid  inconijietency,  657 
orifice,  stenosis  of,  717 
regurgitation,  657 
stenosis,  660 
Trismus,  312.     See  also  Telanus. 
Trommer's  test  for  glycosuria,  996 
Trophic  disorders,  1249 
Tropical  dysentery,  acute,  74 
Trousseau's  sign  in  tetany,  1222 
Trlichter  brust,  760 
Trypanosoma  Evansii,  338 
gambiense,  338 
hominis,  339 
Trypanosomiasis,  338 
Tubt-casts,  1005 
Tubercle,  elementary,  232 
fully  developed,  233 
of  brain,  1 184 
Tubercles,  Farre's,  940 

rabiques,  309 
Tuberculin-test  for  tuberculosis,  272 
Tuberculo-mediastino-pericarditis,  617 
Tuberculosis,  231 
acute,  246 

associated  inflammatory  processes,  234 
bacteriologj',  234 
biology,  235 
bovine,  235 
caseation  in,  233 
chemical  products  in,  235 
chronic,  257 

Calmette's  ophthalmic  reaction  in, 

273 
causal  factors,  257 
cavities  in,  258 

physical  signs,  267 
chest-muscles  and  mammary  glands 

in,  272 
clinical  history,  260 
cutaneous  sj'stem  in,  271 
diagnosis,  272 

tlifferential,  273 
disseminated,  259 
gastro-intestinal  tract  in,  271 
genito-urinary  organs  in,  271 
heart  in,  270 

interstitial  pneumonnia  in,  259 
modes  of  onset,  260 
nerv^ous  system  in,  272 
opsonin  test  in  diagnosis  of,  273 
pathology,  257 
physical  signs,  265 
symptoms,  261 
general,  268 
tuberculin-test  in,  272 
contagious  theory,  238 
diapedesis  of  leukocytes  in,  233 
distribution  of  lesions  in  body,  232 
etiolog>',  234 
from  inoculation,  239 
from  meat  of  tuberculous  animals,  238 
from  milk  of  tuberculous  animals,  238 
geographic  distribution,  232 
giant  cells  in,  233 
historic  note,  231 
local  causes,  242 


Tuberculosis,  miliary,  general,  247 
cerebral  form,  249 
differential    diagnosis,    from    tj'- 

phoid  fever,  24S 
meningeal  form,  249 
pulmonary  form,  248 
ty])h()id  form,  247 
modes  of  infection,  237 
of  alimentary  tract,  276 
of  art  (>ries.  288 
of  bladder,  285 
of  brain,  286 
of  bronchial  glands,  244 
of  cervical  glands,  243 
of  esopliagus,  276 
of  Fallopian  tubes,  285 
of  gciiito-urinarj'  system,  283 
of  heart,  2S7 
of  intestines,  277 

diagnosis,  278 

sjTnptoms,  277 
of  kidneys,  283 
of  lips,  276 
of  liver,  283 
of  lymph-glands,  243 

general  lulxTCulous  adenitis,  245 

local  tuberculous  adenitis,  243 
of  mammarj'  glands,  286 
of  mesenteric  glands,  245 
of  ovaries,  285 
of  palate,  276 
of  pericardium,  279 
of  peritoneum,  280 

diagnosis,  282 

etiology,  281 

sjonptoms,  281 
of  pharj-nx,  276 
of  prostate,  285 
of  serous  membranes,  278 
of  spinal  cord,  287 
of  stomach,  276 
of  testes,  285 
of  tongue,  276 
of  tonsil,  276 
of  ureter,  285 
of  uterus,  285 
of  veins,  288 

of  vesicuke  seminales,  284 
pathologj^  232 
predisposing  causes,  240 
pseudo-,  274 
scderosis  in,  233 
treatment,  289 

clunatic,  292 

dietetic,  295 

of  leading  s3'^mptoms,  297 

pro])hylaxis,  289 

sanatorium,  294 

serum-therapy  in,  296 

special  remedies,  296 
tubercle  of,  elementary,  232 

fully  developed,  233 
Tuberculous  adenitis,  general,  245 

local,  243 
meningitis,  249 

diagnosis,  253 

l)athology,  249 


INDEX. 


im\ 


TubennilouH  meningitis,  prognosis,  253 

.syin])i()ni,s,  2.51 

l,y])('H,  25;j 
pcric^ardiliH,  acuto,  279 

chronic,  2S(),  02:3 
peritonitiH,  clironic,  968 
pleurisy,  279,  589 

sputum,  method  of  examining,  262 
Tumors  of  brain,  1173 
of  dura  mater,  1156 
of  heart,  702 
of  larynx,  520 
of  mediastinum,  611 
of  nerves,  1089 
of  spinal  cord,  1156 
Tunnel  anemia,  376 
Tussis  convulsiva,  223 
Tylosis  lingua;,  750 
Typhlitis,  870 

stercoral,  865 
Typhoid  bacilluria,  1004 
fever,  17 

abortive  form,  45 

afebrile,  32,  45 

ambiguous  period,  31 

ambulatory  form,  45 

and  ulcerative  endocarditis,  differ- 
entiation, 633 

arteries  in,  21 

bacillus  of,  22 

distribution  in  body,  23 

bacteriology,  22 

bilious,  410 

blood  in,  22,  40 

bones  in,  44 

carriers,  25 

channels  of  infection,  26 

circulatory  system  in,  39 

clinical  history,  27 
varieties,  44 

course  of  fever  in,  29 
abnormal,  31 

definition,  17 

diagnosis,  46 
differential,  48 

diazo-reaction  in,  43 

digestive  system  in,  33 

elevation  of  temperature  after,  32 

embolism  in,  40 

erysipelas  in,  44 

etiology,  22 

experimental,  22 

gall-bladder  in,  20 

grave  forms,  45 

heart  in,  21 

hemorrhage  in,  19 

history,  17 

in  aged,  46 

in  children,  46 

incubation  period,  27 

infectious  diseases  associated  with, 
44 

intestinal  hemorrhage  in,  34 

joints  in,  44 

kidneys  in,  20 

larynx  in,  21 

latent,  45 


'^ryi)hoi<l  U'vc.Y,  liver  in,  20,  36 
lungs  in,  21 
malarial  f(!ver  in,  44 
m(!H(^ntcric  glands  in,  19 
mfithods  of  (•,f)nv(^yance  into  body,  25 
mild  forms,  44 
muscles  in,  22,  44 
n(!rvous  complications  in,  42 

system  in,  22,  41 
pathology,  17 
perforation  in,  19,  35 
peritonitis  in,  21 
pharynx  in,  21,  36 
pleurisy  in,  21 
predisposing  causes,  24 
predisposition  in,  24 
prognosis,  49 
pseudo-membranous     inflammation 

in,  44 
recurrences,  52 
relapses,  51 

intercurrent,  51 

spurious,  51 
respiratory  system  in,  37 
rudimentary  forms,  44 
serum-diagnosis,  47 
severe  forms,  45 
shaven-beard  appearance  in,  18 
skin  in,  32 
spleen  in,  21,  36 
stomach  in,  20,  36 
thrombosis  in,  39 
tonsils  in,  37 
treatment,  52 

Brand  method,  56 

complications,  62 

convalescence,  65 

dietetic,  54 

disinfection,  52 

hydrotherapy,  55 
contraindications,  59 
substitutes,  60 

inoculation,  curative,  61 
preventive,  53 
prophylactic,  53 

internal  antipjTetics,  60 

intestinal  antiseptics,  61 

isolation,  53 

prophylactic,  52 

stimulants,  55 
urinary  system  in,  42 
urine  in,  42 
walking,  45 
Widal  reaction  in,  47 
pneumonia,  120 
septicemia,  27,  46 
spine,  42 
Tjrpho-mania,  1192 
Typho-toxin,  23 
Typhus  fever,  67 
abdominal,  17 
clinical  history,  68 
complications,  69 
diagnosis,  70 

differential,  70 
etiology,  68 
prognosis,  71 


1334 


INDEX. 


Tvphus  fever,  relapsing,  71 
syniptoins,  69 
treatment,  71 
la'vissimus,  44 
siderans,  70 
Tyrosinuria,  1002 
Tyrotoxicon,  IGS 


Uffklmanx's  test  for  lactic  acid,  779 
Ulcer,  diffuse  catarrhal,  of  intestine,  854 
duodenal,  850 
latent,  852 
follicular,  853 
intestinal,  850 
of  esophagus,  7(57 
of  stomach,  S04 

and  gastralfiia,  differentiation,  809 
cc)m])li('ati()ns,  808 
diagnosis,  809 

(lifTercntial,  809 
etiology,  805 
hematcmesis  in,  807 
pathology,  804 
perforating,  804 
predisjjosing  causes,  806 
prognosis,  810 
sequels,  808 
simple  or  round,  804 
symptoms,  806 
treatment,  810 
various  forms,  80S 
solitary,  of  intestine,  854 
stercoral,  853 
Ulcerative  colitis,  853 

endocarditis,  632.     See  also  Endocar- 
ditis, ulcerative. 
stomatitis,  741 
Ulnar  ner\'e,  paralysis  of,  1116 
Uncinariasis,  375 
treatment,  377 
Undulant  fever,  319 
Unilateral  ascending  paralysis,  1144 

descending  i)aralysis,  1144 
Unrest,  peristaltic,  of  stomach,  826 
Urates  in  urine,  1000 
Urea,  1003 
Uremia,  1008 

in  chronic  nephritis,  1036 
Traube's  theorj'  of,  1008 
Uremic  amaurosis,  1010 

deafness,  1009 
Ureter,  tuberculosis  of,  285 
Uric-acid  calculi,  1014 
Urinary  system,  diseases  of,  978 

in  typhoid  fever,  42 
Urine,  acetone  in,  998 
albumin  in,  987 
albumose  in,  990 
alkapton  in,  1005 
bacteria  in,  1004 
beta-oxybutjTic  acid  in,  998 
bile-pigment  in,  1004 

tests  for,  893 
blood  in,  984 
blood-corpuscles  in,  1006 
blood-pigments  in,  986 


Urine,  calcium  oxalate  in,  1000 

chlorids  in,  1003 

cholesterin  in,  1005 

chyle  in,  993 

cystin  in,  1003 

diacetone  in,  998 

epithelium  in,  1006 

erythrocvtes  in,  1006 

fat  in,  1004 

fat-globules  in,  1006 

glucose  in,  995 

granular   fatty   degenerated   cells   in, 
1006 

hematoporphyrin  in,  1004 

in    chronic    non-exudative    nephritis. 
1034 

in  typhoid  fever,  42 

incontinence  of,  1060 

indican  in,  991 

inosite  in,  1005 

lactose  in,  1004 

leucin  in,  1002 

leukocytes  in,  1006 

lithic  acid  in,  999 

morphologic  constituents  of,  in  renal 
disease,  1005 

pathologic  states  of,  984 

phosphates  in,  1001 

l)us  in,  992 

red  corpuscles  in,  1006 

retention  of,  1062 

symptoms  of,  1009 

sugar  in,  995 

tyrosin  in,  1002 

urates  in,  1000 

urea  in,  1003 

urobilin  in,  995 
Urobilinicterus,  995 
Urobilinuria,  995 
Urospectrin,  1004 
Urticaria,  giant,  1249 
Uterus,  tuberculosis  of,  285 


Vaccination,  200 
age  for,  201 
antityphoid,  53 
complications  after,  202 
historic  note,  200 
humanized  lymjjh  for,  201 
site  for,  201 
symptoms  after,  202 
technic,  201 
Vaccine  virus,  200 
Vaccinia,  200 
Vagabonds'  disease,  386 
Valvular  disease,  complications,  663 
course  and  duration,  664 
prognosis,  664 
purgation  in,  671 
symptoms,  672 
treatment,  666 

of  stage  of  compensation,  666 

of  non-compensation,  668 
prophylactic,  666 
venesection  in,  671 
endocarditis,  632 


INDEX. 


1335 


Varicella,  202 

and  variola,  differentiation,  195,  196 

compliciations,  203 

diagnosis,  204 

etiology,  202 

gangraenosa,  203 

prognosis,  204 

symptoms,  203 

treatment,  204 
Varicose  aneurysm,  723,  735 
Variola,  186 

abortive  form,  194 

and  varicella,  differentiation,  195,  196 

bacteriology,  188 

black,  193 

circulatory  system  in,  192 

clinical  forms,  193 
history,  189 

complications,  190 

confluent  form,  193 

diagnosis,  194 
differential,  195 

diet  in,  197 

digestive  system  in,  192 

eruption  in,  190 

etiology,  188 

fever  in,  192 

historic  note,  186 

joints  in,  193 

modes  of   conveyance  and  infection, 
189 

nervous  symptoms,  192 

pathology,  187 

predisposing  causes,  188 

prognosis,  196 

renal  symptoms,  193 

respiratory  tract  in,  192 

symptoms,  190 

treatment,  196 
Varioloid,  194 

Varix,  aneurysmal,  723,  735 
Vascular  affections  of  liver,  909 

degeneration  of  brain,  1162 
Vasomotor  disorders,  1249 
Vegetable-poisoning,  1285 
Vegetations,  adenoid,  758 
Veins,  sclerosis  of,  720 

tuberclosis  of,  288 
Venesection  in  lobar  pneumonia,  128 

in  valvular  disease,  671 
Ventricle,  right,  of  heart,  hypertrophy  of, 

679,  681 
Vesiculse  seminales,  tuberculosis  of,  285 
Vesicular  emphysema,  564 
Vicarious  hemoptysis,  546 
Vincent's  angina,  160 
Virchow's  albinism,  565 

white  hepatization,  399 
Virus,  vaccine,  200 
Visceral  neuralgia,  183 

peritonitis,  963 

syphilis,  388,  391,  394 
Visual  aphasia,  1177 
cortical,  1178 
subcortical,  1178 

centers,  1073 
Vomit,  777 


Vomiting,  hystc^ric,  1231 

nervous,  826 
Vulva,  lyinpli-,  from  filariae,  383 

Walkin(j  ))H(!UiiioiiiM,  115 

typhoid  fevcsr,  45 
Wandering  kidney,  978 
Wassermann  nsaction  in  syphilis,  402 
Water-hammer  pulse,  i'A'.'> 
Water-wheel  sounds,  628 
Waxy  infiltration  of  liver,  915 

si)l(!(;n,  948 
Weak  legs,  316 
Weber's  syndrome,  1186 
Weil's  disease,  328 

test  in  syphilis,  402 
Wernicke's  aphasia,  1179  . 
Wet  brain,  1123 
Whip  worm,  374 
White  flux,  846 

infarct,  695 

kidney,  large,  1027 
small,  1028 
Whooping-cough,  222 

bacteriology,  224 

clinical  history,  225 

complications,  226 

diagnosis,  differential,  227 

etiology,  223 

nature,  224 

pathology,  223 

prognosis,  227 

sequels,  226 

treatment,  227 
Widal  reaction  in  typhoid  fever,  47 
Williams'  tracheal  tone  in  sero-fibrinous 

pleurisy,  588 
Winckel's  disease,  458 
Winslow,  foramen  of,  871 
Wintrich's  sign  in  pnemnothorax,  607 
Wood-tick,  387 
Wool-sorters'  disease,  306 
Word-b'indness,  1168 
Word-deafness,  1104,  1168 
Wound-diphtheria,  157 
Wrist-drop,  1279 
Writers'  cramp,  1243 
Wry-neck,  322,  1110 

Xanthin  bases,  1000 
Xerostoma,  752 

Yellow  atrophy,  acute,  of  Uver,  927 
fever,  89 
diagnosis,  93 
etiology,  90 
Faget's  sign  in,  93 
pathology,  90 
prognosis,  93 
treatment,  94 

Zenker's  hyaline  transformation,  700 
Zimb,  387 

Zuckergussleber,  921 
Zygote,  344 


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S.U'XDA'J^S'    BOOKS    OX 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Octavo  of  1195  pages,  witli  289  text-cuts  and 
34  plates.     Cloth,  ;$6.oo  net ;  Half  Morocco,  ;$7.50  net. 

THE  NEW  (6th)   EDITION 

The  demand  for  five  editions  of  this  work  in  a  period  of  five  years  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  new 
subjects  include  Verruga  Peruana,  Leukemia  Cutis,  Meralgia  Paraesthetica,  Dhobie 
Itch,  and  Uncinarial  Dermatitis. 

George  T.  Elliot,  M.  D.,  Professor  of  Dermatology,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment, 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  think  it  holds  first  place." 


Schamber^'s  Diseases  of  the  Skin 
and  Eruptive  Fevers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay  F.  Schamberg, 
M.  D.,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  573  pages,  illustrated.      Cloth,  $3.00  net. 

THE  NEW  (2d)  EDITION 

"  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied  these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  .  The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment." — American  Journal 
of  Medical  Sciences. 


GENITO- URINARY  DISEASES 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania,  with  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated. 

JUST  ISSUED 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
pubhcations  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utilized. 
This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the  stamp  of 
authority.  The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is 
particularly  valuable  because  it  expresses  the  newest  advances.  Every  phase  of 
the  subject  is  considered  :  History,  bacteriology,  pathology,  sociology,  prophylaxis, 
treatment  (operative  and  medicinal),  gonorrhea  during  pregnancy,  parturition 
and  the  puerperium,  diffuse  gonorrheal  peritonitis,  and  all  other  phases.  Further, 
Dr.  Norris  considers  the  rare  varieties  of  gonorrhea  occurring  in  men,  women,  and 
children.     The  text  is  illustrated. 


Sharp's 

Ophthalmology  for   Veterinarians 

ophthalmology  for  Veterinarians.  By  Walter  N.  Sharp,  Isl.  D., 
Professor  of  Ophthalmology  in  the  Indiana  Veterinary  College.  i2mo 
of  210  pages,  illustrated.     Cloth,  $2.00  net. 

JUST  READY 

This  new  work  covers  a  much  neglected  but  important  field  of  veterinary' 
practice.  Dr.  Sharp  has  presented  his  subject  in  a  concise,  crisp  way,  so  that 
you  can  pick  up  this  book  and  get  to  "the  point"  quickly.  He  first  gives  you  the 
anatomy  of  the  eye,  then  examination,  followed  by  the  various  diseases,  including 
injuries,  parasites,  errors  of  refraction,  and  medicines  used  in  ophthalmic  thera- 
peutics.    The  text  is  illustrated. 


SArXDEJiS'     BOOKS    OX 


Barnhill   and  Wales* 
Modern   Otology 

A  Text-Book  of  Modern  Otology.  By  John  F.  Barnhill,  M.  D., 
Professor  of  Otology,  Laryngology,  and  Rhinology,  and  Earnest 
DE  \V.  Wales,  M.  D.,  Associate  Professor  of  Otology,  Laryngology, 
and  Rhinology,  Indiana  University  School  of  Medicine,  Indianapolis. 
Octavo  of  598  pages,  with  314  original  illustrations.  Cloth,  #5.50  net; 
Half  Morocco,  $j.oo  net. 

THE  NEW  (2d)  EDITION 

The  authors,  in  writing  this  work,  kept  ever  in  mind  the  needs  of  the 
physician  engaged  in  general  practice.  It  represents  the  results  of  personal 
experience  as  practitioners  and  teachers,  influenced  by  the  instruction  given  by- 
such  authorities  as  Sheppard,  Dundas  Grant,  Percy  Jakins,  Jansen,  and  Alt. 
Much  space  is  devoted  to  prophylaxis,  diagnosis,  and  treatment,  both  medical 
and  surgical.  There  is  a  special  chapter  on  the  bacteriology  of  ear  affections — 
a  feature  not  to  be  found  in  any  other  work  on  otology.  Great  pains  have  been 
taken  with  the  illustrations,  in  order  to  have  them  as  practical  and  as  helpful  as 
possible,  and  at  the  same  time  highly  artistic.  A  large  number  represent  the 
best  work  of  Mr.  H.  F.  Aitken. 


PERSONAL    AND    PRESS    OPINIONS 


Frank  Allport,  M.  D. 

Professor  of  Otology,  Noriliwestern  University,  Chicago. 

"  I  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen." 

C.  C.  Stephenson.  M.  D. 

Professor  of  Oplittialmology  and  Otology,  College  of  Physicians  and  Surgeons,  Little  Rock 
Arkansas. 

"To  my  mind  there  is  no  work  on  modern  otology  that  can  for  a  moment  compare  with 
'  Barnhill  and  Wales."  " 

Journal  American  Medical  Association 

"  lis  teaching  is  sound  throughout  and  up  to  date.  The  strongest  chapters  are  those  on 
suppuration  of  the  middle  ear  and  the  mastoid  cells,  and  the  intracranial  complications  of  ear 
disease." 


DISEASES   OF   TJIE  EYE. 


DeSchweinitz's 
Diseases  of  the  Eye 


The  New  r6th)   Edition 


Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  deSchweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity of  Pennsylvania,  Philadelphia,  etc.  Handsome  octavo  of  945 
pages,  354  text-illustrations,  and  7  chromo-lithographic  plates.  Cloth, 
;^5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 

WITH  354  TEXT-ILLUSTRATIONS  AND  7  COLORED  PLATES 
THE   STANDARD   AUTHORITY 

Dr.  deSchweinitz' s  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement  placing  it 
far  in  the  front  of  works  on  this  subject.  For  this  edition  Dr.  deSchweinitz  has 
subjected  his  book  to  a  most  thorough  revision.  Fifteen  new  subjects  have  been 
added,  ten  of  those  in  the  former  edition  have  been  rewritten,  and  throughout  the 
book  reference  has  been  made  to  vaccine  and  serum  therapy,  to  the  relation  of 
tuberculosis  to  ocular  disease,  and  to  the  value  of  tuberculin  as  a  diagnostic  and 
therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates,  and 
in  every  way  the  book  maintains  its  reputation  as  an  authority  upon  the  eye. 


PERSONAL  AND   PRESS  OPINIONS 


Samuel  Theobald,  M.D.. 

Clinical  Professor  of  Ophthalmology ,  Johns  Hopkins  University ,  Baltimore. 
"  It  is  a  work  that  I  have  held  in  high  esteem,  and  is  one  of  the  two  or  three  books  upon 
the  eye  which  I  have  been  in  the  habit  of  recommending  to  my  students  in  the  Johns  Hopkins 
Medical  School." 

University  of  Pennsylvania  Medical  Bulletin 

"Upon  reading  through  the  contents  of  this  book  we  are  impressed  by  the  remarkable 
fulness  with  which  it  reflects  the  notable  contributions  recently  made  to  ophthalmic  literature. 
No  important  subject  within  its  province  has  been  neglected." 

Johns  Hopkins  Hospital  Bulletin 

"No  single  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainly  one  of  the 
best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 


SAUNDERS'   BOOKS   ON 


GET  A  •  THE  NEW 

THE    BEST  a\  ill  6  r  1  C  Ci  11  STANDARD 

Illustrated   Dictionary 

New  (6th)  Edition,  Entirely  Reset 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinaiy  Science,  Nursing,  and  kindred 
branches;  with  over  lOO  new  and  elaborate  tables  and  many  illustra- 
tions. By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The  American 
Pocket  Medical  Dictionary."  Large  octavo,  with  986  pages,  bound  in 
full  flexible  leather.      Price,  S4.50  net;  with  thumb  index,  ;$5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

This  dictionary  is  the  "new  standard."  It  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  terms  are  hve, 
active  words,  taken  right  from  modern  medical  hterature. 

Howard  A.  Kelly.  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University ,  Baltimore 

"  Dr.  Borland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  tlie  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  550pages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  $4.50  net ;   Half  Morocco,  ^6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  pracdtioner,  are  in  reality  adapted  only  to  the  specialist  ; 
but  Dr.  Theobald  in  his  book  has  described  ver)'  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  within  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner. 

Charles  A.  Oliver.  M.D.. 

Clinical  Professor  of  Ophthalmology,   Woman's  Medical  College  of  Pemisylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  Most 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


DISEASES    OF   THE   EYE. 


Haab  and  DeSchweinitz*s 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  IC.  dkSciivveinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
1 01  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 
text.     Cloth,  #3.00  net.     In  Saunders'  Hand-Atlas  Series. 

THE   NEW    (3d)    EDITION 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  so  complicated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited   to  the  student  of  ophthalmology  and   to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Ziirich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ^3.00  net.     In  Saunders'  Hand-Atlas  Series. 

THE  NEW   (2d)    EDITION 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


SAr.VDE/^S'  HOOA'S  o.y 


Gradle*s 
Nose,  Pharynx,  and  Ear        i 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.D.,  late  Professor  of  Ophthalmolot^y  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Octavo  of  547  pages,  illustrated, 
including  two  full-page  plates  in  colors.     Cloth,  ^§3.50  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume  presents  diseases  of  the  Nose,  Pharynx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medical  Journal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusiorj 
incident  to  a  categorical  statement  of  everybody's  opinion."' 

Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  797  pages;  with  219  illustrations,  26  in  colors. 
Cloth,  ;$4.oo  net;  Half  Morocco,  ^5.50  net. 

THE    NEW    (4th)    EDITION 

Four  large  editions  of  this  excellent  work  fully  testify  to  its  practical  value. 
In  this  edition  the  author  has  revised  the  text  thoroughly,  bringing  it  absolutely 
down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  extended  con- 
sideration has  been  given  to  treatment,  each  disease  being  considered  in  full,  and 
definite  courses  being  laid  down  to  meet  special  conditions  and  symptoms. 
Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in  vain 
for  anything  he  needs." 


URINE  AND   IMPOTENCE. 


Og'den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  $1.00  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

- 

Pilcher's 
Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.  D.,  Consulting 
Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of  398  pages, 
with  233  illustrations,  29  in  colors.     Cloth,  ^5.50  net, 

DIAGNOSIS  AND  TREATMENT 

Cystoscopy  is  to-day  the  most  practical  manner  of  diagnosing  and  treating 
diseases  of  the  bladder,  ureters,  kidneys,  and  prostate.  To  be  properly  equipped, 
therefore,  you  must  have  at  your  instant  command  the  information  this  book  gives 
you.  It  explains  away  all  difficulty,  telling  you  why  you  do  not  see  something 
when  something  is  there  to  see,  and  telling  you  Jww  to  see  it.  All  theor\-  has 
been  uncompromisingly  eliminated,  devoting  every  line  to  practical,  needed- 
every-day  facts,  telling  you  how  and  when  to  use  the  cystoscope  and  catheter — 
telling  you  in  a  way  to  make  you  know.  The  work  is  complete  in  ever)'  detail. 
Bransford  Lewis,  M.  D.,  St.  Louis  Universiiy . 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy.'  I  think  it  is  the  best 
in  the  English  language  now." — April  2^,  igii. 


lo  SAUNDERS'   BOOKS    OX 

Goepp*s 
Dental   State   Boards 

Dental  State  Board  Questions  and  Answers By  R.  Max  Goepp, 

M.  D.,  author  "  Medical  State  Board  Questions  and  Answers."     Octavo 
of  428  pages.      Cloth,  $2.75  net. 

COMPLETE  AND  ACCURATE 

This  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp' s  successful  work 
on  Medical  State  Hoards.  The  questions  included  have  been  gathered  from  reliable 
sources,  and  embrace  all  those  likely  to  be  asked  in  any  State  Board  examination 
in  any  State.  They  have  been  arranged  and  classified  in  a  way  that  makes  for  a 
rapid. resume  of  every  branch  of  dental  practice,  and  the  answers  are  couched  in 
language  unusually  e.xplicit — concise,  definite,  accurate. 

The  practicing  dentist,  also,  will  find  here  a  work  of  great  value — a  work 
covering  the  entire  range  of  dentistry  and  extremely  well  adapted  for  quick 
reference. 

Haab  and  deSchweinitz's 
Operative  Ophthalmology 

Atlas  and   Epitome  of    Operative    Ophthalmology.       By  Dr.  O. 

Ha.ab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthahnology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  1 54  text-cuts,  and  375  pages  of 
text.     In  Smindcrs  Hand-Atlas  Scries.     Cloth,  $3.50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  will  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author"  s  thirty 
years'  experience  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  Recognizing 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures.  Dr.  Haab  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 

Johns  Hopkins  Hospital  Bulletin 

••  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  can  well 
hold  place  with  more  pretentious  text-books." 


GENITO- URINARY   AND    NO  Si:,      77/A'OA7\     J'/fC 


Greene  and  Brooks' 
Genito-Urinary  Diseases 

Diseases  of    the    Genito=Urinary  Organs  and  the   Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  639  pages,  illustrated.  Cloth,  I5.00  net;  Half 
Morocco,  ^6.50  net. 

THE  NEW   (3d)  EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidtiey  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinary 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Clinical  Professor  of  Otology, 
Medico-Chirurgical  College,  Philadelphia.  i2mo  of  556  pages,  pro- 
fusely illustrated.     Flexible  leather,  ^2.50  net. 

THE  NEW  (2d)  EDITION 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  are  few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Qenito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  Skin.  Edited  by  L.  Bolton  Bangs,  M.  D.,  and 
W.  A.  Hardaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  i^y.QO  net. 


S.irA7:>£A\s"   BOOK'S  OX 


Holland's  Medical 
Chemistry  and  Toxicology 

A  Text-Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.D.,  Piofcssor  of  jMedical  Chemistry  and  Toxicology, 
and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo  of  67^ 
pages,  fully  illustrated.     Cloth,  $3.00  net. 

THE  NEW  (3d)  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  eqiiilib- 
rium,  Kjeldahl's  method  for  determining  nitrogen,  chemistry  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.      .More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse ;  its  illustrations  well  chosen  ;  its  development  logical, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Ivy's  Applied  Anatomy  and 

Oral  Surg(ery  for  Dental  Students 


Applied   Anatomy  and   Oral    Surgery  for  Dental  Students.     By 

Robert  H.  Ivy,  M.D.,  D.D.S.,  Assistant  Oral  Surgeon  to  the  Philadel- 
phia General  Hospital.      i2mo  of  280  pages,  illustrated.     Cloth,  ;^i.  50 

net. 

FOR  DENTAL  STUDENTS 

This  work  is  just  what  dental  students  have  long  wanted^a  concise,  practical 
work  on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in 
mind.  No  one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate 
in  both  dentistry  and  medicine.  Having  gone  through  the  dental  school,  he 
knows  precisely  the  dental  student's  needs  and  just  how  to  meet  them.  His 
medical  training  assures  you  that  his  anatomy  is  accurate  and  his  technic  modern. 
The  text  is  well  illustrated  with  pictures  that  you  will  find  extremely  helpful. 

H.  P.  Kuhn,  M.D.,  M'fs/cni  Dmtal  College,  Kansas  City. 

"  I  am  delighted  with  this  compact  little  treatise.     It  seems  to  me  just  to  fill  the  bill." 


CHEMISTRY,   SKfN,  AND    VENEREAL    DISEASES.  13 

American  Pocket  Dictionary  New  (7th)  Edition 

The  American  Pocket  Micdicae  Dictionary.  I'lditcd  by  W.  A.. 
Newman  Doreand,  M.  D.,  Editor  "American  Illustrated  Medical 
Dictionary."  Containing  the  pronunciation  and  definition  of  the 
principal  words  used  in  medicine  and  kindred  sciences.  6lO  pages. 
Flexible  leather,  with  gold  edges,  $\.oo  net;  with  thumb  index, 
$1.2^  net. 
James  W.  Holland,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 
Philadelphia, 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  I 
can  recommend  it  to  our  students  without  reserve." 

Stelwagon's  Essentials  of  Skin  7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
WAGON,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  291  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  ^i.oo  net.  In 
Saunders'  Question- Comp end  Series. 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  New  (7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  ^^i.oo  net.  In 
Saunders'  Question- Coiupend  Series. 

Martin's  Minor  Surg»ery,  Bandaging,  and  the  Venereal 

Diseases  second  Edition.  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.  Post-octavo,  166 
pages,  with  78  illustrations.  Cloth,  ;^i.oo  net.  In  Saunders' 
Question-  Covipend  Series. 

Vecki's  Sexual  Impotence  New  (4th)  Edition 

Sexual  Impotence.  By  Victor  G.  Vecki,  M.  D.,  Consulting 
Genito-Urinary  Surgeon  to  Mt.  Zion  Hospital,  San  Francisco. 
i2mo  of  400  pages.     Cloth,  ^2.25  net. 

Johns  Hopkins  Hospital  Bulletin 

"  A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The 
treatment  of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and 
judicious." 


14  SAUXDEJ^S'    BOOK'S    O.V 

Wells'   Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ologv  from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  549  pages. 
Cloth,  $3.25  net;  Half  Morocco,  $4.7$  "^t. 

Wm.   H.  Welch,  M.  D.,  Professor  of  Pathology',  Johns  Hopkins  University. 

"  TIr-  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


The  New   (2d)   Edition 


Saxe's  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
formerly  Instructor  in  Genito-Urinary  Surgery,  New  York  Post- 
graduate Medical  School  and  Hospital.  i2ino  of  448  pages,  fully 
illustrated.     Cloth,  $1.75  net. 

Francis  Carter  Wood,  M.  D.,    Adjunct  Professor  of  Clinical  Pathology,   Coliuitbia    Uni- 
versity. 

"It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is, 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear, 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  lulited  by  G.  E.  de  Schweinitz,  M.D.,  and  B.  Alex- 
ander Randall,  M.D.  Imperial  octavo,  1251  pages,  with  766 
illustrations,  59  of  them  in  colors.  Cloth,  $'j.oo  net;  Half  Mo- 
rocco, $8.50  net. 

Grtinwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases    of  the  Larynx.     By  Dr.   L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
$2.50  net.     ///  Saunders   Hand-Atlas  Scries. 


Mracek  and  Stelwagon's  Atlas  of  Skin 


Second 
Edition 


Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr. 
Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry 
W.  STELWAGf)N,  M.D.,  Jefferson  Medical  College.  With  yy  col- 
ored plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders'  Hand-Atlas  Scries.     Cloth,  $4.00  net. 


EYE,    EAR,    NOSE,    AND    TIIKOAT.  i? 

deSchweinitz    and    HoUoway   on   Pulsating    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Hollow  AY,  M.  D."     Octavo  of  125  pages.     Cloth,  $2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

British  Medical  Journal 

"The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  of 
the  disease  will  be  found." 

Jackson  on  the  Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surger}% 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  G.  Preiswerk,  of 
Basil.  Edited,  with  additions,  by  George  W.  Warren,  D.D.S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.      Cloth,  $3.50  net.     In  Saunders'  Atlas  Series. 

Friedrich  and   Curtis   on  Nose,   Larynx,   and   Ear 

RhINOLOGY,   LARYNGOLOGy,  AND    OtOLOGY,   AND   ThEIR    SIGNIFICANCE 

in  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited 
by  H.  Holbrook  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York 
Nose  and  Throat  Hospital.  Octavo  volume  of  350  pages.  Cloth, 
^2.50  net. 


1 6  s.ir.y/y/'SJ^s'  boc^a's  on 

Wolfs  Examination  of   Urine 

A  Lal;okatorv  llANDiiooK  OF  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.Wolf,  M.D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  Uni\'ei'sity  Medical  College,  New 
York.  i2mo  \-olume  of  204  pages,  fully  illustrated.  Cloth,  $1.25  net. 
British  Medical  Journal 

•  riic  nu-ihotls  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
enil  of  the  book  some   extensive   tables  drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Es.-^entials  of  Refkactiox  and  of  Diseases  of  the  P2ye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations. '  Cloth,  $1.00  net.     /u  San?iih'?-s  Qiicstioi-Coinpcnd  Series. 

Johns  Hopkins  Hospital  Bulletin 

'■  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason's  Nose  and  Throat  Fourth  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gle.vson,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  1 12 
illustrations.  Cloth,  ;^i.oo  net.  ///  Sau7iders'  Question  Compends, 
The  Lancet,  London 

,  "  Tiie  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to'enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition.  Revbed 

P^ssentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo   volume  of  214  pages,  with   114  illustra- 
tions.    Cloth,  $1.00  net.      In  Sa2t?iders  Question- Covipend  Series. 
Bristol  Medico-Chirurgical  Journal 

"  We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  tliis,  either  in 
freshness  of  style  or  completeness  of  information." 

Wilcox  on  Genito-Urinary  and  Venereal  Diseases 

The  New  (2d)   Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  i2mo 
of  321  pages,  illustrated.     Cloth,  31.00  net.     Saunders'  Covipends. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo  of  126  pages,  illu.strated.  Cloth,  $1.25  net. 

Edward  Jackson.  M.  D.,  Unhersity  of  Colorado. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


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